For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

Feb 18

COVID-19 Situation Report 385

Centre for Infectious Disease Epidemiology and Research (CIDER) For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

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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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

ii. Global Risk Assessment

Table 1. Risk assessment of COVID-19 by WHO regions (Updated as of 18 Feb 2021, 1200H SGT) Severity of Availability of Treatment/ Overall Environmental Risk Transmissibility Disease Vaccination# Risk Global (n=197 countries) High Moderate High Limited

Globally, 188 (95.4%) countries (excluding Based on CDC Case The number of countries that have * territories ) have reported the outbreak. data, median R0 fatality rate commenced mass vaccination in each is estimated to is currently region are as follows: Combined WPRO Using an incidence >20 cases/100,000 be 5.8 (95% CI at 2.21% and SEARO (10 countries), EURO (39 people over the past 14-days as cut-off for 4.4–7.7), but globally. countries), EMRO (10 countries), a surge in cases, the number of countries the estimated Most cases Americas (12 countries), and Africa (3 reporting a surge in cases in each region effective present as countries).& are as follows: Combined WPRO and reproduction flu-like SEARO (5 countries), number in 171 illness. International clinical trials published on EURO (47 countries), countries 2 September confirm that cheap, widely EMRO (12 countries), Americas (29 ranged from available steroid drugs can help countries), and Africa (14 countries). 0.023 to 2.7.$ seriously ill patients survive Covid-19. The World Health Organization issued Only 4 (2%) countries/territories have no new treatment guidance, strongly reported restrictions on inbound arrivals, recommending steroids to treat while 144 (78%) countries/territories have severely and critically ill patients, but partially reopened their borders – require not to those with mild disease. [4] arrivals to produce a negative COVID-19 test result and/or undergo self-quarantine Researchers have found all regimens of upon arrival. 53 (29%) anticoagulants to be far superior to no countries/territories are totally closed to anticoagulants in COVID-19 patients. international arrivals. [1] More specifically, patients on both a High “therapeutic” or full dose and those on On October 7, the Centers for Disease a “prophylactic” or lower dose, showed Control and Prevention (CDC) confirmed about a 50% higher chance of survival airborne transmission of SARS-CoV-2. [2] and roughly a 30% lower chance of intubation, than those not on The U.S. CDC has revised its guidance on anticoagulants. It was observed that COVID-19 quarantine period from 14 days therapeutic and prophylactic to 7-10 days, based one's test results and subcutaneous low-molecular weight symptoms. Individuals without symptoms heparin and therapeutic oral apixaban only need quarantine for 10 days without may lead to better results. [3] testing; those tested negative can quarantine for 7 days. [14] A new strain known as B.1.525 containing the same E484K mutation The US Centers for Disease Control and found in the Brazilian and South African Prevention (CDC) on 10 Feb announced variants has been detected in Britain that fully vaccinated people did not need [18]. to quarantine if they received their last dose within three months and 14 days after their last shot, the time it takes to develop immunity. [16]

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

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

33 (80.5%) countries have reported As of February Case Vaccine coverage information was outbreaks; but only 5 (12.2%) are 15, the fatality rate available for 10 countries as of 16 reporting a surge in cases. estimated is 1.56%. February 2021. Coverage for: i) at least effective 1 dose was at <50% for 4 countries; ii) 13 (31.7%) countries have either a reproduction full vaccination was at <50% for 2 & constant decreasing change in incidence no. of 22 countries. or no case in the last 14 days. countries ranged from Highest incidence over the past 14 days 0.11-1.8.$ High were reported from Indonesia, Malaysia, Maldives, Philippines and Sri Lanka and highest case numbers were reported from India, Indonesia, Japan, Malaysia and Philippines.

At least 21 countries have closed their borders, 21 countries have opened their borders partially conditionally, and none are allowing free travel. European Region (n=53 countries) High Moderate High High

52 (98.1%) countries have reported with As of February Case Vaccine coverage information was outbreaks; 47 (88.7%) countries are 15, the fatality rate available for 39 countries as of 16 reporting a surge in cases. estimated is 2.23%. February 2021. Coverage for i) at least 1 effective dose was at <50% for 35 countries and 2 (3.8%) country has either a constant reproduction 51-70% for 1 country; ii) full vaccination decreasing change in incidence or no case no. of 52 was at <50% for 34 countries. & in the last 14 days. countries ranged from As of February 14, Italy authorized the High Highest incidence over the past 14 days 0.023-1.2.$ use of the two monoclonal antibodies of were reported from Andorra, Czechia, companies Eli Lilly and Regeneron Israel, Montenegro and San Marino and aimed mainly at more serious patients highest case numbers were reported from with COVID-19 [17]. France, Italy, Russia, Spain and UK.

At least 8 countries have closed their borders, 44 countries have opened their borders partially conditionally, and only 1 country is allowing free travel. Eastern Mediterranean Region (n=22 countries) High Moderate High High

22 (100%) countries have reported with As of February Case Vaccine coverage information was outbreak; 12 (54.6%) countries are 15, the fatality rate available for 10 countries as of 16 reporting a surge in cases. estimated is 2.31%. February 2021. Coverage for: i) at least effective 1 dose was at <50% for 4 countries; ii) High None of the countries has either a reproduction full vaccination was at <50% for 1 constant decreasing change in incidence no. of 20 country. & or no case in the last 14 days. countries ranged from As of June 25, the Abu Dhabi Stem Cell 0.6-2.5.$ Centre has treated more than 2,000

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

Highest incidence over the past 14 days COVID-19 patients using UAECell19. were reported from Bahrain, Jordan, 1,200 have fully recovered. [6] Kuwait, Lebanon and UAE, and highest case numbers were reported from Iran, As of April, an Israeli firm is using Iraq, Jordan, Lebanon and UAE. placenta pluristem cells to treat COVID- 19 patients on a compassionate use At least 6 countries have closed their basis. [5] borders, 15 countries have opened their borders partially conditionally, and only 1 country is allowing free travel.

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

35 (100%) countries have reported with As of February Case Vaccine coverage information was outbreak; 29 (82.9%) countries are 15, the fatality rate available for 12 countries as of 16 reporting a surge in cases. estimated is 2.36%. February 2021. Coverage for: i) at least effective 1 dose was at <50% for 8 countries and 1 (2.9%) country has either a constant reproduction 51-70% for 1 country; ii) full decreasing change in incidence or no case no. of 34 vaccination was at <50% for 7 in the last 14 days. countries countries. & ranged from Highest incidence over the past 14 days 0.33-1.4.$ The Food and Drug Administration has were reported from Barbados, Brazil, St. allowed the combination use of Lucia, St. Vincent Grenadines and USA, baricitinib and Remdesivir under and highest case numbers were reported emergency use authorization. The EUA from Argentina, Brazil, Mexico, Peru and covers dosing of patients (above the age USA. of two) who are on supplemental oxygen, receiving invasive mechanical At least 10 countries have closed their ventilation or extracorporeal membrane borders, 23 countries have opened their oxygenation. [12] borders partially conditionally, and 2 countries are allowing free travel. Health Canada has approved bamlanvimab, for the treatment of High COVID-19 in patients 12 years and older with mild to moderate symptoms who are at risk of severe disease progression. [11]

FDA has allowed emergency use of Eli Lilly & Co’s bamlanivimab for non- hospitalized patients at risk of serious illness due to age or other conditions. [10]

FDA has issued emergency authorisation for convalescent plasma to treat COVID-19. [9]

RLF-100 (aviptadil) by NeuroRx and Relief Therapeutics was approved for emergency use in COVID-19 patients who are too ill to participate in the trial. [8]

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

As of October 22, remdesivir is the first and only FDA-approved COVID-19 treatment in the U.S. [7].

FDA has issued EUA to Eli Lilly’s combination antibody therapy of bamlanivimab and etesevimab to treat mild to moderate COVID-19 patients who are at risk of serious illness or hospitalization. [15]

African Region (n=46 countries) Moderate Moderate High High

46 (100%) countries have reported with As of February Case Vaccine coverage information was outbreak; 14 (30.4%) countries are 15, the fatality rate available for 3 countries as of 16 reporting a surge in cases. estimated is 2.53%. February 2021. Coverage for: i) at least effective 1 dose was at <50% for 1 country; ii) 1 (2.2%) country has either a constant reproduction full vaccination was at <50% for 1 decreasing change in incidence or no case no. of 42 country. & in the last 14 days. countries ranged from Ethiopia has approved the use of Highest incidence over the past 14 days 0.11-2.7.$ Dexamethasone treatment for seriously High were reported from Botswana, Cabo ill COVID-19 patients. [13] Verde, Gabon, Sao Tome and Principe and Seychelles and highest case numbers were reported from Ethiopia, Mozambique, Nigeria, South Africa and Zambia.

At least 9 countries have closed their borders, 38 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 & https://ourworldindata.org/covid-vaccinations; High vaccine coverage defined as >70% population with full vaccination € https://covid19.trackvaccines.org/vaccines/

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021 iii. Global Epidemiology

Table 2. Summary of COVID-19 cases & fatalities globally (Updated as of 18 Feb 2021, 1200H SGT) Case- No. of Total Cases Case- Fatality Countries/ Total Global Outside Total Fatality Rate (%) R0 Territories Cases Mainland Deaths Rate (%) [outside with Cases China [overall] China] 5.8 (95% CI 4.4– 219 110,431,584 110,341,778 2,440,948 2.21% 2.21% 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 2.21 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 385. 18 February 2021

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 18 Feb 2021, 1200 SGT)

Country Total Cases Change Total DeathsChange Total Recovered Region

1 USA 28,453,526 +72306 502,544 +2553 18,596,497 Americas 2 India 10,950,201 +13095 156,038 +89 10,656,845 SEARO 3 Brazil 9,979,276 +57295 242,178 +1195 8,950,450 Americas 4 Russia 4,112,151 +12828 81,446 +467 3,642,582 EURO 5 UK 4,071,185 +12717 118,933 +738 2,282,703 EURO 6 France 3,514,147 +25018 83,122 +310 245,737 EURO 7 Spain 3,107,172 +10829 66,316 +337 2,410,846 EURO 8 Italy 2,751,657 +12066 94,540 +369 2,268,253 EURO 9 Turkey 2,609,359 +7325 27,738 +86 2,496,833 EURO 10 Germany 2,362,364 +9598 67,074 +538 2,154,600 EURO 11 Colombia 2,207,701 +5103 58,134 +185 2,099,628 Americas 12 Argentina 2,039,124 +6064 50,616 +184 1,842,878 Americas 13 Mexico 2,013,563 +8988 177,061 +1075 1,571,071 Americas 14 Poland 1,605,372 +8699 41,308 +280 1,354,598 EURO 15 Iran 1,542,076 +8042 59,184 +67 1,317,612 EMRO 16 South Africa 1,496,439 +2320 48,478 +165 1,399,829 Africa 17 Ukraine 1,280,904 +4286 24,689 +147 1,128,890 EURO 18 Peru 1,252,137 +7408 44,308 +252 1,156,408 Americas 19 Indonesia 1,243,646 +9687 33,788 +192 1,047,676 SEARO 20 Czechia 1,112,322 +12668 18,596 +166 987,515 EURO 21 Netherlands 1,038,156 +3361 15,017 +88 N/A EURO 22 Canada 834,182 +2605 21,435 +38 779,761 Americas 23 Portugal 790,885 +2324 15,649 +127 683,061 EURO 24 Chile 784,314 +2275 19,659 +15 743,306 Americas 25 Romania 768,785 +2815 19,588 +62 714,709 EURO 26 Belgium 741,205 +1717 21,750 +48 50,930 EURO 27 Israel 738,629 +4054 5,473 +32 681,249 EURO 28 Iraq 653,557 +3575 13,204 +12 611,036 EMRO 29 Sweden 622,102 +4233 12,569 +82 N/A EURO 30 Pakistan 565,989 +1165 12,436 +56 528,545 EMRO 31 Philippines 553,424 +1178 11,577 +53 512,033 WPRO 32 Switzerland 545,535 +1253 9,849 +32 490,280 EURO 33 Bangladesh 541,877 +443 8,314 +16 489,254 SEARO 34 Morocco 479,579 +508 8,517 +13 461,466 EMRO

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

35 Austria 437,874 +1735 8,290 +30 415,221 EURO 36 Serbia 426,487 +2467 4,277 +16 31,536 EURO 37 Japan 419,015 +1250 7,102 +87 391,208 WPRO 38 Hungary 391,170 +1548 13,931 +94 299,989 EURO 39 Saudi Arabia 373,702 +334 6,445 +4 364,646 EMRO 40 UAE 358,583 +3452 1,055 +14 343,935 EMRO 41 Jordan 355,106 +2887 4,503 +12 330,805 EMRO 42 Lebanon 346,080 +2479 4,152 +60 250,994 EMRO 43 Panama 333,755 +504 5,672 +17 316,048 Americas 44 Slovakia 282,864 +3168 6,168 +105 255,300 EURO 45 Nepal 273,070 +125 2,055 0 269,394 SEARO 46 Belarus 272,273 +1352 1,876 +9 261,568 EURO 47 Malaysia 272,163 +2998 1,005 +22 229,762 WPRO 48 Ecuador 268,219 +146 15,394 +2 230,377 Americas 49 Georgia 266,948 +486 3,390 +13 259,727 EURO 50 Croatia 238,501 +502 5,375 +18 230,907 EURO 51 Bolivia 238,495 +789 11,303 +29 181,338 Americas 52 Bulgaria 233,342 +1246 9,744 +41 198,888 EURO 53 Azerbaijan 232,491 +154 3,187 +2 227,116 EURO 54 Dominican Republic 231,737 +642 2,990 +15 180,170 Americas 55 Tunisia 225,116 +787 7,651 +34 185,421 EMRO 56 Ireland 211,751 +638 4,036 +56 23,364 EURO 57 Denmark 205,597 +414 2,316 +8 197,746 EURO 58 Kazakhstan 204,924 +869 2,540 0 188,606 EURO 59 Costa Rica 200,888 +434 2,745 +8 166,979 Americas 60 Lithuania 191,821 +557 3,113 +18 176,671 EURO 61 Slovenia 181,606 +1086 3,745 +12 166,220 EURO 62 Kuwait 180,505 +1017 1,019 +5 168,420 EMRO 63 Egypt 175,677 +618 10,150 +49 136,081 EMRO 64 Greece 174,659 +754 6,194 +13 155,913 EURO 65 Moldova 172,815 +1301 3,697 +19 159,339 EURO 66 Palestine 170,527 +1040 1,948 +6 158,709 EMRO 67 Armenia 169,597 +206 3,155 +5 161,476 EURO 68 Guatemala 168,880 +777 6,164 +6 155,920 Americas 69 Honduras 162,584 +857 3,933 +20 63,618 Americas 70 Qatar 158,591 +453 256 0 148,766 EMRO 71 Nigeria 149,369 +1073 1,787 +10 125,722 Africa 72 Ethiopia 149,308 +818 2,237 +14 130,124 Africa 73 Paraguay 147,253 +1037 2,991 +20 123,293 Americas 74 Myanmar 141,690 +31 3,192 0 130,944 SEARO 75 Oman 138,206 +277 1,549 +5 129,752 EMRO 76 Venezuela 134,319 +392 1,297 +5 126,342 Americas

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77 Libya 128,348 +312 2,056 +5 112,731 EMRO 78 Bosnia and Herzegovina 126,781 +368 4,949 +14 109,274 EURO 79 Bahrain 115,057 +696 410 0 107,016 EMRO 80 Algeria 111,247 +178 2,947 +2 76,489 Africa 81 Kenya 103,332 +144 1,801 +4 85,391 Africa 82 North Macedonia 97,803 +347 3,010 +7 88,469 EURO 83 Albania 95,726 +1075 1,600 +18 59,684 EURO 84 China 89,806 +11 4,636 0 84,650 WPRO 85 Kyrgyzstan 85,619 +55 1,446 +2 82,452 EURO 86 S. Korea 85,567 +621 1,544 +6 75,896 WPRO 87 Uzbekistan 79,497 +36 622 0 77,993 EURO 88 Latvia 78,643 +946 1,508 +22 66,208 EURO 89 Ghana 78,271 +1225 565 +10 69,775 Africa 90 Sri Lanka 77,906 +722 422 +13 71,176 SEARO 91 Zambia 71,677 +854 983 +9 64,040 Africa 92 Montenegro 70,174 +404 916 +6 60,805 EURO 93 Norway 67,498 +358 607 +14 63,783 EURO 94 Singapore 59,821 +11 29 0 59,676 WPRO 95 El Salvador 58,023 0 1,767 +9 52,688 Americas 96 Afghanistan 55,557 +17 2,430 +2 48,626 EMRO 97 Estonia 54,300 +856 510 +2 43,054 EURO 98 Luxembourg 53,329 +267 616 +4 49,994 EURO 99 Mozambique 52,629 +829 561 +10 32,857 Africa 100 Finland 51,595 +548 723 +3 40,000 EURO 101 Uruguay 50,208 +483 553 +7 44,481 Americas 102 Cuba 40,765 +824 277 +3 35,324 Americas 103 Uganda 40,102 +39 331 0 14,569 Africa 104 Namibia 36,440 +74 394 +2 34,440 Africa 105 Zimbabwe 35,423 +108 1,418 +4 31,615 Africa 106 Cyprus 32,828 +121 227 +2 2,057 EURO 107 Cameroon 32,098 0 479 0 29,609 Africa 108 Senegal 31,771 +295 769 +9 26,095 Africa 109 Ivory Coast 31,497 +132 180 +1 29,741 Africa 110 Malawi 29,634 +213 976 +8 15,321 Africa 111 Australia 28,912 +3 909 0 26,134 WPRO 112 Sudan 28,025 +40 1,864 +1 22,606 EMRO 113 Botswana 25,802 0 226 0 21,893 Africa 114 Thailand 24,961 +175 82 0 23,697 SEARO 115 DRC 24,602 +179 695 0 15,560 Africa 116 Angola 20,400 +11 496 +2 18,951 Africa 117 Malta 20,246 +199 298 +1 17,523 EURO 118 Jamaica 20,016 +243 381 +3 12,735 Americas

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119 Madagascar 19,598 0 292 0 18,915 Africa 120 French Polynesia 18,321 +22 136 0 4,842 Non 121 Maldives 18,224 +142 58 0 15,768 SEARO 122 Rwanda 17,716 +122 243 +3 15,918 Africa 123 Mauritania 17,041 +25 432 +1 16,315 Africa 124 Eswatini 16,673 +67 637 +3 12,487 Non 125 French Guiana 16,456 0 80 0 9,995 Non 126 Guinea 15,088 +68 85 0 14,577 Africa 127 Syria 15,001 +50 987 +3 8,903 EMRO 128 Cabo Verde 14,848 +63 141 +1 14,338 Africa 129 Mayotte 14,481 +444 85 0 2,964 Non 130 Tajikistan 13,308 0 90 0 13,218 EURO 131 Gabon 13,107 +242 75 0 11,955 Africa 132 Haiti 12,206 0 247 0 9,363 Americas 133 Belize 12,195 +7 314 +1 11,708 Americas 134 Burkina Faso 11,672 +42 138 0 11,012 Africa 135 Réunion 11,562 +655 48 +1 10,576 Non 136 Hong Kong 10,813 +16 195 0 10,269 WPRO 137 Andorra 10,583 +28 107 0 10,066 EURO 138 Lesotho 10,375 +25 279 +25 3,198 Africa 139 Guadeloupe 9,528 0 158 0 2,242 Non 140 Suriname 8,832 +12 168 +1 8,285 Americas 141 Congo 8,419 0 123 0 7,019 Africa 142 Bahamas 8,383 0 179 0 7,071 Americas 143 Guyana 8,313 +51 189 +1 7,519 Americas 144 Mali 8,256 +15 342 0 6,247 Africa 145 Trinidad and Tobago 7,663 +7 138 0 7,366 Americas 146 Aruba 7,513 +52 69 0 7,152 Non 147 Martinique 6,553 0 45 0 98 Non 148 Nicaragua 6,398 0 172 0 4,225 Americas 149 Iceland 6,044 +5 29 0 5,986 EURO 150 Togo 6,007 +54 81 0 5,146 Africa 151 Djibouti 6,006 +25 63 0 5,868 EMRO 152 South Sudan 5,922 +212 79 0 3,876 Africa 153 Equatorial Guinea 5,694 0 87 0 5,426 Africa 154 Somalia 5,500 +127 172 +9 3,750 EMRO 155 Benin 5,143 +104 65 +3 4,119 Africa 156 CAR 4,996 0 63 0 4,885 Africa 157 Niger 4,715 +9 170 +1 4,193 Africa 158 Curaçao 4,658 +3 22 0 4,576 Non 159 Gambia 4,469 0 138 0 3,912 Africa 160 Gibraltar 4,226 +2 87 0 4,082 Non

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161 Channel Islands 4,013 +4 85 0 3,777 Non 162 Sierra Leone 3,825 0 79 0 2,583 Africa 163 Chad 3,724 +35 132 +1 3,223 Africa 164 Comoros 3,413 +20 135 +2 3,000 Africa 165 San Marino 3,394 +42 72 0 3,028 EURO 166 Guinea-Bissau 2,999 +49 46 0 2,482 Africa 167 Eritrea 2,627 +61 7 0 1,973 Africa 168 Saint Lucia 2,576 +27 24 +1 2,275 Americas 169 Liechtenstein 2,540 0 54 +1 2,470 Non 170 Mongolia 2,493 +49 2 0 1,802 WPRO 171 Barbados 2,457 +126 28 +3 1,698 Americas 172 New Zealand 2,344 +4 26 0 2,272 WPRO 173 Vietnam 2,329 +18 35 0 1,574 WPRO 174 Seychelles 2,211 +153 10 0 1,607 Africa 175 Yemen 2,151 +3 618 0 1,431 EMRO 176 Sint Maarten 2,021 +8 27 0 1,940 Non 177 Liberia 1,985 0 85 0 1,794 Africa 178 Turks and Caicos 1,909 +35 13 0 1,596 Non 179 Burundi 1,895 +40 3 0 773 Africa 180 Monaco 1,816 +29 22 +1 1,590 EURO 181 Sao Tome and Principe 1,535 +15 20 +1 1,136 Africa 182 Saint Martin 1,497 +89 12 0 1,050 Non 183 St. Vincent Grenadines 1,462 +5 6 0 632 Americas 184 Papua New Guinea 955 0 10 0 846 WPRO 185 Taiwan 938 +1 9 0 879 WPRO 186 Bhutan 866 0 1 0 856 SEARO 187 Diamond Princess 712 0 13 0 699 NA 188 Bermuda 697 +2 12 0 679 Non 189 Faeroe Islands 658 0 1 0 654 Non 190 Mauritius 603 0 10 0 556 Africa 191 Antigua and Barbuda 525 +82 10 +1 213 Americas 192 St. Barth 512 +57 1 0 247 Non 193 Tanzania 509 0 21 0 183 Africa 194 Cambodia 483 +4 0 0 470 WPRO 195 Isle of Man 437 0 25 0 408 Non 196 Cayman Islands 419 0 2 0 388 Non 197 Caribbean Netherlands 360 0 3 0 244 Non 198 Brunei 185 +1 3 0 178 WPRO 199 Grenada 148 0 1 0 146 Americas 200 Dominica 134 0 0 0 121 Americas 201 British Virgin Islands 114 0 1 0 95 Non 202 Timor-Leste 102 0 0 0 62 SEARO

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203 Fiji 56 0 2 0 54 WPRO 204 Falkland Islands 54 0 0 0 43 Non 205 New Caledonia 52 0 0 0 50 Non 206 Macao 48 0 0 0 46 WPRO 207 Laos 45 0 0 0 41 WPRO 208 Saint Kitts and Nevis 41 0 0 0 39 Americas 209 Greenland 30 0 0 0 30 Non 210 Vatican City 27 0 0 0 15 Non 211 Saint Pierre Miquelon 24 0 0 0 16 Non 212 Montserrat 20 0 1 0 13 Non 213 Anguilla 18 0 0 0 18 Non 214 Solomon Islands 18 0 0 0 14 WPRO 215 Western Sahara 10 0 1 0 8 Non 216 MS Zaandam 9 0 2 0 7 NA 217 Wallis and Futuna 9 0 0 0 5 Non 218 Marshall Islands 4 0 0 0 4 WPRO 219 Samoa 3 0 0 0 2 WPRO 220 Micronesia 1 0 0 0 1 WPRO 221 Vanuatu 1 0 0 0 1 WPRO Total 110,431,584 +399222 2,440,948 +11241 85,303,981

Figure 4. Areas with reported confirmed cases of COVID-19 (8 February – 14 February 2021)

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

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Table 5. COVID-19 cases and deaths reported by provinces in China (Updated as of 18 Feb 2021, 1200H SGT)

Area Existing Change from Total Deaths Change from Recovered Active previous day Diagnosed previous day Cases (Active cases) Cases (Deaths) Hebei 149 -4 1,317 7 0 1,161 Shanghai 86 -2 1,769 7 0 1,676 Jilin 75 -13 573 3 0 495 Guangdong 60 +2 2,180 8 0 2,112 Heilongjiang 42 -7 1,610 13 0 1,555 Beijing 26 -6 1,046 9 0 1,011 Jiangsu 15 0 703 0 0 688 Zhejiang 13 0 1,320 1 0 1,306 Sichuan 12 +1 882 3 0 867 Shaanxi 12 -1 547 3 0 532 Tianjin 12 -1 349 3 0 334 Fujian 10 -2 548 1 0 537 Hunan 6 -1 1,033 4 0 1,023 Shanxi 3 -2 239 0 0 236 Hubei 1 +1 68,151 4,512 0 63,638 Henan 1 0 1,304 22 0 1,281 Liaoning 1 0 404 2 0 401 Inner Mongolia 1 0 367 1 0 365 Yunnan 1 0 231 2 0 228 Anhui 0 0 994 6 0 988 Xinjiang 0 0 980 3 0 977 Jiangxi 0 0 935 1 0 934 Shandong 0 -1 867 7 0 860 Chongqing 0 0 591 6 0 585 Guangxi 0 0 267 2 0 265 Gansu 0 0 187 2 0 185 Hainan 0 0 171 6 0 165 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 385. 18 February 2021 iv. Travel Bans/Advisories & Quarantine Orders [1] Australia - Australia has extended its pause on quarantine-free flights from New Zealand for another 72 hours starting 16 Feb. [2] Canada - Canada's mandatory, 14-day quarantine for most arriving visitors which was to expire on 21 Feb, has been extended to 21 April, 2021. [3] India - Travellers from the UK, Brazil and South Africa taking connecting flights from the international airport they land at will have to get tested and exit the airport only after confirmation of negative test report which may take 6-8 hours. Those who are found negative shall be allowed to take their connecting flights and would be advised quarantine at home for 7 days. These travellers will be tested again after 7 days and if negative, released from quarantine. [4] Lithuania - All countries worldwide have been put on its COVID-19 list of affected countries. Quarantine period is shortened from 14 days to 10 days for all persons wishing to enter the country. [5] Spain - Travellers from South Africa and Brazil will have to quarantine for 10 days upon arrival unless they test negative during their quarantine, in which case they would regain mobility after seven days. [6] Sri Lanka - On 17 Feb, the temporary travel restrictions introduced on visitors traveling from Britain due to the spread of a new COVID-19 variant were lifted with immediate effect. [7] USA – Alaska no longer requires proof of a negative COVID-19 test upon arrival. The change in travel restrictions came on Feb. 14, when the state's emergency declaration expired. [8] Vietnam - Ho Chi Minh City and some northern localities will isolate people returning from Covid-19 hotspots where the disease has been found or are under lockdown or social distancing after Tet holidays for 14 days and tested four times.

v. Lockdowns [1] Canada (Quebec) – Starting 26 Feb, movie theatres will open maintaining two-metre distancing along with swimming pools and indoor rink while, the nightly curfews will remain in place. Outaouais region will become an orange zone. [2] New Zealand - A lockdown in the New Zealand city of Auckland will end at midnight, 17 Feb. [3] Ukraine - Coronavirus-related quarantine has been extended until April 30, 2021 and different epidemiological risk levels in the regions, namely green, yellow, orange, or red has been reintroduced.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021 vi. Military Surveillance

Update: COVID-19 cases in US military [1] As of Feb. 17 there have now been 237,905 total cases of COVID-19, within the DoD: 152,905 military, 24,381 dependents, 45,106 civilians and 15,169 Defense Department contractors. In addition, 108,903 military members, 16,809 dependents, 28,514 civilians and 10,138 contractors have recovered, and 281 DoD-connected personnel have died: 22 troops, 10 dependents, 184 civilians and 65 contractors. Of the cases, 3,502 have required hospitalization, officials said: 1,385 service members, 1,280 civilians, 361 dependents and 476 contractors.

Update: COVID-19 in the U.S. Forces Japan [2] The U.S. military in Japan reported two new coronavirus patients as of 6 p.m. on 17 Feb. Both were already quarantined after recently arriving in Japan, one at Marine Corps Air Station Iwakuni near Hiroshima and the other at Kadena Air Base on Okinawa. vii. WHO Guidance & Other Protocols

The following update was published by the WHO on 17 February 2021:

 Operational considerations to expedite genomic sequencing component of GISRS surveillance of SARS-CoV-2 Available at: https://www.who.int/publications/i/item/WHO-2019-nCoV-genomic-sequencing- GISRS-2021.1

viii. CDC Guidance & Protocols

US CDC

The following update was published by the US CDC on 17 February 2021:

 Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities Available at: https://www.cdc.gov/coronavirus/2019-ncov/community/correction- detention/guidance-correctional-detention.html

EU CDC

The following updates were published by the EU CDC on 16 February 2021:

 Behavioural Insights research to support the response to COVID-19: a survey of implementation in the EU/EEA Available at: https://www.ecdc.europa.eu/en/publications-data/behavioural-insights-research- support-response-covid-19

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021 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. A living systematic review of vaccine trials is also accessable at https://covid-nma.com/vaccines/ or https://covid-nma.com/ .

Vaccines

[1] South Africa - Coronavirus vaccine campaign was launched on 17 Feb, becoming the first country worldwide to administer inoculations by US pharma giant Johnson & Johnson.

Therapeutics No new updates were reported on 18 February 2021.

Vaccine Approval Status

Table 6: Number of approving countries per vaccine as of 12th February, 2021 Vaccine Number of countries approving FBRI EpiVacCorona 1

BioNTech/Pfizer BNT162b2 57

Moderna mRNA-1273 37

CanSino Ad5-nCoV 2

Gamaleya Sputnik V 20

Oxford/AstraZeneca AZD1222 46

Serum Institute of India Covishield 9

Bharat Biotech Covaxin 1

Sinopharm BBIBP-CorV 13

Sinopharm Inactivated 2

Sinovac CoronaVac 7

Source: https://covid19.trackvaccines.org/vaccines/

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

Adverse Reactions & Effects

The following table documents adverse reactions reported from approved vaccines and therapeutics. New updates are bolded.

Table 7: Compilation of reports & guidance on adverse reactions Vaccine Report/Guidance Reference [Canada; Report] One person in Manitoba reportedly had an adverse reaction after receiving the first dose on December 23. There were 490 [1] more individuals vaccinated. [United Kingdom; Report] Two British healthcare workers suffered [2] anaphylactic shock after receiving the vaccine. [United States; Report] A healthcare worker in New York City suffered anaphylaxis after receiving Pfizer BioNTech’s vaccine. The worker is [3] currently in a stable condition. 30,000 people have been vaccinated so far. [United States; Report] Two healthcare workers in northern Idaho and the Treasure Valley, experienced severe allergic reactions after receiving [4] the vaccine. As of the time of reporting, one has fully recovered while the other is expected to be discharged soon. [United States; Report] There have been two cases of severe allergic reaction in Alaska after receiving the COVID-19 vaccine. Symptoms of [5] the latest case include tongue swelling, hoarse voice and difficulty breathing, which kicked in about 10 mins after receving the vaccine. [United States; Report] An individual at Decatur Morgan hospital, Alabama, experienced severe allergic reaction several minutes after [6] getting the vaccine. The patient is currently in a stable condition. [United States; Report] Two healthcare workers from Essentia Health, Pfizer BioNTech Minnesota had non-severe allergic reactions to the vaccine. About 2,500 [7] doses of the vaccines have been administered to frontline workers at Essentia Health. [United States; Report] According to Pfizer’s data submitted to the FDA, the most common side effects were swelling and redness at the vaccine injection site. Other noted common side effects in the trial included [8] fatigue, headache and muscle pain, which had a greater chance of occurring after the second dose than the first dose. [United States; Guidance] The Centers for Disease Control and Prevention (CDC) has issued new guidance on 21 December regarding allergies and coronavirus vaccines after reports of severe allergic [9] reactions to the jab. In the new guidance, the CDC recommends that those who have a severe reaction to the first shot of the vaccine should not receive the second jab. [United States; Guidance] Health experts have said that the side effects of COVID-19 vaccines by Pfizer BioNTech (and Moderna) are short-term and manageable. The American College of Allergy, Asthma & Immunology recently released a guideline on the risk of allergic [10] reactions to Pfizer BioNTech’s vaccine. The guideline is available at https://acaai.org/news/american-college-allergy-asthma-and- immunology-updates-guidance-risk-allergic-reactions-mrna.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

[Canada; Report] Of 11,930 doses of Pfizer BioNTech’s vaccine administered in British Columbia so far there have been 2 cases of [11] allergic reaction. [Israel; Report] On December 28, a 46-year-old man in Jerusalem suffered severe anaphylactic shock one hour after receiving a COVID-19 vaccination. He is the first in Israel to have such a reaction, and is reportedly allergic to penicillin. His condition has since stabilized.

[12] Separately, a 75-year old man died of heart failure at home some hours after receiving Pfizer BioNTech’s vaccine. The man was reported to have heart disease and cancer, and had suffered a number of previous heart attacks. While investigations are still ongoing, preliminary findings indicated that the death did not appear to be connected to the shot. [Finland; Report] On January 2, the first adverse reaction against the [13] vaccine was reported. No further details were released. [Mexico; Report] A 32-year-old doctor in Mexico has been admitted to intensive care unit with seizures, breathing difficulties and possible encephalomyelitis. While the cause of the adverse reaction is still under investigation, preliminary diagnosis indicates encephalomyelitis. The patient condition has been stablized and is receiving treatment to reduce inflammation. [14]

[15] [Update] The doctor was allergic to sulfa drugs and has a family history of allergies. After developing allergic reaction, medication was administered to recover from the symptoms. However, she had subsequently suffered from convulsion. Diagnosis at that time was allergic reaction to the vaccine but the cause for convulsion and reduction of muscle strength is still being studied. [Bulgaria; Report] As of January 4, Bulgaria’s Medicines Agency had received four reports of adverse reactions. One case of dizziness after administration, two cases of local pain at the vaccinated site, and one [16] case of a slight temperature increase. These side effects had passed off in less than a day. [Portugal; Report] A portugese health worker had suffered a sudden death 2 days after being vaccinated on 30 Dec. She did not suffer from any adverse side-effect after vaccinated and did not has any health problem. An autopsy is expected to be conducted soon. [17]

[18] [Update] In a 5 January 2020 press release, the Portuguese Ministry of Justice informed that preliminary data from the autopsy showed “no evidence of a causal relationship between the death and the vaccine that was received.” [Mexico; Report] By January 5, more than 44,000 people have received the first shot. As of January 4, about 110 people had reported allergic reaction to the vaccine but 80% were mild and only 5 people require hospitalization. Only one person was severely affected and remain in [19] hospital. [20] [21] [Update] As of 16 January 2021, 753 adverse events (729 mild and 24 serious) allegedly caused by vaccination and immunization were reported since 24 December 2020. The 24 serious events were reported

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

from Coahuila (7 reports), Mexico City (4 cases), Chihuahua, State of Mexico, Guanajuato, Oaxaca and Yucatan (2 reports each) and Baja California, Hidalgo and Jalisco (1 report each). Of the 24 serious events reports, 6 remain hospitalized while the remaining have been discharged.

[Update] As of 9 Feb, 6,260 negative reactions have been reported nationwide with 36 serious reaction (0.9%). Yucatan has reported 3 serious case of adverse reaction and most of them have discharged. The entities with the most negative reaction cases are Mexico City (6 cases) and Coahuila and State of Mexico (4 each). [United States; Publication] Centre of Disease Control and Prevention (CDC) has reviewed on the allergric reaction to the first dose of vaccine during 14 to 23 December. Among the 1,893,360 first doses administered, 4,393 (0.2%) adverse events were reported. 21 cases of anaphylaxis (11.1 cases per million doses) were detected and 17 of them had history of allergies or allergy reaction. Of the 21 cases, 4 of them were hospitalized including 3 in intensive care and 20 of them had discharged or recovered by 23 December. There were no death reported. [22]

[23] [Update] The total number of cases of anaphylaxis has been updated to [24] 29 as on 6 January. [25]

[Update] CDC has roughly estimated that one in a hundred thousand people who received the Pfizer vaccine had severe allergic reactions. An average rate of 11.1 anaphylaxis cases per one million doses administered was estimated.

[Update] FDA and CDC have a total of 1,170 death between Dec. 14, 2020, and Feb. 7, 2021, among individuals who received Pfizer or Moderna Covid vaccine, accounting for 0.003% of vaccinated people. [United States; Report] A Florida doctor had died several weeks after receiving the vaccine on 18 Dec. He had suffered from hemorrhagic stroke due to a lack of platelets. It is unclear if his death was related to the vaccine while his death is being investigated. It was reported that he had dots on the skin indicating internal bleeding 3 days after the [26] injection. Pfizer and BioNTech had not received any prior indication of [27] possible connection to thrombocytopenia.

[Update] As of 12 Jan, no evidence was obtained to suggest a connection between the vaccine and the death. [Canada; Report] Nine reports of adverse medical reactions which include a total of 65 symptoms, eight of which were considered severe, have been reported as of Jan. 1 but none were considered to be [28] unexpected side effects. [29]

[30] [Update] Fifteen new reports of adverse medical reactions, five of which were considered severe, have been reported as between January 1 and January 8. As of January 8, 24 reports of adverse effects were reported,

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

consisting of 10 serious and 14-nonserious reports. All reports were considered to be expected side effects.

[Update] Sixty-six new reports of adverse medical reactions, 17 of which were considered severe, have been reported as between January 9 and January 15. As of January 15, 90 reports of adverse effects were reported, consisting of 27 serious and 63-nonserious reports. Most frequently reported adverse events were vaccination site reactions, paraesthesia, pruritis, urticaria, headache, hypoaesthesia, nausea and anaphylaxis.

[Update] As of 5 Feb, a total of 371 adverse effects were reported which include 74 serious AEFI and 297 non-serious AEFI. [France; Report] Six reports of serious adverse effects with a favourable outcome were reported in France during the 3rd week of vaccination: 4 [31] cases of allergic reactions and 2 cases of tachycardia. Around 30 cases of non-serious adverse effects have been reported since 12 Jan 2021 [Norway; Report] As of 14 Jan 2021, 29 reports of side effects were reported in Norway. The 29 reports consisted of 13 deaths, 9 serious side effects and 7 less serious side effects. The deaths were all amongst frail and elderly patients in nursing homes, aged at least 80 years. [32] Serious side effects reported included allergic reactions, strong malaise and severe fever. Less serious side effects include severe pain at injection site. [United States; Report] A healthcare worker in Alaksa experienced an allergic reaction to the Moderna COVID-19 vaccine, 10 minutes within [33] receiving it on January 12. There was no information on allergy history of the healthcare worker. [Israel, Report] At least 13 cases of mild facial paralysis have been [34] reported upon receiving the vaccine. [United Kingdom, Report] A severe adverse medical reaction was reported from a medical councillor aged 42 years within minutes after receiving his vaccine on 8 January 2021. The councilor experienced [35] breathing difficulties, fever and muscle aches, and was hospitalized for 1 day before his condition stabilized and eventually recovered. [Ireland, Report] As of 11 January 2021, 81 adverse events from [36] vaccination were reported, all involving expected mild side effects. [Singapore, Report] As of 27 January 2021, a total of 432 AEFIs were reported amongst the 113,000 people who received the vaccine. All reports were mild and reported expected side effects arising from vaccination, except for 3 cases of anaphylaxis (SAE) reported. The cases were in their 20s and 30s, had a history of allergies, but no history of anaphylaxis which would have precluded them from receiving the [37] vaccine. All 3 cases have recovered and were discharged from the [38] hospital after a day’s observation or treatment.

[Update] As of February 1, 2021 all four cases of anaphylaxis following vaccination have recovered, with none requiring intensive care unit support. [Belgium, Report] As of January 26, 2021 a total of 262 AEFIs were [39] reported out of 243,412 vaccines administered, of which 37 were

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

serious AEFIs. Of the serious AEFIs reported, 14 were deaths amongst those aged over 70 years (9 deaths) or 90 years (5 years). [Croatia, Report] As of February 1, 2021 a total of 430 AEFIs were reported, of which 26 were allergic reactions and the rest were mild side [40] effects. The allergic reactions included 2 serious reactions, and 24 milder reactions. [United Kingdom; Report] A study conducted by Zoe, a British health science company had found that 37% of about 40,000 vaccinees in UK who were mostly healthcare workers had reported local side effects (e.g. swelling or pain near injection site) after first dose and 45% after [41] second dose. Systemic side effects (e.g. fatigue) were rare with 14% after first dose and 22% after second dose. The side effect reported were lower as compared to FDA trials. [Romania; Report] A doctor from Valcea county had experienced temporary facial paralysis after receiving the second dose and has since fully recovered. This is the first rare and major side effect reported in [42] Romania. Since 27 Dec, there has been more than 2,100 common and minor side effects reported with a total of 629,279 people vaccinated by 4 Feb. [United Kingdom; Report] The Medicines and Healthcare products Regulatory Agency (MHRA) had reported on the side effects of 7 million vaccine doses (5.4 million Pfizer/BioNTech & 1.5 million of the AstraZeneca) administered by 24 Jan. Yellow card system was used for vaccinated people to report side effect. There was an average of 3 yellow cards per 1,000 doses administered. There were 16,756 yellow [43] card for the Pfizer-BioNTech vaccine; 6,014 for the Oxford University- AstraZeneca vaccine and 50 for unspecified brand of the vaccine. Most reports were related to injection site or otherwise generalized symptoms (e.g. flu-like illness). These symptoms had occured shortly after vaccination and were not associated with more serious or lasting illness. [Netherland; Report] 15 elderly had died within 9 days after administered with vaccine. Most of them with fatal outcome had multiple underlying health issues or serious health problem. Half of them had symptoms identified as side effects e.g. fever after vaccination. These may have contributed to the deterioration of their health. [44] A total of 2,812 side effects have been reported after vaccinated. 95% were administered with Pfizer/BioNTech vaccine, 113 cases were Moderna vaccine and vaccine used for 38 reports were not clear. 14 people who had epilepsy also had seizure after vaccination. Some 25 people had severe allergic reaction to Pfizer/BioNTech vaccine with 8 cases determined as anaplylactic response.

Both the Pfizer and Moderna vaccines can cause lymph nodes to swell, [45] particularly those in the armpit on the side where the shot was received.

[United States; Report] The FDA advisory committee has noted a special Moderna side effect of the vaccine from the clinical trials involving several [46] patients with cosmetic facial fillers. The patients who experienced side

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

effect all had swelling and inflammation in the area that was given the filler. All reactions were resolved following treatment with steroids and antihistamines. [United States; Report] A Boston doctor experienced severe allergic reactions after receiving the Moderna COVID-19 vaccine on December [47] 24. The doctor has a history of shellfish allergy. [Canada; Report] On December 17, the US FDA reported two cases of adverse reactions in individuals who had received the Moderna vaccine. Both patients previously had dermal fillers and experienced some swelling following the vaccination. The cases were likely to have [48] occurred in Toronto, Canada. [49]

[Canada; Surveillance] As of 5 Feb, a total of 280 adverse effects were reported which include 25 serious AEFI and 255 non-serious AEFI. [United States; Report] A frontline worker in Robstown had experienced immediate numbness on the face after receiving the vaccine a week ago [50] but continues to have soreness and redness to her arms. [United States; Publication] Phase 3 clinical trial involving 30,420 volunteers had observed higher frequency of moderate, transient reactogenicity after vaccination in the vaccine group. Serious adverse events were rare and the incidence was similar between the placebo and vaccine groups. Hence there were no safety concern, apart from the [51] transient local and systemic reactions. [52]

[Update] The vaccine showed a 94.1% efficacy rate in its phase 3 trial, and serious adverse events occurred in just 0.6% of patients. A total of 2 deaths were reported in the vaccine group, one was due to cardiopulmonary arrest and the other was a suicide. [United States; Report] On 31 December, the Oregon Health Authority reported a case of anaphylaxis after a healthcare worker had taken the [53] vaccine this week and is recovering in the hospital. [Guidance] A new guidance from the American Society for Dermatologic Surgery (ASDS) has been released regarding side effects from the SARS- CoV-2 mRNA vaccine on dermal fillers. FDA data reports show three [54] participants out of 15,184 who received at least one dose of Moderna’s mRNA-1273 vaccine have developed lip for facial swelling in areas of dermal filler placement. [United States; Report] A Missouri healthcare worker experienced severe allergic reaction after receiving the Moderna COVID-19 vaccine [55] on December 29. The healthcare worker has a history of severe allergy reaction to MRI contrast dye. [United States, Report] Six reports of allergy reactions requiring medical attention 24 hours from vaccination, were reported amongst healthcare workers on 14 January 2021. The healthcare workers were vaccinated with lot 41L20A from the same vaccination site in San Diego. The site is [56] temporarily closed for now and using other vaccines. California health officials recommend suspending the use of lot 41L20A, until investigation are complete. [United States, Report] A fatality was reported in a resident from a retirement home, after receiving the vaccine. Investigation on whether [57] the fatality was linked to receiving the vaccine is underway.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

[United States, Report] As of January 29, 2021 a total of 287 AEFIs were reported amongst 250,000 vaccines administered in Texas, of which 11 were serious AEFIs. The 11 AEFI reports included the death of an 84 years-old woman, permanent disability in another patient, and the remaining spent at most 4 days hospitalized. [58] [59] [Update] As of 5 Feb, 2021, the The Centers for Disease Control had reported that 619,452 second doses have been administered in Texas with 15 significant reports of side effect. Only 4 of them required hospital stay that had lasted less than 5 days. [Croatia, Report] As of February 1, 2021 a total of 13 AEFIs were [60] reported, all of which were mild side effects. [USA, CDC; Report] A side effect of the Moderna vaccine reported by the CDC as arm pain and redness appears to be showing up a bit delayed in [61] some people up to a week. [Argentina; Report] Of the total 32,013 patients who had received the Sputnik V vaccine, 1% (317 patients) had reported mild adverse reaction (fever [62] and headache). [India, Report] Ninety-three reports of adverse events following immunization with Astrazeneca & Oxford Uni. ( and Bharat Biotech) vaccines were reported from Delhi (51 mild and 1 serious report), Haryana (13 mild reports), Maharashtra (14 mild reports) and Kolkata (13 mild and 1 serious report). No fatalities have been reported.

[Update] Between 16 January and 17 January, 447 reports of adverse events following immunization have been reported across India. Only 3 of the reports involved serious adverse events requiring hospitalization, of which only 1 remains hospitalized. [63] [Update] 82 AEFIs were reported across India on 20 January 2021. All [64] AEFIs reported were mild cases. [65] [66] [Update] On the 22 Jan, Day 4 of the coronavirus vaccination drive in [67] Astrazeneca & Delhi, 5,942 people were reportedly administered the shots and adverse [68] Oxford Uni. events following immunisation (AEFI) was reported in 24 persons. [69] [70] [Update] On 24 Jan, the fifth day of India’s Covid-19 vaccination drive, [71] the city of Gurugram reported 3 cases of AEFI amongst 3,055 shots [72] administed. [73] [74] [Update] The Union Ministry of Health and Family Welfare in India announced 23 January that over 10 lakh people had already been immunised in the first six days (up to 21 January), but the total number of AEFIs reported by the ministry in its daily press releases so far adds up to 1,239 out of 15,37,190 inoculations, or 0.08 per cent. Just 11 people have had to be hospitalised (0.0007 per cent), while seven deaths have been reported — six of which are “not causally linked” to the vaccine, while in the seventh case, the post mortem report is awaited.

[Update] A total of 19,50,183 beneficiaries were inoculated in 35,785 sessions till 7.10 pm on Monday 25 Jan, including 3,34,679 in 7,171

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

sessions during the day, the ministry said. A total of 348 adverse events following immunisation (AEFIs) were reported till 7.10 pm on 25 Jan, the 10th day of the vaccination drive.

[Update] A total of 213 ARFIs were reported up till 7 pm on January 29, 2021 across India, of the 33,68,734 vaccines administered

[Update] The Minstry of Health and Family Welfare had reported more than 40 lakh healthcare and frontline workers have been vaccinated. A total of 8,563 AEFIs (0.18%) and 34 hospitalized cases (0.0007%) have been reported. There were 19 deaths of vaccinated people but there has been no evidence on the link between vaccination and the death.

[Sweden, Report] As of 13 Feb, two regions in Sweden have temporarily stopped vaccinating health workers with the Astra Zeneca vaccine, after as many as one in four reported side effects.

[Germany, Report] The Herzogin-Elisabeth-Hospital in Braunschweig and Emden clinic postponed planned vaccinations with the Astrazeneca vaccine. On evening of 16 Feb, Astrazeneca vaccine was given to 88 employees of the Braunschweig clinic, 37 of them called in sick temporarily due to "vaccination reactions." However, there has not been a severe course of side effects so far, and no one has had to go to a hospital with complications. [India, Report] A female volunteer from a village in Andhra Pradesh had died 2 days after administered with the vaccine on 5 Feb. She was normal and there was no symptoms of fever or adverse effect after the [75] vaccination. Post-mortem will be conducted to identify the cause of death. [United States, Report] A 70 year old man had died minutes after receiving the vaccine at NYC’s Javits Center on 7 Feb. He had collapsed Unspecified about 25 minutes after vaccinated and after the mandatory 15 minutes [76] observation. He did not display any adverse reactions or effect to the vaccine. [India, Report] A 50 year old sanitation worker had suffered cardiac arrest and died 24 hours after administered with the vaccine in Anhra Pradesh’s Tirupati. There was no sign of adverse effect during the [77] observation period. Autopsy will be conducted to determine the exact cause of death. Therapeutic/Drug Report/Guidance Reference NIL NIL NIL

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021 x. Scientific Publications with Epidemiology and Clinical Focus

Clinical characteristics, treatment and outcomes of paediatric COVID-19: a systematic review and meta- analysis [424]

Objective: Compare paediatric COVID-19 disease characteristics, management and outcomes according to World Bank country income level and disease severity.

Design: Systematic review and meta-analysis.

Setting: Between 1 December 2019 and 8 January 2021, 3350 articles were identified. Two reviewers conducted study screening, data abstraction and quality assessment independently and in duplicate. Observational studies describing laboratory-confirmed paediatric (0-19 years old) COVID-19 were considered for inclusion.

Main outcomes and measures: The pooled proportions of clinical findings, treatment and outcomes were compared according to World Bank country income level and reported disease severity.

Results: 129 studies were included from 31 countries comprising 10 251 children of which 57.4% were hospitalised. Mean age was 7.0 years (SD 3.6), and 27.1% had a comorbidity. Fever (63.3%) and cough (33.7%) were common. Of 3670 cases, 44.1% had radiographic abnormalities. The majority of cases recovered (88.9%); however, 96 hospitalised children died. Compared with high-income countries, in low- income and middle-income countries, a lower proportion of cases were admitted to intensive care units (ICUs) (9.9% vs 26.0%) yet pooled proportion of deaths among hospitalised children was higher (relative risk 2.14, 95% CI 1.43 to 3.20). Children with severe disease received antimicrobials, inotropes and anti- inflammatory agents more frequently than those with non-severe disease. Subgroup analyses showed that a higher proportion of children with multisystem inflammatory syndrome (MIS-C) were admitted to ICU (47.1% vs 22.9%) and a higher proportion of hospitalised children with MIS-C died (4.8% vs 3.6%) compared with the overall sample.

Conclusion: Paediatric COVID-19 has a favourable prognosis. Further severe disease characterisation in children is needed globally.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021 xi. Sources

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 385. 18 February 2021

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46. https://health.economictimes.indiatimes.com/news/industry/us-healthcare-worker-suffers-allergic- reaction-to-pfizer-vax/79789164 47. https://edition.cnn.com/2020/12/25/health/boston-health-care-worker-allergic-reaction-moderna- coronavirus-vaccine/index.html 48. https://www.ctvnews.ca/health/coronavirus/2-patients-with-facial-fillers-saw-swelling-after- receiving-moderna-vaccine-fda-1.5248564 49. https://health-infobase.canada.ca/covid-19/vaccine-safety/ 50. https://www.kiiitv.com/article/news/health/coronavirus/vaccine/adverse-reactions-from-the- coronavirus-vaccine-are-minor-health-experts-explain-the-reaction-a-woman-had-at-the-drive-thru- clinic-in-robstown/503-cd33e1b5-138c-40e7-8e73-eef1f968e8cb 51. https://www.nejm.org/doi/full/10.1056/NEJMoa2035389 52. https://www.contagionlive.com/view/moderna-vaccine-study-data-shows-94-1-efficacy-serious-side- effects-rare 53. https://katu.com/news/coronavirus/oregon-health-care-worker-hospitalized-after-severe-reaction-to- coronavirus-vaccine 54. https://www.dermatologytimes.com/view/guidance-issued-for-covid-19-vaccine-side-effects-in- dermal-filler-patients 55. https://fox4kc.com/tracking-coronavirus/important-information-to-know-after-metro-healthcare- worker-suffers-severe-allergic-reaction-from-covid-19-vaccine/ 56. https://www.marketwatch.com/story/california-health-official-urges-halt-to-300-000-moderna- vaccinations-after-reports-of-allergic-reactions-01611011648 57. https://www.iheartradio.ca/am800/news/local-retirement-home-resident-dies-after-receiving-covid- 19-vaccine-investigation-launched-1.14400880 58. https://www.click2houston.com/news/local/2021/01/30/my-face-started-tingling-houston-woman- suffers-reaction-after-receiving-moderna-vaccine/ 59. https://www.click2houston.com/news/local/2021/02/06/side-effects-from-2nd-dose-of-covid-19- vaccine-are-normal-common-experts-say/ 60. https://www.total-croatia-news.com/news/50221-ventilators-in-croatia 61. https://local12.com/health/medical-edge-reports/vaccine-side-effect-covid-arm-can-develop-later-in- some-people-cincinnati 62. https://www.livemint.com/news/world/arg-reports-adverse-reaction-to-sputnik-v-doc-gets-side- effects-from-pfizer-jab-11609633103810.html 63. https://www.dailypioneer.com/2021/pioneer-exclusive/52-adverse-events-in-delhi--14-in-maha--13- in-haryana.html 64. https://www.deccanherald.com/national/coronavirus-vaccine-live-news-updates-astrazeneca-oxford- bharat-biotech-covaxin-covishield-healthworkers-free-vaccine-vaccination-drive-India-serum- institute-jan-16-narendra-modi-939594.html#1 65. https://www.firstpost.com/health/covid-19-vaccination-447-recipients-across-india-suffer-adverse- events-post-inoculation-how-aefi-is-tracked-reported-9210391.html 66. https://www.indiatoday.in/coronavirus-outbreak/vaccine-updates/story/coronavirus-vaccine-live- updates-january-20-india-export-world-covishield-covaxin-1760808-2021-01-20 67. https://www.thestatesman.com/cities/delhi/5942-get-jabs-in-delhi-on-day-four-24-aefi-cases- reported-1502947936.html

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Scientific Reports 1. Irfan O, Muttalib F, Tang K, Jiang L, Lassi ZS, Bhutta Z. Clinical characteristics, treatment and outcomes of paediatric COVID-19: a systematic review and meta-analysis [published online ahead of print, 2021 Feb 16]. Arch Dis Child. 2021;archdischild-2020-321385. doi:10.1136/archdischild-2020-321385

31 | 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 385. 18 February 2021

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

Mr Lau Wai Hong Nicholas

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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