The Brink: What was your reaction on hearing the news about the president testing positive?

Barocas: My first reaction is that I wish the president, First Lady, and anyone who is infected a speedy recovery. As a physician, I do not want anyone to suffer or become ill. This is largely why we have been trying to put out the constant message of prevention—masks, social distancing, these are vital measures to prevent infection with COVID-19.

Corley: I wasn’t surprised. I’ve thought for some period of time, it was only a matter of time. I’ve noticed he’s been a little less careful about keeping his distance lately. I don’t wish this upon anybody. I’m concerned for him and his family, as well as the people he may have infected. It’s sad, but not unexpected.

Hamer: This is a worrisome situation. Given the president’s age, obesity (his body mass index is in the lower end of the range for obesity), and potentially other underlying medical conditions, he is at high risk for progression to severe disease and potentially death. If he stays well, then the only impact will be a slowdown of his political campaign. But if he becomes ill, we may have a very complex political situation ahead, potentially losing the Republican candidate, the VP having to step in to run the government, etc.

Senior White House aide Hope Hicks tested positive Wednesday night, and the president and First Lady received positive results within 48 hours. How likely is it that they have been contagious for several days, during which they’ve been interacting with scores of people (many times sans mask or social distancing)? Is it possible a larger cluster is underway within the White House?

Corley: It is possible. I think we’re going to be seeing a lot of people in government put in quarantine, which is concerning for the running of the country.

Barocas: It is concerning that all three of these people have tested positive. If I were advising the White House, I would suggest universal testing, as well as isolation and quarantine. I’d be concerned that there is a cluster. I’m also concerned that the president has been traveling around the country, holding rallies without masks and without distancing, often indoors in poorly ventilated spaces. These factors put scores of people at risk for the virus and for new outbreaks and clusters within those communities. I hope that anyone who has attended a Trump rally in the last week or been in close contact with White House officials seeks a test and/or quarantines themselves.

Bhadelia: When someone tests positive for coronavirus (or develops symptoms), you have to assume they’ve been contagious for 48 hours already. 

Here’s what I think should happen. There are two types of contact tracing, looking forward and backward. Looking forward [from the time of diagnosis], they need to look at everyone the president, FLOTUS, and Hicks have been in contact with in the 48 hours or so before they received a positive test. That time period falls around the debate; they may have been contagious, and anyone who was within six feet of the president, FLOTUS, or Hicks for more than 15 minutes could potentially be exposed. The concern is that the press secretary, Kayleigh McEnany, knew that Hicks was positive on Wednesday, and had exposure to her, and despite that was not quarantining—she still gave a press conference on Thursday. The CDC [Centers for Disease Control and Prevention] guideline is that anyone who’s had contact with a person that’s tested positive should enter 14 days of quarantine.

(President Trump also traveled to New Jersey on Thursday for a fundraising event, which nearly 100 people attended.)

For backward contact tracing, you are looking backwards [from the time of diagnosis] to identify the source. Hicks might not be the source; instead, she could just be the first infected person to be identified. Hicks, FLOTUS, and the president might all have contracted coronavirus from a common source. To get the best look at chains of transmission, you can do something called phylogenetic analysis. The virus changes slightly every time it passes from person to person, and that can be traced using genetic sequencing. I don’t know if that will happen, but that’s been done in other outbreak settings. You’re trying to understand, when everyone is positive for coronavirus, how did it move through the group? 

On Tuesday night during the debate, you had Trump family members who didn’t wear a mask while in the audience, the president was on stage with Joe Biden for about 90 minutes, spewing droplets into a closed space for a long time. Even though he had tested negative for the virus before the debate, at that time the viral load was likely too low or there was a false negative test result. The incubation period for the coronavirus is four to five days. Biden is getting tested today—the likelihood is that even if Biden tests negative today, he’s within the incubation period. He’ll need to be retested.

Hamer: I assume that the White House staff, president, and First Lady are being tested daily, so they probably just made the diagnosis. It is possible that they became infected by Hicks, although they might also have all had a common exposure during the campaign. If they have been tested daily, then the likelihood that they have been infectious for several days is low. We do know that the viral load is highest early on after infection, and may be higher in older than in younger people.

Contagiousness gradually declines during a 7- to 14-day period. There is a potential for a large cluster in the White House given their purposeful refusal to wear masks or practice social distancing.

President Trump is 74 and overweight. What would your concerns be if you were his attending physician? What does the data show us about how other overweight men his age have fared with coronavirus infection?

Barocas: The president’s age and comorbidities put him at risk for more severe disease. People 65 and older account for the vast number of hospitalizations from COVID-19 and for 80 percent of COVID-19 deaths in the United States. Obesity increases the risk of hospitalization by three times and other conditions, including diabetes and hypertension, can increase that risk, as well. It’s important to remember, however, that risk does not equal certainty. Not all people who are 65 and older or with comorbidities will have severe outcomes. If the president does not have severe disease, he should consider himself lucky. If I were his attending physician, I would ensure that we monitor his vital signs and symptoms very closely. One thing to add is that the president’s privilege and access to early interventions and close monitoring likely decrease his risk of severe disease. Someone of similar age and comorbidities without the same privilege is at higher risk.

Bhadelia: Given his age and that he’s overweight, he’s in a higher risk category. Obesity causes a state of chronic inflammation that can contribute to poor outcomes due to infection. If I were the president’s physician, I might consider giving him remdesivir, an [antiviral] medicine that is currently only being given to hospitalized patients with severe disease. It helps bring viral load down. For the president, who should be given the best possible chance, that might be a consideration even though it’s early and he’s not hospitalized. This would be an ideal off-label use of the drug. However, they may wait to see if he becomes severely ill before making that decision.

Corley: The statistics show that for someone that age and obese, the risk factors say he’s got as much as a 20 percent chance of having to be hospitalized. There’s a reasonable probability that he’s going to get sicker. There’s also the possibility he’ll have a mild disease. This is such an interesting pathogen; the disease course varies so dramatically between two people. Anyone who thinks they can predict what this virus is going to do is fooling themselves.

Hamer: I would be very concerned since he is technically obese (mildly) and in his 70s. Both are risk factors for more severe disease and mortality. His age alone puts him in a demographic that has a 7 to 8 percent risk of fatality (based on large studies from China and Italy) and his obesity increases the risk to a higher level.

The Trump administration has frequently flown in the face of science throughout the pandemic. Was Trump contracting the coronavirus only a matter of time?

Corley: The thing that has distressed me the most is how much the current president has politicized this disease. So many of his followers have taken it as a badge of support and courage to not wear masks. And I think that’s responsible for much of the spread today. I think unless people pay attention to their social responsibilities, we’re going to see continued spread of the disease and it will be hard to control. I’m very concerned about the direction we’re taking right now, even in the city of Boston. It’s important for people to stay really serious about wearing masks, practicing hand hygiene, keep social distancing.

Barocas: We know that masks reduce the risk of transmission by nearly 80 percent. Social distancing has been shown to decrease the risk of transmission. There is strong scientific evidence for these basic public health interventions. Anyone who is not routinely following these preventive measures is rolling the dice. The virus is simply looking to make a home for itself in anyone who has not installed a home protection system. The president is no exception.

Bhadelia: One of the faults in the White House strategy for COVID-19 prevention is that they have heavily depended on testing only, which should only be one part of a more comprehensive strategy to keep people safe. Nobody in the White House wore a mask; this is a perfect example of why we have to take these COVID-19 health measures (wearing a mask, practicing social distancing) to prevent a transmission of infection. 

Instead, the president and White House staff are meeting indoors for long periods of time because of this overconfidence they get from relying on testing, which sets them up to be part of a much bigger COVID-19 cluster. Their strategy has been faulted from the beginning. 

The scary part of this is that for most Americans, we don’t have the luxury of using rapid testing to screen all the people we come into contact with. The stance the president has taken is that coronavirus is no big deal, but now, even in his very secure bubble, it has spread. I hope this increases public awareness about the fact that we’re still in the middle of a pandemic, and that it changes the minds of his supporters who think this is all a hoax. 

It’s likely that a lot more people within Trump’s circle will find that they are infected. The president, First Lady, and Hicks were not in a vacuum this week, they were surrounded by people.