Rabbi Aaron E. Glatt, MD, RAA/Igud’s Director of Halacha and Medicine Commision
There is a lot of new information to impart this week, and Iy”H I will expand on these important subjects motzei Shabbos on our Zoom talk.
We will move up the start time to 9:15 PM this week, and consider earlier times going forward.
What has happened this week in our area?
Hatzalah has sent out notices to various communities in the greater NYC area regarding a slight increase they are seeing in COVID-19 calls. Boruch Hashem, the increase has been small, and the notices were sent out not to frighten or scare people but to remind everyone that COVID-19 is NOT over, and for the EMTs to take necessary precautions. This is a critical message to be heard in communities where there have been very few cases and little regard for masking and distancing.
Nassau County Hatzalah has also had some COVID-19 calls for the first time in a while.
The increases in cases, hospitalizations, and sadly, rachmana letzlan, deaths in Israel, as well as in some European countries previously “under control”, along with ongoing surges still in some US states, should serve as a significant wakeup call that COVID-19 could still drastically change our upcoming school and Yomim Noraim programs.
The state, city and county DOH are very carefully monitoring exposures and daily COVID-19 numbers, and are again imploring us to work with them should there be any new exposures.
What is new from the CDC?
1) The CDC updated its COVID-19 testing guidelines. They now state: If you have been in close contact (within 6 feet) of a person with a COVID-19 infection for at least 15 minutes but do not have symptoms, you do not necessarily need a test unless you are a vulnerable individual or your health care provider or State or local public health officials recommend you take one. What does that mean?
Suboptimal testing capabilities for COVID-19 have been the single most damaging issue we have faced in dealing with COVID-19. Delays in obtaining results, accuracy of the results, and inadequate resources for mass testing have negatively impacted our ability to prevent COVID-19 spread. This issue is not addressed by the updated guidelines, which is still the crux of the problem…
What this practically means however to me as a clinician and epidemiologist is that we MUST still test individuals exposed to COVID-19 as possible at the opportune times. A positive test result remains very helpful to reinforce the absolute seriousness of the exposure, and testing should be obtained where possible to promote optimal quarantine compliance. However, as before, nothing new here, we must recognize that a negative COVID-19 test is worthless to rule out infection. A 14 day quarantine is still required for all exposed individuals.
2) Contrary to what many people saw in the news, the CDC did not dramatically change their travel recommendations this week. They stated there still is ongoing COVID-19 transmission within the United States and throughout the world, and as a result, you may be exposed on your travels even though you feel well and have no symptoms. You can be highly contagious without symptoms and spread virus. You and your travel companions (including children) pose a transmission risk, and regardless of where you traveled or what you did during your trip, stay at least 6 feet away from other people not from your household – both indoors and outdoors. Wear a mask to keep your nose and mouth covered. You must still follow state recommendations – so in NY, there still is a mandatory 14 day quarantine for people traveling back from certain states and countries.
If you had a known (or possible) COVID-19 exposure, stay home for 14 days after your last contact with that person and monitor your health. Watch for fever (100.4◦F), cough, shortness of breath, or other symptoms of COVID-19.
3) The IDSA updated its antibody testing guidelines last week (that is what the NT Times article mentioned, and I alluded to last motzei Shabbos). Actually, little new information was delivered despite all the questions raised on the chat. Essentially, antibody testing has strengths and limitations, and in the appropriate setting, under the guidance of experts, it can provide useful information.
What is new from the FDA?
A big brouhaha emerged this week regarding convalescent plasma therapy, as the FDA announced emergency use authorization (EUA) for such products Sunday. To be honest, there was significant scientific controversy as to whether this should have been done at this time based upon the published scientific data. Indeed, senior officials exaggerated its benefit, which was followed by public retractions regarding efficacy. Very unfortunate.
My own personal opinion on the subject, which I stated prior to this EUA, and which I still believe is correct based upon the presented evidence, is that high titer COVID-19 convalescent plasma is somewhat effective in lessening the severity and / or shortening the length of COVID-19 illness in selected patients. Optimal usage criteria remain unknown and further studies are essential. Fortuitously, there is significant experience with the safety of plasma therapy – and the overwhelming evidence is that it is a very safe treatment.
Should I go to Uman?
NO. Absolutely no. Have people forgotten that measles spread like wildfire in Uman (do we have such a short memory?) and that Uman could be the world’s worst COVID-19super-spreaderevent? Last year roughly 30,000 people went to Uman for Rosh Hashanah alone.
Israeli Health officials (Minister Yuli Edelstein, Deputy Health Minister Yoav Kisch, Health Ministry Director General Hezy Levy, and coronavirus czar Professor Ronni Gamzu) all strongly urged people NOT to go to Uman this year. They stated: “With all the pain entailed, the national responsibility implies that this is not the time to fly to Uman to the grave of Rabbi Nachman of Breslov.” They urged the Ukrainian government to enforce a ban on these celebrations this year, as part of the entire global community’s effort to stop this horrific pandemic.
In addition, they said: “Responsibility means not gathering together around the holiday table. If we all act with responsibility and follow instructions, we will also be able to beat this and we will be victorious without having to harm the routines of Israel’s citizens. In this issue as well, we will be an example for other countries.”
Will men’s mikva’os open this year erev Rosh Hashana / Yom Kippur?
Unless you are planning to use the ocean or another natural body of water kosher for ritual immersion, it is highly unlikely that most men’s mikvaos will be able to open safely and handle the volume usually demanded. Each mikvah and each Rav will have to decide if and how a men’s mikvah might open properly, and not engender a super-spreader event.
HaRav Schachter shlita has paskened that one does not need to do hatoras nedarim even if you always went to a mikvah in previous years but cannot do so this year. Another option this year is to rely upon the principle of “9 kavim” (a certain measure of water) in a shower. Ask your Rav…
And speaking of hatoras nedarim, that can and should be done via socially distanced groups, and HaRav Schachter has even permitted this to be done via Zoom if necessary.
Please note, and I cannot stress enough, that this entire discussion is only regarding men’s mikvaos, and has absolutely NOTHING to do with women’s mikvah usage, which remains very safe, and is strongly recommended, and for which there is no alternative in Halacha.
What will tashlich look like this year?
Probably, hopefully, exactly the way chazal intended it to be!
Meaning, it will be a private gathering at a body of water, utilizing tefillah and introspection as a way to symbolically release our sins through expressions of teshuva, repentance and atonement. Wow.
Certainly, it should not be the improper social gatherings that chazal actually strongly protest against every year! And even if this year were not inappropriate from a spiritual perspective, it would still be dangerous from a social gathering perspective.
Is wearing a mask dangerous? Will it make it harder to fast?
Not wearing a mask is very dangerous, and for non-medical, non-rabbinical, non-expert people and papers to continue to espouse that we must letG-d handle all infections is blasphemy and foolishness. Hypocrisy abounds – why is going to a dentist allowed but other medical care is wrong?
There is no scientific evidence that mask wearing causes one to breathe more carbon dioxide or that it could make you sick.
Lack of drinking leads to dehydration. Certainly, excessive heat facilitates dehydration, but there is nothing to suggest that wearing a mask increases dehydration.
To be best prepared, a person should discuss with their Rav any fasting questions before Yom Kippur. In general, if a person is fasting and there is a medical concern about potentially becoming dehydrated, they should stay home (or go home if already in shul) and remain quietly at home and / or in bed as possible. If symptoms begin, drink as per your Rav’s guidelines. Anything more significant, drink a lot and call Hatzalah as needed.
Should I take the flu vaccine now? Will it impact enrolling in a COVID-19 vaccine trial?
The CDC recommends taking flu vaccine earlier this year than in the past. We don’t want even one single extra case of flu making it harder for us to deal with COVID-19. While some have expressed concern that if you get a flu vaccine in August, you might not have protection in April as the vaccine will have worn off, there’s no real evidence to support this. I don’t think that’s true in a normal year, and I certainly recommend flu vaccination sooner rather than later for everyone.
Some COVID-19 vaccine trials will not allow potential recipients to get flu vaccine within 2 weeks of their entry into the study. So now is a perfect time to either enroll in a COVID-19 study, or get flu vaccine if you are not expecting to be enrolled in a COVID-19 vaccine trial right away.
Any proven cases of getting COVID-19 a second time?
The answer to this is finally YES. In a paper accepted in Clinical Infectious Diseases, scientists from the University of Hong Kong reported the case of an asymptomatic 33-year-old man with a second episode of Covid-19 episode 4½ months after his initial symptomatic infection. This case is considered proven based upon whole genome sequencing which demonstrated 24 different nucleotide sequences suggesting they were different strains and not dead genetic material. Two other cases were reported yesterday, and I suspect there will be more.
This is a very important finding, however, it must be understood in perspective. While it clearly suggests what we suspected – COVID-19 immunity might not be lifelong – it must be appreciated that these are the first proven cases after 20,000,000 plus COVID-19 diagnoses worldwide. So, while it is critically important to realize immunity may not last forever, at least in the short term, immunity is actually quite good.
What other new information was published?
1) Superspreading events are real and are a great concern! An unpublished paper (but data released for all to examine) demonstrated through genetic analysis that a Biogen conference in Boston in March sparked numerous cases of COVID-19 throughout the country and the world. People traveled to this conference from across the world, were exposed to contagious individuals attending the event, and then travelled back to their homes across the world carrying the virus. The virus’s genome is like a genetic barcode; by tracking it, researchers traced the infections to their source. Genetic sequencing of the virus revealed the connections between seemingly disparate communities and showed how an indoor “superspreading event” accelerated and sustained transmission.
2) The European Respiratory Journal reported that people with asthma were not overrepresented among patients with severe COVID-19 pneumonia. Worst outcomes were actually observed in patients with major comorbidities, but not asthma.
One of the most common concerns people ask me is – are they at increased risk with a “history” of asthma. This paper certainly supports that unless you have significant underlying illness secondary to asthma, you are probably not considered at any increased risk.
3) While I am not surprised, it is sad that people still send me “information” and talk about the benefits of hydroxychloroquine (HCQ). Well, the European Journal of Clinical Pharmacology reviewed 53 randomized trials that evaluated the safety of HCQ. This meta-analysis indicated that the risk of adverse effects in the HCQ group was significantly increased compared with the control group.
I wish HCQ had worked, we used it in a lot of patients early on, with great hope. Unfortunately, the published evidence shows not only doesn’t it benefit patients, but it has the potential to hurt them.
4) The MMWR described Rhode Island’s positive experience reopening childcare centers following strict protocols, providing evidence that it can be done safely in the COVID-19 era.
A total of 666 of the state’s 891 childcare centers reopened, providing care to 18,945 children. The investigators concluded: “The apparent absence of secondary transmission within 662 of the childcare programs was likely the result of efforts to contain transmission and child care programs’ adherence to protocol requirements, in particular maximum class sizes and use of face masks for adults.”
In four centers however, secondary transmission couldn’t be ruled out. At one of those centers, health department investigators found that state regulations weren’t being adhered to, and five children, four staff members, and one parent acquired COVID-19. The program had to be closed, with 60 children and 21 staff members quarantined for 2 weeks.
If we follow the guidelines, there is a chance we can open successfully. If we don’t…
May the safe sounds of Elul Shofar blowing herald in a year of peace and health for Klal Yisroel.
Kesiva vachatima tova, and good Shabbos.