By Rabbi Dr. Aaron E. Glatt, MD
I cannot begin to express the joy I experienced attending the first minyan held in the Young Israel of Woodmere Joseph K. Miller main shul this Wednesday evening for Mincha / Maariv. The happiness and full-faced smiles, clearly evident even through the 100% masked audience, was palpable. May Hashem allow all of us – men, women and children – to fully return to shul in the near future.
More positive news – several NY regions are about to enter into Phase 3, and Nassau County entered Phase 2 yesterday, with more businesses reopening. Day camps have permission to open if they follow certain guidelines, although a sleep-away camp decision is still pending. Outdoor socially distanced graduation ceremonies of up to 150 people will be allowed beginning June 26th, and the Governor announced today that public pools and playgrounds will open as summer arrives (details to follow), with many more re-openings and loosening of some restrictions potentially on the immediate horizon.
I will iy”H discuss further expanding our bubbles, summer plans for adults and children (camps, vacations and travel), shidduchim and public in person Torah learning, on Motzei Shabbos at 9:45 pm in our usual zoom chat room, Meeting ID: 980 3243 6809; Password: 5TFRBM. We will again leave time for a 10-minute Q & A following the talk.
HOWEVER – I wanted to focus this update on serious concerns I have regarding what some physicians, leaders and community members are saying and doing regarding the idea that “COVID-19 is over”. My remarks are absolutely not chas veshalom against any specific individual or community, and they are totally based upon objective scientific facts as possible or best evidence-based medicine. I also stress that only time will tell what the correct approach to the current fact pattern should have been, and my remarks are strongly colored by the psak of all of the gedolim who I have spoken with, who unanimously said we cannot be meikal (lenient) in questions of pikuach nefashos (matters of life and death). I too wish that we could just go back to our former life, as many seem to be doing – but do the current data support that?
What are the current COVID-19 facts? How many new cases are there?
Boruch Hashem things are unbelievably better than they were – at least in some places, including our community, and many of the surrounding Jewish communities in the greater NY and NJ region. Chasdei Hashem. The unanswerable question is – will this continue? And why are the numbers good if people are not being as careful as recommended?
There are 20 states (not NY) in the US where new cases of COVID-19 are significantly rising, including several states with significant Jewish populations. New cases of coronavirus nearly doubled this month in California and Texas, after both states reopened. NYS is still having ~ 700 new cases per day; NYC ~ 400 new cases per day, and in the past 24 hours alone, Nassau County had 45 new cases. All Nassau County hospitals are still admitting several patients daily, and each of the 5 Towns (not including Far Rockaway which has more) has essentially 1 new case every other day. These are objective facts, not open to interpretation, and they only represent identified new cases using a test that is at best only 70-80% sensitive in picking up such cases. These cases are living in and around us, and there is no way to know a priori who they are.
Why do I focus on Jewish populations? For several reasons. Our populations from distant communities mix very easily and often, via increased connectivity through minyanim, semachot, other major Jewish life events, going / returning to family, businesses travel, etc. The potential for even one person coming in on an airplane from an area where cases still exist, as just happened yesterday in Bergen County, is very real. Or we could have a new case right here at home via interactions with an infected co-worker, neighbor, shopper, housekeeper, friend or business associate, which can lead to a “superspreader event” heaven forbid – which all of us have seen, to our great sadness.
Won’t herd immunity protect us? What percentage of our community has antibodies? Unfortunately, these answers are unknown. Antibody prevalence is possibly in the 15-20% neighborhood, nowhere near the level needed to stop COVID-19 spread in it tracks. Even in communities with more pronounced infection rates approaching 50%, that is still not enough to prevent significant deaths from occurring heaven forbid should new cases occur. Please see this link (https://hamodia.com/prime/now-look-lingering-questions-risks-covid-19/) in Hamodia where two well respected expert infectious diseases physicians besides myself address this subject, all reaching the same conclusion that Dr. Anthony Faucci stated publicly this week: “Now we have something that turned out to be my worst nightmare. In the period of four months, it has devastated the world… It just took over the planet, and it isn’t over yet.” The exact opposite of what has been stated by too many in our community that “COVID is over”?
But didn’t the WHO say this week that asymptomatic transmission doesn’t occur?
Not exactly. Indeed, they actually retracted an offhand comment made by an employee of the WHO, who herself was initially misquoted. She actually said that asymptomatic transmission was estimated to cause “only” 2.2% of the cases. Fauci called the WHO statement “incorrect”, and remarked: “Given the abundance of evidence that 25% to 45% of infected people don’t have symptoms, combined with how far and fast the virus has spread even with protocols in place, it’s clear that someone doesn’t have to be outright ill with COVID-19 to give it to someone else”.
Additionally, an analysis in this week’s Annals of Internal Medicine suggested that as many as 40-45% of COVID-19 cases may be asymptomatic. The authors concluded: “The early data that we have assembled on the prevalence of asymptomatic infection suggest that this is a significant factor in the rapid progression of the COVID-19 pandemic.”
So why aren’t people concerned by these facts?
Which people aren’t concerned? Israel is certainly very concerned about this. COVID-19 was almost eradicated from artzeinu hakedosha – but a new spike in cases resulted in the government saying that Israelis have taken the easing of restrictions “a little too far”. Indeed, Prime Minister Netanyahu ordered mandatory mask-wearing and prohibited gatherings of over 50 people. Health Minister Edelstein warned that in order to avoid another nationwide lockdown Israelis need to stop treating COVID-19 regulations as “recommendations.” “We are heading rapidly toward more than 200 patients a day. We were at a lull. The disregard for regulations caused this spike. There is no magic involved: If you treat the instructions as recommendations, the coronavirus won’t leave us. It’s that simple”.
Poskim? HaRav Schachter and HaRav Willig shlita, and many other gedolim, are certainly very concerned and are not advocating major relaxations in masking and distancing behaviors. They paskan we must follow the government public health regulations requiring masks when in close proximity with others not in our “bubble”. Data I present below demonstrate (again) the value of wearing masks, and how even if someone is exposed to COVID-19, masks will prevent many infections and outbreaks.
Infectious diseases physicians? Every infectious diseases physician I have spoken with has stated without any ambiguity that we must wear masks at minyanim. Both the Agudah and OU/RCA guidelines, which were developed with the input from at least 10 infectious diseases physicians and public health experts state this as well.
What is the bottom line?
At this time, we strongly still urge people to be very cautious, and continue social distancing and mask precautions. This is for everyone – antibody status or COVID history notwithstanding – as per the official CDC position, which still states: “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.” NOTE: I personally think this CDC recommendation is too conservative, and for individual cases I have modified this advice in specific situations. However, what halachic position allows one to totally ignore this expert CDC recommendation for an entire community?
Any exciting new medical information about masks and distancing this week?
1) Young adult service members aboard the USS Theodore Roosevelt aircraft carrier during a COVID-19 outbreak were less likely to be infected if they wore face coverings and practiced physical distancing. (Morbidity and Mortality Weekly Report).
2) Proceedings of the Royal Society: Even if facemask use began after the start of the first lock-down period, benefits still accrue by reducing the risk of the occurrence of further COVID-19 waves. Even at lower levels of adoption, benefits accrue to the facemask wearers. These analyses may explain why some countries, where adoption of facemask use by the public is around 100%, have experienced significantly lower rates of COVID-19 spread and associated deaths.
Facemask use by the public, when used in combination with physical distancing or periods of lock-down, may provide an acceptable way of managing the COVID-19 pandemic and re-opening economic activity. A key message would be: “my mask protects you, your mask protects me”.
Conclusion: Facemask use by the public could significantly reduce the rate of COVID-19 spread, prevent further disease waves and allow less stringent lock-down regimes. The effect is greatest when 100% of the public wear facemasks. It follows that the adoption of this simple technology ought to be re-evaluated in countries (I would add – and communities) where facemask use is not being encouraged.
3) Two studies in Nature suggest that shutdown orders in China, Europe, and the US prevented many COVID-19 infections. In one study, “shutdown orders prevented about 60 million novel coronavirus infections in the United States and 285 million in China.” In the other study, “epidemiologists at Imperial College London estimated the shutdowns saved about 3.1 million lives in 11 European countries, including 500,000 in the United Kingdom, and dropped infection rates by an average of 82 percent, sufficient to drive the contagion well below epidemic levels.”
4) Do “double bubbles” work? Two households that merge only with each other but otherwise practice social distancing with everyone else, seem to have helped successfully lower new COVID-19 cases, in New Zealand, one of the first countries to use the strategy. A few European countries, including Germany, as well as Canada also implemented this strategy as part of their reopening plans. New Brunswick permitted its population to double bubble April 14, followed by Newfoundland and Labrador. Weeks later, these provinces—which had low case numbers prior to being allowed to double bubble—still have not seen a rise in daily new Covid-19 cases.
5) No need though to distance from your pets! Only a small number of companion animals worldwide have been naturally infected with COVID-19, and the CDC states that while human-to-animal transmission can occasionally occur, animals are not known to play a role in spreading COVID-19. Companion animals that test positive though should be monitored and separated from persons and other animals until they recover.
Tell me something new about therapy?
1) Regeneron is going to shortly start a therapeutic trial using a combination of two synthetically produced antibodies that bind to different parts of COVID-19. The hope is that the virus won’t be as likely to develop resistance with a combination product attacking different pieces of the virus, versus a single antibody medication. Using an FDA approved adaptive trial design, they are about to commence a placebo-controlled study in 50 patients examining this theory.
2) Another very large randomized COVID-19 trial showed no clinical benefit from hydroxychloroquine (HCQ). A total of 1542 patients received HCQ versus 3132 patients receiving standard care. 28-day mortality was higher (25.7%) in the HCQ group vs. 23.5% in the usual care. There was also no evidence of benefit on hospital stay duration or other outcomes. These data convincingly rule out any meaningful mortality benefit of HCQ in hospitalized COVID-19 patients.
I will try and provide more information motzei Shabbos regarding these common questions I am frequently asked:
Would you send your kids to a safe summer camp?
Can we let our kids play outdoors with other kids?
Can we safely take a car vacation or airplane trip?
Enjoy the wonderful shul experience for those fortunate enough to have returned this week to our holy and very much missed batei knessios.
Have a great Shabbos,
Rabbi Aaron E. Glatt, MD