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SARS-CoV-2 Seroprevalence and Symptom Onset in Culturally Linked Orthodox Jewish Communities Across Multiple Regions in the United States

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Can severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks occur simultaneously across culturally bound minority communities?

Findings  In this cross-sectional study of 9507 ambulatory adults, a near simultaneous surge in coronavirus disease 2019 symptom onset and high seroprevalence in as many as 32.5% community members were found among geographically distinct yet culturally bound religious communities. This surge corresponded to social events surrounding the festival of Purim, prior to widespread recognition of epidemic mitigation strategies.

Meaning  These findings suggest that parallel outbreaks may occur within culturally bound communities during holiday periods, which could be exacerbated in the absence of national, culturally sensitive guidance.


Importance  Data on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence in the United States are still emerging.

Objective  To elucidate SARS-CoV-2 seroprevalence and symptom onset in a culturally linked community across 5 states in the United States.

Design, Setting, and Participants  This cross-sectional study included adults (aged ≥18 years) recruited from the orthodox Jewish community across 5 states (California, Connecticut, Michigan, New Jersey, and New York) in 3 geographically distinct areas of the United States between May 13 and July 6, 2020. Participants completed an online survey and underwent SARS-CoV-2 antibody testing.

Main Outcomes and Measures  Seroprevalence and date of symptom onset of SARS-CoV-2.

Results  Overall, 9507 adults (mean [SD] age, 39.6 [15.0] years; 3777 [39.7%] women) completed the SARS-CoV-2 survey, of whom 6665 (70.1%) had immunoglobin G anti–SARS-CoV-2 antibody levels assessed. A high seroprevalence of SARS-CoV-2 antibodies was observed across all communities, with the highest proportion of positive testing observed in New Jersey (1080 of 3323 [32.5%]) and New York (671 of 2196 [30.6%]). Most individuals with a positive SARS-CoV-2 immunoglobin G antibody test reported a date of symptom-onset between March 9 and March 31, 2020 (California: 135 of 154 [87.7%]; Connecticut: 32 of 34 [94.1%]; Michigan: 44 of 50 [88.0%]; New Jersey: 964 of 1168 [82.5%]; New York: 571 of 677 [84.3%]). This start date was coincident with the Jewish festival of Purim, celebrated March 9 to 10, 2020, with extensive intracommunity spread in the weeks following (mean and mode of peak symptom onset, March 20, 2020), occurring in the absence of strong general and culture-specific public health directives.

Conclusions and Relevance  This cross-sectional study of orthodox Jewish adults across the US found that socioculturally bound communities experienced early parallel outbreaks in discrete locations, notably prior to substantive medical and governmental directives. Further research should clarify optimal national, local, community-based, and government policies to prevent outbreaks in social and cultural communities that traditionally gather for holidays, assemblies, and festivals.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: February 1, 2021.

Published: March 10, 2021. doi:10.1001/jamanetworkopen.2021.2816

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Zyskind I et al. JAMA Network Open.

Corresponding Authors: Jonathan I. Silverberg, MD, PhD, MPH, Department of Dermatology, George Washington University, 2150 Pennsylvania Ave NW, Ste 2B-425, Washington, DC 20037 (; Avi Z. Rosenberg, MD, PhD, Department of Pathology, Johns Hopkins University, 720 Rutland Ave, Ross Bldg, Room 632D, Baltimore, MD 21205 (

Author Contributions: Dr Silverberg had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Zyskind and Rosenberg contributed equally to the work. Drs Rosenberg and Silverberg are co–senior authors.

Concept and design: Zyskind, Rosenberg, Zimmerman, Glatt, Joyner, Lieberman, Bigajer, Stok.

Acquisition, analysis, or interpretation of data: Zyskind, Rosenberg, Zimmerman, Naiditch, Glatt, Pinter, Theel, Joyner, Hill, Bigajer, Stok, Frank, Silverberg.

Drafting of the manuscript: Zyskind, Rosenberg, Naiditch, Glatt, Pinter, Silverberg.

Critical revision of the manuscript for important intellectual content: Rosenberg, Zimmerman, Naiditch, Glatt, Theel, Joyner, Hill, Lieberman, Bigajer, Stok, Frank, Silverberg.

Statistical analysis: Rosenberg, Naiditch, Silverberg.

Administrative, technical, or material support: Zyskind, Rosenberg, Zimmerman, Naiditch, Pinter, Theel, Joyner, Hill, Lieberman, Bigajer, Stok, Frank, Silverberg.

Supervision: Zyskind, Rosenberg, Zimmerman, Glatt, Lieberman, Silverberg.

Conflict of Interest Disclosures: Dr Theel reported receiving personal fees from Roche Diagnostics Advisory Board and Accelerate Diagnostics Consulting outside the submitted work. Dr Hill reported performing coronavirus disease 2019 tests for ResourcePath outside the submitted work. No other disclosures were reported.

Funding/Support: Grant 1R35HL139854 from the National Heart, Lung, and Blood Institute and gifts from the National Basketball Association and United Health Group (Dr Joyner) supported the design and conduct of the study.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The following organizations and individuals gave much of their time and expertise to organize the onboarding and testing of the nearly 7000 participants in this study: The Mayo Clinic, The Gates Foundation, Streamline Verify, DealMed, Lakewood Bikur Cholim (Yehudah Kaszirer, BA, Leeba Lederer, Shlomo Ingber, MBL, Chaim Lichtenstein, BTL, Avromi Millworm, Raizy Werner, Levi Friedman, Yehoshua Lapidus), Duvy Perkowski, BTL, Boruch Ber Bender, BTL, and Achiezer Staff, Shalom Jaroslowitz, MSN, FNP, Stellar Scientific, Yankee Friedman, MBA, Joseph Zyskind, Flatbush Hatzolah Volunteer Corps, Chasky Rosenberg, Los Angeles Hatzolah Volunteer Corps, Sarah Weisshaus, RN, BSN, Leon Freue, BA, NREMT-P, Aron Rothman, BS, NRP, Aryeh Edell, Yitzchok Rabinowitz, NREMT-P, Robbie Zeitz, BA, Avi Gantz, Debra Stok, LMSW, Judy Zyskind, DDS, Detroit Hatzolah, Nachi Soloff, Lou Scheiner, and Chaim Einhorn, BS. None of these individuals were compensated for their time.

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