For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 2021
Apr 23
COVID-19 Situation Report 449
Centre for Infectious Disease Epidemiology and Research (CIDER) For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 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 449. 23 April 2021
ii. Global Risk Assessment
Table 1. Risk assessment of COVID-19 by WHO regions (Updated as of 23 Apr 2021, 14:00 SGT) Severity of Availability of Treatment/ Overall Environmental Risk Transmissibility Disease Vaccination# Risk Global (n=198 countries) High Moderate High Limited
Globally, 189 (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 2.12% and SEARO (31 countries), EURO (52 people over the past 14-days as cut-off for 4.4–7.7), but globally. countries), EMRO (18 countries), a surge in cases, the number of countries the estimated Most cases Americas (33 countries), and Africa (40 reporting a surge in cases in each region effective present as countries).& are as follows: Combined WPRO and reproduction flu-like SEARO (14 countries), number in 172 illness. International clinical trials published on EURO (50 countries), countries 2 September confirm that cheap, widely EMRO (16 countries), Americas (30 ranged from available steroid drugs can help countries), and Africa (11 countries). 0.0014 to 1.7.$ 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 143 (77%) 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. 52 (28%) 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 449. 23 April 2021
Western Pacific Region and South-East Asia Region (n=41 countries) Moderate Moderate Moderate High
33 (80.5%) countries have reported As of Apr 19, Case 31 countries have commenced outbreaks; but only 14 (34.2%) countries the estimated fatality rate vaccination as of 23 April 2021. are reporting a surge in cases. effective is 1.32%. Coverage was available for the reproduction following: i) at least 1 dose was at <50% 12 (29.3%) countries have either a no. of 23 for 23 countries; 51-70% for 1 country; constant decreasing change in incidence countries >70% for 1 country ii) full vaccination or no case in the last 14 days. ranged from was at <50% for 15 countries; 51-70% & 0.53-1.7. $ for 0 country.
Highest incidence over the past 14 days Indonesia has approved Russian drug High were reported from India, Malaysia, Avifavir for emergency use. [22] Maldives, Mongolia and Philippines and highest case numbers were reported from China has approved the use of 3 Bangladesh, India, Indonesia, Japan and traditional chinese medicines, Qingfei Philippines. Paidu Formula, Huashi Baidu Formula and Xuanfei Baidu Formula, for COVID- At least 19 countries have closed their 19 treatment. [20] borders, 21 countries have opened their borders partially conditionally, and none are allowing free travel. European Region (n=53 countries) High Moderate Moderate High
52 (98.1%) countries have reported with As of Apr 19, Case 52 countries have commenced outbreaks; 50 (94.3%) countries are the estimated fatality rate vaccination as of 23 April 2021. reporting a surge in cases. effective is 2.10%. Coverage was available for the following reproduction i) at least 1 dose was at <50% for 49 2 (3.8%) countries have either a constant no. of 52 countries and 51-70% for 1 country; ii) decreasing change in incidence or no case countries full vaccination was at <50% for 41 in the last 14 days. ranged from countries; 51-70% for 1 country. & 0.0014-1.3.$ Highest incidence over the past 14 days On February 28, France authorized its High were reported from Croatia, Cyprus, first ever use of synthetic monoclonal France, Sweden and Turkey and highest antibody, bamlanivab by Eli Lilly, for use case numbers were reported from France, on severe COVID-19 patients. [19] Germany, Italy, Poland and Turkey. As of February 14, Italy authorized the At least 9 countries have closed their use of the two monoclonal antibodies of borders, 43 countries have opened their companies Eli Lilly and Regeneron borders partially conditionally, and only 1 aimed mainly at more serious patients country is allowing free travel. with COVID-19 [17]. Eastern Mediterranean Region (n=22 countries) High Moderate Moderate High
22 (100%) countries have reported with As of Apr 19, Case 18 countries have commenced outbreak; 16 (72.7%) countries are the estimated fatality rate vaccination as of 23 April 2021. reporting a surge in cases. effective is 2.01%. Coverage was available for the reproduction following: i) at least 1 dose was at <50% High None of the countries have either a no. of 19 for 8 countries; 51-70% for 0 country ii) constant decreasing change in incidence countries full vaccination was at <50% for 7 or no case in the last 14 days. ranged from countries; 51-70% for 0 country. & 0.51-1.3.$
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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 2021
Highest incidence over the past 14 days As of June 25, the Abu Dhabi Stem Cell were reported from Bahrain, Jordan, Centre has treated more than 2,000 Kuwait, Palestine and Qatar, and highest COVID-19 patients using UAECell19. case numbers were reported from Iran, 1,200 have fully recovered. [6] Iraq, Jordan, Pakistan and Tunisia. As of April, an Israeli firm is using At least 5 countries have closed their placenta pluristem cells to treat COVID- borders, 16 countries have opened their 19 patients on a compassionate use borders partially conditionally, and only 1 basis. [5] country is allowing free travel.
Region of the Americas (n=35 countries) High Moderate High High
35 (100%) countries have reported with As of Apr 19, Case 33 countries have commenced outbreak; 30 (85.7%) countries are the estimated fatality rate vaccination as of 23 April 2021. reporting a surge in cases. effective is 2.42%. Coverage was available for the reproduction following: i) at least 1 dose was at <50% 1 (2.9%) countries have either a constant no. of 33 for 30 countries and 51-70% for 0 decreasing change in incidence or no case countries country; ii) full vaccination was at <50% in the last 14 days. ranged from for 17 countries; 51-70% for 0 country. & 0.77-1.5.$ Highest incidence over the past 14 days With the increase of multiple variants of were reported from Argentina, Chile, COVID-19, the U.S. FDA will limit the use Colombia, Paraguay and Uruguay, and of monoclonal antibody treatments highest case numbers were reported from developed by Regeneron and Eli Lilly Argentina, Brazil, Canada, Colombia and due to concerns the medications are not USA. effective against these new strains. Eli Lilly’s bamlanivimab will not be At least 10 countries have closed their distributed to California, Arizona and borders, 23 countries have opened their Nevada, where those variants are more borders partially conditionally, and 2 common. [21] countries are allowing free travel. FDA has issued EUA to Eli Lilly’s High 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]
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. [12]
Health Canada has approved bamlanvimab, for the treatment of COVID-19 in patients 12 years and older with mild to moderate symptoms who are at risk of severe disease progression. [11]
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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 2021
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]
As of October 22, remdesivir is the first and only FDA-approved COVID-19 treatment in the U.S. [7]. African Region (n=47 countries) Moderate Moderate High High
47 (100%) countries have reported with As of Apr 19, Case 40 countries have commenced outbreak; 11 (23.9%) countries are the estimated fatality rate vaccination as of 23 April 2021. reporting a surge in cases. effective is 2.52%. Coverage was available for the reproduction following: i) at least 1 dose was at <50% 2 (4.3%) countries have either a constant no. of 45 for 37 countries and 51-70% for 1 decreasing change in incidence or no case countries country ii) full vaccination was at <50% in the last 14 days. ranged from for 9 countries; 51-70% for 1 country. & 0.11-1.7.$ Highest incidence over the past 14 days Ethiopia has approved the use of High were reported from Botswana, Cabo Dexamethasone treatment for seriously Verde, Eswatini, Gabon and Seychelles, ill COVID-19 patients. [13] and highest case numbers were reported from Botswana, Ethiopia, Kenya, Madagascar and South Africa.
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. $ 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://www.bloomberg.com/graphics/covid-vaccine-tracker-global-distribution/; High vaccine coverage defined as >70% population with full vaccination
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iii. Global Epidemiology
Table 2. Summary of COVID-19 cases & fatalities globally (Updated as of 23 Apr 2021, 14:00 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– 219 145,363,174 145,272,608 3,085,826 2.12% 2.12% 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 2.12 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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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 23 Apr 2021, 14:00 SGT) Country Total Cases Change Total DeathsChange Total Recovered Region
1 USA 32,669,121 +67070 584,226 +896 25,236,658 Americas 2 India 16,263,695 +332730 186,928 +2256 13,648,159 SEARO 3 Brazil 14,172,139 +49344 383,757 +2070 12,673,785 Americas 4 France 5,408,606 +34318 102,164 +283 4,242,893 EURO 5 Russia 4,736,121 +8996 107,103 +397 4,361,807 EURO 6 Turkey 4,501,382 +54791 37,329 +354 3,909,935 EURO 7 UK 4,398,431 +2728 127,345 +18 4,171,798 EURO 8 Italy 3,920,945 +16046 118,357 +360 3,330,392 EURO 9 Spain 3,456,886 +10814 77,496 +132 3,156,955 EURO 10 Germany 3,238,054 +29382 81,693 +311 2,865,000 EURO 11 Argentina 2,796,768 +27216 60,620 +537 2,449,793 Americas 12 Poland 2,731,256 +12763 64,168 +695 2,380,787 EURO 13 Colombia 2,720,619 +19306 70,026 +430 2,538,020 Americas 14 Iran 2,335,905 +24092 68,366 +453 1,837,590 EMRO 15 Mexico 2,319,519 +3708 214,095 +498 1,841,964 Americas 16 Ukraine 2,004,630 +14277 41,700 +434 1,552,267 EURO 17 Peru 1,734,606 +7800 58,604 +343 1,661,792 Americas 18 Indonesia 1,626,812 +6243 44,172 +165 1,481,449 SEARO 19 Czechia 1,612,832 +2971 28,787 +76 1,520,263 EURO 20 South Africa 1,571,348 +1413 53,995 +55 1,496,756 Africa 21 Netherlands 1,435,854 +9611 17,002 +19 1,196,364 EURO 22 Canada 1,155,834 +8370 23,822 +59 1,045,244 Americas 23 Chile 1,148,320 +6917 25,532 +179 1,081,117 Americas 24 Romania 1,039,998 +2989 26,943 +150 959,126 EURO 25 Iraq 1,010,304 +8450 15,128 +30 884,181 EMRO 26 Philippines 971,049 +8742 16,370 +105 846,691 WPRO 27 Belgium 964,526 +4357 23,909 +42 815,371 EURO 28 Sweden 932,076 +7736 13,882 +19 752,000 EURO 29 Israel 837,807 +315 6,346 0 829,424 EURO 30 Portugal 832,891 +636 16,956 +4 791,171 EURO 31 Pakistan 784,108 +5870 16,842 +144 682,290 EMRO 32 Hungary 760,967 +3607 26,001 +214 469,592 EURO 33 Bangladesh 736,074 +4014 10,781 +98 642,449 SEARO 34 Jordan 697,487 +2097 8,474 +45 658,287 EMRO 35 Serbia 673,520 +2719 6,130 +35 608,270 EURO
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36 Switzerland 644,396 +2265 10,555 +9 575,624 EURO 37 Austria 602,494 +2405 10,026 +29 565,513 EURO 38 Japan 546,425 +4929 9,764 +54 491,661 WPRO 39 Lebanon 516,600 +1512 7,057 +30 437,808 EMRO 40 Morocco 507,938 +600 8,976 +7 493,873 EMRO 41 UAE 504,872 +2081 1,565 +4 486,920 EMRO 42 Saudi Arabia 409,093 +1055 6,869 +11 392,448 EMRO 43 Bulgaria 394,594 +1681 15,721 +103 321,400 EURO 44 Malaysia 384,688 +2875 1,407 +7 361,267 WPRO 45 Slovakia 378,150 +677 11,357 +53 255,300 EURO 46 Ecuador 365,393 +2550 17,965 +161 309,541 Americas 47 Panama 361,992 +314 6,198 +2 351,949 Americas 48 Belarus 348,486 +1170 2,463 +10 338,927 EURO 49 Greece 326,395 +2756 9,788 +75 284,050 EURO 50 Croatia 316,308 +2885 6,738 +46 293,454 EURO 51 Azerbaijan 307,980 +2047 4,274 +39 272,575 EURO 52 Kazakhstan 300,733 +2894 3,512 +29 257,278 EURO 53 Georgia 300,264 +1226 3,981 +10 283,557 EURO 54 Bolivia 294,391 +1330 12,758 +27 243,064 Americas 55 Tunisia 294,138 +2305 10,063 +70 244,517 EMRO 56 Nepal 292,152 +2365 3,117 +5 276,345 SEARO 57 Palestine 287,680 +1652 3,115 +19 256,559 EMRO 58 Dominican Republic 262,935 +531 3,441 +6 220,159 Americas 59 Kuwait 262,766 +1459 1,493 +11 245,824 EMRO 60 Paraguay 260,382 +2676 5,633 +72 213,710 Americas 61 Moldova 248,009 +618 5,668 +25 235,054 EURO 62 Ethiopia 247,989 +1505 3,496 +22 185,107 Africa 63 Denmark 245,761 +893 2,467 +2 233,614 EURO 64 Ireland 245,310 +615 4,866 +10 226,618 EURO 65 Lithuania 237,950 +1417 3,818 +16 215,031 EURO 66 Costa Rica 235,274 +1776 3,125 +10 199,779 Americas 67 Slovenia 234,811 +744 4,187 +11 219,232 EURO 68 Egypt 219,774 +872 12,914 +48 165,348 EMRO 69 Guatemala 218,145 +1816 7,345 +36 194,075 Americas 70 Armenia 211,399 +881 3,969 +25 191,158 EURO 71 Honduras 204,828 +1469 5,047 +66 77,431 Americas 72 Qatar 199,980 +800 407 +7 177,164 EMRO 73 Bosnia and Herzegovina 194,371 +1256 8,164 +82 152,007 EURO 74 Venezuela 188,063 +1318 1,987 +22 171,043 Americas 75 Oman 185,278 +1508 1,942 +16 165,051 EMRO 76 Uruguay 175,891 +3290 2,160 +77 145,464 Americas 77 Libya 174,216 +533 2,936 +12 159,630 EMRO
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78 Bahrain 168,201 +1036 614 +7 156,981 EMRO 79 Nigeria 164,588 +100 2,061 0 154,578 Africa 80 Kenya 154,392 +904 2,560 +20 105,367 Africa 81 North Macedonia 149,221 +603 4,595 +39 126,234 EURO 82 Myanmar 142,674 +13 3,206 0 131,914 SEARO 83 Albania 130,114 +134 2,364 +6 103,582 EURO 84 Algeria 120,363 +189 3,181 +9 83,900 Africa 85 Estonia 119,218 +429 1,120 +11 105,471 EURO 86 S. Korea 117,458 +797 1,811 +3 107,071 WPRO 87 Latvia 113,561 +578 2,088 +9 103,230 EURO 88 Norway 109,581 +444 735 +1 88,952 EURO 89 Sri Lanka 98,722 +672 634 +4 93,884 SEARO 90 Cuba 97,967 +1207 559 +12 92,050 Americas 91 Montenegro 96,187 +139 1,451 +7 91,905 EURO 92 Kyrgyzstan 93,006 0 1,566 0 87,554 EURO 93 Ghana 91,928 +145 777 +5 89,729 Africa 94 Zambia 91,189 +70 1,240 +2 89,117 Africa 95 China 90,566 +19 4,636 0 85,624 WPRO 96 Uzbekistan 88,280 +345 641 +1 85,232 EURO 97 Finland 85,077 +280 902 +3 46,000 EURO 98 Mozambique 69,523 +86 805 0 62,394 Africa 99 El Salvador 68,161 +154 2,089 0 64,208 Americas 100 Luxembourg 65,813 +209 790 +2 61,936 EURO 101 Cameroon 64,809 0 939 0 57,821 Africa 102 Singapore 60,904 +24 30 0 60,603 WPRO 103 Cyprus 59,792 +927 296 +1 39,061 EURO 104 Afghanistan 58,542 +196 2,565 +4 52,348 EMRO 105 Thailand 50,183 +2070 121 +4 30,189 SEARO 106 Namibia 47,172 +218 616 +7 45,136 Africa 107 Botswana 45,855 +1153 691 +7 41,338 Africa 108 Ivory Coast 45,715 +18 277 0 45,283 Africa 109 Jamaica 44,502 +165 751 +7 20,170 Americas 110 Uganda 41,529 +54 341 0 40,898 Africa 111 Senegal 39,975 +65 1,097 +1 38,719 Africa 112 Zimbabwe 38,018 +38 1,555 0 35,073 Africa 113 Madagascar 34,069 +477 579 +10 27,152 Africa 114 Malawi 33,989 +14 1,145 +3 31,864 Africa 115 Sudan 32,695 +84 2,300 +11 26,411 EMRO 116 Malta 30,096 +33 411 0 29,166 EURO 117 Australia 29,626 +38 910 0 26,461 WPRO 118 DRC 29,350 +117 752 +4 26,135 Africa 119 Mongolia 27,956 +1264 69 +8 14,258 WPRO
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120 Maldives 27,084 +164 71 0 24,065 SEARO 121 Angola 25,051 +168 572 +2 22,901 Africa 122 Rwanda 24,262 +150 328 +1 22,649 Africa 123 Gabon 22,228 0 136 0 18,908 Africa 124 Guinea 21,745 +79 139 0 19,080 Africa 125 Syria 21,725 +141 1,496 +13 15,376 EMRO 126 Cabo Verde 21,500 +321 199 +1 18,689 Africa 127 Mayotte 19,849 0 169 0 2,964 Non 128 Réunion 19,343 0 141 0 17,653 Non 129 French Polynesia 18,725 +3 141 0 4,842 Non 130 French Guiana 18,693 +148 97 +1 9,995 Non 131 Eswatini 18,426 +3 671 0 17,722 Africa 132 Mauritania 18,192 +17 454 0 17,553 Africa 133 Guadeloupe 13,669 0 185 0 2,242 Non 134 Somalia 13,459 0 689 0 5,593 EMRO 135 Mali 13,420 +84 456 +5 7,732 Africa 136 Tajikistan 13,308 0 90 0 13,218 EURO 137 Burkina Faso 13,212 +45 156 +1 12,862 Africa 138 Haiti 12,944 0 251 0 11,945 Americas 139 Andorra 12,942 +25 123 0 12,375 EURO 140 Togo 12,698 +41 121 0 10,512 Africa 141 Belize 12,596 +11 320 +2 12,164 Americas 142 Guyana 12,234 +102 277 +3 10,555 Americas 143 Curaçao 12,022 +39 99 +4 10,011 Non 144 Hong Kong 11,719 +14 209 0 11,315 WPRO 145 Lesotho 10,723 +3 316 0 6,267 Africa 146 Djibouti 10,697 +64 130 +1 10,007 EMRO 147 Martinique 10,611 0 68 0 98 Non 148 South Sudan 10,504 +18 114 0 10,250 Africa 149 Aruba 10,469 +32 95 +1 10,024 Non 150 Papua New Guinea 10,338 0 99 0 7,364 WPRO 151 Congo 10,084 0 139 0 8,208 Africa 152 Bahamas 9,868 0 194 0 9,140 Americas 153 Suriname 9,865 +74 191 +2 8,965 Americas 154 Trinidad and Tobago 9,383 +167 157 0 8,065 Americas 155 Cambodia 8,193 +446 59 +5 2,924 WPRO 156 Benin 7,720 0 97 0 7,510 Africa 157 Equatorial Guinea 7,505 0 106 0 7,016 Africa 158 Nicaragua 6,835 0 181 0 4,225 Americas 159 Iceland 6,379 +17 29 0 6,223 EURO 160 CAR 6,175 0 85 0 5,112 Africa 161 Yemen 6,020 +60 1,157 +10 2,393 EMRO
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162 Gambia 5,820 +32 173 +2 5,272 Africa 163 Seychelles 5,170 +154 26 +1 4,675 Africa 164 Niger 5,143 +2 191 0 4,812 Africa 165 San Marino 5,045 +1 88 0 4,822 EURO 166 Chad 4,735 +4 169 0 4,376 Africa 167 Saint Lucia 4,455 +11 70 0 4,290 Americas 168 Gibraltar 4,291 0 94 0 4,182 Non 169 Channel Islands 4,055 0 86 0 3,956 Non 170 Sierra Leone 4,044 +2 79 0 2,914 Africa 171 Comoros 3,824 +2 146 0 3,645 Africa 172 Barbados 3,806 +9 44 0 3,716 Americas 173 Burundi 3,732 +26 6 0 773 Africa 174 Guinea-Bissau 3,721 +8 66 0 3,205 Africa 175 Eritrea 3,597 +33 10 0 3,406 Africa 176 Liechtenstein 2,851 +2 57 +1 2,715 Non 177 Vietnam 2,824 +12 35 0 2,490 WPRO 178 New Zealand 2,600 0 26 0 2,542 WPRO 179 Monaco 2,423 +1 31 0 2,311 EURO 180 Turks and Caicos 2,371 0 17 0 2,316 Non 181 Sao Tome and Principe 2,292 +4 35 0 2,227 Africa 182 Bermuda 2,261 +35 22 +2 1,394 Non 183 Sint Maarten 2,212 0 27 0 2,167 Non 184 Liberia 2,091 0 85 0 1,936 Africa 185 St. Vincent Grenadines 1,827 0 10 0 1,703 Americas 186 Saint Martin 1,720 +18 12 0 1,399 Non 187 Timor-Leste 1,657 +148 3 +1 795 SEARO 188 Isle of Man 1,584 +2 29 0 1,545 Non 189 Caribbean Netherlands 1,553 0 15 0 1,462 Non 190 Antigua and Barbuda 1,217 0 31 0 995 Americas 191 Mauritius 1,205 +1 16 +1 996 Africa 192 Taiwan 1,086 +4 11 0 1,041 WPRO 193 Bhutan 992 +6 1 0 906 SEARO 194 St. Barth 958 +24 1 0 462 Non 195 Diamond Princess 712 0 13 0 699 NA 196 Faeroe Islands 663 0 1 0 660 Non 197 Cayman Islands 531 0 2 0 509 Non 198 Tanzania 509 0 21 0 183 Africa 199 Wallis and Futuna 440 0 5 0 44 Non 200 Brunei 223 0 3 0 210 WPRO 201 British Virgin Islands 194 0 1 0 183 Non 202 Dominica 172 0 0 0 165 Americas 203 Grenada 159 +2 1 0 155 Americas
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204 New Caledonia 124 0 0 0 58 Non 205 Laos 94 +6 0 0 49 WPRO 206 Fiji 86 +8 2 0 65 WPRO 207 Falkland Islands 63 +1 0 0 62 Non 208 Macao 49 0 0 0 48 WPRO 209 Saint Kitts and Nevis 44 0 0 0 44 Americas 210 Greenland 31 0 0 0 31 Non 211 Anguilla 29 0 0 0 25 Non 212 Vatican City 27 0 0 0 15 Non 213 Saint Pierre Miquelon 25 0 0 0 24 Non 214 Montserrat 20 0 1 0 19 Non 215 Solomon Islands 20 0 0 0 18 WPRO 216 Western Sahara 10 0 1 0 8 Non 217 MS Zaandam 9 0 2 0 7 NA 218 Vanuatu 4 0 1 0 3 WPRO 219 Marshall Islands 4 0 0 0 4 WPRO 220 Samoa 3 0 0 0 2 WPRO 221 Micronesia 1 0 0 0 1 WPRO Total: 145,363,174 +890491 3,085,826 +13550 123,646,217
Figure 4. Areas with reported confirmed cases of COVID-19 (12 April – 18 April 2021)
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 449. 23 April 2021
Table 5. COVID-19 cases and deaths reported by provinces in China (Updated as of 23 Apr 2021, 14:00 SGT) Area Existing Change from Total Deaths Change from Recovered Active previous day Diagnosed previous day Cases (Active cases) Cases (Deaths) Yunnan 61 -2 337 2 0 274 Shanghai 59 +1 1,955 7 0 1,889 Guangdong 46 +5 2,327 8 0 2,273 Fujian 24 -2 586 1 0 561 Sichuan 16 0 967 3 0 948 Shaanxi 16 0 587 3 0 568 Hainan 16 0 187 6 0 165 Zhejiang 10 +2 1,331 1 0 1,320 Beijing 10 0 1,057 9 0 1,038 Jiangsu 8 0 716 0 0 708 Tianjin 8 -2 383 3 0 372 Shandong 7 0 876 7 0 862 Shanxi 7 0 249 0 0 242 Hubei 5 0 68,157 4,512 0 63,640 Henan 5 0 1,312 22 0 1,285 Hunan 4 0 1,044 4 0 1,036 Guangxi 3 0 270 2 0 265 Chongqing 2 +2 593 6 0 585 Inner Mongolia 2 0 379 1 0 376 Gansu 1 0 193 2 0 190 Heilongjiang 0 0 1,610 13 0 1,597 Hebei 0 0 1,317 7 0 1,310 Anhui 0 0 994 6 0 988 Xinjiang 0 0 980 3 0 977 Jiangxi 0 0 937 1 0 936 Jilin 0 0 573 3 0 570 Liaoning 0 -1 408 2 0 406 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 449. 23 April 2021 iv. Travel Bans/Advisories & Quarantine Orders [1] Australia - Flights from India will be reduced by 30% and travelers from high-risk countries will be required to have a PCR Covid-19 test 72 hours prior to leaving the last port they are in before travelling to Australia. The Australian Border Force will also limit departure exemptions for people travelling to high-risk countries like India, allowing travel only for urgent situations. [2] Canada – Starting midnight on 22 April, all direct passenger flights from India and Pakistan will be banned for 30 days. [3] Indonesia – Covid-19 regulations have been tightening at ports and road starting 23 April until seven days after the mudik ban on May 17. Air, rail and most sea travelers are required to present a negative PCR/antigen test result obtained 24 hours before departure or a negative GeNose breathalyzer test taken at the airport. [4] Saudi Arabia - Saudi Arabia’s ban on international flights from 20 countries will stay even after May 17, when the kingdom will resume international flights. The countries are: Argentina, Brazil, Egypt, France, Germany, India, Indonesia, Ireland, Italy, Japan, Lebanon, Pakistan, Portugal, South Africa, Sweden, Switzerland, Turkey, UAE, UK and US. [5] Singapore – Starting 11.59pm on Friday, all long-term pass holders and short-term visitors with recent travel history, including transit history, to India within the last 14 days will be barred from entering Singapore until further notice. [6] UAE – Starting 11.59 pm on Saturday, April 24, travel from India will be banned along with those passengers that come from India through other countries unless they were staying for 14 days in those countries. The ban is in effect for 10 days. UAE citizens, diplomatic delegations, official delegations and flights of businessmen are exempted but will have to undergo a mandatory 10 day quarantine along with RT-PCR test on the day of arrival, day 4 and on day 8.
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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 2021 v. Lockdowns [1] Canada – Starting 8 a.m. on 23 April until at least 20 May, tightened measures will be in place in the Halifax Regional Municipality as well as the communities of Hubbards, Milford, Lantz, Elmsdale, Enfield, South Uniacke, Ecum Secum, and Trafalgar. People have been advised to avoid travelling to any of these areas and some of the measures include limiting indoor and outdoor gatherings to 5, no indoor dining, retail businesses and malls can operate at 25% capacity and closing of hair salons and spas. [2] India (Jharkhand) – Starting 23 April until 29 April, lockdown has been imposed with some exemptions which include continuing of essential services and religious places which will remain open but the gathering of devotees will not be allowed. [3] India (Puducherry) – A weekend lockdown has been announced across the Union Territory between April 23, Friday 10 AM and April 26, Monday 5 AM which includes shops and businesses to function only up to 2 PM every day. [4] Italy - On 21 April, Italy approved significant reopening of the country from Monday 26 April until 31 July. The four-tier colour-coded system will return while a ban on movement around the country will come to an end with help of a 'Green Pass' allowing travel between all of Italy's 20 regions. Restaurants, bars and all catering venues in yellow and white zones will be able to serve at outdoor tables. Outdoor sports will resume on 26 April and swimming pools from 15 May. From 26 April and until the end of the current academic year all school children can attend lessons in the classroom. [5] Laos - Starting 23 April, a two-week lockdown in Vientiane has been ordered at least until May 5 with all international borders closed alongside provincial borders. Residents in the capital are banned from leaving their homes except for essential tasks. [6] Pakistan - Smart lockdowns in three localities, Gulberg, North Karachi and North Nazimabad have been extended till May 5.
vi. Military Surveillance
South Korea - COVID-19 cases in USFK [1]
As of 22 April, nine American service members and five American citizens affiliated with the USFK tested positive for COVID-19. Eight service members, one civilian and two dependents arrived at Osan Air Base in Pyeongtaek, from the U.S. between March 19 and April 19. The remaining individuals arrived at Incheon International Airport on April 8 and 16. The total number of infections reported among the USFK-affiliated population is now 839.
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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 2021 vii. WHO Guidance & Other Protocols
The following updates were published by the WHO on 23 April 2021:
Interim recommendations for use of the ChAdOx1-S [recombinant] vaccine against COVID-19 (AstraZeneca COVID-19 vaccine AZD1222, SII Covishield, SK Bioscience): Interim guidance, first issued 10 February 2021, updated 21 April 2021 Availbale at: https://www.who.int/publications/i/item/WHO-2019-nCoV-vaccines- SAGE_recommendation-AZD1222-2021.2 Annexes to the interim recommendations for use of the ChAdOx1-S [recombinant] vaccine against COVID-19 (AstraZeneca COVID-19 vaccine AZD1222, SII Covishield, SK Bioscience): Grading of evidence - Evidence to recommendations tables Available at: https://www.who.int/publications/i/item/WHO-2019-nCoV-vaccines- SAGE_recommendation-AZD1222-annexes-2021.2 Interim recommendations for use of the ChAdOx1-S [recombinant] vaccine against COVID-19 (AstraZeneca COVID-19 vaccine AZD1222, SII Covishield, SK Bioscience) Available at: https://www.who.int/publications/i/item/WHO-2019-nCoV-vaccines- SAGE_recommendation-AZD1222-2021.1
viii. CDC Guidance & Protocols
US CDC
The following update was published by the US CDC on 23 April 2021:
Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-after- vaccination.html
EU CDC
The following update was published by the EU CDC on 23 April 2021:
Forecasting COVID-19 cases and deaths in Europe - new hub will support European pandemic planning Available at: https://www.ecdc.europa.eu/en/news-events/forecasting-covid-19-cases-and- deaths-europe-new-hub
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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 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] European Union (EU) - Use of Johnson & Johnson’s one-shot COVID-19 vaccine to countries in the EU will resume after the European Medicines Agency (EMA) announced that the risk of blood clots was outweighed by its benefits. [2] Israel – On 22 April, the biggest real-world study in Israel showed that vaccine developed by Pfizer and BioNTech was 80% effective against symptomatic infection for people with heart or chronic kidney diseases, 86% for people with type 2 diabetes, 75% for cerebrovascular disease, and 84% for people suffering from immunodeficiency. For people who were vaccinated and were already suffering three or more chronic conditions or risk factors, it was 88% effective in preventing symptomatic infection. It was more than 90% effective against severe disease for people with type 2 diabetes, heart or cerebrovascular disease and 100% for people suffering from immunodeficiency.
Therapeutics
[3] United States – NIH approved 2 new clinical trials for COVID-19; 1) a phase 3 clinical evaluating the experimental formulation of aviptadil acetate and Veklury in hospitalized COVID-19 patients with acute respiratory distress syndrome; and 2) a phase 3 clinical trial evaluating over-the- counter medications that people with COVID-19 can take at home. Roughly 13,500 participants in this new study will receive a placebo or one of seven treatments in the mail, with the list of medications still being finalized. [4] United States – On 2 April, FDA confirmed granting a third hospital, an unnamed health facility in the US, compassionate special permit (CSP) to use the anti-parasitic drug Ivermectin as a treatment for COVID-19.
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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 2021
Vaccine Approval Status
Table 6: Number of approving countries per vaccine as of 21 April 2021 Developer Vaccine Number of countries approving Anhui Zhifei Longcom RBD-Dimer 2 Bharat Biotech Covaxin 6 CanSino Ad5-nCoV 5 Chumakov Center Kovivac 1 FBRI EpiVacCorona 2 Gamaleya Sputnik V 62 Johnson & Johnson Ad26.COV2.S 40 Moderna mRNA-1273 46 Oxford/AstraZeneca AZD1222 91 BioNTech/Pfizer BNT162b2 83 Serum Institute of India Covishield 33 Sinopharm BBIBP-CorV 35 Sinopharm Inactivated 2 Sinovac CoronaVac 22 Source: https://covid19.trackvaccines.org/vaccines/
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. [1] There were 490 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 [3] worker is 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 [4] after receiving the vaccine. As of the time of reporting, one has Pfizer BioNTech 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 the latest case include tongue swelling, hoarse voice [5] 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 [6] after getting the vaccine. The patient is currently in a stable condition. [United States; Report] Two healthcare workers from Essentia [7] Health, Minnesota had non-severe allergic reactions to the
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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 2021
vaccine. About 2,500 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 [8] trial included 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 [9] s allergic 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 [10] allergic 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. [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 [13] the 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 [14] receiving treatment to reduce inflammation. [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
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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 2021
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 [16] vaccinated site, and one 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 hospital.
[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 [19] were reported from Coahuila (7 reports), Mexico City (4 cases), [20] Chihuahua, State of Mexico, Guanajuato, Oaxaca and Yucatan (2 [21] 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) [22] were detected and 17 of them had history of allergies or allergy [23] reaction. Of the 21 cases, 4 of them were hospitalized including 3 [24] in intensive care and 20 of them had discharged or recovered by [25] 23 December. There were no death reported.
[Update] The total number of cases of anaphylaxis has been updated to 29 as on 6 January.
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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 2021
[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 [26] indicating internal bleeding 3 days after the injection. Pfizer and [27] BioNTech had not received any prior indication of 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 unexpected side effects.
[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, consisting of 10 serious and 14-nonserious reports. All reports were considered to be expected side effects.
[28] [Update] Sixty-six new reports of adverse medical reactions, 17 of [29] which were considered severe, have been reported as between [30] January 9 and January 15. As of January 15, 90 reports of adverse [31] 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.
[Update] As of 26 March 2021, a total of 1,659 adverse effects were reported, of which 1,347 were non-serious AEFI and 312 were 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 cases of allergic reactions and 2 cases of [32] tachycardia. Around 30 cases of non-serious adverse effects have been reported since 12 Jan 2021
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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 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 [33] least 80 years. 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 [34] within 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 [35] 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 [36] experienced 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 [37] 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 [38] precluded them from receiving the vaccine. All 3 cases have [39] recovered and were discharged from the 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 reported out of 243,412 vaccines administered, of which 37 were [40] 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 [41] mild side 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 [42] dose and 45% after 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.
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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 2021
[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 [43] reported in 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 [44] were 16,756 yellow 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.
[45] 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, particularly those in the armpit on the side where the shot [46] was received. [France; Report] Between December 27 and February 18, France recorded 5,331 unwanted side effects out of 3,330,296 injections. The most common side-effects included flu-like symptoms, such as fever and muscle pain, and were more prominent after the second [47] dose. There were 75 cases of serious high blood pressure that led to symptoms like dizziness, 56 cases of cardiac issues and 10 cases of facial paralysis. [Australia, Report] The first serious AEFI in Australia involved anaphylactic reaction in a Queensland nurse following vaccination. [48] The nurse has a history of anaphylaxis and have since recovered from the reaction. [Japan, Report] The first serious AEFI in Japan involved [49] anaphylactic reaction in a female Japanese medical worker in her [50] 30s, following vaccination on 5 March 2021. The medical worker [51]
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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 2021
has a history of asthma, and whose condition have improved after taking proper medicine.
[Japan, Update] Five more anaphylaxis cases following vaccination were reported through Japan on 8 March 2021, bringing the total number of such cases to 8. The new cases occurred in women in their 20s to 50s, of which four had asthma or a history of other drug allergies. All cases’ condition improved after taking medication. Anaphylaxis reaction was linked for vaccination for three of the cases, while the causal relationship was unclear or impossible to evaluate in the remaining 2 cases.
[Japan, Update] A total of 25 cases of anaphylaxis were reported amongst 148,000 doses administered as of 10 March 2021. The cases were primarily women (24 cases). The anaphylaxis rate in Japan is relatively higher than that reported in United States (5 cases/million doses) and Britain (20 cases/million doses) [Australia; Report] As of 16 March, 19 reports of anaphylaxis were reported nationally after vaccinated with Pfizer (14 reports) and [52] AstraZeneca (5 reports). More than 183,000 doses have been administered. [Hong Kong Report] A chronically ill 66-year-old man died on March 19, three days after receiving the BioNTech vaccine. He was the eighth person to die after getting a jab since vaccination was [53] launched. The previous seven chronically ill people died after receiving the Chinese-made Sinovac jab. But no link between the deaths and the jabs has been established so far. [Hong Kong, Report] As of March 26, there has been 1 known report of Bell’s palsy following vaccination with the Pfizer- [54] BioNTech vaccine in Hong Kong. No direct link was found between the cases and the vaccinations. [Japan, Report] As of March 21, 47 cases of anaphylaxis have been reported after 580,000 doses of Pfizer-BioNTech vaccine administered. This implies an anaphylaxis rate of 81 cases per 1 million doses administered, much higher than 5 in every 1 million [55] doses in the United States and 20 cases per million doses in Britain. The rate is subject to change since Japan is further behind in the vaccination rollout. [United Kingdom, Report] A 2 reports of blood clot in the brain [56] have been reported amongst recipients as of 24 March 2021. [Australia; Report] As on 28 March 2021, 36.3% of 80,533 people receiving the vaccine reported adverse events after the first dose [57] while 60.7% reported at least one AE following their second dose since vaccination started on 22 February 2021. [Hong Kong; Report] Two pregnant women had suffered from miscarriages after administered with the BioNtech vaccine but [58] links with the vaccination has not been established. [New Zealand; Report] From 20 Feb to 13 Mar, 22,588 doses were administered with 65 new non serious and 3 new serious cases [59] reported from the last update. Two of the serious cases were
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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 2021
allergic reaction while the third case was a reactogenicity reaction. Previous report up to 6 Mar has identified 147 adverse reactions including 3 serious reactions. [Israel; Report] Herpes zoster reactivation (shingles) identified in six vaccinated patients with comorbid autoimmune/ inflammatory [60] diseases in two centers since Dec 2020 suggest new adverse event linked to the vaccine. [Saudi Arabia, Publication] A cross sectional study was conducted with 455 Saudi Arabia inhabitants. Common side-effects were injection site pain, headaches, flu-like symptoms, fever, and tiredness, less common side effects were fast heartbeat, whole body aches, difficulty breathing, joint pain, chills, and drowsiness [61] and rare side effects were Bell’s palsy and lymph nodes swelling and tenderness. There were more reports on difficulty of breathing in recipients who were previously infection as compare to not infected. Most side effects reported were consistent with the vaccine’s fact sheet for recipients and caregiver. [United Kingdom, Report] Based on the UK’s Yellow Card tool, there were 2.5 time more cases of severe side effects and related death after vaccinated with Pfizer than with AstraZeneca. As of 5 [62] April, there were 22 fatalities among 21.6 million doses of AstraZeneca and 40 fatalities among 15.4 million doses of Pfizer administered. [United States; Report] The FDA advisory committee has noted a special side effect of the vaccine from the clinical trials involving several patients with cosmetic facial fillers. The patients who [63] experienced side 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 [64] December 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 occurred in Toronto, Canada. Moderna [65] [Canada; Surveillance] As of 5 Feb, a total of 280 adverse effects [66] were reported which include 25 serious AEFI and 255 non-serious [67] AEFI.
[Canada; Surveillance] As od 26 March 2021, a total of 1,165 AEFIs were reported, of which 1,106 were non-serious AEFIs and 59 were serious AEFIs. [United States; Report] A frontline worker in Robstown had experienced immediate numbness on the face after receiving the [68] vaccine a week ago but continues to have soreness and redness to her arms. [United States; Publication] Phase 3 clinical trial involving 30,420 [69] volunteers had observed higher frequency of moderate, transient [70]
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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 2021
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 transient local and systemic reactions.
[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 [71] had taken the 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 [72] data reports show three 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 [73] vaccine 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 [74] vaccination site in San Diego. The site is 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 [75] whether the fatality was linked to receiving the vaccine is underway. [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. [76] [77] [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 [78] 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 [79] bit delayed in some people up to a week. [France; Report] Since January 22, 148 cases of unwanted side [80] effects were reported in France. A total of 129,510 people have
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received at least one doses of the Moderna vaccine. The side effects were mainly skin issues, muscle pain, and digestive issues. Four people had severe side effects including cardiac problems. [United States, Report] A 39-years-old female with no known health problems or comorbidities died 4 days after her second [81] vaccine shot. Investigations are in progress to determine the link of the death with the vaccine. [United States, Report] Boston researchers report delayed skin reaction to Moderna COVID-19 vaccine which includes skin rash at [82] the injection site and the timing of it might be confusing. [Argentina; Report] Of the total 32,013 patients who had received Sputnik V the vaccine, 1% (317 patients) had reported mild adverse reaction [83] (fever 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. [84] [85] [Update] 82 AEFIs were reported across India on 20 January 2021. [86] All AEFIs reported were mild cases. [87] [88] [Update] On the 22 Jan, Day 4 of the coronavirus vaccination drive [89] in Delhi, 5,942 people were reportedly administered the shots and [90] Astrazeneca & adverse events following immunisation (AEFI) was reported in 24 [91] Oxford Uni. persons. [92] [93] [Update] On 24 Jan, the fifth day of India’s Covid-19 vaccination [94] drive, the city of Gurugram reported 3 cases of AEFI amongst 3,055 shots administed.
[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 sessions during the day, the ministry said. A total of 348
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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.
[Update] A total of 91 minor AEFIs were reported out of the 833,000 people vaccinated in the state, as of 8 March 2021 [Sweden, Report] As of 13 Feb, two regions in Sweden have temporarily stopped vaccinating health workers with the Astra [95] 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 [96] 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. [France; Report] Between February 6 and 18, 971 cases of unwanted side effects were reported in France. Of these, 93% were flu-like symptoms and 72% disappeared within 24 hours. The most common side effects were pain and inflammation at injection [97] site, digestive issues, and muscle pain. There were four serious cases – one stroke, two with loss of taste and a death. There was however, no suggestion that any death was directly caused by the vaccine. [Netherlands; Report] The side effects center Lareb, Netherlands reported that side effects like fever and chills were more likely to [98] be severe after the AstraZeneca vaccine. [South Korea; Report] South Korean authorities are probing two deaths reported days within receiving the AstraZeneca COVID-19 vaccine. One was a 63-year-old nursing home patient with cerebrovascular disease who died after showing symptoms of blood poisoning and pneumonia. The other was an individual in their 50s with a cardiac disorder and diabetes, who died after [99] suffering multiple heart attacks. Officials are investigating the [100] cause of the deaths. [101] [102] [South Korea, Update] Three more deaths following vaccination were reported on 4 March 2021, raising the total number of post- vaccination fatalities to 5. The 3 new deaths were all reported amongst long-term care hospital patients, of which 2 of the deceased aged 52 and 58 years old had preexisting comorbidities
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and the remaining fatality was in her 20s. Investigations are underway to assess the association between all 5 deaths and vaccine.
[South Korea, Update] Eight of the 11 deaths following vaccination were concluded to not be linked to the vaccine, following initial investigation which did not recognize causality between adverse reactions and death after vaccination. The investigation team linked the deaths to exacerbation of underlying diseases in the deceased. Investigation for the 3 remaining deaths are still underway.
[South Korea; Update] Suspended vaccination with the Astrazeneca vaccine for people younger than 60 years old, from 7 April 2021 while awaiting results from the EMA safety review regarding blood clots as a side effect from vaccination. [Austria, Report] Vaccination with a batch of the vaccine was suspended following reports of a death of a 49-year-old woman from severe coagulation disorder, and a case of pulmonary embolism in a 35-year-old woman following vaccination. Blood clotting is not a known side effect of vaccination and the [103] relationships of the 2 reports are currently under investigation. [104]
[Austria, Update] The European Medicines Agency reported no evidence linking the deaths of 2 people reported above, to the vaccination. [Denmark, Report] Vaccination of AstraZeneca will be suspended for 14 days after a 60 year old women who had received the vaccine from the same batch as Austria had formed a blood clot [105] and died. However, it is unable to conclude any link at the moment as investigation are being conducted. [Philippines, Report] As of 10 March 2021, 978 individuals administered with Sinovac (892) and AstraZeneca (86) had experienced suspected adverse event. At least 85 vaccinees administered with AstraZeneca were non-serious and 1 was serious. 872 vaccinees administered with Sinovac were non- serious and 20 were serious.
[Update] 2.21 percent of those who received Sinovac's CoronaVac [106] experienced suspected side effects, and it was 5.19 percent for [107] those inoculated with AstraZeneca's product. [108]
[Update] Among the 24,209 vaccinated individuals administered with Coronavac and AstraZeneca in Region 2 (Cagayan Valley), at least 516 had reported minor adverse effect and are in stable condition. Of the 20 individuals with serious effects, 4 deaths were reported. Three of which were co-incidental who were positive for Covid-19 with comorbidities before vaccination and were not link to the vaccine. The other death was indeterminate.
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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 2021
[India, Report] Two senior citizens in West Bengal had died after administered with Covishield vaccine. Primary findings suggested [109] that it was due to cardiac ailments. [Norway, Report] Three health workers below 50 years old who were administered with AstraZeneca vaccine recently have been [110] treated for bleeding, blood clots and low count of blood platelet. It is uncertain if the cases are linked to the vaccine. [Spain, Report] The Community of Castilla y Leon has reported two cases of possible adverse effects after administered with AstraZeneca- University of Oxford vaccine in Valladolid. An individual who was diagnosed with non-infectious immunological [111] encephalitis is in stable condition and progressing favourably. The other individual had stroke and had been treated and discharged. Specific cause-effect relationship was not able to established at the moment. [Italy, Report] The northern region of Piedmont will stop using a batch (ABV5811) of the AstraZeneca vaccine following the death of a teacher after vaccination on Saturday. Italy had also banned the [112] use of another batch (ABV2856) on 11 Mar after the deaths of two men in Sicily. No link has been established. As of 14 March, AstraZeneca has reported no evidence of increased risk of blood clots in a review of the safety data of more than 17 million people vaccinated with its vaccine in EU and UK. 15 events of deep vein thrombosis and 22 events of pulmonary [113] embolism have been reported thus far which is similar to the other licensed vaccine. AstraZeneca and the European health authorities have and are conducting additional testing and there were no cause of concern. [Sweden, Report] Vaccination of AstraZenca vaccine will be suspended for precautionary measure until EMA investigcation is done. The Swedish Medical Products Agency has noted 10 cases of [114] blood clots and one case of low levels of platelets in those vaccinated as of 15 Mar. [Denmark, Report] On 20 March, two people reported experiencing brain hemorrhages after receiving the AstraZeneca [115] Covid vaccine, one of whom died and a female civil servant in her 30s, was critically ill. [India, Report] A 62-year-old woman died on 20 March, three days after taking the Covid-19 vaccine in Karnal district. An autopsy was [116] performed and the report is awaited before a conclusion on the reason for the death can be reached. [Finland, Report] On 20 March, two cases of cerebral venous sinus thrombosis were reported within 4–10 days of receiving the AstraZeneca COVID-19 vaccine. Both patients had medical risk [117] factors for blood clots, and the analysis of the cases is still incomplete. As a precautionary measure, the use of the AstraZeneca vaccine in Finland has been suspended. [Taiwan, Report] On March 24, four reports of non-serious adverse reactions have been reported after over 3,000 medical personnel [118] were vaccinated with AstraZeneca vaccine. Sixty-three percent
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reported pain at the site of the injection, 55% reported muscle ache, 52,6% fatigue, 43% headache and 41.8% reported chills.
[Global, Report] Drug regulators in Europe are investigating 62 cases of rare blood clotting worldwide, cerebral venous sinus thrombosis (CVST), which occurred following the use of [119] AstraZeneca’s vaccine. Forty-four cases were reported among 9.2 million vaccinees in the European Economic Area. The figure cited does not include all cases of the condition reported in Germany. [Netherland, Report] Five reports of extensive thrombosis with low platelet counts in 7 to 10 days post-vaccination were reported in women aged between 25 and 65 years old; 3 cases had extensive [120] pulmonary embolisms, 1 case had a brain haemorrhage and one case died. The vaccine has since been temporarily suspended in use for people below 60 years old in Netherlands. [United Kingdom, Report] A total of 22 reports of blood clot in the brain accompanied by low platelet counts, and 8 reports of blood clotting problems with low platelet count have been reported [121] amongst the 18.1 million doses administered as of 24 March 2021. Of the 30 reports, 7 individuals have died. [Australia, Report] A case of serious thrombosis with low platelet count was reported in a 44-year-old man, days after receiving the [122] vaccine, on 2 April 2021. Investigation to assess the causal link with the vaccine is currently underway. [Australia; Report] Since 22 February 2021, a total of 21,378 mild AEs were reported of the 31,786 people receiving the vaccine. Fatigue was the most commonly reported AE (53.8%), followed by [123] headache (47.4%), muscle or body aches (45%) and injection site pain (44.9%). [Belgium; Update] Banned vaccination with the Astrazeneca [124] vaccine for people aged under 56, for 4 weeks from 7 April 2021. [Brunei; Update] Suspended vaccination with the Astrazeneca vaccine nationwide, from 7 April 2021 while awaiting results from [125] the EMA safety review regarding blood clots as a side effect from vaccination. [Global; Update] As of early April, 169 cases of rare brain blood clot following vaccination have been reported to the European Medicines Agency (EMA), from the 34 million doses administered in the European Economic Area. The EMA have found possible links between the vaccine and the occurrence of the brain blood clots, but reiterated on its benefits of protection.
[126] The World Health Organisation has reviewed the latest [127] information from EMA and the United Kingdom’s Medicines and other Health products Regulatory Agency (MHRA) and considered the causal relationship between the side effect and the vaccine plausible but not confirmed, and specialized studies are needed. The WHO notes that the brain blot clot event reported is very rare, in low numbers reported amongst the almost 200 million individuals vaccinated with this vaccine candidate globally.
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[Australia, Report] A 48 year old diabetic woman had developed blood clots and died on 15 Apr after receiving the AstraZeneca vaccine on 9 Apr but link between the death and vaccine has not been established. [128]
[129] [Update] The Australia medical regulator has ruled that the blood clot developed in the 48 year old woman is a side effect of the vaccine and would review again if test results and/or autopsy show otherwise. [Nigeria, Report] A total of 8,439 mild adverse events and 52 moderate to severe adverse events have been reported. No deaths [130] or cases of blood clots related to the vaccine has been reported. [Report] EMA is investigating on another possible side effect, capillary leak syndrome associated to the vaccine. Five cases have [131] been reported so far but link with the vaccine has not been established. [Canada, Report] A man in the 60s from Alberta has a confirmed case of blood clot linked to the AstraZeneca vaccine and is receiving treatment and recovering from it. This is the second case [132] of vaccine-induced immune thrombotic thrombocytopenia in more than 700,000 AstraZeneca or CoviSHIELD/AstraZeneca doses vaccinated in Canada. [France, Report] Nine new cases of thrombosis and four related deaths in individuals vaccinated with AstraZeneca vaccine was [133] reported for 2 to 8 April. This bring the total cases of thrombosis and blood clotting issue in France to 23 and eight total deaths. [Saudi Arabia, Report] Seven blood clots with possible association to AstraZeneca vaccine have been recorded after receiving 34 complaints of side effects. However, immunological platelet [134] deficiency and clotting syndrome associated with the vaccine have not been confirmed in the cases. [Philippines, Report] As of 7 March 2021, a total of 41 mild AEFIs were reported from 1,075 shots administered amongst health care [135] workers in Cebu city. [Thailand, Report] Seven people had developed temporary partial paralysis after administered with CoronaVac. All had improved [136] CoronaVac after taking medicine to dissolve blood clots. [Update, Thailand] The adverse side-effects that were reported in 7 recipients. who developed “stroke-like” symptoms after receiving the first dose of the CoronaVac have recovered [137] following medical treatment. Contrary to earlier reports, no blood clots were found in any of the 7. [Hong Kong, Report] A total of 61 mild AEFIs were reported, of which 45 required hospitalisation, were reported amongst the 91,800 Sinovac doses (and 1,200 doses by Pfizer BioNTech) SinoVac administered as of 6 March 2021. A death following vaccination [138] was reported in a 71-year-old man on 8 March. The deceased received his first dose on 3 March and investigation regarding the cause of death is underway. Two other deaths following
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vaccination, reported between 6 and 8 March were assessed to not linked with vaccination following investigation. [Philippines, Report] Philippine health authorities on 18 Mar ruled out a COVID-19 vaccine as the cause of death of a 47-year-old [139] health care worker who died on Saturday, days after she received a jab of China's Sinovac vaccine. [Hong Kong, Report] As of March 26, there have been 11 known reports of Bell’s palsy following vaccination with the Sinovac [140] vaccine in Hong Kong. No direct link was found between the cases and the vaccinations. [Canada; Surveillance] As of 26 March 2021, there were 22 non- [141] serious AEFIs reported [Ghana; Report] A total of 1,679 adverse effects were reported from the 490,000 doses administered, of which 9 reports were serious AEs. However, only a report involving a case of febrile illness was considered related to the vaccine after investigation. [142] Covishield Remaining 1,670 reports were mild AEs, of which headache, fever, weakness, body pains, chills, pains at injection point, malaise and dizziness were most commonly reported. [Canada; Report] As of 15 April, the first case of rare blood clot was reported in Quebec and the affected person was recovering at [143] home. [United States, Report] Vaccinations with Johnson & Johnson's COVID-19 shot have been paused at a North Carolina site after 18 [144] people had adverse reactions on Thursday. Four have been taken to area hospitals. [United States, Report] The Centers for Disease Control indicated in an alert Tuesday 13 April that the Johnson & Johnson vaccine could resume as soon as Wednesday 14 April. The alert came after a chaotic day when the Food and Drug Administration recommended there be a "pause" for the vaccine, leading virtually [145] every state to halt use of the single-dose shot. The CDC's Advisory Johnson & Committee on Immunization Practices will convene Wednesday 14 Johnson April for an emergency session, with a vote scheduled on "updated Ad26.COV2.S recommendations for use". [Global, Report] European Medicines Agency reported a possible link between Johnson & Johnson vaccine and rare blood clot incidents but the benefit outweighed the risk. Inclusion of warning [146] on rare but fatal blood clots with low blood platelets within 3 weeks of vaccination was recommended. [USA, Report] A woman in Texas has been hospitalized with possible blood clots associated with Johnson and Johnson’s coronavirus vaccine. So far, officials are examining six reports of [147] clots, including a death, out of more than 6.8 million one-dose vaccinations that have been given. [China, Report] The incidence of adverse effects due to the two inactivated vaccines of Sinopharm was 1.06% based on mass-scale Sinopharm [148] emergency use in China on 519,543 people as of 1 Dec. This is lower compared to the results from phase 2 clinical trial.
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[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 [149] adverse effect after the 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 about 25 minutes after vaccinated and after the [150] mandatory 15 minutes 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 [151] effect during the observation period. Autopsy will be conducted to determine the exact cause of death. [India, Report] A 72-year-old female anganwadi worker died on 6 March, after receiving the first dose on 17 February 2021 in Jiribam district, Manipur. The deceased had reportedly complained about fever and health weakness on the same day after receiving [152] the vaccine, and been receiving treatment in different hospitals since then before eventually hospitalized on 27 February after her health condition deteriorated. [India, Report] A total of 8 AEFI cases, of which 1 was a serious Unspecified AEFI, were reported from the 32,714 doses given at the Brihanmumbai Municipal Corporation on 8 March 2021. The [153] serious AEFI was reported in a 65-year-old man after he received vaccination at the centre. [India, Report] A 69-year-old man collapsed on the chair within seconds, and passed away within 2 hours after receiving the [154] vaccine at a nursing home in Oshiwara. The cause of death is still under investigation. [India, Report] A 65-year-old man had died two days after being vaccinated on 10 March in Andhra Pradesh’s Eluru. No abnormality was reported during the observation after vaccinated. He had fallen ill the next day and his condition improved before passing [155] away. Primary medical reports showed that he was suffering from paralysis, diabetes, and some other serious health issues. Autopsy will be conducted to confirm the cause of death. Two suspected cases of blood clots in South Korea have been [156] reported after vaccination [India, Report] Two minor AEFis were reported from the 52,408 doses given on 3 April 2021, in New Delhi. As of mid-March 2021, 13 serious adverse events have been reported nationwide, of [157] which 6 were assessed to be attributed to vaccination, 6 were [158] assessed to be not attributable to vaccination and one case was unclassifiable. 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 449. 23 April 2021 x. Scientific Publications with Epidemiology and Clinical Focus
Longitudinal assessment of symptoms and risk of SARS-CoV-2 infection in healthcare workers across 5 hospitals to understand ethnic differences in infection risk [489]
Background: Healthcare workers (HCWs) have increased rates of SARS-CoV-2 infection compared with the general population. We aimed to understand ethnic differences in SARS-CoV-2 seropositivity among hospital healthcare workers depending on their hospital role, socioeconomic status, Covid-19 symptoms and basic demographics.
Methods: A prospective longitudinal observational cohort study. 1364 HCWs at five UK hospitals were studied with up to 16 weeks of symptom questionnaires and antibody testing (to both nucleocapsid and spike protein) during the first UK wave in five NHS hospitals between March 20 and July 10 2020. The main outcome measures were SARS-CoV-2 infection (seropositivity at any time-point) and symptoms. Registration number: NCT04318314.
Findings: 272 of 1364 HCWs (mean age 40.7 years, 72% female, 74% White, ≥6 samples per participant) seroconverted, reporting predominantly mild or no symptoms. Seropositivity was lower in Intensive Therapy Unit (ITU) workers (OR=0.44 95%CI 0.24, 0.77; p=0.0035). Seropositivity was higher in Black (compared to White) participants, independent of age, sex, role and index of multiple deprivation (OR=2.61 95%CI 1.47-4.62 p=0.0009). No association was seen between White HCWs and other minority ethnic groups.
Interpretation: In the UK first wave, Black ethnicity (but not other ethnicities) more than doubled HCWs likelihood of seropositivity, independent of age, sex, measured socio-economic factors and hospital role.
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xi. Sources
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Travel Bans/Advisories & Quarantine Orders 1. https://www.theguardian.com/australia-news/2021/apr/22/western-australia-calls-for-temporary- ban-on-travellers-from-india-after-hotel-quarantine-covid-outbreak 2. https://www.thestar.com/politics/federal/2021/04/22/canada-bans-flights-from-india-pakistan-as- covid-19-surges-across-region.html 3. https://coconuts.co/jakarta/news/mudik-ban-starts-today-as-covid-19-task-force-updates-policy/ 4. https://www.khaleejtimes.com/coronavirus-pandemic/covid-19-saudi-travel-ban-on-uae-india- pakistan-among-20-countries-to-stay-after-may-17 5. https://www.scmp.com/week-asia/health-environment/article/3130678/singapore-ban-non-resident- visitors-india-amid-fears
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6. https://www.financialexpress.com/lifestyle/travel-tourism/uae-bans-travel-from-india-from-sunday- due-to-worsening-covid-19-situation-reports/2238396/
Lockdowns Refer to Situation Report 91 for all updates before 1st May 2020
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Military Surveillance 1. https://en.yna.co.kr/view/AEN20210422007900325?section=national/defense
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38 | P a g e Centre for infectious di sease epidemiology and research
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40 | P a g e Centre for infectious di sease epidemiology and research
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42 | P a g e Centre for infectious di sease epidemiology and research
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43 | 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 449. 23 April 2021
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44 | 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 449. 23 April 2021
Scientific Reports 1. Valdes AM, Moon JC, Vijay A, et al. Longitudinal assessment of symptoms and risk of SARS-CoV-2 infection in healthcare workers across 5 hospitals to understand ethnic differences in infection risk [published online ahead of print, 2021 Apr 15]. EClinicalMedicine. 2021;100835.
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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 449. 23 April 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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