Below is an update on the Covid situation from Rav Dr. Aaron Glatt, RAA/Igud’s Director of Halacha and Medicine Commision, dated May 27, 2020 (the situation changes day to day).
COVID-19 Update May 27, 2020
Rabbi Aaron E. Glatt, MD
I wish everyone a safe and enjoyable Shavuos. This update is extensive – read at your own risk.
We very much look forward to having minyanim iy”H this coming week, starting with Ma’ariv Wednesday evening. In addition, Long Island officially started the first phase of reopening its economy today after more than a two-month shutdown. I will discuss these issues and commonly asked questions on our motzei Shabbos 9:40 PM shul zoom, Meeting ID: 980 3243 6809; Password: 5TFRBM.
We want to stress and remind everyone that NO ONE should feel obligated to attend such minyanim, especially anyone with an absolute contraindication or their own personal health concerns about catching COVID-19. Our poskim have strongly stated that even if you have a yartzheit or are saying kaddish or always have previously attended minyanim, you should not in any way feel pressured or obligated to attend minyan.
What new studies of importance were published this week?
Several new papers provide important additional data on optimally managing COVID-19.
1) A new article in Gastroenterology revealed that one third of patients with COVID-19 had GI symptoms at the time of presentation! 22% of patients had diarrhea; 16% had nausea; 9% had vomiting; and 7% had abdominal pain. GI lab abnormalities were present in almost two thirds. This has colored my concern regarding people using someone else’s bathroom, and why I have been recommending that sharing bathrooms is a potential transmission concern.
Fortunately, GI symptoms were actually associated with lower rates of death and ICU admission.
2) Sweden has utilized quite a different methodology to try and control COVID-19. They actually encouraged transmission to occur to a certain extent to maximize herd immunity, an approach different than most countries have practiced. Their Public Health Agency released data from their ongoing antibodies study that showed that only 7.3% of people in Stockholm had developed antibodies against COVID-19 by late April. This figure was a bit lower than expected, although a larger percentage is expected at this point in May. Unfortunately, their death rate according to Johns Hopkins University was higher than U.S. rate, and also much higher than neighbors Norway and Finland, all of which enacted strict lockdown measures. Nearly half of their 4,000+ COVID-19 deaths occurred in the elderly living in various care facilities.
An official statement from the country’s government stated: “It’s still far too early to draw any clear conclusions or comparisons connected to the coronavirus pandemic,” but “we are open with that the strategy has failed to protect the elderly living in care homes.”
3) Researchers at NYU found that inflammation and low levels of blood oxygen were associated with the worst outcomes in Covid-19 patients, even more so than advanced age and comorbidities. Indeed, 53% of hospitalized patients were younger than 65. Blood oxygen below 88% upon admission and inflammation markers in the body correlated with with critical illness. This strongly supports monitoring newly diagnosed COVID-19 patients with oximeters to measure oxygen levels as an outpatient, something we recommended early on.
4) A related study in the Annals of Internal Medicine on 2013 patients (92% who did not need hospitalization) again showed that loss of smell was one of the most prevalent symptoms. A whopping 87% reported loss of smell, and 56% reported taste dysfunction. Nearly half had these as their initial symptom, while others had non-specific symptoms initially. It is important to remind everyone of two things. A) Loss of smell can be due to many other causes, including other viruses; B) Viral load is high even early in the course of illness. Therefore, I think this has practical ramifications for use. People going to minyan and / or to other public gatherings must self-assess for symptoms and should actively check sense of smell before going out in public where they could theoretically transmit virus.
5) Two studies this week in major British journals put additional nails in the coffin of hydroxychloroquine (HCQ) usage. A smaller paper in the BMJ compared 150 hospitalized patients (148 with only mild to moderate disease) treated with or without HCQ. They concluded that administration of HCQ did not result in improvement versus standard care, and side effects were higher in HCQ recipients.
A much larger paper in The Lancet analyzing almost 100,000 hospitalized patients in 671 hospitals on six continents demonstrated similar findings. HCQ with or without a macrolide antibiotic offered no benefit in treating patients with COVID-19 and, indeed was associated with arrhythmias (more than 5-fold increase) and higher rates of mortality – 10% in control patients, versus 16% to almost 24% in treated patients.
In a Jewish medical ethics talk I gave this week at a conference, I therefore said, based upon these results that from a halachic perspective, it might actually be prohibited to take these medications for COVID-19 outside of a pre-hospitalization or prophylactic usage study setting.
Anything new regarding antibody testing? Should I get tested?
Here is a summary of the newly updated CDC Guidelines re COVID-19 antibody testing.
- Recurrence of COVID-19 illness appears to be very uncommon, suggesting that the presence of antibodies could confer at least short-term immunity to infection.
- Experimental primary infection in primates and subsequent development of antibodies resulted in protection from reinfection after the primates were rechallenged.
- Antibody development correlates with a marked decrease in viral load in the respiratory tract.
Taken together, these observations suggest that the presence of antibodies may decrease a person’s infectiousness and offer some level of protection from reinfection. However, the CDC states definitive data are lacking, and it remains uncertain whether individuals with antibodies (neutralizing or total) are protected against reinfection; and if so, what concentration of antibodies is needed to confer protection. More to come…
Practical Best strategies to improve test usage:
- MUST use a test with a very high specificity, perhaps 99.5% or greater
- Alternatively, focus testing on persons with a high pre-test probability of having antibodies, such as persons with a history of COVID-19-like illness that was never proven. Our own experience has shown that some people who thought they had COVID actually had a different virus.
Where can antibody testing be especially useful?
- To diagnose COVID-19 illness for persons who present 9-14 days after illness onset.
- To establish late complications of COVID-19 illness, such as multisystem inflammatory syndrome in children, when COVID-19 was not previously diagnosed.
- There should be no change in clinical practice or use of personal protective equipment (PPE) by health care workers and first responders who test positive for antibody.
Additional considerations on the use of serologic tests
At this time, antibody testing should NOT be used to make decisions about grouping persons residing in or being admitted to congregate settings, such as schools, dormitories, or correctional facilities. (My note – I think this will change…)
Click on this link for full guidelines:
What has been happening with already existing minyanim?
I was on multiple calls this week that provided me with totally discordant information. Some minyanim in the NYC / Long Island area that I heard about were conducted in accordance with acceptable protocols to minimize risk to participants. On the other hand, I was unfortunately shocked to hear of minyanim with participants well above the legal and safe limit, davening in confined spaces, and to hear about shul shalosh seudos also occurring, in flagrant disregard of all published guidelines. But the most troubling and scary conversation, was when a frum physician stated that his patient was a participant in a minyan, became symptomatic, and tested positive for acute COVID-19 infection. He refused to allow the minyan participants to be told because “they would kill him”. I guess the fact that he might literally kill them wasn’t a concern. Whenever any minyan does open, it must absolutely follow the strictest guidelines – or else it cannot open.
How will we know if there is a problem?
After discussion with some colleagues, we are going to try and put together a 5 Towns / Far Rockaway “early warning system”. We are asking all medical practitioners in our community to please email every time a new patient is diagnosed with COVID-19. Details of this program will follow, to enable us iy”H to detect as soon as possible any uptick in cases.
Can you provide some more details regarding sharing pools?
One of the most common questions I have been getting is sharing pools with other families not living in that household. With warmer weather coming, and lack of clarity still regarding whether there will be any summer programs available for our children, people fortunate enough to have a pool will be beseeched by many to share this wonderful resource. While the are no clear absolute evidence-based guidelines, here are some of my recommendations based upon available evidence.
As I have mentioned several times recently, the official CDC position is:
“There is no evidence that COVID-19 can spread to people through the water used in pools, hot tubs, or water playgrounds. Proper operation and disinfection of pools, hot tubs, and water playgrounds should kill the virus that causes COVID-19. Limit close contact with people outside your home in public spaces, both in and out of the water.”
Additional CDC recommendations include:
Hand Hygiene and Respiratory Etiquette
- Encouraging all to wash their hands often and cover coughs and sneezes.
Cloth Face Coverings
- Encouraging cloth face coverings as feasible. Face coverings are most essential in times when physical distancing is difficult.
- Do NOT wear face coverings in the water. Cloth face coverings can be difficult to breathe through when they’re wet.
- Stay home if anyone has symptoms of COVID-19, or if they tested positive for COVID-19 and / or were exposed to someone with COVID-19 within the last 14 days.
- Ensuring adequate supplies to support healthy hygiene, such as soap, hand sanitizer, paper towels, tissues, and no-touch trash cans.
- Cleaning and disinfecting frequently touched surfaces and shared objects. For example:
- Handrails, slides, and structures for climbing or playing
- Lounge chairs, tabletops, pool noodles, and kickboards
- Door handles and surfaces of restrooms, handwashing stations, diaper-changing stations, and showers
- In addition, I do not recommend that more than one family unit (or “bubble”, once we eventually expand a family to include other family units not living in your house) be together in the pool area at the same time to maximize safety. I do not have a precise time interval between different units, but a half an hour seems reasonable.
- There absolutely should be no sharing towels between different family units, and ideally use the bathroom before you come to someone else’s pool.
Many of these ideas are appropriate for family BBQs and minyanim as well and will be discussed more motzei Shabbos.
What about going to my dentist?
Finally, for my dental colleagues, the CDC just updated its Guidance for Dental Settings which included:
Recommendations for resuming non-emergency dental care during the COVID-19 pandemic.
Facility and equipment considerations, sterilization and disinfection, and considerations for the use of test-based strategies for patient care.
Provision of dental care to both patients with COVID-19 and patients without COVID-19.
Cick Here for more info
Anyone in need of dental care should not be afraid to get it, as well as all medical care (and vaccinations for children), as healthcare workers and hospitals are taking necessary precautions to make these visits safe. Ask them if you have any concerns!
May we all enjoy Yom Tov and have a wonderful Shabbos.