On Oct. 2, President Donald Trump revealed that he and First Lady Melania Trump had tested positive for COVID-19. Here we answer common questions about the risks of the disease, treatments available and the shortcomings of testing.
What do we know about Trump’s risk of developing serious COVID-19?
Without knowing all of Trump’s medical history, it is difficult to know how dangerous his SARS-CoV-2 infection might be. On the morning of Oct. 2, news outlets reported — and White House Chief of Staff Mark Meadows confirmed — that the president was experiencing only mild symptoms.
White House Press Secretary Kayleigh McEnany reiterated the symptoms were “mild” in the afternoon, though Trump was taken to Walter Reed National Military Medical Center and would be “working from the presidential offices at Walter Reed for the next few days,” McEnany said.
At 74 years old, Trump is at higher risk of developing a more severe case of COVID-19 than younger people. Figures from the Centers for Disease Control and Prevention, based on data available through Aug. 6, show that people ages 65 to 74 are five times as likely as 18- to 29-year-olds to be hospitalized and 90 times more likely to die.
Other CDC data show that for the month of August, 6.5% of people between the ages of 70 and 79 who were diagnosed with COVID-19 died, and 18% were hospitalized, although some data on death or hospitalization is missing or unknown.
Trump is also a man — and males have consistently had worse outcomes, on average, than females — and his last physical showed he was mildly obese, with a body mass index of 30.5 (30 is considered obese).
According to the CDC, obesity increases the risk of a severe illness from COVID-19 and may triple the risk of hospitalization. It’s not entirely understood why this is, but carrying too much extra weight has been linked to impaired immune function and fat tissue can also push up on the diaphragm, making it more difficult to breathe.
Most people, however — even those with risk factors — do not get seriously ill, so the president’s chances for a mild infection are still good. He is also not known to have many of the other risk factors for serious disease, such as diabetes or kidney disease, and is likely to receive the best possible medical care.
Scientists are just beginning to understand why certain people fare so poorly with a SARS-CoV-2 infection while others never develop symptoms or only get mildly ill. Recent research suggests that one difference, which may apply to about 14% of severe cases, is that some people don’t produce enough type I interferons early in infection. The proteins are key players in fighting off viruses and help kick off a robust immune response, although too much of them later on could be detrimental.
In some cases, a poor interferon response may result from people having antibodies that inappropriately target and cripple the interferon, whereas others may be due to faulty genes. The offending antibodies are much more common in males. Older people may also have defects in how their bodies mount this type of early, or innate, immune response.
Other research also indicates that older people are less likely to produce a sufficient T cell response to SARS-CoV-2. T cells are part of the body’s later, more specific immune response, and assist with producing antibodies and also kill off infected cells. With fewer of these cells, older patients don’t create a coordinated response to fight off the virus and are more likely to have poor outcomes.
What do we know about the president’s health?
The president’s doctor, Navy physician Sean P. Conley, provided the latest update on Trump’s health on June 3. He said the president “remains healthy.” Trump was 6’3″ and weighed 244 pounds; his cholesterol was 167, lower than the previous physical. (A reading below 200 is considered desirable.) His blood pressure was normal: 121/79.
About six months prior to that report, in November 2019, Trump made an unannounced visit to Walter Reed National Military Medical Center, which he and his staff later said was to conduct part of his annual physical. Conley’s memo said his summary included information both from November and an April exam Conley conducted.
The president was taking rosuvastatin, a medicine for cholesterol, finasteride, used to treat an enlarged prostate or hair loss, and aspirin daily.
In 2018, then-White House physician Dr. Ronny Jackson revealed Trump underwent a coronary calcium CT scan that showed the presence of plaque. Dr. Rachel Bond of Lenox Hill Hospital in New York told CNN the score of 133 on the test indicates “he certainly has coronary artery disease because calcium is present. But this is also common for someone his gender, race and age.”
Who in the White House has tested positive over the course of the pandemic?
Before Trump and First Lady Melania Trump revealed they had tested positive for COVID-19, Hope Hicks, counselor to the president, tested positive, as of Oct. 1.
CNN reported that three journalists who work at the White House, as well as a White House staffer in the press area of the West Wing, had tested positive on Oct. 2.
Before these cases, National Security Adviser Robert O’Brien tested positive in late July; campaign fundraiser Kimberly Guilfoyle, the girlfriend of Donald Trump Jr., tested positive the July 4 weekend; and Katie Miller, Pence’s spokesperson, tested positive in early May.
Others testing positive for COVID-19 include an unidentified White House staffer, unidentified member of Pence’s staff, a White House valet, former acting chair of the White House Council of Economic Advisers Tomas Philipson, a Marine with the unit operating Marine One, and a cafeteria worker in the Eisenhower Executive Office Building.
Before a Trump campaign rally on June 20, six members of the Trump campaign advance team tested positive, and two more staffers tested positive afterward.
What COVID-19 treatments are available and how effective are they?
Despite Trump’s repeated insistence that great progress has been made on COVID-19 treatment, there are no Food and Drug Administration-approved drugs for COVID-19 and only one medication has been shown in a clinical trial to improve mortality.
As we explained before, when Trump attributed an 85% decline in the case fatality rate since April to “pioneering therapies,” most treatment consists of supportive care. And as University of Pennsylvania infectious disease fellow Dr. Aaron Richterman told us in an email, “We have a long way to go in our treatment.”
In a clinical trial, the antiviral drug remdesivir shortened the time to recovery among hospitalized patients to a median of 11 days from 15 days. The medication received an emergency use authorization, or EUA, from the FDA, but that is limited to use among hospitalized patients.
Convalescent plasma may be effective, but the jury is still out on that — and for now, the National Institutes of Health treatment guidelines do not consider it a standard of care and neither recommend for nor against its use. Like remdesivir, it too is only available under its EUA to those who are hospitalized with COVID-19.
The steroid dexamethasone is the only medication to have demonstrated a survival benefit in COVID-19 patients. As a drug previously approved for other uses, dexamethasone can be given to any patient off-label, but data indicate the drug is only effective for those who need supplemental oxygen — and may harm those with less severe cases. Accordingly, the NIH guidelines do not recommend dexamethasone in patients who do not require supplemental oxygen.
There is hope that a new line of drugs known as monoclonal antibodies will prove to be effective and could serve as a “bridge” until the arrival of a vaccine. These drugs are similar in concept to convalescent plasma, but are made of optimized synthetic antibodies that may be safer and more potent than the antibodies isolated from human plasma.
Although still being tested in clinical trials, at least two companies have announced positive preliminary findings.
On Sept. 16, pharma company Eli Lilly released initial data from a phase 2 trial of its SARS-CoV-2 neutralizing antibody that reported the therapy reduced the amount of virus in outpatients and also cut the rate of hospitalization.
On Sept. 29, biotech company Regeneron similarly announced that its antibody cocktail reduced viral levels and reduced symptoms among non-hospitalized COVID-19 patients.
Neither company, however, has published its data yet and the results should not be viewed as definitive.
As of Oct. 2, there is no reason yet to think the president needs any particular treatment, as his symptoms are mild, and as the FDA notes, people in that category “are able to recover at home.”
Still, Trump’s physician said in the afternoon of Oct. 2 that the president had received an 8 gram dose of Regeneron’s antibody cocktail “as a precautionary measure.” According to Regeneron’s press release, that is the “high” dose the company is currently testing.
What are the testing procedures at the White House?
On April 3, the White House announced that anyone in “close proximity” to Trump and Vice President Mike Pence would be tested.
On July 21, White House Press Secretary Kayleigh McEnany said the president himself is tested “multiple times a day,” but Trump contradicted that hours later. He said: “I do take probably, on average, a test every two days, three days. And I don’t know of any time I’ve taken two tests in one day, but I could see that happening.”
On Aug. 3, Politico reported that executive branch employees were told they would be subject to random testing. A White House spokesperson told Politico: “As part of our ongoing efforts to protect the health and safety of the entire White House Complex, randomized testing of Executive Office of the President staff, which has been ongoing for several months, will become mandatory rather than voluntary.”
News reports and Trump’s former campaign manager Corey Lewandowski have indicated the White House uses an Abbott labs test, which can provide results in 15 minutes. Lewandowski said in an interview on the “Today” show on Oct. 2 that he received such a quick-results test twice this week when seeing Trump.
Why didn’t the White House’s testing regimen prevent the president from becoming infected?
Rigorous testing procedures can help identify cases and reduce the risk of an outbreak, but can’t ensure that no one will get infected.
As Harvard epidemiologist Michael Mina explained on Twitter, frequent testing worked in the sense that the transmission chain “is severed.” But, he added, tests are “not prophylactics.”
“They alone cannot stop the test taker from getting infected. But can serve to stop onward spread from the tester,” he wrote. “To stop from getting infected, masks/social distancing are needed.”
It’s also important to recognize the inherent limitations in diagnostic tests. Even if someone tests negative, that doesn’t necessarily mean that a person isn’t infected — only that the test didn’t detect the presence of the virus at that specific time.
Given that it can take a few days or even longer for the virus to become detectable, a negative result means someone still could be infectious and other public health measures should still be taken.
The White House was reportedly using Abbot’s ID NOW test as a rapid test for screening staff. The test is a molecular test that looks for the viral genome in a nasal swab sample, but is faster and less sensitive than the standard PCR tests.
Mina said in an Oct. 2 press call that the test was very good — perhaps the best rapid test available. But no test is perfect, and the test is not actually designed to be used the way the White House deployed it.
The FDA’s EUA was revised in mid-September to specify that testing is intended to be “from individuals who are suspected of COVID-19 by their health care provider within the first seven days of the onset of symptoms.” In other words, the test is meant for those who have symptoms, not for surveillance.
What is the status of a COVID-19 vaccine?
There are currently four companies running phase 3 trials of a coronavirus vaccine in the U.S. One or more vaccines may be available by the end of the year or by early 2021 to select groups, assuming the trials go well and the shots are found to be safe and effective. Members of the general population who are not prioritized for vaccination, however, are not expected to be able to receive a vaccine until later in 2021.
The leading company, in terms of timing, is Pfizer/BioNTech, which has enrolled 35,469 participants in its trial and given 24,298 volunteers both doses of its mRNA vaccine as of Sept. 28. It is the only company that still claims to be able to have an answer on whether its vaccine is safe and effective prior to Nov. 3.
Moderna’s phase 3 trial of its mRNA vaccine has enrolled 27,232 participants as of Sept. 25, 15,454 of whom have received two doses. Moderna’s CEO said on Sept. 30 that the earliest he expected the company to be able to file an EUA with the FDA is Nov. 25, with a wider approval coming perhaps in March 2021.
Oxford-AstraZeneca’s viral vector vaccine trial is still on pause in the U.S. pending an investigation into a possible severe side effect in a volunteer in the U.K.
Johnson & Johnson’s vaccine, which also uses a viral vector, albeit a different one, began phase 3 testing on Sept. 23. It is the only candidate of the four to require only one dose and not to need subzero temperatures.
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