Trump Has COVID, but Does COVID Have Trump?

America woke up to shocking news Friday: The president and first lady of the United States tested positive for COVID-19. What now for the first family, for the country and for the presidential campaign?

At present, it is unknown when and how the president and his wife became exposed to COVID-19, though that didn’t stop rampant speculation among the media, given that last week was particularly action-packed for the president.

Nor did it stop the media blame game, though medical research and guidance from public-health officials on masks has been all over the map since March. 

For her part, House Speaker Nancy Pelosi (D-Calif.) couldn’t resist criticizing President Trump’s inconsistent mask-wearing as “a brazen invitation” for contracting COVID-19, though she herself has not worn a mask when she should have based on current recommendations.

And it should be noted that the president is hardly the only politician skeptical about mask-wearing. One local elected official in Pennsylvania was recently caught on a hot mic calling the face mask “political theater.”

From the White House to Walter Reed

The incubation period for COVID-19—the interval between becoming infected and experiencing one or more symptoms—averages five to six days, but can be as long as two weeks. During this period, someone with the virus can pass it on to others.

President Trump and his staff are tested daily with Abbott’s ID NOW nucleic acid amplification coronavirus test, which can deliver positive results in as little as five minutes and negative results in less than 15 minutes. 

In the first few days after becoming infected, a rapid COVID test can show a false negative result if the level of viral RNA is too low to be detected. It is possible that the Trumps became infected several days before they began to develop noticeable symptoms, and were confirmed COVID-positive late Thursday night with polymerase chain reaction (PCR) testing that is the gold standard for diagnostic COVID testing.

President Trump is generally at increased risk of COVID-related complications because he is male, over the age of 70, and slightly overweight (at 6 feet, 3 inches in height and 243 pounds, his body mass index—a weight-to-height ratio—is 30.4). According to the CDC the overall survival rate for COVID patients in his age group is 94.6 percent—and his odds are at least that good, if not better, considering that as of his last complete physical exam on February 14, 2019, he doesn’t have underlying health conditions like diabetes, hypertension, or chronic respiratory disease, which are associated with more severe illness and complications.

In addition to the murky timeline between when President and Mrs. Trump were exposed to COVID-19 and when they tested positive for infection, there was at first conflicting information about whether the president had mild symptoms at onset, a combination of mild and moderate symptoms at onset, or mild symptoms that progressed to moderate symptoms within a period of hours.

Early Friday evening, the president was admitted to Walter Reed National Military Medical Center. The public was told it was “out of an abundance of caution.” 

The White House released a video statement recorded shortly before President Trump left the White House. Though he looked a bit wan, he wasn’t coughing, didn’t seem out of breath and his voice was strong. And when he boarded Marine One for the trip to Walter Reed, President Trump was able to climb the steps into the helicopter easily—not leaning heavily on the handrails—but his customary snappy salute to the Marine guard uncharacteristically seemed an afterthought. He was likely preoccupied, thinking about the unknowns surrounding his diagnosis and treatment, given that he had lost a dear friend to COVID-19 earlier this year.

But in an interview with Fox News the following night, Chief of Staff Mark Meadows divulged that the president “had a fever and his blood oxygen level had dropped rapidly.” Until then, the public had been told that the president had experienced only a mild cough, nasal congestion and fatigue.

Meadows’ remarks were meant to quell a growing media firestorm over whether the president was ever administered supplemental oxygen—a detail White House Physician Sean Conley had been unnecessarily cagey about during the first briefing on the president’s medical status earlier in the day.

Being a couple of dozen years younger than her husband, slim, and in good health, Melania Trump is 99.5 percent likely to survive COVID, and her symptoms are mild enough that she is being treated at the White House.

A Mix of OTC and Experimental Medication

At Sunday’s briefing on President Trump’s condition, Conley explained that the decision to hospitalize him “for more thorough evaluation and monitoring” was made because he had “a high fever, and his oxygen saturation was transiently dipping below 94 percent” Friday morning, which raised concerns about “rapid progression of illness.” Though the president wasn’t short of breath, he was given supplemental oxygen for about an hour in the White House residence, and responded very quickly to the intervention: “After about a minute on only two liters [of oxygen] his saturation levels were back over 95 percent.”

Silent hypoxia,” which occurs when oxygen saturation falls below 90 percent, has been reported in COVID patients and can lead to heart and kidney damage, as well as to sepsis-induced multiple organ failure.

The treatments being administered to President Trump at Walter Reed address challenges that arise in both early-stage and later-stage (days seven to 10) COVID-19 infection.

Several of the therapies slow or stop the proliferation of the virus to reduce the viral load in the body and give the body’s own immune system time to ramp up. These include: Vitamin D and zinc to boost the immune system—zinc also slows the replication of the virus; injections of the antiviral drug Remdesivir; and an experimental “cocktail” of synthetic polyclonal antibodies manufactured by Regeneron Pharmaceuticals that supplements the body’s own production of a type of white cell known as a B cell, which produces antibodies to a pathogen that target them for destruction by killer T cells.

Conley went to the FDA for an Emergency Use Authorization to administer Regeneron’s polyclonal antibody “cocktail” because it is in Phase 3 clinical trials and not yet FDA-approved. Though the president is the first patient not enrolled in a clinical trial to be treated with the synthetic antibodies, any doctor can ask FDA for permission to treat an early-stage patient who is likely to benefit from the treatment.

Other medications the president is being given are meant to attenuate inflammation triggered by an overreaction of the immune system to the virus known as “cytokine storm” that can cause serious complications like blood clots in the heart and lungs. These include: aspirin, to prevent blood clotting; famotidine (Pepcid), a histamine-2 (H2) blocker that has been shown in studies to blunt the inflammatory response of the cytokine storm, as well as to modulate immune system response; and melatonin, which also mitigates cytokine storm. Vitamin D can also reduce incidence of cytokine storm and help prevent complications related to blood clots.

Side Effects and Drug Interactions to Watch For

The president’s brief hypoxic episode Friday morning is not the only reason he needed to be hospitalized. The medications he is taking can cause side effects that must be monitored and addressed—and the side effects and possible drug interactions of the experimental synthetic antibodies are not fully known.

Remdesivir, which is administered intravenously, can adversely affect liver and kidney function. The president received the first dose of 200 mg Friday evening, and a second dose of 100 mg on Saturday evening. President Trump “tolerated [the second] infusion well” and his liver and kidney function “have remained normal,” and he will continue to receive 100 mg maintenance doses for another three days, according to Johns Hopkins pulmonary critical care specialist Dr. Brian Garibaldi, another member of the treatment team.

Remdesivir may also cause oxygen saturation to fall below 95 percent. Coincidentally or not, the president did experience a second transient hypoxic episode Saturday morning—after having received the initial infusion the night before—during which his blood saturation level dropped to “about 93 percent,” but there was no shortness of breath and lung scans show “nothing of any major clinical concern,” according to Conley.

It is unclear whether the president was given supplemental oxygen a second time, but he was started on the corticosteroid dexamethasone—which is typically given to patients who have required supplemental oxygen to prevent lung inflammation that can lead to viral pneumonia or acute respiratory distress syndrome (ARDS). Side effects of dexamethasone range from mild (skin and gastrointestinal) to severe (pancreatitis or potentially fatal allergic reaction) and the president is being monitored for any adverse reaction while he remains on the drug.

In addition, Conley has not indicated whether famotidine is being administered to President Trump intravenously or orally, and at what dosage. As the drug is used to inhibit excessive gastric acid secretion, high intravenous doses could cause pneumonia, cardiac failure and arrhythmias.

Some Good News

President Trump’s staff released a second video statement Saturday evening from the suite of offices at Walter Reed reserved for use by him and his executive staff, a photograph of him at work on presidential business in a conference room later that night, and a third video statement Sunday evening. All three showed him looking progressively stronger and healthier than he had on Friday evening. 

Doctors have been monitoring President Trump’s lung function with a spirometry test, which measures airflow into and out of the lungs. “He’s maxing it out,” said Dr. Conley on Sunday. “He’s doing great.”

As a result of the progress he’s made, his doctors are making discharge plans to get him back in the White House on Monday. “If he continues to look and feel as well as he does today, our hope is that we can plan for a discharge as early as tomorrow to the White House where he can continue his treatment course,” said Dr. Garibaldi.

President Trump’s medical team considers him an “essential worker.” As the president himself said Saturday evening: “I was given [the choice] to stay in the White House, lock yourself in, don’t ever leave. Don’t even go to the Oval Office . . . Don’t see people, don’t talk to people. . . . I can’t do that. I had to be out front. This is America. . . . This is the most powerful country in the world. I can’t be locked up in a room upstairs and totally safe . . . As a leader you have to confront problems. There’s never been a great leader that [stayed locked away].”

And true to form, President Trump—presumably with the OK from his medical team—surprised the large group of supporters who have been holding a prayer vigil for him outside the hospital with a drive-by in an SUV early Sunday evening. Seeing the president waving and giving them his trademark thumbs up was no doubt sweeter to the cheering crowd than the chocolate Chief of Staff Mark Meadows handed out Friday night.

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