TLS EXCLUSIVE: Dr. Naor Bar Zeev on COVID-19

The first human infection with the novel coronavirus is estimated to have occurred in China probably in late November 2019, as a result of a human coming into close proximity with either a bat, or possibly (there is some uncertainty) through a rare, beautiful and humble creature called a pangolin. By January 30 the World Health Organization declared a Public Health Emergency of International Concern. The following day the United States Secretary of Health and Human Services declared a public health emergency. On March 11 the WHO formally declared a pandemic, meaning the infection was demonstrating sustained community-wide spread in many countries. As we were reading the words “ve’haír shushan navocha”, Iran was struggling to contain the widespread emergence of this virus, followed by Italy, Spain and other countries in Europe. China, Taiwan and South Korea implemented unprecedented lockdowns of many millions, followed by many other countries in quick succession. The impact on economies, communities, families and personal and daily life has been enormous, and is only just beginning.

The scientific and public health community has engaged with this challenge to a degree never before seen. Within a few short weeks of the first case, Chinese scientists made public the full genetic sequence of the virus. Immediately teams around the world started working in parallel on diagnostic tests and potential treatments. Using cutting edge reverse-engineering type techniques where the genetic code is used to identify target proteins for therapy and prevention. In the 3 months since its first emergence, as I write these lines, over 1000 scientific articles on the novel coronavirus have been published, and many more are underway. 64 interventional clinical trials have been started, and are registered on clinicaltrial.gov where their protocols are publicly available. These trials are investigating potential antiviral therapies, other disease modifying agents, active vaccinations and other forms of immunotherapy to prevent or treat the disease now named COVID-19.

What are the key features that make this virus different from all the rest we encounter? Doesn’t influenza virus also cause a lot of disease and deaths every year? Is this corona thing just hype or hysteria? How should we respond?

The novel coronavirus has a few features that make it difficult to contain.

1. It spreads rapidly, it is more infectious than influenza though much less infectious than measles.
2. Viral replication in the body peaks early in the illness before symptoms have fully developed, making people who are not yet feeling unwell potentially infectious to others.
3. Some evidence (from persons on the Diamond Princess cruise ship) suggests that the amount of virus in persons with and without symptoms is of similar magnitude, again making seemingly healthy persons potentially infectious.
4. COVID-19 is a mild illness in most people. This is double-edged sword. On the one hand it means that most people who get it will not feel very bad and will get better, which is good news. On the other hand it means that a lot more people will be moving around the community with minimal or no symptoms and unbeknownst to themselves will be driving community transmission onward.
5. Because this virus is new to humans, the world’s population is entirely susceptible to it. Nobody has immunity to it.

Moreover, the availability of diagnostic testing remains mostly restricted to those with severe disease for now. So-called “rapid tests” (think of a pregnancy test for example) that don’t require an advance laboratory are not yet available. Meaning that many mild infection remained undetected. Even cases that turn out to be severe take a few days to be noticed (but they are infectious in those first few days), so that the number of positive tests today is a gross underestimate of the true number of both cases that in a few days will become severe enough to test, and of cases that remain mild. In short – there is a lot more coronavirus in your community today than the number of confirmed cases. It is this undetected true number that is driving the rapid inflation in cases. The spread of coronavirus is currently growing exponentially. This means that the number of new cases each day is a multiple of the number of cases the previous day. This inflation becomes very rapid very quickly, the line of increase is not straight but curving ever-upwards. (Soon I’ll explain how we can bend that curve back down.)

The large number of undetected cases is also a double-edged sword. On the positive side it means that the fatality rate of the virus is probably a lot lower than it currently seems. This is because the fatality rate is calculated by taking the current number of deaths and dividing it by the current known number of infection cases. If this denominator is actually a lot larger (because most cases are undetected so not counted), then the proportion dying becomes a lot smaller. For example, Iran and Italy have reported high case fatality rates. Some have said maybe this is because they have an older population. While that may be true, in actual fact, the high initial case fatality rate is a good indication of widespread and undiagnosed community transmission. On the negative side widespread and undiagnosed community transmission means more cases will continue to occur.

I’ve explained why early on the case fatality may be overestimated. But there are also good reasons why the true case fatality rate can be an underestimate initially. This is because it takes some time for deaths to occur. The number of deaths today reflect the number of cases 3 or so weeks ago, not now. The number of cases 3 weeks ago was a lot less, making the apparent fatality rate estimate be lower than its true value. So, estimating the true fatality rate (or even severe disease rate) is not easy at this stage. Although overall, it will likely end up being lower than current reports. But even the lowest end of the fatality estimates are much higher than that of seasonal influenza. And because transmission is continuing, even a very small proportion applied to a very large number, is itself also a large number. I am saying that even with low case fatality rates we will sadly have a lot of deaths. These deaths will occur because of widespread community transmission. But this transmission is something YOU really DO have the capacity to reduce!

Hope you are still with me… not easy to halt kop with this difficult sugya!

Most infected persons will have mild symptoms, some will have moderate symptoms (fever, cough), a minority of cases will have more severe illness (shortness of breath), and a few will have very severe illness. Persons at greatest risk are older adults and persons with other medical conditions like heart, circulatory or lung diseases or diabetes. Chasdei Hashem ki lo tamnu ki lo chalu rachamav (Eicha 3:22) – children seem to be spared from severe disease. Children can get infection but will have mostly mild disease. There has been to date a single reported case of severe disease in a child. In seasonal influenza children contribute greatly to community transmission. In coronavirus this seems to not be as important a driver of transmission. However, close congregation of many children in one closed space – like a school – may indeed still be important. The closure of schools is an attempt to stop this transmission among the children, and then subsequently to the wider community, especially to those at risk of severe disease, like these children’s grandparents.

The elderly and the vulnerable need special protection. The UK has announced that all older persons should enter isolation for 4 months. Such a drastic move is again totally unprecedented. It will take a lot of chesed and hadras pnei zaken (veáfilu kol seiva bemashma (kiddushin 33a) and yad chazaka hil’ talmud toirah 6:10 – veáfilu zaken goy, mehadrin oiso bidvorim venoisnim lo yad lesomcho) and major efforts by communities to support our parents and grandparents, teachers, leaders, gedoilim. We must all follow public health directives and consider very carefully how best to support and manage our older family members. We love them, we value them, we want them around for many years to come. We must make every effort to protect them both directly, and indirectly by practising handwashing and so-called “social-distancing”, and certainly by isolating ourselves when we are at all unwell. Specific directives are being issued by local and national public health authorities. These directives should be followed with exactness. Chamira sakanta me’issura! These are challenging times in every sense. I am not purporting to invoke halakhic categories here, this is not for a hedyot to do. But only to recognise that the present halakhic challenges are complex and difficult. I am however qualified and even required to state unequivocally and in no uncertain terms that this is an issue of pikuach nefesh.

If everyone takes it upon themselves as a personal chiyuv to do what they can to reduce transmission, EVEN IF THEY ARE FEELING WELL, then that exponential curve I mentioned will be able to be bent downwards. This has a MASSIVE impact on the final total number of cases (which can be shown mathematically very easily). SMALL PERSONAL MEASURES BY EVERYONE CAN MAKE A VERY VERY BIG DIFFERENCE ON THE TOTAL NUMBER OF CASES OVER TIME. And in turn fewer cases means fewer deaths. As I explained cases are currently circulating undetected, meaning the time to implement these protective steps is NOW.

1. Clean your hands often. Remember yadayim askaniyois hen, it is not easy to remember what you have touched. Wash lechaschila with soap and water for 20 seconds and bedieved with alcohol gels, especially after coughing or blowing your nose (discard immediately any tissues) or after returning from a public place, or entering your car.

2. Avoid touching high-contact objects in public – door handles, handrails, fuel bowsers. Respectfully avoid shaking hands. Wash your hands thoroughly with soap if you do any of these things. Regularly clean high contact areas at home also.

3. Remain aware to not touch your eyes, nose and mouth, except immediately after thoroughly washing your hands. This is a difficult thing to do. Play games with your children to remind them and you to not touch one’s own face.

4. Avoid crowds. This is very challenging especially for frum communities. This is an issue which is well discussed in the shuti”m (see R’Akiva Eiger – michtav be’inyan hamageifa 5591 is instructive and being widely circulated which is how I learned of it, sadly not from my own learning). I’m clearly not qualified to address the halakhic issues, but do please discuss with your Rov.

5. Avoid travel. Minimise even internal travel within the US, since this helps seed virus from community to community.

6. Stay informed. Check CDC and WHO guidance regularly.

7. Be up to date with your seasonal influenza (especially if there are readers in the Southern Hemisphere which will be entering winter) and if required – your pneumococcal vaccines. This will not affect coronavirus risk, but will make coinfection less likely.

All these gezeiros are challenging. Is the tzibbur yachol laamod bahen? Let us really hope so. Strict adherence by every single one of us to these guidelines will reduce community transmission. It will not stop it, but will slow it enough that the health system will be able to cope and provide care to the most severe cases. In mass casualty events, life saving therapy is not given to those who need it most, but to those most likely to survive. Setting aside the medical ethics here and the halakhic questions – this is how things work in mass casualty events, and is happening now with coronavirus in places like Italy. We can avoid getting to that by taking action now.

What about vaccines? What about pharmacological therapies?

This is also a big issue. As I have written in the Lakewood Scoop previously, vaccine safety is of paramount importance, even in a pandemic with many deaths. In the 2003 SARS coronavirus outbreak, developmental work on vaccines raised concern in animal experiments about vaccine safety. Following the 2012 MERS coronavirus outbreak, such safety concern signals were not found in the animal experiments. But these issues are important enough that very rigorous safety testing will have to be undertaken. There won’t be shortcuts, things have to be done methodically and carefully, with very detailed and close monitoring of safety data. An analogous situation happened to the RSV vaccine in the 1960’s. This delayed vaccine development on that important disease of infants by 50 years. Today such a delay for coronavirus vaccine development is not going to happen, but it does mean delays until a vaccine is available. And even if a safe vaccine is developed, the immune system is less responsive to vaccines with advancing age, meaning that communal public health measures will remain important to protect the elderly, even once a vaccine is available. And even once available, production to mass scale will be very challenging.

Other immune therapies are in development and may end up being critically important. They may serve to treat severe cases, they may serve to provide temporary protection to front-line health care workers. They will not be able to be used to induce widespread community protection or to cause cessation of viral transmission, things that only vaccination can achieve.

Drugs are also in active development. This is happening very fast. These will be useful for severe disease, but will not prevent infection.

This virus will not go away. Over the next 2-3 years much of humanity will become infected, most with mild symptoms. But it will come and cannot be stopped. But very importantly, the swiftness and magnitude of its spread CAN be delayed enough so that care can be provided for those who most need it. We can and we must act now.

The world is now approaching a temporary standstill. No travel, no trade, people are home with their families. Veshav’sa ha’aretz shabbos la’Shem. The fear of this tiny invisible creation should shake us into yirá of its and our Creator, and from there, as the rambam so beautifully describes, we come to a greater and greater ahavas Hashem. As we see with our eyes the awe of keter hamalkhus we beseech: Avinu – mena mageifa minachalasecha!

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