We thank Hashem for allowing many of us to have reached the unbelievable milestone of returning to tefillah betzibbur, our beloved communal minyanim. Throughout the difficulties of this plague, which has taken such a toll on life and health, emotional and physical, we longed for this return. As impossible as it sometimes appeared, we accomplished this while emphasizing safety – and recognizing it is still not safe for all to attend. Some will argue that many returned sooner, with no harm. My response to them is thank G-d. As long as we all follow poskim, all of whom require being machmir (stringent) regarding pikuach nefashos (life threatening) situations, Hashem will watch over us all.

Have Shavuos, the Memorial Day Weekend, the multiple large public protests, and the opening up of some businesses, beaches and general society generated new COVID cases?
While it is too early to definitely answer this question, there has NOT been any change in the strong downward trend in new COVID-19 cases in our community and the metropolitan area. Hospitals, physician practices and Hatzalah are almost back to normal operations, with very few new infections.
But it is totally wrong to “high five” and forget the three core principles that got us to where we are:
1) Masks,
2) Social Distancing, and
3) Handwashing.

Four studies demonstrated the value of these interventions this week.

A CDC study showed that you could prevent a major epidemic which could have spread among 10,579 basic trainees at a joint military base in San Antonio-Lackland. Instead, there were just five COVID-19 cases, three in persons who were contacts of the index patient. Unchecked, hundreds, if not thousands of cases would have been expected. Likewise, a Lancet paper showed that physical distancing, face masks, and eye protection clearly prevent person-to-person transmission of COVID-19.

Cumulative hospitalizations in four states with stay-at-home orders decreased projected exponential growth curves, as per a research letter in JAMA. Observed hospitalizations consistently fell outside of the 95% prediction bands of the projected exponential growth curve.

A Canadian study in the Annals of Internal Medicine showed hospitals would have rapidly exceeded ICU capacity, and observed substantially higher mortality, without physical distancing interventions. Their model demonstrated the challenges associated with relaxation of physical distancing measures without a concomitant increase in other public health measures. Specifically, when the number of contacts between individuals return to more than 50% of normal, disease activity resurged rapidly and ICUs quickly reached capacity, a very scary scenario indeed.

What are the practical implications for public health practice?
Despite documented outbreaks of COVID-19 in congregate settings, screening, testing, administrative measures, quarantine, isolation, and source control can limit transmission of COVID-19 and ensure continuity of critical activities.

I implore everyone to please continue with our practices, which are literally lifesaving. I know two minyanim where a COVID-19 infected person inadvertently attended minyan before he was diagnosed, and in both cases, no additional infections were identified – because all attendees wore masks and socially distanced. We are unfortunately seeing new cases in Eretz Yisroel and other locales around the world, and we must maintain vigilance if we are to further open our society.  I look forward to iy”H discussing opening up our bubbles on Motzei Shabbos at 9:45 pm in our usual zoom chat room, Meeting ID: 980 3243 6809; Password: 5TFRBM. We will have a 10-minute Q & A following the talk.

Is the summer going to make the virus go away?
Maybe a little – but not without doing our part outlined in the previous paragraphs.
A study published in a major Infectious Diseases journal showed that temperatures greater than 52°F on a given day were associated with a lower rate of new cases, whereas daily temperatures below 52°F had the opposite result. Likewise, 1-unit higher UV index was associated with a lower rate of infection at 5 days. Interestingly, precipitation made no difference.

Conclusion: Disease transmission does decline slightly with increasing temperature versus cooler temperatures. However, the association between temperature and transmission is small. Transmission is likely to remain high even at warmer temperatures unless other factors are implemented.

Any exciting new medical information this week?
1)  Some of the most common questions I am asked are regarding vaccines. Many entrants in the vaccine lottery exist, but five companies, each taking a different approach, are progressing in good stead. Moderna, and Oxford University / AstraZeneca, are on target to enter the next phase of clinical trials, and Johnson & Johnson, Merck and Pfizer respectively are also well situated for more trials. Despite promising early results, substantial challenges still must be overcome, but the news is positive.

2) University of Minnesota Medical School researchers published in the New England Journal of Medicine the much awaited first randomized clinical trial testing hydroxychloroquine (HCQ) for post-exposure prevention of COVID-19. This study asked the question: should doctors (or family members of a newly diagnosed patient) take HCQ to prevent getting sick? The answer, a resounding NO.

HCQ did not prevent COVID-19 better than placebo. Further, 40% on HCQ developed non-serious side effects. There was no benefit to prevent infection among those who also took zinc or vitamin C. At least we have some hard data shows HCQ did not prevent COVID-19 infection. More information though still is needed to make definitive statements regarding the futility of such prophylaxis.

As an aside, I am sure everyone has read about the two now retracted HCQ studies which I had mentioned in past emails. We live in a strange world. It remains unclear what happened, although practically speaking, the retractions do not change HCQ recommendations.

3) Human derived plasma therapy still appears promising, with results of a major study which we are involved in being readied for submission. But other applications, including synthesizing and cloning the antibodies are moving forward too. Lilly, AbCellera Biologics Inc., and the U.S. National Institute of Allergy and Infectious Diseases are working on such an experimental therapy, LY-CoV555, which blocks the virus from attaching to and entering human cells, thus neutralizing it.

4) Gilead, makers of Remdesivir which is currently available only intravenously, is exploring a subcutaneous injection formulation as well as a dry powder version to be inhaled. Remdesivir cannot be given orally as a pill because it would be degrade in the liver before being absorbed.
5) Many people are still asking – is safe to get non-COVID medical care? ABSOLUTELY. Do not push it off. New York and New Jersey had 44,000+ deaths “above normal” from mid-March to May, according to the CDC. While Covid-19 tragically caused many of these “excess” deaths, more people also died from heart disease, diabetes and Alzheimer’s than for the same period in previous years. These “excess” deaths may be undercounts of Covid-19, or indirectly linked to the pandemic because of concerns regarding the safety of going to a hospital or doctor for fear of catching COVID.
6) Diabetes is well known for causing trouble in many other disease states, and this is clearly the case for COVID-19. 10% of diabetic patients died and 20.3% required intubation / respirator within 7 days of admission. Take home message: social distancing and preventing infection is critical for diabetics.
7) Boruch Hashem, it is very nice to know that there have not been new Post COVID-19 Pediatric Inflammatory cases. With the decrease in total new cases, this will hopefully continue and our children will remain mostly unaffected from serious COVID-19 illness.
8) Finally, a Sinai study of 15 breast milk samples obtained from donors previously infected with COVID-19 tested positive for secretory antibody reactivity. These data indicate that there is strong immune response in human milk after infection. Mothers protect their children in so many different ways!

Will summer camps open? Will this be the week you tell us we can hug our grandchildren?
Find out motzei Shabbos! I look forward to davening for good news in a minyan.
Have a great Shabbos.