COVID-19 Situation Report 321

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 321. 16 December 2020

Dec 16

Centre for Infectious Disease Epidemiology and Research (CIDER) For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 321. 16 December 2020

i. Background

In December, China notified the World Health Organization (WHO) of several cases of human respiratory illness, which appeared to be linked to an open seafood and livestock market in the city of Wuhan. The infecting agent has since been identified as a novel coronavirus, previously known as 2019-nCoV and now called SAR-CoV-2; The new name of the disease has also been termed COVID-19, as of 11th February 2020. Although the virus is presumed zoonotic in origin, person-to-person spread is evident. Screening of travellers, travel bans and quarantine measures are being implemented in many countries. Despite these precautions, it is anticipated that more cases will be seen both inside China and internationally. The WHO declared the outbreak of COVID-19 constitutes a Public Health Emergency of International Concern on 30 January. On 11 March, 2020, WHO declared the coronavirus outbreak a pandemic as the global death toll rose above 4,600 and the number of confirmed cases topped 125,000. This report aims to update Global Risk Assessment, Global Epidemiology, Quarantine Orders, Travel Ban/Advisory by countries, WHO’s and CDC’s Guidance and Protocols and Scientific publication on a daily basis. New updates in the tables are bolded.

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ii. Global Risk Assessment

Table 1. Risk assessment of COVID-19 by WHO regions (Updated as of 16 Dec 2020, 15:00 SGT) Severity of Availability of Treatment/ Overall Environmental Risk Transmissibility Disease Vaccination# Risk Global (n=197 countries) High Moderate High Limited

Globally, 187 (94.9%) countries Based on CDC Case Researchers have found all regimens of * (excluding territories ) have data, median R0 is fatality rate anticoagulants to be far superior to no reported the outbreak. estimated to be is currently anticoagulants in COVID-19 patients. More 5.8 (95% CI 4.4– at 2.22% specifically, patients on both a “therapeutic” Using an incidence >20 7.7), but the globally. or full dose and those on a “prophylactic” or cases/100,000 people over the estimated Most cases lower dose, showed about a 50% higher past 14-days as cut-off for a effective present as chance of survival and roughly a 30% lower surge in cases, the number of reproduction flu-like chance of intubation, than those not on countries reporting a surge in number in 175 illness. anticoagulants. It was observed that cases in each region are as countries ranged therapeutic and prophylactic subcutaneous follows: Combined WPRO and from 0.3 to 2.2.$ low-molecular weight heparin and therapeutic SEARO (9 countries), oral apixaban may lead to better results [3]. EURO (50 countries), EMRO (13 countries), Americas International clinical trials published on 2 (24 countries), and Africa (6 September confirm that cheap, widely countries). available steroid drugs can help seriously ill patients survive Covid-19. The World Health Only 5 (3%) countries/territories Organization issued new treatment guidance, have no reported restrictions on strongly recommending steroids to treat inbound arrivals, while 143 severely and critically ill patients, but not to (77%) countries/territories have those with mild disease. [4] partially reopened their borders – require arrivals to produce a According to the World Health Organisation, High negative COVID-19 test result 48 potential vaccines are currently in clinical and/or undergo self-quarantine trials, but only 11 are in phase 3 as of upon arrival. 52 (28%) November 21. [5] countries/territories remain totally closed to international arrivals. [1]

On October 7, the Centers for Disease Control and Prevention (CDC) confirmed airborne transmission of SARS-CoV-2. [2]

The U.S. CDC has revised its guidelines regarding COVID-19 quarantine period, from 14 days to seven to 10 days, depending on one's test results and symptoms. If individuals do not develop symptoms, they only need quarantine for 10 days without testing; if they test negative, that period can be reduced to seven days. [39]

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Western Pacific Region and South-East Asia Region (n=41 countries) High Moderate Moderate Limited

32 (78.1%) countries have As of December Case As of October, Japan, Singapore, India and reported outbreaks; but only 9 14, the estimated fatality rate Australia, and Indonesia have approved the (22%) are reporting a surge in effective is 1.55%. use of Remdesivir for treatment. [6,7,8,9,10] cases. reproduction no. of 22 countries As of August, Japan and Taiwan have approved 15 (36.6%) countries have either ranged from 0.31- the use of Dexamethasone for treatment. a constant decreasing change in 1.3.$ [11,12] incidence or no case in the last 14 days. As of October, India and Indonesia have approved the use of Favipiravir for treatment. Highest incidence over the past [13] 14 days were reported from Malaysia, Maldives, Myanmar, As of June 25, the Ad5-nCoV developed by the Nepal and Sri Lanka and highest military and CanSino Biologics has been case numbers were reported approved for military use for a year. While from Bangladesh, India, phase 1 and 2 clinical tirals have shown its Indonesia, Japan and Malaysia. potential, its commercial success cannot be High guaranteed. [14] At least 17 countries have closed their borders, 25 Only July 22, China approved the emergency countries have opened their use of vaccine by Sinopharm. High risk group borders partially conditionally, such as medical workers, customs and border and none are allowing free officials were eligible to receive the vaccine. travel. [15]

On Dec 3, Indonesia approved the use of vaccines from local pharmaceutical company PT Bio Farma, United Kingdom-based AstaZeneca, China’s Sinopharm/Sinovac Biotech, US pharma Moderna and Pfizer/BioNTech for vaccination programs. [16]

As of December 15, Singapore has approved the use of Pfizer’s vaccine. [38]

European Region (n=53 countries) High Moderate Moderate Limited

52 (98.1%) countries have As of December Case As of May, Britain started providing Remdesivir reported with outbreaks; 50 14, the estimated fatality rate to COVID-19 patients who are most likely to (94.3%) countries are reporting effective is 2.14%. benefit [17]. a surge in cases. reproduction no. of 52 countries Russia secured regulatory approval for the use 1 (1.9%) country has either a ranged from 0.59- of its antiviral drug Coronavir, to treat mild and High constant decreasing change in 1.5.$ moderate patients of Covid-19 [18]. incidence or no case in the last 14 days. As of 2 December, UK has granted emergency authorization for Pfizer-BioNTech’s COVID-19 Highest incidence over the past vaccine and will start rolling it out next week. 14 days were reported from It is set to prioritize healthcare workers, eldery Croatia, Georgia, Lithuania, and other vulnerable population. [19] Luxembourg and Turkey, and

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 321. 16 December 2020 highest case numbers were Moscow began its first mass vaccination by reported from Germany, Italy, distributing the Sputnik V COVID-19 shot via 70 Russia, Turkey and UK. clinics on Dec 5. Vaccine would first be made available to doctors and other medical At least 7 countries have closed workers, teachers and social workers. [20] their borders, 44 countries have opened their borders partially As of December 8, the UK has begun mass conditionally, and only 2 vaccination using Pfizer’s vaccine. [40] countries are allowing free travel.

Eastern Mediterranean Region (n=22 countries) High Moderate High Limited

22 (100%) countries have As of December Case A As of April, an Israeli firm is using placenta reported with outbreak; 13 14, the estimated fatality rate pluristem cells to treat COVID-19 patients on a (59.1%) countries are reporting effective is 2.49%. compassionate use basis. [21] a surge in cases. reproduction no. of 22 countries As of June 25, the Abu Dhabi Stem Cell Centre No country has either a constant ranged from 0.64- has treated more than 2,000 COVID-19 decreasing change in incidence 1.3.$ patients using UAECell19. 1,200 have fully or no case in the last 14 days. recovered. [22]

Highest incidence over the past Bahrain has granted emergency approval for 14 days were reported from the use of a COVID-19 vaccine candidate on Iran, Jordan, Lebanon, Palestine frontline workers from Nov 3. The vaccine and UAE, and highest case candidate is a partnership between numbers were reported from Sinopharm’s China National Biotec Group Iran, Jordan, Morocco, Pakistan (CNBG) and Abu Dhabi-based artificial and Palestine. intelligence and cloud computing company Group 42 (G42). [23] At least 7 countries have closed their borders, 14 countries have As of December 14, Bahrain and Kuwait have opened their borders partially granted emergency use authorisation for the High conditionally, and only 1 country Pfizer/BioNTech COVID-19 vaccine. [24,25] is allowing free travel. As of December 9, Israel received its first shipment of Pfizer vaccines and plans to start administering the vaccines on Dec 20. [26]

As of December 11, Egypt has received its first shipment of Sinopharm’s vaccine. [27]

As of December 14, Bahrain has approved Sinopharm’s vaccine [28].

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 321. 16 December 2020

Region of the Americas (n=35 countries) High Moderate High Limited

35 (100%) countries have As of December Case As of October 22, remdesivir is the first and reported with outbreak; 24 14, the esimated fatality rate only FDA-approved COVID-19 treatment in the (68.6%) countries are reporting effective is 2.51%. U.S. [29]. a surge in cases. reproduction no. of 31 countries RLF-100 (aviptadil) by NeuroRx and Relief No country has either a constant ranged from 0.45- Therapeutics was approved for emergency use decreasing change in incidence 1.6.$ in COVID-19 patients who are too ill to or no case in the last 14 days. participate in the trial. [30]

Highest incidence over the past FDA has issued emergency authorisation for 14 days were reported from convalescent plasma to treat COVID-19. [31] Belize, Brazil, Costa Rica, Panama and USA, and highest FDA has allowed emergency use of Eli Lilly & case numbers were reported Co’s bamlanivimab for non-hospitalized from Brazil, Canada, Colombia, patients at risk of serious illness due to age or Mexico and USA. other conditions. [32] High At least 11 countries have Health Canada has approved bamlanvimab, for closed their borders, 22 the treatment of COVID-19 in patients 12 years countries have opened their and older with mild to moderate symptoms borders partially conditionally, who are at risk of severe disease progression. and 2 countries are allowing [33] free travel. The Food and Drug Administration has allowed the combination use of baricitinib and Remdesivir under emergency use authorization. The EUA covers dosing of patients (above the age of two) who are on supplemental oxygen, receiving invasive mechanical ventilation or extracorporeal membrane oxygenation. [34]

As of December 11, Canada and the US have approved the Pfizer-BioNTech Covid-19 vaccine. [35,36] African Region (n=46 countries) High Moderate Moderate Limited

46 (100%) countries have As of December Case Ethiopia has approved the use of reported with outbreak; 6 (13%) 14, the estimated fatality rate Dexamethasone treatment for seriously ill countries are reporting a surge effective is 2.22%. COVID-19 patients. [37] in cases. reproduction no. of 45 countries 1 country (2.2%) has either a ranged from 0.49- constant decreasing change in 1.6.$ High incidence or no case in the last 14 days.

Highest incidence over the past 14 days were reported from Botswana, Cabo Verde, Mauritania, Namibia and South Africa and highest case numbers

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 321. 16 December 2020 were reported from Algeria, Ethiopia, Kenya, South Africa and Uganda.

At least 10 countries have closed their borders, 37 countries have opened their borders partially conditionally, and no country is allowing free travel. *Only WHO member states are included. 30 territories that have reported cases (with the exception of Palestine) are excluded from the tabulation of total countries affected/imported/local cases and case fatality rate. Refer to WHO situation reports or table 4 for information. # Ongoing clinical trials of vaccines and treatment are summarised in section X %This is by no means an exhaustive list of lockdowns imposed globally. Tally is subjected to publication bias whereby certain countries may receive less media attention and hence, coverage on their travel bans implemented. $ https://epiforecasts.io/covid/posts/global/ ^Differences between R0 and effective R can be found here https://www.coronavirustoday.com/r-number-refers-either-basic-or-effective- reproduction-number

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 321. 16 December 2020

iii. Global Epidemiology

Table 2. Summary of COVID-19 cases & fatalities globally (Updated as of 16 Dec 2020, 15:00 SGT) Case- No. of Total Cases Case- Total Fatality Countries/ Outside Total Fatality Global Rate (%) R0 Territories Mainland Deaths Rate (%) Cases [outside with Cases China [overall] China] 5.8 (95% CI 4.4– 218 73,821,896 73,735,126 1,642,044 2.22% 2.22% 7.7)^ ^Based on early release as of 10th April, 2020: https://wwwnc.cdc.gov/eid/article/26/7/20-0282_article

Table 3. Comparison with other viruses Virus Incubation Period (Days) Case Fatality Rate (%) R0 Median = 5.1$ SARS-CoV-2 2.22 5.8 (95% CI 4.4–7.7) ^ (2-14) or up to 24* SARS-CoV 2-7 9.6 2.0 <1 (higher in health care MERS-CoV 5 (2-14) 34 setting) Swine Flu 1-4 0.02 1.2-1.6 *Data on 1099 patients from 552 hospitals in 31 provinces of China ^https://wwwnc.cdc.gov/eid/article/26/7/20-0282_article $Data on 181 cases outside china

Figure 1. Growth Factor of Daily New Cases (Mainland China+ Other countries)

Growth Factor = every day’s cases/cases on previous day. A growth factor above 1 indicates an increase, whereas one between 0 and 1 is a sign of decline, with the quantity eventually becoming zero. A growth factor below 1 (or above 1 but trending downward) is a positive sign, whereas a growth factor constantly above 1 is the sign of exponential growth. *Huge jump in cases on Feb. 12 is attributed to the change in diagnostic criteria in China.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 321. 16 December 2020

Figure 2. Growth Factor excluding mainland China

Figure 3. Growth Factor of Novel Coronavirus Daily Deaths (Mainland China + Other Countries)

Growth Factor = every day’s cases/cases on previous day. A growth factor above 1 indicates an increase, whereas one between 0 and 1 is a sign of decline, with the quantity eventually becoming zero. A growth factor below 1 (or above 1 but trending downward) is a positive sign, whereas a growth factor constantly above 1 is the sign of exponential growth. Source: https://www.worldometers.info/coronavirus/coronavirus-cases/

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Case Breakdown by Countries Live update of COVID-19 global cases can be found at https://storymaps.arcgis.com/stories/a1746ada9bff48c09ef76e5a788b5910

Table 4. Breakdown of COVID-19 confirmed cases and deaths (Updated as of 16 Dec 2020, 15:00 SGT) Total Total Country Change Change Total Recovered Region Cases Deaths 1 USA 17,143,942 +200962 311,073 +2982 10,007,956 Americas 2 India 9,932,908 +26401 144,130 +384 9,456,449 SEARO 3 Brazil 6,974,258 +44849 182,854 +909 6,067,862 Americas 4 Russia 2,707,945 +26689 47,968 +577 2,149,610 EURO 5 France 2,391,447 +11532 59,072 +790 179,087 EURO 6 Turkey 1,898,447 +32102 16,881 +235 1,661,191 EURO 7 UK 1,888,116 +18450 64,908 +506 N/A EURO 8 Italy 1,870,576 +14839 65,857 +846 1,137,416 EURO 9 Spain 1,771,488 +9452 48,401 +388 N/A EURO 10 Argentina 1,510,203 +6981 41,204 +163 1,344,300 Americas 11 Colombia 1,444,646 +10130 39,356 +161 1,328,430 Americas 12 Germany 1,378,518 +21377 23,692 +805 1,003,300 EURO 13 Mexico 1,267,202 +11228 115,099 +801 938,089 Americas 14 Poland 1,147,446 +6874 23,309 +349 879,748 EURO 15 Iran 1,123,474 +7704 52,670 +223 833,276 EMRO 16 Peru 987,675 +1545 36,817 +63 922,314 Americas 17 Ukraine 919,704 +10622 15,744 +264 535,417 EURO 18 South Africa 873,679 +7552 23,661 +210 764,977 Africa 19 Indonesia 629,429 +6120 19,111 +155 516,656 SEARO 20 Netherlands 628,577 +6633 10,168 +86 N/A EURO 21 Belgium 611,422 +2211 18,178 +124 41,973 EURO 22 Czechia 586,251 +5172 9,743 +134 511,798 EURO 23 Iraq 577,363 +1391 12,614 +11 511,639 EMRO 24 Chile 575,329 +1499 15,949 +18 548,190 Americas 25 Romania 565,758 +6171 13,698 +204 465,050 EURO 26 Bangladesh 494,209 +1877 7,129 +40 426,729 SEARO 27 Canada 475,214 +6352 13,659 +106 385,975 Americas 28 Philippines 451,839 +1106 8,812 +55 418,867 WPRO 29 Pakistan 445,977 +2731 9,010 +105 388,598 EMRO 30 Morocco 403,619 +2793 6,711 +52 362,911 EMRO 31 Switzerland 388,828 +4271 6,266 +112 311,500 EURO 32 Israel 360,630 +1124 3,014 +10 338,784 EURO 33 Saudi Arabia 360,155 +142 6,069 +10 350,993 EMRO 34 Portugal 353,576 +2638 5,733 +84 280,038 EURO 35 Sweden 341,029 +20931 7,667 +153 N/A EURO 36 Austria 327,679 +2628 4,648 +118 287,750 EURO 37 Hungary 285,763 +1893 7,237 +107 83,115 EURO

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38 Serbia 277,248 +5884 2,433 +53 31,536 EURO 39 Jordan 265,024 +2547 3,437 +30 226,245 EMRO 40 Nepal 250,180 +936 1,730 +14 238,569 SEARO 41 Ecuador 202,356 +176 13,896 +21 177,951 Americas 42 Panama 196,987 +2368 3,411 +29 164,855 Americas 43 Georgia 194,900 +3837 1,883 +44 164,786 EURO 44 UAE 187,267 +1226 622 +4 165,023 EMRO 45 Bulgaria 184,287 +2743 6,005 +167 87,935 EURO 46 Azerbaijan 183,259 +4273 2,007 +41 119,005 EURO 47 Japan 181,870 +2217 2,643 +58 153,519 WPRO 48 Croatia 179,718 +2360 2,778 +73 155,079 EURO 49 Belarus 164,059 +1911 1,282 +9 141,443 EURO 50 Dominican Republic 155,797 +613 2,367 +3 121,323 Americas 51 Costa Rica 154,096 +927 1,956 +20 121,031 Americas 52 Armenia 150,218 +1098 2,556 +27 128,694 EURO 53 Lebanon 148,877 +1264 1,223 +13 104,207 EMRO 54 Bolivia 147,716 +371 9,026 +2 126,720 Americas 55 Kuwait 146,710 +261 913 +1 142,599 EMRO 56 Kazakhstan 143,735 +749 2,147 +59 128,218 EURO 57 Qatar 141,272 +151 241 0 138,919 EMRO 58 Slovakia 135,523 +2034 1,251 +46 100,303 EURO 59 Guatemala 130,082 +677 4,476 +31 118,793 Americas 60 Moldova 128,656 +1403 2,625 +27 111,314 EURO 61 Oman 126,719 +215 1,475 +3 118,505 EMRO 62 Greece 126,372 +1199 3,785 +98 9,989 EURO 63 Egypt 122,609 +523 6,966 +23 105,450 EMRO 64 Ethiopia 117,542 +300 1,813 +4 96,307 Africa 65 Denmark 116,087 +2992 961 +11 82,099 EURO 66 Honduras 114,943 +301 3,001 +12 52,392 Americas 67 Palestine 113,409 +2307 1,023 +23 88,967 EMRO 68 Tunisia 113,241 +1880 3,956 +62 86,801 EMRO 69 Myanmar 110,667 +1155 2,319 +27 89,418 SEARO 70 Venezuela 108,480 +355 965 +5 103,271 Americas 71 Bosnia and Herzegovina 102,330 +869 3,457 +66 67,649 EURO 72 Slovenia 98,281 +1536 2,149 +42 75,017 EURO 73 Lithuania 96,452 +1431 863 +38 41,665 EURO 74 Paraguay 95,353 +1130 1,991 +20 67,953 Americas 75 Algeria 93,065 +468 2,623 +14 61,307 Africa 76 Kenya 92,459 +404 1,604 +11 73,979 Africa 77 Libya 92,017 +660 1,319 +5 62,144 EMRO 78 Bahrain 89,444 +176 348 0 87,490 EMRO 79 China 86,770 +12 4,634 0 81,821 WPRO 80 Malaysia 86,618 +1772 422 +3 71,681 WPRO 81 Kyrgyzstan 78,151 +241 1,317 +1 71,270 EURO

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82 Ireland 76,776 +327 2,134 +8 23,364 EURO 83 Uzbekistan 75,396 +155 612 0 72,661 EURO 84 North Macedonia 74,732 +881 2,169 +22 50,852 EURO 85 Nigeria 74,132 +758 1,200 +3 66,494 Africa 86 Singapore 58,341 +16 29 0 58,233 WPRO 87 Ghana 53,270 +256 327 0 51,965 Africa 88 Albania 50,000 +809 1,028 +12 25,876 EURO 89 Afghanistan 49,703 +219 2,001 +26 38,500 EMRO 90 S. Korea 45,442 +1078 612 +12 32,947 WPRO 91 El Salvador 42,397 +517 1,219 +14 38,481 Americas 92 Luxembourg 42,250 +350 418 +8 33,486 EURO 93 Montenegro 42,148 +345 597 +12 32,097 EURO 94 Norway 41,852 +518 395 +2 34,782 EURO 95 Sri Lanka 34,121 +643 154 0 24,867 SEARO 96 Finland 31,459 +349 466 +5 20,000 EURO 97 Uganda 28,168 +402 225 +1 10,005 Africa 98 Australia 28,056 +11 908 0 25,690 WPRO 99 Latvia 26,472 +587 357 +5 17,477 EURO 100 Cameroon 25,359 +145 445 +2 23,851 Africa 101 Sudan 21,864 +273 1,372 +17 12,667 EMRO 102 Ivory Coast 21,775 +70 133 0 21,335 Africa 103 Estonia 18,682 +297 157 +3 11,669 EURO 104 Zambia 18,428 +106 368 +1 17,487 Africa 105 Madagascar 17,587 0 259 0 16,992 Africa 106 Senegal 17,216 +70 350 0 16,243 Africa 107 Mozambique 17,042 +40 144 +1 15,117 Africa 108 Namibia 16,913 +187 164 +1 14,981 Africa 109 Angola 16,362 +85 372 0 8,990 Africa 110 French Polynesia 15,870 +123 97 +1 4,842 Non 111 Cyprus 15,789 +339 84 +2 2,057 EURO 112 DRC 14,597 +84 358 +2 12,773 Africa 113 Guinea 13,457 0 80 0 12,713 Africa 114 Maldives 13,392 +13 48 0 12,760 SEARO 115 Botswana 12,873 0 38 0 10,456 Africa 116 Tajikistan 12,777 +36 88 0 12,212 EURO 117 French Guiana 11,906 +51 71 0 9,995 Non 118 Jamaica 11,875 +83 276 +3 8,212 Americas 119 Zimbabwe 11,522 +164 310 +1 9,599 Africa 120 Mauritania 11,431 +296 236 +8 8,248 Africa 121 Cabo Verde 11,395 +34 110 0 11,055 Africa 122 Malta 11,303 +49 177 +3 9,420 EURO 123 Uruguay 10,418 +389 98 +3 6,895 Americas 124 Haiti 9,597 +9 234 0 8,280 Americas 125 Cuba 9,588 +96 137 0 8,592 Americas

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126 Belize 9,511 +134 211 +14 4,514 Americas 127 Syria 9,452 +150 543 +13 4,494 EMRO 128 Gabon 9,351 0 63 0 9,204 Africa 129 Réunion 8,534 0 42 0 8,037 Non 130 Guadeloupe 8,524 +52 154 +3 2,242 Non 131 Hong Kong 7,722 +98 123 +5 6,345 WPRO 132 Bahamas 7,698 +24 164 +1 6,081 Americas 133 Andorra 7,382 0 79 0 6,706 EURO 134 Eswatini 6,912 +87 132 +2 6,476 Non 135 Trinidad and Tobago 6,900 +15 123 0 6,204 Americas 136 Rwanda 6,832 +85 57 +1 6,036 Africa 137 Congo 6,200 0 100 0 4,988 Africa 138 Malawi 6,080 +10 187 0 5,659 Africa 139 Guyana 5,973 +30 156 0 5,144 Americas 140 Nicaragua 5,887 0 162 0 4,225 Americas 141 Mali 5,878 +42 205 +4 3,697 Africa 142 Djibouti 5,749 +16 61 0 5,628 EMRO 143 Mayotte 5,616 +65 53 +1 2,964 Non 144 Martinique 5,575 0 42 0 98 Non 145 Iceland 5,571 +7 28 0 5,401 EURO 146 Suriname 5,381 +22 117 0 5,231 Americas 147 Equatorial Guinea 5,195 +10 85 0 5,061 Africa 148 Aruba 5,079 +23 46 0 4,911 Non 149 CAR 4,936 0 63 0 1,924 Africa 150 Somalia 4,579 0 121 0 3,529 EMRO 151 Burkina Faso 4,300 +91 73 +2 2,940 Africa 152 Thailand 4,261 +15 60 0 3,977 SEARO 153 Gambia 3,785 +3 123 0 3,653 Africa 154 Curaçao 3,699 +38 11 0 1,889 Non 155 Togo 3,295 +29 66 0 2,821 Africa 156 South Sudan 3,222 +16 62 0 3,043 Africa 157 Benin 3,090 0 44 0 2,972 Africa 158 Sierra Leone 2,451 +6 75 0 1,853 Africa 159 Guinea-Bissau 2,447 +3 44 0 2,378 Africa 160 Niger 2,361 +39 82 0 1,329 Africa 161 Lesotho 2,307 +30 44 0 1,398 Africa 162 Channel Islands 2,192 +60 48 0 1,339 Non 163 New Zealand 2,100 +4 25 0 2,032 WPRO 164 Yemen 2,085 +1 606 0 1,384 EMRO 165 San Marino 1,982 +48 52 +1 1,685 EURO 166 Chad 1,784 +13 102 0 1,611 Africa 167 Liberia 1,676 0 83 0 1,358 Africa 168 Liechtenstein 1,579 +13 21 +1 1,366 Non 169 Vietnam 1,405 +3 35 0 1,252 WPRO

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170 Sint Maarten 1,269 +20 26 0 1,111 Non 171 Gibraltar 1,104 +22 6 0 1,040 Non 172 Sao Tome and Principe 1,010 0 17 0 952 Africa 173 Mongolia 918 +1 0 0 384 WPRO 174 Saint Martin 801 0 12 0 675 Non 175 Turks and Caicos 771 +2 6 0 741 Non 176 Taiwan 749 +9 7 0 612 WPRO 177 Burundi 735 +6 1 0 640 Africa 178 Papua New Guinea 729 +4 8 0 601 WPRO 179 Diamond Princess 712 0 13 0 699 NA 180 Eritrea 711 0 0 0 564 Africa 181 Monaco 678 +7 3 0 609 EURO 182 Comoros 633 +5 7 0 606 Africa 183 Faeroe Islands 530 +2 0 0 506 Non 184 Mauritius 524 +1 10 0 489 Africa 185 Tanzania 509 0 21 0 183 Africa 186 Bermuda 456 +25 9 0 247 Non 187 Bhutan 439 +1 0 0 408 SEARO 188 Isle of Man 373 0 25 0 344 Non 189 Cambodia 362 0 0 0 319 WPRO 190 Cayman Islands 302 +4 2 0 277 Non 191 Barbados 297 +1 7 0 273 Americas 192 Saint Lucia 278 0 4 0 240 Americas 193 Seychelles 202 +15 0 0 184 Africa 194 Caribbean Netherlands 177 +2 3 0 166 Non 195 St. Barth 162 0 1 0 127 Non 196 Brunei 152 0 3 0 147 WPRO 197 Antigua and Barbuda 148 0 5 0 138 Americas 198 St. Vincent Grenadines 98 0 0 0 81 Americas 199 Dominica 88 0 0 0 83 Americas 200 Grenada 85 +16 0 0 41 Americas 201 British Virgin Islands 76 0 1 0 72 Non 202 Fiji 46 0 2 0 38 WPRO 203 Macao 46 0 0 0 46 WPRO 204 Laos 41 0 0 0 34 WPRO 205 New Caledonia 36 0 0 0 35 Non 206 Timor-Leste 31 0 0 0 30 SEARO 207 Saint Kitts and Nevis 28 0 0 0 23 Americas 208 Vatican City 27 0 0 0 15 Non 209 Falkland Islands 23 +6 0 0 17 Non 210 Greenland 19 0 0 0 18 Non 211 Solomon Islands 17 0 0 0 5 WPRO 212 Saint Pierre Miquelon 14 0 0 0 14 Non 213 Montserrat 13 0 1 0 12 Non

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214 Western Sahara 10 0 1 0 8 Non 215 Anguilla 10 0 0 0 4 Non 216 MS Zaandam 9 0 2 0 7 NA 217 Marshall Islands 4 0 0 0 4 WPRO 218 Wallis and Futuna 3 0 0 0 1 Non 219 Samoa 2 0 0 0 2 WPRO 220 Vanuatu 1 0 0 0 1 WPRO Total 73,821,896 +619,615 1,642,044 +13,806 51,347,400

Figure 4. Areas with reported confirmed cases of COVID-19 (7 – 13 December 2020)

Source: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 321. 16 December 2020

Table 5. COVID-19 cases and deaths reported by provinces in China (Updated as of 16 Dec 2020, 15:00 SGT) Change Existing Change from Total from Area Active previous day Diagnosed Deaths Recovered previous day Cases (Active cases) Cases (Deaths) Shanghai 88 -1 1,418 7 0 1,323 Sichuan 41 0 838 3 0 794 Guangdong 40 +3 2,021 8 0 1,973 Fujian 31 -1 503 1 0 471 Inner Mongolia 26 -1 342 1 0 315 Shaanxi 16 -1 502 3 0 483 Yunnan 13 +1 226 2 0 211 Heilongjiang 11 0 960 13 0 936 Shandong 11 +1 859 7 0 841 Jiangsu 9 0 684 0 0 675 Beijing 8 +1 957 9 0 940 Henan 7 0 1,295 22 0 1,266 Zhejiang 6 0 1,297 1 0 1,290 Tianjin 5 +1 303 3 0 295 Shanxi 2 0 222 0 0 220 Chongqing 1 0 590 6 0 583 Guangxi 1 0 264 2 0 261 Hubei 0 -1 68,149 4,512 0 63,637 Hunan 0 0 1,020 4 0 1,016 Anhui 0 0 992 6 0 986 Xinjiang 0 0 980 3 0 977 Jiangxi 0 0 935 1 0 934 Hebei 0 0 373 6 0 367 Liaoning 0 0 289 2 0 287 Gansu 0 0 182 2 0 180 Hainan 0 0 171 6 0 165 Jilin 0 0 157 2 0 155 Guizhou 0 0 147 2 0 145 Ningxia 0 0 75 0 0 75 Qinghai 0 0 18 0 0 18 Tibet 0 0 1 0 0 1

Source: https://ncov.dxy.cn/ncovh5/view/pneumonia

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 321. 16 December 2020

iv. Travel Bans/Advisories & Quarantine Orders

[1] Myanmar - Domestic flights in Myanmar resume today but international commercial passenger flights remains banned until at least December 31. The ban could be extended beyond the first quarter of 2021. Strict rules and mandatory COVID-19 testing within 36 hours before domestic flights apply. [2] Singapore will launch a special segregated travel lane for travellers on short-term stays up to 14 days. The lane will be open to a limited number of businesses, official, and high economic value travellers from all countries. While travellers cannot have travelled to other countries in the past 14 days and would have to undergo compulsory COVID-19 testing, they would not be subject to any quarantine or controlled itinerary upon arrival. Applications will open in mid-January 2021.

v. Lockdowns

[1] Canada - Restrictions in Quebec will tighten from Christmas – with non-essential businesses, primary and secondary schools shut until at least January 11. Only businesses such as grocery stores, pharmacies, hardware stores and car-repair shops can remain open. Big box stores will also be forbidden from selling non-essential goods. All regions under the orange alert level have been moved to red, the maximum level. Most of the province are already in the red zone since October, which saw the closure of bars, restaurant dining rooms, gyms and entertainment venues. [2] Denmark - Partial lockdown restrictions that were introduced to 31 more municipalities last week have been extended to the entire nation. The lockdown will come into effect in the 29 remaining municipalities mostly in North Jutland and South Jutland starting December 16. Restrictions are set to remain in place until January 3, 2021. Public dining and leisure facilities will be closed, with food and beverage outlets only allowed to operate takeaway services. Indoor areas at all attractions, entertainment and leisure facilities are closed. Schools will be closed as much as possible while public sectors workers not in critical functions must work from home. [3] Grenada - Starting December 14, Grenada will be placed under a partial lockdown. Gatherings are limited to 10 people, businesses are to close by 10pm, and restaurants and bars are limited to takeout only. This comes as a cluster of 26 new infections was linked to a Sandals resort. Prior to this spike, the nation only recorded 45 confirmed cases since March. [4] Luxembourg - Restrictions in Luxemburg have been extended until January 15. In addition to the curfew that runs from 11pm to 6am, there will be new rules preventing dining in closed public spaces like shopping centres. [5] Norway - Restrictive measures in Norway have been extended until mid-January. This means the continued closure of sport centers, cinemas, suspension of mass gatherings and cultural/sport events, banned alcohol sales in public caterers, and that gatherings during the holidays are restricted to 10 guests twice.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 321. 16 December 2020

vi. Military Surveillance

South Korea - COVID-19 in Military [1] As of December 15, the defense ministry recorded 18 new coronavirus cases in army soldiers and officer, bringing the case tally in the military population to 469. Fourteen were from the same unit in the city of Paju, where cluster infections arose following two soldiers' return from holidays. Two cases were recorded in the Gangwon Province, in a soldier who was on vacation, and a quarantined officer who had an infected family member. The last two cases were reported from the western city of Incheon and the border country of Cheorwon respectively.

United States/Germany - Death in Baumholder soldier [2] A Baumholder soldier died of the coronavirus on December 15, marking the first death in a soldier assigned to the US. Army Europe and Africa (USAREUR-AF), and first active-duty soldier to die from COVID- 19.

vii. WHO Guidance & Other Protocols

The following update was published by the WHO on 15 December 2020:

 CORRIGENDA – Evidence to recommendations: COVID-19 mitigation in the aviation sector Available at: https://www.who.int/publications/m/item/corrigenda-evidence-to-recommendations- covid-19-mitigation-in-the-aviation-sector

viii. CDC Guidance & Protocols

US CDC

The following updates were published by the US CDC on 15 December 2020:

 Operational Considerations for Schools Available at: https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/schools.html  Ventilation in Buildings Available at: https://www.cdc.gov/coronavirus/2019-ncov/community/ventilation.html  Vaccinating Healthcare Workers Available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/hcp.html

EU CDC

No new update was published by the EU CDC on 15 December 2020.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 321. 16 December 2020

ix. Vaccines/Therapeutics Development

Noteworthy reports are included to inform main developments of COVID-19 pharmaceutics. Past updates are available from situation report 211 onwards. A global map and registry of trials is also visualised & accessible at: https://www.covid-nma.com/dataviz/ and trial results are available at: https://covid- nma.com/living_data/index.php

Vaccines

[1] India - On December 11, a new vaccine candidate from Gennova Pharmaceuticals, in association with the Department of Biotechnology, a research agency under the government of India, was approved for human trials in India. Phase I trials of HGC019, which is based on mRNA platform, will commence in early January with enrolment of 120 participants. [2] United Kingdom - Valneva has started phase I/II trials of its vaccine candidate in the United Kingdom on December 16. The trials will involve 150 volunteers across 4 National Institute for Health Research testing sites in Birmingham, Bristol, Newcastle and Southampton. Valneva’s vaccine is the fifth to enter clinical trials in the UK, following Oxford/AstraZeneca, Imperial College London, Novavax and Janssen. The UK was the first country in the West to start a mass vaccination programme using Pfizer’s vaccine on December 8.

Therapeutics

[3] South Korea - As of December 15, South Korea’s Ministry of Food and Drug Safety has approved CT- P59, Celltrion’s candidate antibody treatment for patients with life-threatening conditions and with no other means of treatment. The drug is currently undergoing second and third phase clinical trials, and Celltrion plans to seek emergency-use approval for the treatment before year-end.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 321. 16 December 2020

x. Scientific Publications with Epidemiology and Clinical Focus

Only abstracts of new publications will be included in this section.

Fever in the ICU: A Predictor of Mortality in Mechanically Ventilated COVID-19 Patients [1]

Purpose: While fever may be a presenting symptom of COVID-19, fever at hospital admission has not been identified as a predictor of mortality. However, hyperthermia during critical illness among ventilated COVID-19 patients in the ICU has not yet been studied. We sought to determine mortality predictors among ventilated COVID-19 ICU patients and we hypothesized that fever in the ICU is predictive of mortality.

Materials and methods: We conducted a retrospective cohort study of 103 ventilated COVID-19 patients admitted to the ICU between March 14 and May 27, 2020. Final follow-up was June 5, 2020. Patients discharged from the ICU or who died were included. Patients still admitted to the ICU at final follow-up were excluded.

Results: 103 patients were included, 40 survived and 63(61.1%) died. Deceased patients were older {66 years[IQR18] vs 62.5[IQR10], (p = 0.0237)}, more often male {48(68%) vs 22(55%), (p = 0.0247)}, had lower initial oxygen saturation {86.0%[IQR18] vs 91.5%[IQR11.5], (p = 0.0060)}, and had lower pH nadir than survivors {7.10[IQR0.2] vs 7.30[IQR0.2] (p < 0.0001)}. Patients had higher peak temperatures during ICU stay as compared to hospital presentation {103.3°F[IQR1.7] vs 100.0°F[IQR3.5], (p < 0.0001)}. Deceased patients had higher peak ICU temperatures than survivors {103.6°F[IQR2.0] vs 102.9°F[IQR1.4], (p = 0.0008)}. Increasing peak temperatures were linearly associated with mortality. Febrile patients who underwent targeted temperature management to achieve normothermia did not have different outcomes than those not actively cooled. Multivariable analysis revealed 60% and 75% higher risk of mortality with peak temperature greater than 103°F and 104°F respectively; it also confirmed hyperthermia, age, male sex, and acidosis to be predictors of mortality.

Conclusions: This is one of the first studies to identify ICU hyperthermia as predictive of mortality in ventilated COVID-19 patients. Additional predictors included male sex, age, and acidosis. With COVID-19 cases increasing, identification of ICU mortality predictors is crucial to improve risk stratification, resource management, and patient outcomes.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 321. 16 December 2020

xi. Sources

Global Risk Assessment 1. https://www.trip.com/travel-restrictions-covid-19/ 2. https://losangeleno.com/coronavirus-los-angeles/october-1/ 3. https://www.europeanpharmaceuticalreview.com/news/126922/study-shows-anticoagulation- therapy-beneficial-for-covid-19-patients/ 4. https://www.nytimes.com/2020/09/02/health/coronavirus-steroids.html 5. https://www.brusselstimes.com/news/belgium-all-news/141746/coronavirus-prime-minister-advises- belgians-not-to-go-skiing/ 6. https://www.channelnewsasia.com/news/asia/covid-19-japan-remdesivir-drug-treatment- coronavirus-12711690 7. https://www.straitstimes.com/singapore/remdesivir-approved-for-covid-19-treatment-in-singapore 8. https://indianexpress.com/article/coronavirus/covid-treatment-remdesivir-6457718/ 9. https://www.straitstimes.com/asia/australianz/australia-approves-remdesivir-as-virus-treatment 10. https://www.thejakartapost.com/news/2020/10/06/bpom-approves-emergency-use-of-antiviral- drugs-to-treat-covid-19-patients.html 11. https://english.kyodonews.net/news/2020/07/a1c46f037245-japan-oks-dexamethasone-as-second- drug-for-coronavirus-treatment.html 12. https://www.channelnewsasia.com/news/asia/taiwan-covid-19-approves-dexamethasone- treatement-12989166 13. https://www.reuters.com/article/us-health-coronavirus-glenmark-pharms-idUSKBN23Q2E9 14. https://www.channelnewsasia.com/news/asia/cansino-s-covid-19-vaccine-candidate-approved-for- military-use-in-china-12880134 15. https://www.livescience.com/china-approved-covid-19-vaccine-emergency-use-medical-workers.html 16. https://www.thejakartapost.com/news/2020/12/05/indonesia-greenlights-adoption-of-major-covid- 19-vaccines.html. 17. https://www.channelnewsasia.com/news/world/britain-anti-viral-drug-remdesivir-covid-19- coronavirus-12772266 18. https://www.pharmaceutical-technology.com/news/russia-nod-coronavir-covid-19/ 19. https://www.sciencemag.org/news/2020/12/wonderful-news-wake-uk-greenlights-pfizers-covid-19- vaccine 20. https://www.channelnewsasia.com/news/world/russia-moscow-covid-19-mass-vaccination-sputnik-v- shots-13706044 21. https://news.abs-cbn.com/overseas/04/22/20/israeli-firm-treating-covid-19-patients-with-placenta- cells-reports 22. https://www.khaleejtimes.com/coronavirus-pandemic/uae-stem-cell-therapy-for-coronavirus-treats- over-2000-patients-1200-fully-recover- 23. https://www.reuters.com/article/health-coronavirus-bahrain/bahrain-announces-emergency- approval-for-use-of-covid-19-vaccine-candidate-idUSS8N2GL00I 24. https://www.todayonline.com/world/bahrain-approves-pfizerbiontech-covid-19-vaccine 25. https://www.newindianexpress.com/world/2020/dec/13/after-pfizer-biontech-now-chinese-covid-19- vaccine-gets-bahrains-nod-2235736.html 26. https://www.straitstimes.com/world/middle-east/israel-to-receive-initial-shipment-of-pfizer- coronavirus-vaccine

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 321. 16 December 2020

27. http://www.xinhuanet.com/english/2020-12/11/c_139582385.htm 28. https://www.newindianexpress.com/world/2020/dec/13/after-pfizer-biontech-now-chinese-covid-19- vaccine-gets-bahrains-nod-2235736.html 29. https://www.dailytarheel.com/article/2020/11/university-baric-lab-researchers 30. https://www.todayonline.com/world/relief-neurorx-say-emergency-treatment-rlf-100-helps-critically- ill-covid-patients 31. https://www.channelnewsasia.com/news/world/us-plasma-treatment-covid-19-donald-trump-fda- 13046312 32. https://www.reuters.com/article/us-health-coronavirus-eli-lilly-fda-idUSKBN27P35L 33. https://bc.ctvnews.ca/vancouver-developed-covid-19-treatment-approved-for-use-1.5201168 34. https://www.outsourcing-pharma.com/Article/2020/11/23/FDA-grants-EUA-for-combo-COVID-19- treatment 35. https://sg.news.yahoo.com/canada-approves-pfizer-biontech-covid-200403301.html 36. https://www.channelnewsasia.com/news/world/us-approves-first-covid-19-vaccine-pfizer- emergency-use-13756474 37. https://tribune.com.pk/story/2246746/3-ethiopia-use-dexamethasone-covid-19-patients/ 38. https://www.channelnewsasia.com/news/singapore/singapore-approves-pfizer-biontech-covid-19- vaccine-phase-3-13769570 39. http://www.xinhuanet.com/english/2020-12/03/c_139560671.htm 40. https://www.gov.uk/government/news/fifth-covid-19-vaccine-starts-uk-clinical-trials

Travel Bans/Advisories & Quarantine Orders 1. https://www.ttrweekly.com/site/2020/12/myanmars-tourism-remains-grounded/ 2. https://www.ctvnews.ca/health/coronavirus/singapore-announces-plans-to-allow-entry-to-business- travellers-from-all-countries-1.5231597

Lockdowns Refer to Situation Report 91 for all updates before 1st May 2020 1. https://www.thepeterboroughexaminer.com/ts/politics/2020/12/15/quebec-premier-legault-to- announce-additional-covid-19-lockdown-measures-today.html 2. https://www.thelocal.dk/20201215/update-denmark-extends-coronavirus-partial-lockdown-to-entire- country 3. https://www.washingtonpost.com/travel/2020/12/15/sandals-resort-grenada-covid-outbreak/ 4. https://luxtimes.lu/luxembourg/42540-lawmakers-extend-partial-lockdown 5. https://www.urdupoint.com/en/world/norway-extends-covid-19-restrictions-until-mi-1114879.html

Military Surveillance

1. https://en.yna.co.kr/view/AEN20201215003100325 2. https://www.stripes.com/news/europe/army-confirms-baumholder-soldier-died-of-coronavirus- complications-1.655417

Vaccine/Therapeutics Development 1. https://www.livemint.com/news/india/india-gives-nod-to-conduct-trials-of-gennova-s-covid-19- vaccine-11608031317794.html 2. https://www.gov.uk/government/news/fifth-covid-19-vaccine-starts-uk-clinical-trials

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 321. 16 December 2020

3. https://www.channelnewsasia.com/news/asia/south-korea-celltrion-s-candidate-covid-19-drug-gets- approval-for-special-case-use-13776658

Scientific Reports

1. Choron RL, Butts CA, Bargoud C, Krumrei NJ, Teichman AL, Schroeder ME, Bover Manderski MT, Cai J, Song C, Rodricks MB, Lissauer M, Gupta R. Fever in the ICU: A Predictor of Mortality in Mechanically Ventilated COVID-19 Patients. J Intensive Care Med. 2020 Dec 15:885066620979622. doi: 10.1177/0885066620979622. Epub ahead of print. PMID: 33317374. 1.

3 | P a g e Centre for infectious di sease epidemiology and research

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 321. 16 December 2020

Acknowledgement:

Dr. Pang Junxiong, Vincent

Ms Chua Ee Yong Pearleen

Ms Chua Hui Lan

Ms Gwee Xiao Wei Sylvia

Ms Koh Jiayun

Ms Shah Shimoni Urvish

Ms Wang Min Xian

Any queries? Email Sylvia Gwee @ [email protected]

Centre for Infectious Disease Epidemiology and Research

Saw Swee Hock School of Public Health National University of Singapore Tahir Foundation Building 12 Science Drive 2 #10-01 Singapore 117549

For more information, please visit:

Our NUS website: https://sph.nus.edu.sg/partnerships/cider/ Our blog: https://blog.nus.edu.sg/nuscider/

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