On motzei Shabbos Acharei-Kedoshim, May 2, 2020, Rabbi Dr. Aaron Glatt offered the following medical and halachic update. Below the video is a letter he sent to his community erev Shabbos, May 1.
I have not wanted to inundate people with medical information that can be easily obtained elsewhere, but I was asked to provide some brief written updates which I will expand upon this Motzei Shabbos May 2, iy”H at 9:30 PM by Zoom Conference.
Our shul and all of the local Rabbonim have agreed upon the medical and halachic importance of maintaining the strictest social distancing restrictions at this time, even as we BH have been seeing very impressive decreases in the number of hospital admissions, ICU admissions and deaths from COVID. At the beginning of April, total cases were growing 8%-9% per day; this has slowed to a rate of 3%-4% per day in the past week. Data from NYS and from Nassau County certainly are in agreement.
The obvious question is:
WHY must we still maintain such strict social distancing policies in the face of an improving hospital and public health numbers?
The answer is quite simple. We are by no means out of the woods. We are still collectively seeing nearly 5,000 new COVID cases daily in NY, and the hospitals in Nassau County are all still seeing at least double digit COVID admissions daily. Put into perspective: In the US on March 1 there were two deaths in the entire country; by April 1, 4,000+ deaths; today, May 1, there have been over 60,000 deaths in the US directly from COVID.
In addition, we are now recognizing that non-COVID mortality rates were higher than expected during these past few months, an “innocent bystander” side effect of COVID as people are scared to seek medical care.
Plus, testing for COVID illness and antibodies is not where it must be to control the pandemic, and public health screening of contacts is still rudimentary. In other words – if we stop doing what we are doing (which has been so successful) we risk going back to the catastrophic overwhelming of the medical system in no time.
What have we learned to help prevent further spread besides social distancing?
A much higher percentage of patients can transmit virus even though they have no current symptoms. People are capable of transmitting virus in the days before symptoms start and in the days after the symptoms resolve. Patients on the average have detectable virus for 2-3 weeks after onset of symptoms, with some patients having positive viral swabs even for weeks beyond that.
Furthermore, studies suggest that up to 20% of patients (even higher in children) never develop symptoms. Unless you actively trace and test, you will never identify these cases before they transmit.
Furthermore, people with COVID-19 can have a myriad of symptoms – ranging from mild signs to severe illness. Physicians need to look for more and diverse illness presentations, although it must be stressed that many patients with these symptoms have non-COVID causes.
Indeed, the CDC just updated its list of possible COVID symptoms. These symptoms usually appear 2-14 days after exposure to the virus:
- Shortness of breath or difficulty breathing
- Repeated shaking with chills
- Muscle pain
- Sore throat
- New loss of taste or smell
I would personally add, based upon published studies, that new gastrointestinal symptoms (diarrhea, nausea, vomiting), pink eye (conjunctivitis) and even rarely stroke may be subtle presentations of COVID-19 illness. Viral infections often cause rashes or blotchy areas, but at this time there is no specific rash pattern that’s associated with COVID-19. While rashes and “COVID toes” have been associated with COVID more than other viral infections, these symptoms haven’t been widespread so far.
In addition, fatigue, cough, loss of smell and taste may persist for a while after fever and other symptoms subside. Exercise intolerance is very common, including sometimes the need for oxygen supplementation till full recovery occurs.
When will be going back to our normal lives?
Critical factors must be maintained for “re-opening” to occur. The following must occur before Governor Cuomo will re-open business and remove maximal social distancing rules:
- There must be a continuous 14 day downward trend in all COVID markers.
- The rate of transmission (how many news cases are caused by each identified COVID patient) must be under 1.0.
- Hospitals must have a cushion of 30% or more beds above capacity today.
- State and local health authorities will hire 30 contact tracers for every 100,000 cases.
Until that time, elective surgery and full reopening of the Downstate region (including NYC, Nassau County) will not occur. This will be looked at next week and again on May 11th. It would appear that halacha would at least follow these minimum standards if not stricter ones.
Will schools and camps re-open?
One of the major future steps that will need to be taken to open up society in the COVID era is re-opening of the schools and camps. A recent Lancet paper showed that 107 countries implemented national school closures by March 18, 2020. It is unknown whether school measures are effective in coronavirus outbreaks. School closures were deployed rapidly across mainland China and Hong Kong for COVID-19. However, there are no data on the relative contribution of school closures to transmission control. Data from the SARS outbreak in mainland China, Hong Kong, and Singapore suggest that school closures did not contribute to the control of the epidemic. Recent modelling studies of COVID-19 predict that school closures alone would prevent only 2–4% of deaths, much less than other social distancing interventions.
Very preliminary evidence, based upon a case study with limited confirmatory data found:
- A China/World Health Organization joint commission did NOT find a single case of a child transmitting COVID-19 to an adult.
- Children are more likely than adults to be asymptomatic: 32% of affected children aged 6-10 years were asymptomatic. Viral levels (and hence contagiousness) are lower in such patients.
- To date, BH, pediatric deaths from COVID are extremely rare.
- Very few newborns or infants get Covid-19 and they generally do well in overcoming the virus.
- Vertical spread (mommy to baby in utero) is very rare.
If this information is corroborated, this would have huge potential impact on both school and camp openings in the near future.
HOWEVER, the official CDC position remains that child to adult transmission is a real public health threat. They state: “The key to slowing the spread of COVID-19 is to limit contact as much as possible. While school is out, children should not have in-person playdates with children from other households. If children are playing outside their own homes, it is essential that they remain 6 feet from anyone who is not in their own household.” Many other authoritative sources likewise caution against changing the current polices based upon such limited data. More to come…
Can I go to my doctor safely?
Patients with pressing medical needs are urged not to delay treatment if they need cardiac, cancer, OB/GYN, emergency or other care. Many Emergency Departments have designated areas for non-COVID-19 cases. Patient safety is always a top concern and the community should not hesitate to seek needed care at the hospital.
“Telehealth” (virtual visits via technology) are becoming much more common and may be an appropriate way to get follow up care. Absolutely do not neglect appropriate medical visits, laboratory and radiographic testing, as this may lead to serious and even life threatening conditions.
Anything new regarding antibody testing?
Essentially everything I sent out last week remains true. No new information is available yet whether the presence of antibodies means immunity, and if so, for how long. The sole definitive purpose of antibody tests today is solely for the purpose of determining your eligibility as a plasma donor. Using antibody testing to determine if you can in any way stop social distancing is dangerous; it could heaven forbid cause someone to get sick and die.
Anything new about treatment?
Actually, there is new information coming out almost daily about various therapeutic modalities.
In an NIAID study, which began Feb. 21 this year and compared the antiviral agent remdesivir with placebo in more than 1,000 patients, remdesivir decreased the time to recovery from 15 days for those who got a placebo to 11 days for those who received the drug. Also 5 days of therapy worked as well as 10 days. The mortality rate trended toward being better in the remdesivir arm, 8% vs. 11%, but the result had not reached statistical significance.
However, the very same day, a paper in The Lancet showed no statistically significant benefit from remdesivir in 237 adult patients admitted to 10 hospitals in China for severe COVID-19. The study however did not enroll enough patients to truly evaluate its success, but it seemed to work better if started sooner.
More information is also now available regarding plasma therapy, stem cells, interleukin 1 and 6 inhibitors, and other experimental agents. Have to leave some things for Motzei Shabbos!
Vaccines: While more than 70 experimental vaccines are in development around the world, the first trial began enrolling patients last week! Scientists at the University of Oxford, UK, have created a vaccine, called ChAdOx1 nCoV-19, which is made from a harmless chimpanzee virus that has been genetically engineered. The technique has been shown to generate strong immune responses in other diseases, and the investigators claim it has an 80% chance of success. Besides the Oxford study, Pfizer has accelerated vaccine testing, which has already started in Germany, and could start in the US this week. They are contemplating emergency use in the fall, with possible public availability emergency-use basis in early 2021. This is phenomenal – considering that the typical average time it takes for a vaccine takes to develop from its preclinical phase to a market entry is about 11 years – and even then, the probability of success is only 6%, according to a 2013 PLOS ONE study. At this time, a vaccine still represents one of the best public health measures to control COVID-19.
Rabbi Aaron E. Glatt, MD