Rabbi Aaron E. Glatt, MD
Not surprisingly, we have another week of mixed Covid-19 news.
COVID-19 hospitalizations and deaths unfortunately continue to increase across the US, approaching the horrific peak April levels. Fortunately, new US cases rose less rapidly than a week ago. Restrictions instituted were helpful in curbing some spread. Unfortunately, travelers from 10 more states (31 states now in total) were added to our tristate region quarantine list. Fortunately, despite all of the increases in the US, we Boruch Hashem have NOT seen significant complications in the Five Towns.
What does it mean to us when relatives or friends come in from quarantined places? I am frequently asked this question, and I never recommend that we break the law or go against Department of Health regulations. The official NYS position states: “The requirements of the travel advisory do not apply to any individual passing through designated states for a limited duration (i.e., less than 24 hours) through the course of travel”. If this is the case, quarantine is not necessary.
From a pure medical perspective, for frum travelers and their immediate family who have been healthy – no symptoms at all; with no known COVID-19 exposures; and the frum community they came from has almost no COVID cases; such travelers are at low risk of being a COVID-19 carrier, and pose a low risk to the family they are traveling to and staying with.
What about schools?
The CDC is updating options for schools and will release additional resources shortly on how to reopen schools safely. I will discuss school openings from the perspective of students, teachers and parents, as well as yomim noraim queries and other commonly asked questions at our 9:45 motzei Shabbos zoom: Meeting via YouTube link obtainable from firstname.lastname@example.org.
Any more exciting news regarding vaccines?
Yes, indeed there was a lot of positive new information regarding COVID-19 vaccines!
As I have said on multiple occasions, it is my belief that we will return to “normal unmasked socially closer lives” – when a successful safe vaccine is available to the general population.
Over 30 candidate vaccines for COVID-19 have reached human trials to date. Besides the Moderna data I presented last week, several other vaccine candidates reported robust preliminary outcomes.
A University of Oxford phase I/II vaccine trial involving 1,077 healthy adult volunteers, testing against a meningitis vaccine in the control group, was published in The Lancet. This vaccine alters the genes of a common chimpanzee adenovirus (cold virus) which mimics COVID-19, and is intended to induce a COVID-19 immune response in its recipients.
And indeed their vaccine did induce a powerful immune response yet caused few serious side effects. While recipients had minor side reactions like fever, chills and muscle pain more often than those who got the control meningitis vaccine, there were no serious side effects. More than 10,000 participants in Britain, Brazil and South Africa are now receiving doses, and a Phase III test involving 30,000 participants in the US will begin this week, along with a similar test of the Moderna vaccine.
In the same issue of The Lancet, Chinese researchers published data on ~ 500 volunteers who received their experimental COVID-19 vaccine which uses a similar technique as Oxford except their vaccine is produced from a human adenovirus. China’s government actually gave approval for their military to use this vaccine now, even as it continues experimental trials in Abu Dhabi and other places.
Pfizer and Biopharmaceutical New Technologies (BNT) vaccines BNT162b1 and BNT162b1 were granted fast track status by the FDA, and they are enrolling up to 30,000 subjects in a phase 2b/3 trial starting this week. If successful, they claim they can manufacture up to 100 million doses by the end of 2020 and 1.2 billion doses by end of 2021.
Preliminary results on 60 participants in a German vaccine trial on one of these Pfizer-BioNTech vaccines showed a strong immune response at all dosages studied. Similar to Moderna, their vaccine uses genetically engineered mRNA to engender a vigorous immune response.
As part of “Operation Warp Speed”, the US signed a ~ $2 billion agreement with Pfizer / BNT to obtain 100 million vaccine doses if and when it is cleared by the FDA, and to acquire 500 million more doses if needed. The US made similar arrangements previously with AstraZeneca for at least 300 million doses of the Oxford vaccine, with Novavax to fund its vaccine and to manufacture millions of doses, plus deals with Moderna, Johnson & Johnson and Regeneron Pharmaceuticals. Very promising news indeed.
Any proven published cases of individual getting COVID-19 a second time?
Still nothing. While reports continue to surface in the lay press, the CDC officially commented this week: “Currently, 6 months after the emergence of SARS-CoV-2, there have been no confirmed cases of SARS-CoV-2 reinfection”. They did qualify this, saying: “However, the number of areas where sustained infection pressure has been maintained, and therefore reinfections would be most likely observed, remains limited”. More to come – but you have heard me say that before .
A Mount Sinai study on 19,860 COVID-19 patients published on the medRxiv server showed again that most patients (more than 90%) with mild-to-moderate COVID-19 symptoms developed antibodies which persisted for at least 3 months. Anti-spike protein antibodies correlated best with COVID-19 neutralization. Very interestingly, patients with low titers neutralized spike protein less frequently (only ~ 50%) whereas 90% of those with higher titers had neutralizing capabilities, and 100% of those in the highest range had neutralizing activity. This might be very important re vaccines and natural immunity.
Do I still need to wear a mask?
The Institute for Health Metrics and Evaluation at the University of Washington provided updated information suggesting that the widespread use of masks could potentially help significantly reduce – by over 66.4% – new cases and death if “universal masks” were applied across the country. Similarly, conclusions from a paper in PLOS Medicine demonstrated that individual adoption of handwashing, mask-wearing, and social distancing, is an effective strategy to mitigate and delay the epidemic. They also noted that by initiating earlier government-imposed social distancing, communities will be better prepared for any increased COVID-19 cases.
Likewise, the CDC updated guidance for when a person with COVID-19 cab be considered no longer contagious. This has huge implications.
- For people with severe illness or severely immunocompromised, the recommended duration was extended to 20 days after symptom onset (or, for such asymptomatic individuals, 20 days after their initial positive test).
- For people with milder illness who are not immunocompromised, the recommended duration was decreased to 10 days after symptom onset (or, for such asymptomatic individuals, 10 days after their initial positive test).
- Both of the above scenarios also reduced the resolution of fever requirement to:
o instead of saying there should be no fever for “at least 72 hours”, it was changed to “at least 24 hours” since last fever without fever-reducing medications
Can I wash my hands on Tisha B’av? Everyone is hopefully very familiar with the important rabbinical prohibition against washing for pleasure on Tisha B’av. However, people may be less familiar with the halachic imperative to wash hands for medically appropriate reasons, e.g. before preparing food for children, healthcare staff working in the hospital, etc. HaRav Schachter shlita, our poseik hador, wrote a teshuva on this subject, which I would like to expand upon after my discussions with him.
HaRav Schachter shlita wrote that a situation which is not pikuach nefashos (not every handwashing is medically essential) where handwashing is performed just to be extra cautious but not for pleasure – e.g. a person always washes their hands after opening mail or a package – such a person can wash their hands after opening mail on Tisha B’av. However, If you don’t usually wash your hands in such situations, you cannot wash them on Tisha B’av. In a truly safeik pikuach nefashos situation though, where it is medically indicated to wash hands, then of course all MUST wash their hands. Thus, all MUST wash hands in the hospital, etc., regardless of your “personal choices” in other circumstances.
I also discussed with HaRav Schachter whether one needs to mask solely because others have a pikuach nefashos concern. He reiterated – you are halachically obligated to mask if other people are concerned about spread of COVID-19 even if you personally do not think there is any reason to be concerned.
What other new information was published this week?
1) JAMA Internal Medicine showed significant variations in outcome in a multicenter study of 2,215 COVID-19 ICU treated in 65 different US hospitals. Risk-adjusted mortality varied widely by hospital, ranging from 6.6% to 80.8%!
Patients admitted to smaller hospitals with fewer ICU beds had three times the risk of death versus larger hospitals with more ICU beds. The authors speculated that mortality variation were due to many factors, including: “the limited high-quality evidence on which to base clinical practice, variation in hospital resources to implement personnel-intensive interventions, variation in the availability of certain medications (e.g. remdesivir), or unmeasured variation in patient and practitioner characteristics across centers.” Where you get treated for COVID-19 did make a difference… although maybe, as we are becoming more knowledgeable about diagnosing and treating COVID-19 and normative practice guidelines are established, improved uniformity of outcome can occur.
The latter idea is supported by the fact that COVID-19 ICU patient mortality has dropped by ~ one-third since the pandemic began due to better care. An analysis of 24 COVID-19 studies published in the journal Anaesthesia (not a typo – British journal) found the overall mortality rate of COVID-19 patients in ICUs fell from 60% to 42% during the study period.
2) An article in JAMA Dermatology identified that 29% of their COVID-19 patients had some form of mouth rash. Rashes occurred late, on average around 12 days after other symptoms began, and they were mostly small purple, red, or brown spots in the mouth. Something new every day.
3) I briefly mentioned last motzei Shabbos a major Emerging Infectious Diseases just published paper from South Korea demonstrating the highest COVID-19 transmission rates were in household contacts of school-aged children between 10-19 years of age, with the lowest in household contacts of children 0–9 years old. They concluded that mitigation strategies including physical distancing optimized the likelihood of reducing individual, family, and community disease. Implementation of such recommendations should be encouraged to reduce transmission.
4) Synairgen, a British company, announced results (not yet published) from a Phase II double-blind placebo-controlled COVID-19 trial in 101 randomized patients taking an inhaled formulation of interferon beta called SNG001. This study performed at 9 British hospitals demonstrated that those who received SNG001 had a 79% lower risk of developing severe disease and were more than twice as likely to recover from COVID-19 vs. those on placebo. Another modality that needs further exploration!
5) The European Journal of Endocrinology showed that a BMI of between 30 to 34.9 was linked to an increased risk of ICU admission and respiratory failure in COVID-19 patients. A BMI of 35 significantly increased death. This supported the recent CDC recommendation that a BMI of 30 or higher is considered a significant risk factor for worse COVID-19 outcome.
6) The CDC, WHO and many other public health organizations sounded again a grave concern: COVID-19 has greatly disrupted normal childhood vaccinations. I would stress again to all parents that any child behind in their vaccination schedule should get this corrected ASAP.
Can I be with my loved ones in the emergency room?
Until recently, NYS has not allowed visitors to come into the emergency room because of COVID-19 transmission concerns. This of course is very difficult for concerned family members. Fortunately, this has now somewhat changed. Visitors can come in for a short period of time albeit depending on numerous factors. These restrictions are solely to protect everyone, and not to make a harrowing difficult situation even worse.
May Tisha B’av be a holiday this year;
may we see the rebuilding of our holy Temple,
in our holy rebuilt Yerushalayim.
Have a great Shabbos.