Rabbi Aaron E. Glatt, MD, , RAA/Igud’s Director of Halacha and Medicine Commision
I thank all of you that asked me to continue writing these updates, which I will do as I have time and as there is sufficient new information to impart.
I will Iy”H continue our motzei Shabbos Zoom talk addressing common COVID-19 questions that might be applicable to all. We will move up the start time to 9:30 PM this week, and as Shabbos ends earlier, move to earlier times going forward.
How are we doing regarding new cases in our area?
While the number of new COVID-19 cases nationwide has begun to slow over the past few weeks, the United States is still recording more than twice the number of new daily COVID-19 cases than in June.
Unfortunately, and most importantly, we are seeing increased cases in selected NYC and Long Island locations, related to travel, camps and other risk behaviors. The Nassau County Executive and Commissioner of Health informed me that Lawrence and Cedarhurst currently have the highest new case totals in all of Nassau County. This should be of great concern.
The NYC DOH also called me regarding troubling increases specifically after two “super-spreader” events, a wedding in Brooklyn and a weekend sheva brachos in the Catskills. I am called every day by physicians, schools, patients and the DOH regarding similar exposures and how to handle them and the quarantine concerns they create. The DOH has stated that such new cases have the potential to put school openings and Yomim Noraim minyanim in jeopardy.
The most common problem I am asked to help with, but cannot easily answer, is what to do for the person with an unclear exposure – usually when the parties were not wearing a mask. I am unable to provide guidance in such situations, and sadly, the default position is to quarantine for 14 days.
Likewise, the city, state and county DOH are imploring people to work with them, not against them in trying to appropriately identify who was exposed and who should be quarantined. This has the potential to be a huge kiddush Hashem, or heaven forbid, the opposite. Ultimately the DOH will do what they deem necessary to address such exposures from weddings, weekend gatherings (sheva brachos, family reunions), camps, that have been the cause of some of the most recent exposures in communities that “have no COVID” anymore. Various branches of the DOH have asked me to remind everyone that if you are quarantined, you absolutely must adhere to the restrictions mandated, and that the DOH takes this very seriously. They will use every measure at their disposal to ensure that spread of illness is curtailed.
What is new from the CDC?
1) We are learning more about COVID-19 in children every day, which is so critical as we start the school year. While there are fewer cases of COVID-19 in children age 0-17 years compared to adults, the number and rate of cases in children in the United States have been steadily increasing. The incubation period is the same for children as adults, 2-14 days with an average of 6 days.
Signs or symptoms of COVID-19 in children include:
- Nasal congestion or rhinorrhea
- New loss of taste or smell
- Sore throat
- Shortness of breath or difficulty breathing
- Abdominal pain
- Nausea or vomiting
- Poor appetite or poor feeding
Children may have many of these non-specific symptoms, may only have a few (such as only upper respiratory symptoms or only gastrointestinal symptoms), or may be asymptomatic. The signs and symptoms of COVID-19 in children are similar to other infections and noninfectious processes, including influenza, streptococcal pharyngitis, and allergic rhinitis. The lack of specificity of signs or symptoms and the significant proportion of asymptomatic infections make symptom-based screening for identification of COVID-19 in children particularly challenging. Evidence suggests that as many as 45% of pediatric infections are asymptomatic.
Boruch Hashem, hospitalization rates in children are significantly lower than in adults, as children have less severe illness from COVID-19. The rate of hospitalization among children is very low (8 / 100,000) versus adults (165 / 100,000), but hospitalization rates in children are increasing.
2) The CDC updated its isolation guidance acknowledging that people can continue to test positive for up to 3 months after a COVID-19 diagnosis yet are not considered infectious to others after 10 days with resolving symptoms. Therefore, retesting in the 3 months following initial infection is not necessary unless that person is exhibiting new symptoms of COVID-19 and the symptoms cannot be associated with another illness.
Thus, all people with COVID-19 should be isolated for at least 10 days after symptom onset and until 24 hours after their fever subsides without the use of fever-reducing medications.
There have been more than 15 international and U.S.-based studies recently published looking at length of infection, duration of viral shed, asymptomatic spread and risk of spread among various patient groups. Researchers have found that the amount of live virus in the nose and throat drops significantly soon after COVID-19 symptoms develop. Additionally, the duration of infectiousness in most people with COVID-19 is no longer than 10 days after symptoms begin (up to 20 days in people with severe illness or those who are severely immunocompromised). CDC will continue to closely monitor the evolving science for information that would warrant reconsideration of these recommendations.
What is new from the FDA?
FDA issued an emergency use authorization (EUA) to Yale School of Public Health for its SalivaDirect COVID-19 diagnostic test, the fifth saliva test so authorized, but the first that uses a new method of processing saliva samples. FDA Commissioner Stephen M. Hahn, M.D. said this authorization will “create innovative, effective products to help address the COVID-19 pandemic and to increase capacity and efficiency in testing.” Assistant Secretary for Health and COVID-19 Testing Coordinator, Admiral Brett P. Giroir, M.D. said: “The SalivaDirect test for rapid detection of SARS-CoV-2 is yet another testing innovation game changer that will reduce the demand for scarce testing resources.”
Several unique features make this SalivaDirect test very promising.
- A) Eliminates nasopharyngeal swabs that make other tests difficult and uncomfortable;
- B) Saliva can be collected in any sterile container, by the patient;
- C) Does not require a separate nucleic acid extraction step so less prone to shortages and testing delays;
- D) Rapidity of results (hours);
- E) Ability to easily batch tests
- F) Less expensive;
- G) Potential for DAILY testing for schools and work;
- H) Uses common reagents and instruments, meaning the test could be performed in most labs;
- I) Does not rely on proprietary equipment and uses commercially available testing components.
What mask should I use?
We have discussed numerous times the extreme importance of wearing a mask that covers the mouth and nose whenever in close proximity to others not living in their household. This is one of the best ways to prevent your transmitting Covid-19 as well as getting Covid-19, and as mentioned, not being in an insoluble quandary after a questionable exposure.
New data support wearing either a standard three-ply surgical mask or a three-ply cotton face covering as optimal. While data are limited, these appear superior to single or double-ply cloth face coverings, and are certainly better than a bandanna, “gaiters” or scarfs covering the mouth and nose, which I do not recommend that people use. N95 or KN95 masks are usually worn only by healthcare workers in close proximity to selected patients with COVID-19. They require fit testing to be worn properly.
Masks that have air vented outside should absolutely not be worn. While they offer some protection to the wearer, they put everyone else potentially at risk from breathing the exhaled air through the vent.
What still needs to be done upon return from camp or bungalow colonies?
We all need to be vigilant about potential spread of COVID-19 when people return from camp, bungalow colonies, and trips to other communities. Certainly, there have been cases identified from all these venues, and each scenario needs to be individually assessed for the risk it poses. I again stress that if the DOH recommends quarantine, be it for an individual case or from general travel, quarantine must be adhered to in order to prevent serious illness spreading. I recommend a very careful evaluation of each camp or bungalow situation with appropriate testing and quarantine as indicated by the particular circumstances. When in doubt, I favor caution, testing and quarantine.
What are best ideas for safe Shofar blowing?
In general, outdoors poses less of a risk. However, if appropriately distanced with all listeners wearing masks, indoors can be safe as well. Testing for active COVID-19 is not a routine recommendation I make, but is something left to the discretion of the local shul based on local incidence and concern. Such testing is not fool proof or without cost and effort. Prior COVID-19 infection or bona fide presence of antibodies is helpful but not a requirement for safety.
To optimize safety, I recommend as many of the following as possible. Have the blower be a person with prior COVID-19; blow as far away as possible from others; have the end of the shofar (where sound comes out) covered with a mask; blow into an open window; blow into an enclosure; blow in another room or outside (with the sound able to be heard in the room where the people are). All of these have been discussed and approved by HaRav Mordechai Willig, shlita. Blowing in chodesh Elul, is less risky as it is only a few blasts at the end of davening, but I still recommend using the above ideas as possible. Public outdoor gatherings on Rosh Hashana for women and others to hear the 30 sounds should also follow these guidelines. I am actually more concerned with the ensuing public gatherings than the shofar risk!
Any data on safety of Shofar blowing and singing?
There are limited data. One local ophthalmologist put dye in his shofar, blew into paper, and used a split lamp to look for traces of the dye, but didn’t find any.
A paper entitled “COVID-19 Transmission Risks from Singing and Playing Wind Instruments – What We Know So Far” conducted experiments measuring airflow while playing wind instruments. From evaluating the Vienna Philharmonic Orchestra they noted that normal breathing showed a cloud of fog of approximately 50 cm emitted from the nose and mouth. This was unchanged for string instruments while playing versus while at rest. For winds, “aerosols” were not reported or were “hardly visible” from the opening at the end of the wind instrument, with the exception of the flute. They conclude that a musician’s exhaled air is not expected to expand by more than approximately 80 cm, which is within the 6 foot distance recommended for distancing.
Spahn et al. conducted a risk assessment on data from wind players and singers with the Bamberg Symphony Orchestra. They concluded that a minimum of 2 meters (6.5 feet) distance between musicians (including winds) was sufficient, as no additional movement of indoor air during playing was detected at this distance. Therefore the risk of droplet transmission, if distancing is followed, was very low. Similarly, the authors provided similar recommendations for singing (2 meters apart). Of note, the authors proposed a number of preventive measures to mitigate the potential risk of COVID-19 transmission during musical activities, including reducing the duration of the activity to allow for regular airing out of the space and applying cloth protection to the bells of wind instruments where feasible.
These studies are NOT definitive, and clearly much more needs to be assessed before declaring no risk. However, utilizing the guidelines I suggested, I do not think that shofar blowing will be a significant mode of transmission, be’ezras Hashem. And davening and singing should be curtailed as possible according to the each shul’s Rav, dependent upon local physical considerations and local COVID-19 incidence.
Is it better to daven indoors or outdoors for the Yomin Noraim?
Outdoor minyanim at this time of the year remain optimal, very viable and safe venues for people concerned about indoor shuls and longer than usual davening. Same applies to shofar blowing.
However, as long as indoor minyanim are properly supervised, meaning appropriate masking and distancing, indoor minyanim in low COVID-19 incidence areas can be equally safe and may offer advantages regarding comfort and kavanah that outdoor minyanim may lack because of environment or weather. Ultimately, it is a personal choice.
Any more exciting news regarding vaccines?
Health and Human Services Secretary Alex Azar reported there are currently six vaccines under contract with the US government with good safety profiles and with studies documenting neutralizing antibodies at a level at or above what people recovering from COVID-19 produce in their own bodies. Very good news indeed, with still the hope that one or more of these vaccines will receive emergency use authorization from the FDA before the end of 2020. In addition, large clinical trials of vaccine in China, Russia, Pakistan and other countries are also underway.
Many people have expressed a concern that any vaccine approval will be rushed and therefore not as safe as our vaccines usually are. To address this, FDA officials will use the regular tried and tested guidelines whether and when a vaccine can be made available. Commissioner Stephen Hahn, MD, and other senior FDA officials insisted that they would maintain “unwavering regulatory safeguards” in evaluating COVID-19 vaccines. Before any approvals are granted, they promised, the agency will convene its vaccines advisory committee to review candidates, and all traditional standards for efficacy and safety will be respected.
According to an AHRQ-funded modeling study in the American Journal of Preventive Medicine, based on a model that simulated the spread of the COVID-19 virus through the U.S., for a COVID-19 vaccine to end the pandemic without social distancing measures, it would require about 75% of the U.S. population to get vaccinated. This does not take into account natural immunity, and obviously depends on vaccine efficacy and the long term immunity generated.
We at Mount Sinai South Nassau, as well as other academic centers in the NYC region, are moving forward with vaccine trials. More information to follow….
Any proven cases of getting COVID-19 a second time?
Cases are still being assessed, and I personally have little doubt that some cases will be proven, especially as we move further away from March and April. It still remains very reassuring, that with upwards of 20 million COVID-19 cases worldwide, there are very few proven reinfection cases. This is critically important for herd immunity, and partially explains why certain communities have very few new COVID-19 cases despite not adhering to masking guidelines.
What new information was published?
1) Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases recommended against routine temperature checks to screen for COVID-19, despite the fact that this is still a policy guideline for hospitals and schools in many jurisdictions. “Temperatures are notoriously inaccurate, many times, and are especially unreliable on hot summer days.”
The Occupational Safety and Health Administration states that temperature checks are most beneficial when employees take their temperature at home and act accordingly based on the result, versus employers testing employees upon arrival at work. In schools, the CDC has recommended daily temperature screenings of staff and students, if possible, but does not specify whether tests should be conducted on site or before arriving at the location.
2) A study in JAMA identified no COVID-19 infections (asymptomatic or symptomatic) among community health workers after the addition of face shields to their personal protective equipment. Previously, there were infections when just wearing masks. Face shields may have reduced ocular exposure or contamination of masks or hands, and / or may have diverted movement of air around the face. This study supports what I have been recommending that teachers of pre-school and younger children unable to wear masks, wear a mask plus eye protection. It is unknown if a face shield is superior to goggles at this time.
I hope many people are planning on following the advice of the Mateh Ephraim to say 10 chapters of Tehillim every day during Chodesh Elul. In this merit of reciting sefer tehillim twice during Elul,
may we all have a kesiva vachatima tova.
Have a great Shabbos.