Thread by @Bob_Wachter

1/ Covid (@UCSF) Chronicles, Day 199

OK, now this is now officially mind-blowing. Of course, today’s thread will be all about the President’s illness, what might come next, and what it means.

2/ Once Hope Hicks tested positive, the thinking was that she might have given it to Trump on flights Tues (to OH for debate) or Wed (rally in MN) tinyurl.com/y4e5sgmf But that theory was kiboshed yesterday: the >3 day incubation period meant the exposure was likely earlier.

3/ The perfect timing would have been last weekend. Perhaps a big event where people were mask-less, not distanced, with backslaps and hugging.

Like the Saturday nomination ceremony at the White House for #AmyConeyBarrett.

4/ Yes, it was outside (that's good), but this video shows massively unsafe behavior by many at the ceremony, including Utah @SenMikeLee, who, we now learn, also has Covid tinyurl.com/y4o8clu5 In fact, we now know that 6 people at that ceremony (and counting) are positive...

5/ ...including Lee, Trump, Melania, @NotreDame prez John Jenkins, @SenThomTillis of NC, and an unnamed reporter tinyurl.com/y3pogyr8 A true super-spreader event.

Interestingly, Hope Hicks wasn't there – whether she gave it to someone who was, or vice versa, isn’t clear yet.

6/ Could Trump have given it to Biden on Tuesday? Points against: they were 12ft apart. tinyurl.com/yxj8ejdv Plus, I assumed Trump tested neg Tues, further lowering the risk (even if he already was infected, a viral level too low to test pos usually means less infectious).

7/ But now we learn that Trump didn’t get tested on Tuesday tinyurl.com/yxgz62ff. It will be important to hear his testing chronology Monday-Thursday in order to sort this all out. (I’ve not yet seen that reported, but the news is coming too fast to catch it all.)

8/ And we know that loud talking and/or yelling (as I recall, he did that) are another risk factor for spread tinyurl.com/y4qmxn9s

Reassuringly, Biden has tested negative so far, but as has been reported…

9/ … 2-3 days out is too early to be reassured. Biden needs work under the assumption that he might be infected until we have several days of negative tests. This is already an epic shit-show – can you imagine if Biden has it too… and got it from Trump. The mind boggles.

10/ Melania is also infected; she sat at debate close to others w/o masks (she wore one except when she went on stage to hold Trump’s hand, oddly) tinyurl.com/yxayds8c They all need tests pronto.

By the way, her mortality risk, as a healthy 50 year old woman, is pretty low.

11/ As is now appreciated (today everybody became an expert in Covid mortality risk), Trump’s risk (as of last pm) was already high, based on being 74, obese & male. At time of diagnosis, his risk of death was ~5-8% (vs overall population risk of ~0.6%) tinyurl.com/y5h7wgob

12/ But today went on, with jaw-dropping news hourly. That 5-8% risk is for ALL 74 year old obese men, including 20-40% of people w/ Covid who never have symptoms. Once we learned he had symptoms, the odds worsened.

The initial symptoms of fever/lethargy weren’t too worrisome...

13/ ... (though lethargy raises 25th Amendment questions, either by itself or if it progresses to confusion, as it often does). Given his risk, it was clear that there would be a scramble over monoclonal antibodies, as I predicted last night tinyurl.com/y4r5t9vv

14/ Why? Because the therapies that have been shown to work (dexamethasone & remdesivir) only do so in hospitalized patients. Though remdesivir hasn’t been studied in outpatients, it would have been reasonable to give him an IV slug in the WH (it appears that didn't happen).

15/ In fact, there’s no approved treatment for ambulatory patients at high risk of deterioration. But the early, not yet published, trials of monoclonal antibodies are promising, the treatment seems safe, and it makes sense to give it in this special case tinyurl.com/ybzo5x68

16/ To give it, Trump’s doc invoked "compassionate-use." tinyurl.com/y6lzhp2f Yes, it’s line-jumping & ethicists will have a field day, but it doesn’t bother me much. Based on data to date, it’s likelier than not to be beneficial, even if it’s not proven enough for approval.

17/ OK, so that was the situation as of mid-afternoon. Clearly he’s ill, we wonder if he has to hand the reins to Pence, he's at high risk for deterioration, but otherwise things seemed stable.

Then the shocker: he's off to Walter Reed “for a few days.” tinyurl.com/yydfwtug

18/ Now we're down a bad loop of the algorithm: not only with symptoms, but symptoms (such as shortness of breath or cough) or signs (such as low oxygen) bad enough that his docs think he needs to be in the hospital. They wouldn't do that if he only had a fever & muscle aches…

19/ … It might mean he's now sleepy or confused (25th Amendment!), or, more likely, short of breath, cough &/or low oxygen level, indicating lung involvement. Yes, the threshold to hospitalize the president is probably lower than for average person, but still – it's not good.

20/ And that it occurred the day after his first symptoms – whereas patients are often stable for 3-10 days before crashing – is worrisome.

The odds on the chart in #18 are for all comers, not necessarily high-risk patients like Trump. At this point, his risk of death is >10%.

21/ Listen next for whether he goes to the ICU. If so, he'll have to hand over leadership, temporarily at least, to VP Pence. And his mortality rate goes up more, particularly if he needs to go on a respirator, in which case it’s 20-40%, even with the best care in the world.

22/ If he goes to ICU & recovers, avg length of stay will be several weeks; thru 11/3 would be unsurprising. I’ll leave it to the political hacks to sort out what this means for the campaign. Boris Johnson got a short-lived approval bump after his recovery, but it quickly eroded.

23/ Treatment now: in addition to the monoclonal antibodies, he’ll be getting dexamethasone & remdesivir; I don’t know about convalescent plasma on top of antibodies (no studies of them together). But basically, he’s getting all there is, there’s no “VIP treatment” to offer.

24/ My antipathy for Trump as a human and a leader is real, even though I tried to stay modestly apolitical on Twitter until that became impossible. But he’s a human with a family and, while I fervently hope he loses the election, I also hope he pulls through.

25/ By teaching the nation – including his followers – how serious this virus can be and how important masks and distancing are, in illness Trump may end up saving tens of thousands of lives – far more than when he was well.

Wouldn't that be the ultimate irony.