8 questions we still have about Trump’s case of Covid-19

Over the weekend, as news about President Trump’s case of Covid-19 grabbed global attention, STAT outlined some of the key unknowns about the president and his health.

Consider this a sequel.

Below, we sort through some of our biggest remaining questions about Trump and his infection, some of which could be answered in the coming days.

The president started feeling sick Thursday and tested positive for Covid-19 that night, his doctors have said. He was hospitalized at Walter Reed National Military Medical Center on Friday following a dip in his oxygen levels. He’s received the antiviral remdesivir, the steroid dexamethasone, and an experimental cocktail of monoclonal antibodies that is still in clinical trials. He returned to the White House Monday evening, and his doctor said Wednesday that Trump has been symptom-free for 24 hours.

What is Trump’s condition?

Trump’s medical team did not hold a briefing Tuesday as they did the three days prior, but in a memo, Sean Conley, the president’s physician, wrote that the president had no symptoms and that his oxygen saturation levels were a healthy 95% to 97%. “Overall he continues to do extremely well,” Conley wrote. On Wednesday, in a new memo, Conley wrote that Trump has not had a fever for four days and has not received any supplemental oxygen since Saturday, when he experienced what was at least the second drop in his oxygen levels.

That generally jibes with how the medical team has described the president every day since Saturday.

It’s possible that Trump really is feeling well and bounced back from the fever and fatigue he felt last Thursday, perhaps boosted by some of the treatments he’s been on. But the rosy descriptions of the president’s demeanor and energy by his medical team have confused outside experts given that all the therapies he’s received make it sound like this is a very sick patient, at least on paper. Conley has said, however, that the medical team has thrown everything they can at Trump because he is the president.

Meanwhile, the medical team still hasn’t answered some questions outside experts have said would be helpful to know more about Trump’s condition, including how high his fever reached last week, how low his oxygen levels got, and what his lung imaging has shown over time. The images could show whether Trump has had pneumonia or inflammation in his lungs.

When was Trump’s last negative test?

Trump tested positive for SARS-CoV-2 — the virus that causes Covid-19 — Thursday night, his doctors have said. But both the medical team and White House officials have been cagey about when he last tested negative. “I don’t want to go backwards,” Conley said when asked about it on Monday.

This has led to speculation that Trump perhaps wasn’t regularly tested, meaning the White House might have missed a chance to detect his illness earlier and to isolate an infectious Trump. On Thursday, for example, Trump went to New Jersey for events before testing positive.

Neither Trump nor Democratic presidential nominee Joe Biden was tested at the site of last Tuesday’s presidential debate, Chris Wallace of Fox News, who moderated the debate, has said.

If Trump recovers, what explains that?

It’s important to remember that the most probable outcome for Trump, despite being in higher-risk categories as a 74-year-old overweight man, is to recover from his infection. That’s what happens with the majority of people who get Covid-19, even those who have factors that make it more likely they’ll have a severe case or die.

But Trump also received an aggressive course of treatments during what appears to be the early part of his illness, a combination of therapies that few if any other Covid-19 patients have been given at this point in the infection. With just one patient, it’s impossible to disentangle what role, if any, each of the treatments had in his recovery overall or its pace.

When did he contract the virus?

The best guesses of when Trump contracted SARS-2 is likely over the weekend before he tested positive or late in the last full week of September. The president started feeling sick on Thursday, Oct. 1, his medical team has said, and most people who do show symptoms generally do so about five days after being infected. Other people who interacted with Trump those days have also since been diagnosed with Covid-19, including a number of people who were at the announcement of Amy Coney Barrett’s nomination to the Supreme Court on Sept. 26 at the White House.

But trying to pinpoint when and where Trump caught the coronavirus is likely impossible, given that he was around so many different people at so many different moments in those few days.

If Trump started feeling symptoms Thursday, how was he so sick by Friday that his oxygen levels dropped and he needed supplemental oxygen?

Once people start showing symptoms of Covid-19, it typically takes another five to seven days before those who develop more serious cases get sicker. How Trump went from fatigue and fever Thursday to a drop in his oxygen levels Friday, then, is a bit of a head-scratcher.

There are a few possibilities. Perhaps Trump was infected earlier than people think, and he was further along in the course of his illness by the end of last week than realized. Some people have wondered if he had a reaction to the infused monoclonal antibody therapy.

Nahid Bhadelia, the medical director of Boston Medical Center’s Special Pathogens Unit and an infectious disease physician, pointed out to STAT that the five-to-seven day span between symptoms and respiratory problems was the average. Perhaps Trump’s disease just moved more quickly than that.

“This would be a faster course than average,” Bhadelia said. But she added, “everybody’s course is different.”

What are the next few days like for the president?

Trump’s condition, based on what his medical team has said, appears to have improved. But any clinician who has treated Covid-19 will tell you that people can appear to be recovering only then to get much sicker — sometimes very rapidly. When that happens, it typically occurs about a week or more after people start feeling ill.

That means that Trump will need to be closely monitored for several more days at least, something his doctors have acknowledged at several points. In announcing that the president was being discharged Monday, Conley cautioned that “he might not be entirely out of the woods yet.”

Will he stick to guidelines about isolating?

Trump could still be infectious, so under recommendations from the Centers for Disease Control and Prevention, he should be isolated for 10 days after he became sick. (In certain cases, people who had severe illness should isolate for up to 20 days, the CDC has suggested.)

The concern is now that he’s back at the White House, Trump won’t stay away from other people. On Monday, he was filmed taking off his mask as he stepped back into the White House. If he doesn’t isolate, he could put additional administration officials and all the other people who work to keep the White House running at risk.

The White House on Tuesday released updated measures for people who work in the White House residence, but Trump has not been a model for keeping up with precautions. He has a history of mocking federal health guidelines aimed at reducing the spread of the coronavirus and has acted in ways that have alarmed experts since he was diagnosed with Covid-19, including by leaving Walter Reed to wave to supporters from the inside of a car that had at least two other people in it.

Will this change how Americans view the pandemic?

Any hope that Trump would take Covid-19 more seriously after being sick himself is not being realized. Even before he was released from Walter Reed, he told the public via tweet they should not be “afraid” of the disease, even as it’s killed more than 200,000 of their fellow Americans, despite all the efforts to slow the spread of the virus. On Tuesday, he again misleadingly compared Covid-19 to the flu, though there is a higher mortality rate overall for Covid-19 and scientists and clinicians are still uncovering new complications that some survivors of Covid-19 might have to live with. There are also vaccines and approved therapeutics for the flu, which, as of now, do not exist for Covid-19.

Trump’s comments this week could only cement the views of Americans who dismiss the threat of the pandemic and refuse to take the steps that can protect themselves and their communities.