Welcome to the weekly newsletter of Igud HaRabbonim, the Rabbinical Alliance of America, in which we share news for and about members, including communal news, announcements, publications, Divrei Torah, press releases and media mentions.
In this newsletter:
• COVID-19 Update July 23, 2020
• Chaplaincy Commission Update
• Divrei Torah Dvorim
• New Publication: Tisha B’Av in the Time of Corona Virus
• New Publication: Halachos of the Nine Days
• Upcoming Yahrtzeits 4 Av-11 Av
• 5TJT: Civility
• JNS: Supreme Court
• The Rabbinical Alliance of America Issues an Urgent Call for the Restoration of Civility and Respect in These Challenging Times
• Rav Dr. Aaron Glatt: Covid Update July 16 & July 18
Please let us know about your family simchos and l"a aveilus, book publications and career changes or milestones, so we can share as chaveirim our life events. Send updates to firstname.lastname@example.org.
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 ID 980 3243 6809; use this new Password: SUMMER2020; by phone: 929 205 6099 or via YouTube link obtainable from email@example.com.
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 notpikuach 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 allMUST 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.
From the desk of Rabbi Leonard (Yehuda) Blank, MS, BCC
Director of Chaplaincy Commission and External Affairs
Rabbinical Alliance of America/Igud HaRabbonim
July 23, 2020
In the book “One Small Spark” by Rabbi Yechiel Spero (ArtScroll Mesorah Publications, Ltd) “Tell Me Something Nice” he relates about the close relationship Rav Aharon Rokeach ztkl had with a cousin of his who served as rav in a small village near Haifa. One year on an erev Rosh Hashanah when that relative came to join the Rebbe, in a conversation the Rebbe asked him what was doing in his village and the cousin responded “If all the villages and cities in Eretz Yisrael had such good Jews as we have in our village,the entire country would be different.” The Rebbe was displeased with his cousin’s response. The cousin noticed how displeased the Rebbe was. Rabbi Spero shared how the Rebbe was known for the love he had toward every Jew. He would find the goodness of others rather than finding fault. The cousin eventually realized what bothered the Rebbe. To the Rebbe,even though the cousin was praising those in his village, he was still speaking derogatory about all the other Jews in Eretz Yisrael. That year erev Yom Kippur when the cousin came to greet the Rebbe, the Rebbe asked his cousin if he had anything good to tell him. He shared with him the positive reasons he was unable to get a taxi ride from any of the drivers that day because of their concern about being able to fast should they have done all that traveling which was a six-hour trip those days from Haifa to Yerushalayim. He eventually got a ride with someone going his way. The Rebbe was incredibly pleased to have heard such a positive report about all those drivers who will be fasting on Yom Kippur. There was no reference to anything about the taxi driver’s observance -just that they were all going to be fasting on Yom Kippur. (The entire beautiful story can be found on pages 255 -257). All to often the Yetzer Hara find ways for people to add something negative about someone else. How often will a critic share his /her opinion about a rav and his drasha, the voice or tunes of a chazan, how the food and or service was at someone’s simcha and so on. Aharon HaKohain was so special as he was able to bring shalom between others. I have mentioned previously, being sincere, being erlich is important. The former Mashgiach of MTJ Yeshiva, HaGoan HaRav Michael Barenbaum ztkl used to say, it is not enough for one to say I am observant, one must be erlich. Just as HaRav Rokeach I mentioned in the story above had such love for his fellow Jews. I often hear amazing stories of the patience chaplains have listening, being so sincere with those who they care for in nonjudgmental ways. Often bringing peace of mind, body, and soul especially during difficult, trying, and challenging times. I often discuss the goodness, the kindness, the professionalism of chaplains, because frequently, I have been asked to share the many aspects and qualities of chaplains. Personally, I have been zoche to be affiliated with Rabbanim, chaplains and professionally in the secular world as well. It is my affiliations with those whose love of the Aibershta, the love of their fellow Jews and care for their fellow human beings always seeking opportunities of Kiddush H that have made me the greatest impact. There is such a need of becoming closer to the Ribono Shel Olam, with Ahavas H, Ahavas Torah and to appreciate each other. At a senior center I was going to be giving a presentation, a woman came in wearing extremely youthful modern clothing, makeup, accessories, and a hairstyle in various shades of color. The other women present started making comments to each other, while looking or I should say staring at her. That woman felt so uncomfortable, she got up and left. I engaged the other women present and asked how they felt about her leaving without focusing on what she was wearing. Some of their comments ranged from she should be ashamed of herself trying to be someone or something she is not, to at her age why, and who does she think she is anyways, she is an embarrassment amongst other comments. I asked if anyone knows who that woman was. Response, no one. I asked if she was causing any harm to anyone (maybe a distraction, but she sat down in the last row, behind everyone. Their response was only if they turned around to look at her. I asked was she disturbing anyone. Again, the response was no. I asked how they felt she was making them uncomfortable or making them feel embarrassed. No response. I asked if they themselves ever felt like wearing a different outfit, makeup or hairstyle from what they usually wear, and they said yes. After some discussions about their own feelings about why that woman left and how easy it was for them to speak not nice things about someone else, especially someone that has no relationship to them was an eye opener. We also discussed ways they could have welcomed that woman, invited her to sit with the others – what would have been so terrible instead of being hurtful. The same holds true in shul. When someone new comes to daven or attend a shiur, is there a policy of welcoming a guest? What about being at a table at a simcha or dinner and there is someone who appears not connected to the others at the same table, isn’t it a nice welcome and maybe a form of hachnasos orchim welcoming a guest who might just be sitting by himself while everyone else is having conversations with each other – but not with that person? Regarding the mitzvos of bikur cholim and necham availus, what about the days and weeks after returning home from the hospital or recuperating at home, or after the sheloshim- yes the sheloshim it is possible the avel or the choleh might still want a phone call, to check in on that person who you know. The only way of knowing if that person wants a check in or can I get something for you, or would you like to talk a little is by asking or offering. At first that person might say no, but really would like that call and if not now, maybe in a few days or so. Being sincere is an important aspect of caring. What else is important is trying to be understanding of what the person might be going through and what his or her needs might be, but at the present time, not being said.
To my dear wife Keila Lutza bas Shalom HaKohain A”H who I so miss. Not just for her companionship, her delicious meals, for being such a wonderful Bubby, but her constant inspiration and appreciation of what H meant to her, to me and to Klal Yisrael. Though she always knew there was no cure, until the last weeks of her life when the symptoms got so difficult, she never gave up hope. Life would go on for as long as possible. Even with the periodic difficulties and challenges, there was the hope, there was the faith, there was the determination to utilize every moment the Aibershta gave her the breath of life. I am so grateful for the precious gift Hakadosh Boruch Hu gave me and my family of my wife. Her prayers were as strong and meaningful for as long as possible. I dedicate my maysim tovim to my wife and mispallel, I can continue the mesorah with Torah, Avodah, Gemilus Chasadim, tefilah with kavaneh, meaning and to continue to bring her neshama nechama. I would like to share with you the next time my dedication to the CCHF Asher Yatzar Chart that meant so much to her. May we be zoche that this coming Tisha B Av be a yom tov.
The Rabbinical Alliance of America — Igud HaRabbonim, representing over 950 American rabbis — issues an urgent call for the restoration of civility and respect in New York City in these challenging times. Disagreement, even vehement disagreement, must take place within the boundaries of constructive debate. In order to improve society, we must make a future in which we can live together. Violence moves us farther away from that goal.
Sadly, heightened tensions in New York City between protesters and police have led to verbal altercations and physical violence. In the name of peace and unity, RAA Executive Vice President Rabbi Mendy Mirocznik declared, “The issues of systemic racism and legal inequities must be resolved. In that process, we cannot in any manner countenance the violence directed at the intrepid men and women who serve valiantly in the NYPD. We are descending into anarchy, well into a dangerous zone where innocent people fear for their lives.”
Mirocznik’s comments were a response to the violence that took place early Wednesday morning on the Brooklyn Bridge, when anti-police demonstrators assaulted seven police officers, including NYPD Chief of Department Terrance Monahan.
“The reprehensible attack on Chief Monahan and other police officers, while they were arresting a violent protester, crosses a moral and ethical boundary. As a society that is ostensibly predicated on civility and respect, we cannot tolerate a message that assaulting or harming police officers is acceptable behavior,” Rabbi Mirocznik added.
Because tensions between diametrically opposed factions in New York City are at a boiling point, Mirocznik called for local community boards, elected officials and neighborhood activists to convene for respectful dialogue to calm the hostilities and restore peace, stability, respect and civility to this great city.
Mirocznik said that as the summer progresses, he expects more demonstrations and violence, which heightens the need to quell the menacing atmosphere that has gripped New York City. “With crime soaring to unprecedented heights in New York and dozens of shootings taking place within hours of each other, residents of this great city are naturally uneasy and even frightened. The time is long overdue for the forces of peace to take a greater initiative in tackling this problem before it completely spirals out of control.”
Mirocznik further stated that we must “take the time to demonstrate our appreciation of the men and women of law enforcement. When you see a first-responder or police officer, please take a moment to thank them and tell them how much you appreciate their service. We are surviving the pandemic of Covid 19 thanks to their steadfast dedication to the residents of this city. We must always be grateful for the law enforcement officers who heroically do their job in an exemplary fashion.”
Mirocznik added, “the recent budget cuts to the NYPD are detrimental to the safety and security of all residents of New York City, particularly the Jewish community. We had already seen positive results from community outreach and partnership programs, Neighborhood Coordinating Officers, as well as the youth officer program and tremendous outreach efforts by the NYPD. These efforts produced a tangible reduction in crime and the building of communication, trust with the community. We are saddened by the possibility of the cutting of these successful programs for budgetary reasons.”
In the few short weeks since the disbanding of the anti-crime unit, we have experienced a crime wave of shootings and homicides, demonstrating the effectiveness of these discontinued anti-crime programs. The RAA calls upon our elected representatives to take note of this tragic reality and to adequately fund and staff the programs that will reverse the spiraling descent of crime. In order to protect innocent lives and maintain peace in the city, we need to increase mutual respect, constructive dialogue, and protection for the most vulnerable. Now is the time for local community leaders to bring the city together for dialogue, reconciliation, and progress.
Below is an update on the Covid situation from Rav Dr. Aaron Glatt, RAA/Igud’s Director of Halacha and Medicine Commision, dated July 9, 2020 (the situation changes day to day). He will provide a live update on Motzei Shabbos, July 18 at 9:45pm NY time
I am concerned about an increase in both Long Island and NYC COVID-19 cases, with a slight increase in hospitalizations in NYC, Erie County and Albany. While small, this is something that needs to be watched very carefully.
In Suffolk, one July 4th BBQ resulted in 22% of the attendees getting COVID-19. Substitute Shabbos Kiddush for July 4th and realize what this means. In some parts of California, indoor religious services are no longer allowed. Some Florida shuls stopped minyanim, and Israel minyanim have been decreased to a maximum of 19 people with a potential new lockdown if things do not improve. 41 states in the US have seen an increase in cases since July started; 8 states doubled cases in the last 14 days. 22 states are on our Tri State quarantine advisory, up 8 from last week. Anyone suggesting we are in the post COVID-19 era is imbibing excessively at too many kiddushim.
Despite this, Boruch Hashem, we have NOT seen significant complications in the Five Towns.
I will address the ramifications of these new cases for both children and adults, answer commonly asked questions, and begin discussing what the yomim noraim will look like at our 9:45 motzei Shabbos zoom.
Any proven published cases of individual getting COVID-19 a second time?
Still nothing yet. Doesn’t mean it can’t happen; doesn’t mean it won’t.
Interestingly, a just published paper in Lancet Infectious Diseases added to the speculation on this subject. During follow-up of 651 COVID-19 “recovered” patients, 23 (3%) tested positive after at least 2 negative swabs. The median duration from hospital discharge to a positive retest was 15 days. At the time of the positive retest, seven patients (30%) had antibody for both IgM and IgG, five (22%) were only IgG-positive (IgM-negative) with the remaining 11 patients (48%) negative for any antibodies. 15 patients (65%) were asymptomatic at the time of the retest; eight (35%) had at least one symptom associated with active COVID-19. At the time of the last follow-up, all 23 patients with a positive retest were alive. No viral transmission could be ascribed to these patients with a positive retest.
What does this paper tell us? While already frequently quoted, I am not sure it really provides any new information. Many recovered COVID-19 patients have intermittently positive swabs, and antibody development in this study is far less than that seen in every other paper, suggesting their laboratory testing might be suboptimal. In any event, the chronological proximity of their “second case” to the original episode of COVID-19 is the most compelling evidence AGAINST their correctly describing new COVID-19 in previously infected persons.
Anything new about transmission?
1) MMWR published a very interesting report that face coverings prevented COVID-19 spread in a high likelihood exposure scenario. To wit: Among 139 clients exposed to two symptomatic hair stylists with confirmed COVID-19, NO secondary cases were reported since both the stylists and the clients wore face masks. What are the implications for public health practice? Professional and social interactions in the community present opportunities for spread of COVID-19. Broader implementation of face covering could mitigate the spread of infection in the general population.
2) JAMApublished an important paper providing additional evidence that universal masking reduces transmission of COVID-19. Prior to implementation of universal masking in late March 2020, new infections were increasing exponentially, from 0% to 21.3% (a mean increase of 1.16% per day). However, after universal masking was instituted, positive tests quickly and steadily declined to only 0.49% per day.
CDC Director Dr. Robert Redfield, CDC’s chief medical officer Dr. John Brooks and Deputy Director for Infectious Diseases Dr. Jay Butler wrote a commentary in JAMA which stated: “The science shows face masks work both to protect the wearer and to protect others from coronavirus, and everyone needs to wear one when around other people in public. At this critical juncture when COVID-19 is resurging, broad adoption of face coverings is a civic duty (I would have said a mitzvah), a small sacrifice reliant on a highly effective low-tech solution that can help turn the tide favorably in national and global efforts against COVID-19.”
I again add – is wearing a mask really so difficult? Are you 100% sure all the experts are wrong? Not wearing a mask is potentially putting school and shul openings, yomim noraim minyanim, travelling (to Israel, within the US, anywhere) at risk. Is not wearing a mask and eating at kiddushim that important?
Can children transmit COVID-19?
This week was a particularly difficult week in Eretz Yisroel. Hashem yeracheim. The Health Ministry evening reported on Monday 1,578 coronavirus infections in the previous 24 hours; total cases crossed the 40,000 mark; serious COVID-19 cases surged to 183, a leap of 32 in one day; and cases doubled in six days. The number of coronavirus patients in hospitals continued to rise, increasing from 524 hospitalizations as of Tuesday morning to 547 Wednesday morning. Of those, 195 are in serious condition, up from 192 on Tuesday and 186 on Monday. A further 125 patients are in moderate condition. Think back a month ago when Israel was featured widely as one of only 7 countries who “beat COVID-19”. On May 17th, Israel reported only 10 new cases of COVID-19 in the entire country.
Why? Some Israeli experts attribute this increase to school openings and transmission from children to adults. On May 17th, the government opened the entire system at once. By June 3rd, just two weeks later, more than 244 students and staff tested COVID-19 positive. According to the education ministry, 2,026 students, teachers, and staff since contracted COVID-19, with an additional 28,147 in quarantine. Now, ~ 400 summer kindergartens / schools that were supposed to be open have been shut.
However, this Israeli experience is in direct contradistinction to the experience in Iceland and the Netherlands, which published the exact opposite conclusion.
In a New England Journal of Medicine paper analyzing 722 contacts of infected children in Iceland, not a single instance of an infected child passing on the virus was identified. In contrast, the infected adults, who had many fewer contacts (102) transmitted infection.
Data from the Netherlands also showed that children play a minor role in the spread of COVID-19. Virus was mainly spread between adults and from adults to their children. They concluded that:
Spread of COVID-19 among children or from children to adults is less common.
Children appear significantly less likely to acquire COVID-19 than adults when exposed.
There are significantly fewer children infected in the community than adults.
Children are rarely the index case in a household cluster in the literature to date.
It is not clear how likely a COVID-19 infected child is to pass on infection compared to an adult, but there is no evidence that they are any more infectious or superspreaders.
6-foot distancing is less important for them.
Children up to 12 years of age do not have to keep 6-foot distancing from each other and adults.
Israel versus Iceland and the Netherlands? As usual, I suspect the correct answer is somewhere in between. Based on available data, I feel comfortable telling adults with grandchildren in day camps that they can continue to be with their grandchildren if the kids are healthy and there are no known cases in camp. If grandparents are still concerned, take extra precautions and wear a mask when around them.
What other new information was published this week?
1) Data presented at the Virtual COVID-19 Conference (part of the 23rd International AIDS Conference) showed remdesivir was associated with an improvement in clinical recovery and a 62% reduction in mortality compared with standard care. 74.4% of remdesivir-treated patients recovered by day 14 versus 59.0% of patients receiving standard care. The mortality rate at day 14 for patients treated with remdesivir was 7.6% versus 12.5% among patients not taking remdesivir.
2) Two new studies again showed that blood type did not make a really significant difference in COVID-19 outcomes, although both did demonstrate that it was slightly better to have type O. One paper showed type A blood had a slightly worse outcome, but the other article did not, although the latter paper showed B and AB did slightly worse. Bottom Line: There are very slight associations between blood group, intubation and death among COVID-19 patients. This has no practical import.
3) Two adult cases of post-infectious inflammatory syndrome – previously only seen in children – were described by physicians at Maimonides (who reported a case in a 36-year-old woman, in the American Journal of Emergency Medicine) and at NYU (who reported a case in a 45-year-old man, in the Lancet). This is the first time re COVID it is good to be above 50 .
4) CDC published that the infectiousness level of asymptomatic people is 75% relative to symptomatic patients and that the likely overall mortality of COVID-19 is 0.65%. The common similar figure for influenza is 0.1%.
5) More studies demonstrated the benefits of the interleukin-6 inhibitor tocilizumab. A single-center observational study published in Clinical Infectious Diseases noted a 45% reduction in death, and a second study in the Journal of Infection demonstrated half the death rate compared with standard care.
6) Another JAMA study found that 87.4% of patients recovered from COVID-19 reported persistence of at least 1 symptom, particularly fatigue and dyspnea. Patients with community-acquired pneumonia can also have persistent symptoms, suggesting that these findings may not be exclusive to COVID-19, but this is a concern. Continued monitoring after discharge for long-lasting effects is needed.
7) Another presentation at the Virtual COVID-19 Conference showed that hepatitis C medications had some benefit against COVID-19. Of 66 similar patients in the study, 33 received sofosbuvir and daclatasvir (hepatitis C medications) and 33 received standard care. After 14 days of treatment, 29 patients (88%) in the sofosbuvir and daclatasvir group improved compared with only 22 (67%) in the control group. The treated group also had a shorter hospital stay and lower mortality (3 deaths versus 5 in the control group. Plus, no serious adverse events were reported. Of course, larger, well-designed studies are need to confirm these results.
8) Finally, a study in the Annals of Internal Medicine looked at regulatory T Cells – “Tregs” for treating severe COVID-19. Tregs normally migrate to inflamed tissues, dampening inflammatory responses. This paper from Johns Hopkins discussed 2 patients with severe COVID-19 treated successfully with cryopreserved, allogeneic Tregs derived from cord blood. While very preliminary, this represents another totally new treatment modality.
9) An unpublished detailed review showed antibodies developed in the vast majority of COVID-19 patients when sampled at least 8 days after symptom onset. However, antibody titers declined in a very significant percentage of these patients over time, especially those with milder illness originally. Again, the big question remains: What does the initial presence and subsequent loss of antibody mean? More to come…
Does this mean I should get retested to see if my antibody titer has decreased?
No! At this time, outside of a study setting, we do NOT recommend getting routinely retested for antibody, as we do not know what the results portend.
Anything exciting regarding vaccines?
Yes! The New England Journal of Medicine published an open-label trial of 45 healthy adults, 18 to 55 years old, who received two doses of the Moderna vaccine candidate, mRNA-1273 in their arm, 28 days apart. 15 participants each received a low, medium or high dose of vaccine. After the second vaccination, serum-neutralizing activity was detected in all participants, with values generally similar to those in the upper half of control convalescent serum specimens. Adverse events occurred in more than half the participants, and included fatigue, chills, headache, myalgia, and pain at the injection site. Systemic adverse events were more common after the second vaccination, and particularly with the highest dose. These findings support further development of this vaccine, which is partially funded by the National Institute of Allergy and Infectious Diseases.
Bottom Line: These safety and immunogenicity findings support advancement of the mRNA-1273 vaccine to later-stage clinical trials. The strong neutralization response coupled with a better adverse effects profile makes the “medium” dose more favorable than the “high” dose. A phase 2 trial of mRNA-1273 in 600 healthy adults, evaluating doses of 50 μg (“low”) and 100 μg (“medium”) is already underway, and a large phase 3 trial of the 100 μg dose is starting July 27th. Exciting!
Several other vaccines similarly reported very good preliminary data. Pfizer and Biopharmaceutical New Technologies vaccines BNT162b1 and BNT162b1 were granted fast track status by the FDA. They are enrolling up to 30,000 subjects in a phase 2b/3 trial starting this month. 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. Over 30 candidate vaccines for COVID-19 have reached human trials to date! Very positive news from the vaccine world indeed.
As I have said on multiple occasions, it is my belief that im yertza Hashem we will return to“normal unmasked socially close lives” – when a successful safe vaccine is available to the general population.
Can I visit my loved ones in a nursing home?
Until today, NYS has not allowed visitation to nursing home patients because of COVID-19 transmission concerns and tragically, thousands of deaths in nursing homes and long-term care facilities. This has been most difficult for all involved. Fortunately, NY is now easing those restrictions for facilities certified as virus-free. Visitors will be allowed if a facility hasn’t had any COVID-19 cases for 28 days.
However, even then, the rules are quite restrictive. Only two visitors are allowed per resident, and only 10% of residents may receive visitors at the same time. Visitors must submit to temperature checks, wear a mask and remain socially distanced. Call before you visit so as not to be disappointed!
As we enter the “9 Days”, we daven for Hashem to have mercy on Klal Yisroel and the entire world. May we spend Tisha Bav, without any travel restrictions, in the rebuilt city of Yerushalayim!