Thread by @NAChristakis

POTUS is now reported to have COVID symptoms, which, combined with his other baseline risk factors, is concerning. cnn.com/2020/10/02/pol… Most likely, he will recover, but the medical path is not assured and the political implications are substantial.

POTUS is confirmed to have fever and cough, consistent with *lower* respiratory infection. If hospitalized, this will indicate even greater severity. The coming week will be very indicative of likely path he will take through this serious viral illness.

If he is hospitalized in the coming days (and not simply and truly out of an abundance of caution), POTUS will be facing a roughly 1 in 6 chance of death from COVID19.

If he is intubated, the risk will be higher still.

People to whom he spread the disease may also get sick. 3/

Even in the last few minutes, POTUS is now heading to Walter Reed hospital. If he is admitted, this will be a concern. Remember that coronavirus infection can cause patients to “crump” extremely fast. They can become very sick very fast. 4/

The timing of all this will be worked out soon, but there is a chance that POTUS himself could wind up being the source of a super-spreader outbreak in his staff and among others, given his centrality in his network. 5/

POTUS just walked across White House lawn to Marine One and climbed a few stairs with ease. That is a positive sign, and less consistent with hospitalization for cause. Hopefully, we will be told reliable and precise information as this case unfolds, to minimize speculation. 6/

Many credible docs on twitter , such as @jflier, are judging that the administration of an unproven drug to POTUS is a bad sign. Again, absent reliable information, it’s so hard to be sure. 7/

Given the number of cases, it is at this point a rebuttable presumption that there was a super-spreading event of COVID19 at the White House. There will quite likely be more cases emerging, and secondary transmissions too. 8/

Here is a dashboard to track the POTUS COVID-19 outbreak via @bhrenton et al: public.tableau.com/profile/peter.… 9/

Photos via @gtconway3d

In a time of a pandemic, this sets a bad example and is not good public health practice. It’s not fair to the friends and family of all these people either. 10/

It will be interesting to see how this pattern develops. There is a correlation, of course, between where people are seated here and the likely intimacy of their social interactions before and after this event. cnn.com/2020/10/02/pol… 11/

This photo, via @DemFromCT, shows behavior that is very irresponsible. These people have a duty to keep the White House functioning, an obligation to their friends and relatives to whom they could transmit it, and an obligation to set an example of safe practice for the USA. 12/

POTUS may have shortness of breath, if new reports are accurate. This is not a good sign from the point of view of his health. rawstory.com/2020/10/trump-… 13/

From the news conference just completed, these observations:

POTUS likely was on oxygen at some point. That is important (unless again for an “abundance of caution”).

Dates of prior negative tests have not been revealed.

He could be moved to an ICU within 24 hours.

14/

I think POTUS is probably sicker (and for longer) than they are telling us. And if, as a 74 yo obese man, he has gotten that sick this fast, there is a high chance that he will continue to worsen. He could be in ICU within 48 hrs. It is hard to say given lack of transparency. 15/

This story is so fast-moving. That’s what serious COVID-19 infection is like in the elderly or those seriously ill. Patients “crump” rapidly. This just in! He *is* sicker than described. 16/

Late afternoon, October 3: POTUS releases 4 minute video addressing camera. To me, he seems slightly short of breath, but otherwise in decent shape. Yet COVID19 is tricky. He says he is getting "several treatments" and will be in hospital for few days. cnn.com/politics/live-… 17/

Commentary by @emptywheel on the video and photographs released yesterday by POTUS document many staged elements, with implications for conclusions about his respiratory and health status.

Still waiting to see if he winds up requiring oxygen or intubation or dexamethasone. 18/

On the use of the only decent drug we have so far for the treatment of serious COVID19, dexamethasobe, see this prior thread: 19/

Updated photo of Rose Garden super-spreader event, with Chris Christie. As noted earlier, we are likely to hear of more cases. Via @davidrosenthal 20/

October 4 briefing. We now learn that on Oct 2, POTUS had high fever and oxygenation dips. Not good. Docs worried about rapid progression at that time. They have now started dexamethasone. IMO, is he is still early in course, risks may outweigh benefits (see thread above). 21/

In short, docs & White House were misleading yesterday, they admit. This degrades trust. Can we believe them now?

They did not share X-ray or lab findings.

POTUS is apparently improving and is not on oxygen now. But COVID19 patients can suddenly worsen, still. We shall see. 22/

I want to be clear:

If POTUS is NOT that sick, then starting dexamethasone might actually HARM him, as noted here:

If he IS that sick, then the use of dexamethasone means they are minimizing how ill he is.

NB @iwashyna 23/

Using data in RCT that showed efficacy of dexamethasone, and making rough adjustment for age, sex, & condition, and as noted above, POTUS risk of death may now be as high as 1/3.

So the upbeat presentation by his doctors is confusing. I don't know if they are being truthful. 24/

In addition to the risk of death, which I think is as high as 25-33% (if we can believe facts we've been given), POTUS faces other neurological risks, including from COVID-19 itself and, now, its treatment. via @jflier 25/

Fine analysis by my colleague @hmkyale regarding the antibody treatment given to POTUS. Note that, given how POTUS differs from trial participants, I suspect this treatment will be of minimal value in him. Impossible to say for sure, however. 26/

“VIP syndrome” is a cycle of patient (or other) demands resulting in unsound clinical judgment in efforts to meet unrealistic expectations resulting in bad outcomes. It takes a lot of self-discipline & restraint in a doctor to avoid this. ncbi.nlm.nih.gov/pmc/articles/P… h/t @DKThomp 27/

During past pandemics, including in 1890 and 1918, many world leaders contracted infections, as discussed in #APOLLOSARROW (amazon.com/Apollos-Arrow-…). We are seeing this again in 2020, with Johnson, Bolsonaro, and Trump. It partly relates to politicians having bigger networks. 28/

POTUS released a one-minute video of himself 30 minutes ago, looking hale, and then went on a short excursion around hospital. cnn.com/politics/live-…

He seems well (which is the point of this), but it's also possible he is getting quite an energy kick from dexamethasone. 29/

This is one reason it's so hard to be sure what is happening, and whether VIP syndrome might be playing a role. Ordinary patients who truly need to be hospitalized and get IV drugs are not ordinarily allowed to leave hospital grounds, because it would make them worse. 30/

I see that, once again, and unsurprisingly, I agree with @jflier: 31/

I am mystified by the prediction that the president might be discharged from the hospital tomorrow. It doesn’t fit all the other facts of his condition, as disclosed. And it sets up bad optics or bad medical care..... 32/

If he is not discharged, it will signal that he is not doing as well as hoped or has had a reversal of his claimed trajectory.

Of course White House has medical facilities, but a return to hospital after discharge, if required soon, would be bad medicine and bad politics. 33/

If I had to predict, more likely than not, POTUS will not be discharged on Monday. Of course, he could insist, & White House has medical facility.

If we hear that he’s on oxygen again, or is getting “respiratory support” but is “resting comfortably,” that will be a bad sign. 34/

With respect to POTUS COVID, here is a fine political analysis and comparison to UK Prime Minister Johnson — highlighting how political considerations affect communication of health information, if not actual medical care, via @jennirsl @nytopinion nytimes.com/2020/10/04/opi… 35/

It’s possible that monoclonal antibody treatment given to POTUS on Friday may have saved his life, per @EricTopol. Impossible to be sure, but there may have been an inflection in his course then. For a good review of this therapeutic approach, see: cell.com/trends/pharmac…  36/

As noted above, POTUS risk profile given demographics was high (age, male, obesity), but it markedly increased when he had blood oxygen desaturation, (probably) an abnormal lung CT scan, and was hospitalized. So mortality risk was >32%. See: isaric4c.net/risk/ 37/

As of a few minutes ago, the White House press secretary is also positive, further expanding the reach of the super-spreader event.

The White House has an obligation to systematically collect and release test results and to conduct systematic contact tracing. 38/

Subject to properly defining the at-risk population in the White House; given what is known about spread of SARS-CoV-2 and nature of social network in White House; and given brief duration of this initial outbreak, I'd guess that ~10% of people will be positive, maybe more. 39/

This still-under-development network map of White House (with a core group w high network tie saturation) released earlier today by @ValdisKrebs properly anticipated Kayleigh McEnany being positive. We know Mike Pence is negative (so far). People near red nodes are at risk. 40/

Two of White House press secretary Kayleigh McEnany's deputies, Chad Gilmartin & Karoline Leavitt, have now tested positive for coronavirus, per @CNN.

The irresponsibility of not doing more to prevent outbreak in *White House* itself is a transgression of national security.

41/

Updated photo highlighting COVID19 positive cases from the White House super-spreader event. There will be still more cases emerging soon in all likelihood, as noted above in this thread. via @davidrosenthal. 42/

POTUS announces, via twitter 15 minutes ago, that he is leaving the hospital at 6:30 PM tonight. Medically, this makes no sense. Politically, I can see the motivation, but if he is re-admitted within a few days, this will seem worse, politically, I would think. We shall see. 43/

I am concerned that this part of POTUS' tweet -- "I feel better than I did 20 years ago!" -- may reflect the mania that dexamethasone can induce (but we do now know how many doses of what size and time course he has received). Here is one easy paper: …files-live.s3.us-east-2.amazonaws.com/files/s3fs-pub… 44/

Psychiatric symptoms and mania are not uncommon with steroids. Here is a review: sciencedirect.com/science/articl… In rare cases, the effects can persist even after treatment is stopped: pubmed.ncbi.nlm.nih.gov/26644319/ Honestly, There should be plan in case POTUS deteriorates (25 Amendment). 45/

While we're engaged in at-a-distance diagnosis and Kremlinology, remember that a person may have both Narcissistic Personality Disorder (mayoclinic.org/diseases-condi…) and steroid-induced mania, as per Hickam's Dictum, "A man can have as many diseases as he damn well pleases." 46/

His doctors say, moments ago: 47/

More (non-political) staff at White House testing positive: 48/

POTUS walked up the balcony steps at the White House, after discharge from the hospital, which is a good sign from a clinical point of view. Unclear if he was winded but he seemed OK. He’s not out of the woods, yet, however. We shall see. 49/

His lips are pursed and he looks a little winded in this close-up. We shall see. 50/

Another take, with which I agree (except I think risk of death faced by POTUS is, still, higher than 10%), by @DrRobDavidson who makes quite a few distinct points. The public health messaging of POTUS actions is supremely irresponsible. 51/

POTUS’s respiratory rate, if you look carefully at balcony video, is ~30/minute. That’s very high — as expected given his condition. If he’s afebrile, it’s because of dexamethasone.

His vitals aren’t normal.

Luckily, this patient has good medical care at home in White House 52/

A third White House press staffer has tested positive for coronavirus, @CNN has learned, meaning that three of Kayleigh McEnany's deputies are now working from home. 53/

And now this: US Coast Guard Lt. Cdr. Jayna McCarron, a White House Military Office aide who regularly carries the nuclear "Football" for Donald Trump, has contracted COVID-19. McCarron last accompanied Trump to Bedminster, NJ, on Thursday. 54/

For a variety of reasons, I increasingly think there is a good chance POTUS himself was the point source of the super-spreading event at the White House. This may also partly explain why the administration is turning down CDC offers to do an analysis, and contact tracing. 55/

And now Stephen Miller is positive. Networks matter for the spread of infectious disease. White House super-spreading event. 56/

Analysis like this is *part* of the reason I think POTUS may have been patient zero of the White House outbreak. Via @PeterJ_Walker 57:

As of yesterday (Tuesday) afternoon, day after return to White House, POTUS “reports no symptoms,” which is a good clinical sign. In a brief statement, Dr Conley reports the President’s oxygen saturation level is 95-97%, also very good. Not out of woods, but better at moment. 58/

White House was screening with Abbott's BinaxNOW antigen test, which was only for people with symptoms. It's 2000X less sensitive than PCR, and so sub-optimal here, especially if other precautions (like masking & distancing) are not in place. nytimes.com/2020/10/06/hea… 59/

New update released by POTUS doctors today states that patient is 'symptom free' and off oxygen for past 24 hours and has a normal respiratory rate. That is very good clinical news. Not fully out of the woods (next few days critical), but good news, However.... 60/

Interesting that IgG antibodies were detectable on Monday (10/5/20). IgM antibodies can be detectable within a few days (3-5 days) but IgG *may* take longer (depends on test cdc.gov/coronavirus/20…). Detection of antibodies as of 10/5 helps place date of infection. 61/

POTUS released this video an hour ago. He seems improved since yesterday. He may have turned the corner, despite indeed facing serious risk from COVID19 in the past week. Another week or so and I think he may be out of the woods (though he is still infectious!). We shall see. 62/

Rising case count at the White House superspreading event, up to 34. abcnews.go.com/Politics/34-pe… 63/

SARS-CoV-2 at White House at least since September 26: bloomberg.com/news/articles/… 63/

It would be helpful to have more information regarding the type of IgG test administered to POTUS on Monday to clarify whether it was simply detecting the Regeneron IgG administered a few days earlier — which has a half-life of 21 days. Via @bradloncar 64/

Update, again from a distance, on POTUS health as of today. He was able to do a long interview this morning. I won’t comment on false claims he made about his contagiousness etc. But his clinical condition does seem stable. cnn.com/2020/10/08/pol… We shall see in a few days. 65/

As of yesterday, despite the coughing on an interview, POTUS had only slightly elevated respiratory rate, and his physicians say he continued to improve. Clinically, he is on a positive trajectory. However, he cannot assume he won't be infectious in a few days. 66/

Has the president expressed public concern for his wife or Gov. Christie (still hospitalized) or the Senators or other people likely infected at the White House? 67/

Dr Fauci offers partial analysis of the super-spreading event at the White House: 68/

Chris Christie released from hospital this morning. So far, almost all the ~30 (known) people infected in the White House super-spreading event appear to be on the mend, it seems. cnn.com/2020/10/10/pol… 69/

More details are now emerging confirming POTUS was, in fact, quite sick when he first got symptoms, and that dexamethasone was used for indications. POTUS seems to have had a very fortunate course of illness, so far; but he faced a real risk of death. 70/

Based on 247 patients in China early on, POTUS has had a rapid, if standard, course of COVID-19 for patients who survived. He is, however, surely still infectious to others. thelancet.com/pdfs/journals/… via @TheLancet 71/

More recent study of 1,150 patients with COVID-19 in USA reveals similarly high risk of death that POTUS faced. His ongoing cough is typical. thelancet.com/journals/lance… via @TheLancet /72

Dr Conley releases more detail about POTUS, based on which he *may* not be infectious. 73/

For an explanation of what likely went wrong at the White House, and how incomplete (if not incompetent) public health management resulted in the unfortunate super-spreading event there, see this new thread on the "Swiss cheese model": 74/

From where it began, POTUS seems headed to complete recovery. We’ve not been told the dates of his negative tests prior to infection, nor full extent of super-spreading event at White House. But things are far better than they could’ve been at outset. cnn.com/2020/10/12/pol… 75/

Another case (that we know of) from the White House super-spreading event. cnn.com/2020/10/13/pol… 76/

Update: POTUS seems to have escaped unscathed, 12 days from his (announced) positive COVID test result. 77/

Updated graphic of White House Super-Spreader event, courtesy of
@orgnet @ValdisKrebs, to include recently revealed cases. [Now with typo corrected! :-) ] 78/

Chris Christie was seriously ill, in ICU for seven days. Now says COVID19 is serious. Also got access to antibody cocktail (which we don’t yet have RCT evidence for). amp.cnn.com/cnn/2020/10/15… 79/

And now more information comes out that, as I (and other doctors) had inferred at the time, former POTUS Trump was indeed quite sick and at risk of ICU admission, if not death, when he had COVID-19 months ago. nytimes.com/2021/02/11/us/… via @noahweiland @maggieNYT et al 80/