COVID-19 Critical Intelligence Unit: COVID-19 cases, testing, variants, vaccines, hospitalisations and deaths

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COVID-19 Monitor COVID-19 cases, testing, variants, vaccines, hospitalisations and deaths 21 October 2021

Table 1: NSW key indicators as at 17 October 2021*

*Please see notes and sources at the end of this document.

Key indicators Date: 17 Oct (previous week: 10 Oct)

Average daily COVID-19 locally acquired cases, week to 17 Oct 362 Compared to previous week 556 (-194) Growth factor for locally acquired cases 0.94 Doubling time (days) NA

Average daily COVID-19 deaths, week to 17 Oct 4 Compared to previous week 8 (-4)

COVID-19 patients under the care of NSW Health, as at 17 Oct 4,964 Compared to previous week 7,825 (-2,861)

COVID-19 patients in hospital, as at 17 Oct 605 Compared to previous week 766 (-161) Percentage of patients unvaccinated 63.7% Percentage of patients fully vaccinated 14.9%

COVID-19 patients in intensive care units (ICU), as at 17 Oct 131 Compared to previous week 152 (-21) Percentage of patients unvaccinated 77.9% Percentage of patients fully vaccinated 6.9% Percentage of total ICU beds 24.9% Compared to previous week 28.3% (-3.4%)

Rates per million Average daily COVID-19 locally acquired cases, week to 17 Oct (previous week) 43.0 (-23) COVID-19 under the care of NSW Health, as at 17 Oct 589.9 COVID-19 patients in hospital, as at 17 Oct 71.9 Hospital rate among unvaccinated / fully vaccinated 16+ population 554.1/19.7 COVID-19 patients in ICU, as at 17 Oct 15.6 ICU rate among unvaccinated / fully vaccinated 16+ population 142.0/2.0

COVID-19 vaccination, as at 17 Oct Number of persons aged 16+ given 1+ dose 6,056,736 Percentage of persons aged 16+ given 1+ dose 91.4% Compared to previous week +1.7% (Average increase, the past four weeks) (+2.3%) Number of persons aged 16+ fully vaccinated 5,300,137 Percentage of persons aged 16+ fully vaccinated 80.0% Compared to previous week +6.7% (Average increase, the past four weeks) (+6.8%)

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Background Jurisdictions globally are facing different situations when it comes to COVID-19 cases, distribution of new variants, patient outcomes, vaccine rollout and testing. Understanding how these variables interplay as the pandemic progresses can provide insights for NSW.

Evidence • While there is evidence of a reduction, or waning, of serum antibodies to SARS-CoV-2 post-

vaccination, vaccines continue to provide effective protection against symptomatic and severe disease and death.1-3

• Some jurisdictions, such as Israel, have seen high rates of hospitalisation concurrent with waning immunity, while others, such as the United Kingdom, have seen a decline in hospitalisations and deaths despite decreasing antibody levels.4, 5

• In areas with high case numbers, alternative testing approaches to the gold standard polymerase chain reaction (PCR) testing may be considered.6 These approaches include at-home testing, frequent rapid antigen tests, age-group-target testing, using samples of individuals from different households, or electronic screening using self-reported data.7-12

• Rapid antigen tests have value as a screening step before PCR testing to confirm diagnosis, in particular with outbreaks where there is high local disease prevalence (such as currently in Sydney).9, 13, 14

• The Therapeutic Goods Administration will allow applications for regulatory approval to supply RAT for use at home in Australia after 1 November 2021.15

• Viruses constantly change through mutation and new variants are expected over time.16 For SARS-CoV-2, there are four variants of concern as determined by the World Health Organization:

o Alpha (B.1.1.7), originated in the United Kingdom and currently reported in 196 countries. o Beta (B.1.351), originated in South Africa and currently reported in 145 countries. o Gamma (B.1.1.28.1 or P.1), originated in Brazil and currently reported in 99 countries. o Delta (B.1.617.2), originated in India and currently reported in 193 countries.17-19

• COVID-19 vaccines are effective at preventing severe disease. Real-world effectiveness data on hospitalisations and mortality following vaccination (namely Pfizer, AstraZeneca, Moderna and Sinovac) show vaccines are 71% to 98% effective at preventing COVID-19-related hospitalisation and 88% to 97% effective at preventing COVID-19-related death.20-23

• Generally, vaccines are effective at neutralising Alpha, while there is reduced neutralisation for Gamma, Beta and Delta. All variants elicit cross-reactive neutralising antibodies.18, 24-27

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Table 2: Summary of public health, healthcare and vaccination measures (select countries and NSW) as at 18 October 2021*

7-day average confirmed cases

7-day average confirmed cases (per million)

% Total population fully vaccinated

COVID-19 patients in hospital

COVID-19 patients in hospital (per million)

COVID-19 patients in ICU

COVID-19 patients in ICU (per million)

NSW 362 43.0 65.6% 605 71.9 131 15.6

Australia 2,269 88.0 56.5% 1,502 58.2 297 11.5

United Kingdom 43,618 639.5 66.5% 7,097 104.1 791 11.6

United States 84,932 255.1 56.3% 51,841 155.7 16,309 49.0

Israel 1,413 160.7 64.9% 540 61.4 186 21.2

Denmark 717 123.3 75.7% 83 14.3 15 2.6

Portugal 637 62.6 86.4% 334 32.8 55 5.4

Canada 3,622 95.1 73.0% 2,299 60.4 745 19.6

Ontario 428 28.9 73.1% 260 17.5 159 10.7

Quebec 562 65.3 75.0% 303 35.2 77 8.9

*Please see notes and sources at the end of this document.

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COVID-19 testing rates Figure 1 shows the daily rate per thousand population (rolling seven-day average) of COVID-19 tests in NSW, Australia, United Kingdom, United States, Canada, Israel, Portugal and Denmark, from April to October 2021.

Figure 1: Daily rates of COVID-19 tests (select countries and NSW), April – October 2021

Note: When comparing testing data across different countries, differences in ways of reporting may affect interpretation of data.

Source: Data for the selected countries sourced from Our World in Data.28 Data for NSW sourced from NSW Health via the Notifiable Conditions Information Management System.29 Both accessed 19 October 2021.

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COVID-19 confirmed cases Figure 2 shows the daily rate per million population (rolling seven-day average) of confirmed COVID-19 cases in NSW, Australia, United Kingdom, United States, Canada, Israel, Portugal and Denmark, from March 2020 to October 2021.

Figure 2: Daily rates of COVID-19 cases (select countries and NSW), March 2020 – October 2021

Note: Limited testing and delayed reporting likely result in underestimation of the actual number of confirmed cases.

Source: Data for the selected countries sourced from Our World in Data.28 Data for NSW sourced from NSW Health via Notifiable Conditions Information Management System.29 Both accessed 19 October 2021.

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COVID-19 vaccination rates Figure 3 shows the daily (rolling seven-day average) vaccination rate per hundred population in NSW, Australia, United Kingdom, United States, Canada, Israel, Portugal and Denmark, from April to October 2021.

Figure 3: Daily vaccination rates (select countries and NSW), April – October 2021

Note: Vaccination rates are shown for the full population (all ages) for all locations, including NSW.

Source: Data for the selected countries sourced from Our World in Data.28 Data for NSW is sourced from NSW Health via the Australian Government Department of Health Australian Immunisation Register.30 Both accessed 19 October 2021.

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COVID-19 mortality rates Figure 4 shows the daily (rolling seven-day average) mortality rate per million population in NSW, Australia, United Kingdom, United States, Canada, Israel, Portugal and Denmark, from April to October 2021.

Figure 4: Daily mortality rates (select countries and NSW), April – October 2021

Note: Limited testing and challenges in the attribution of the cause of death means that the number of confirmed deaths may not be an accurate count of the true number of deaths from COVID-19.

Source: Data for the selected countries sourced from Our World in Data.28 Data for NSW sourced from NSW Health via the Notifiable Conditions Information Management System.29 Both accessed 19 October 2021.

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COVID-19 cases, testing, variants, vaccines, hospitalisations and deaths* The following graphs (figures 5-10) show COVID-19 cases and vaccination rates; hospitalisation and death rates; and the variant distribution for NSW, Australia, United Kingdom, United States, Canada and Israel.

Series a: COVID-19 cases and vaccinations The graphs in series ‘a’ show COVID-19 cases and vaccination rates specific to NSW and each of these countries, from March 2020 to October 2021. They include:

• the daily rate per million population (rolling seven-day average) of confirmed COVID-19 cases • the cumulative number of people who have received at least one vaccine dose (per 100 population) • the cumulative number of people fully vaccinated (per 100 population).

These graphs should be interpreted with caution as there are other factors that may influence the number of cases in addition to vaccination rates, including the level of social restrictions.

The cumulative number of people vaccinated per hundred population (at least one dose or fully vaccinated) is based on the full population (all ages) for all locations and countries, including NSW, to enable accurate comparability. The number of people fully vaccinated in Australia is only available from late May 2021 onwards.

Note, there is variation in both ‘x’ axis and ‘y’ axis scales and some gaps in time series across these graphs due to missing data.

Series b: COVID-19 hospitalisation and death rates The graphs in series ‘b’ show COVID-19 hospitalisation and death rates for NSW and each of these countries. Specifically, they show the daily number of hospitalised patients (per million population) and the daily number of new deaths (rolling seven-day average and per million population), from March 2020 to October 2021.

Note, there is variation in both ‘x’ axis and ‘y’ axis scales and some gaps in time series across these graphs due to missing data.

Series c: COVID-19 variant distribution The graphs in series ‘c’ show the COVID-19 variant distribution for each of these countries. Specifically, they show COVID-19 variant distribution for cases sequenced, and the percentage of total COVID-19 cases sequenced, from April 2021 to October 2021.

For most countries, weekly counts are shown; however, only monthly counts were available for Canada. No variant information is available for NSW.

Note, there is variation in both ‘x’ axis and ‘y’ axis scales and some gaps in time series across these graphs due to missing data.

*Please see further notes and sources at the end of this document.

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NSW Figure 5a: COVID-19 cases and vaccinations, NSW, March 2020 – October 2021

Figure 5b: COVID-19 hospitalisation and mortality rates, NSW, March 2020 – October 2021

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Australia Figure 6a: COVID-19 cases and vaccinations, Australia, March 2020 – October 2021

Figure 6b: COVID-19 hospitalisation and mortality rates, Australia, March 2020 – October 2021

Figure 6c: COVID-19 variant distribution for sample of cases that have been sequenced, Australia, April – October 2021

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United Kingdom Figure 7a: COVID-19 cases and vaccinations, United Kingdom, March 2020 – October 2021

Figure 7b: COVID-19 hospitalisation and mortality rates, United Kingdom, March 2020 – October 2021

Figure 7c: COVID-19 variant distribution for sample of cases that have been sequenced, United Kingdom, April – October 2021

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United States Figure 8a: COVID-19 cases and vaccinations, United States, March 2020 – October 2021

Figure 8b: COVID-19 hospitalisation and mortality rates, United States, March 2020 – October 2021

Figure 8c: COVID-19 variant distribution for a sample of cases that have been sequenced, United States, April – October 2021

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Canada Figure 9a: COVID-19 cases and vaccinations, Canada, March 2020 – October 2021

Figure 9b: COVID-19 hospitalisation and mortality rates, Canada, March 2020 – October 2021

Figure 9c: COVID-19 variant distribution for a sample of cases that have been sequenced, Canada, April – October 2021

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Israel Figure 10a: COVID-19 cases and vaccinations, Israel, March 2020 – October 2021

Figure 10b: COVID-19 hospitalisation and mortality rates, Israel, March 2020 – October 2021

Figure 10c: COVID-19 variant distribution for a sample of cases that have been sequenced, Israel, April – October 2021

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NSW key indicators

Notes

• Data is presented for all indicators as at 17 October 2021 (previous week, 10 October 2021), data accessed on 19 October 2021.

• Average daily locally acquired cases and average daily deaths are based on the seven days to 17 October (previous week, seven days to 10 October).

• For any given day, the growth factor for locally acquired cases is a ratio of cases notified in the seven days ending that day, to the cases notified in the seven days ending the day before.

• The doubling time is the time required in days until the current number of locally acquired cases doubles, based on the growth factor.

• COVID-19 patients under the care of NSW Health include patients on the ward, ICUs, hospital in the home, out of hospital care and community clinics. Patients in hospital include cases on the ward and in ICUs. The NSW ICU numbers reflect adult intensive care cases; paediatric and neonatal ICU data is counted in the number of cases on wards.

• Estimated per million population rates calculated using population estimates at 30 June 2021, based on the Australian Bureau of Statistics estimated resident population and population projections based on data from the NSW Department of Planning, Industry and Environment.31 Elsewhere in this document (in the figures), 2019 population figures are used in line with international data available.

• Figures for the 16+ population used in calculating per million population rates for vaccination are drawn from NSW Health via the Australian Government Department of Health Australian Immunisation Register.30

• The rate of hospitalisation and ICU admission (per million) among the unvaccinated population is calculated as the number of unvaccinated COVID-19 cases in hospital against the estimated total number of the unvaccinated population. The rate of hospitalisation and ICU admission (per million) among the vaccinated population is calculated as the number of COVID-19 cases in hospital who have received at least two doses of vaccination, against the estimated total number of the fully vaccinated population. Rolling seven-day average was applied. Rates were age-standardised to NSW 2021 population estimates.

Sources • New cases for NSW sourced from NSW Health via Notifiable Conditions Information Management

System.29

• Vaccination data sourced from NSW Health via the Australian Government Department of Health Australian Immunisation Register.30

• Hospital capacity, admissions and proportion of vaccinated cases data is sourced from NSW Health via the Patient Flow Portal and is taken from a 7pm snapshot, 17 October 2021.32

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Summary of public health, healthcare and vaccination measures (select countries and NSW)

Notes • For the selected countries and Canadian provinces, data is presented for 18 October 2021,

accessed on 19 October 2021. For some measures, data were not available for 18 October, in which case the latest available data is shown. For NSW, data is presented for 17 October, accessed on 19 October 2021.

• Average daily confirmed cases are based on a seven-day average.

• Proportions for the fully vaccinated are based on the full population. Population figures to calculate proportion covered for NSW are drawn from NSW Health via the Australian Government Department of Health Australian Immunisation Register.30

• For NSW, estimated per million population rates for all indicators other than vaccination are calculated using population estimates at 30 June 2021 based on the Australian Bureau of Statistics estimated resident population and population projections based on data from the NSW Department of Planning, Industry and Environment.31 Elsewhere in this document (in the figures), 2019 population figures are used in line with international data available.

• Patients in hospital include both cases on the ward and in ICUs. For NSW, the current ICU numbers reflect adult intensive care cases. Paediatric and neonatal ICU data is counted in the number of cases on wards. For Ontario and Quebec, patients in hospital may be lower than patients in ICU as the in hospital numbers only include people still testing positive for COVID-19 while patients in ICU also include those who are in ICU due to COVID-19 but have since tested negative.

Sources • New cases for selected countries sourced on 19 October 2021 from Our World in Data.28 New

cases for NSW sourced from NSW Health via the Notifiable Conditions Information Management System.29 New cases for Ontario and Quebec sourced from COVID-19 Tracker Canada.33

• Vaccination data for selected countries sourced on 19 October 2021 from Our World in Data.28 Vaccination data for NSW sourced from NSW Health via the Australian Government Department of Health Australian Immunisation Register.30 Vaccination data for Ontario and Quebec sourced from COVID-19 Tracker Canada.33

• Data on the number of COVID-19 patients in hospital and ICUs were sourced on 19 October 2021 from:

o Our World in Data for all countries (aside from Australia) 28 o COVID LIVE for Australia, which verifies data against Australian state and territory

government health departments34 o NSW Health via the Patient Flow Portal for NSW, taken from a 7pm snapshot, 17

October 202132 o COVID-19 Tracker Canada for Ontario and Quebec.33

COVID-19 cases, testing, variants, vaccines, hospitalisations and deaths

Notes • With regards to the figures on COVID-19 variants, all SARS-CoV-2 sequences were downloaded

from the GISAID EpiCOVTM Database. PANGO lineage (variant) classification for each individual sequence was provided by GISAID.35

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• Dates displayed are based on the sample collection date. Sequences with collection dates specifying the year only were excluded, while collection dates specifying the year and month were assigned to the 15th of that month.

• Sequences with lengths ≤20,000 base pairs were removed from the analysis; as were non-human hosts.

• Only a non-random sample of cases are sequenced. For many countries, the proportion of cases sequenced is very low. As a result, this report does not indicate the true prevalence of the variants but rather a best estimate currently available.

• All data used to generate these graphs is subject to the GISAID terms and conditions.36

Sources • Data on variants enabled by GISAID. Accessed 19 October 2021.35

• Data on total number of cases and vaccinations for the selected countries are sourced from Our World in Data; accessed 19 October 2021.28

• Data on total number of cases for NSW are sourced from NSW Health via the Notifiable Conditions Information Management System.29 Data on vaccinations for NSW are sourced from NSW Health via the Australian Government Department of Health Australian Immunisation Register.30 All accessed 19 October 2021.

• Data on the number of hospitalisations and new deaths for the United Kingdom, the United States, Canada and Israel were sourced from Our World in Data.28, 34 Data on the number of hospitalisations and new deaths for Australia were sourced from COVID LIVE, which verifies data against Australian state and territory government health departments.29, 33 Data on the number of hospitalisations for NSW are sourced from NSW Health via the Patient Flow Portal.32 Data on the number of deaths for NSW are sourced from NSW Health via the Notifiable Conditions Information Management System.29 All accessed 19 October 2021.

Method The NSW Health Critical Intelligence Unit maintains living evidence tables on COVID-19 vaccines and SARS-CoV-2 variants.19, 37 To inform this brief, a review of the evidence included in the living tables was undertaken on 27 April 2021 and these are reviewed each week for new relevant information.

Countries were chosen based on contemporary relevance with regards to the variables of interest in the NSW and Australian context (cases, tests, variants, vaccines and patient outcomes).

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36. GISAID. GISAID EpiFlu™ Database Access Agreement [Internet]. Germany: GISAID; 2021 [cited 14 September 2021]. Available from: https://www.gisaid.org/registration/terms-of-use/.

37. COVID-19 Critical Intelligence Unit. Living evidence - COVID-19 vaccines [Internet]. Sydney, Australia: NSW Agency for Clinical Innovation; 2021 [cited 14 September 2021]. Available from: https://aci.health.nsw.gov.au/covid-19/critical-intelligence-unit/covid-19-vaccines.

SHPN: (ACI) 210934 | ISBN: 978-1-76081-975-0 | TRIM: ACI/D21/856-25