COVID-19 Update by Rabbi Dr. Glatt: Transmission, Vaccines, Nursing Home, Children & More

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: Meeting ID 980 3243 6809; use this new Password: SUMMER2020; by phone: 929 205 6099 or via YouTube link obtainable from [email protected].

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) JAMA published 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!

Have a great Shabbos.