“Flirting with Coronavirus”, “I hope he dies”, “Political Stunt – he was never positive”, “Steroid Induced Psychosis”, “Homicidal Negligence”. This curious cacophony of unrestrained antipathy against President Donald J Trump is an extreme example of how a universal non-discriminatory virus has become a double-edged “weapon of mass indoctrination” by politicians, Big Tech, Big Pharma and media (social or otherwise).
Joining the fray is an increasing number of doctors. Honestly, the unapologetic flip-flopping by world experts and the silence (and now, silencing) of other medical experts has made us all complicit in keeping the science murky. No wonder, after nine months, the average Joe is still confused, and no longer as compliant.
Let’s use this case to learn what is currently known about Covid-19. What are the odds against a 74-year-old mildly obese (BMI of 30.4 kg/m2) male with Covid-19, walking out of the hospital 3½ days later, to climb, unassisted, two flights of stairs, without calling 911?
Issue 1: “Did he REALLY get Covid-19?” Yes
False positive rates are close to zero for RT-PCR and rapid antigen tests. These tests are very specific — when positive, are almost always true positives, unless there have been laboratory contamination or technical quality assurance issues.
The Trumpworld Coronavirus Tracker listed by date, the 22 in the White House cluster who have tested positive since the first case on 30 September. Trump and Melania’s tests were positive on 1 October. The Rose Garden SCOTUS ceremony, (allegedly the super-spreader event) was on 26 September.
Issue 2: “Was he given oxygen?” Possibly, initially, making the early transfer to a tertiary hospital a sound clinical judgement
The need for supplementary oxygen is a ballpark figure for the severity of Covid-19 lung infection, but lung Xray, CAT and ultrasound scans are more accurate.
Reporters knew that Covid-19 pneumonia can cause oxygen deprivation (hypoxia) without the patient being aware of any noticeable breathing difficulties. By the time patients realise they are short of breath, they have already deteriorated into the life threatening stage of moderate-to-severe pneumonia.
Covid-19 “happy hypoxia” (“silent hypoxemia”) is detected with a pulse oximeter. This monitoring device, when clipped to the fingertip, measures oxygen saturation in the peripheral arteries. A healthy individual with normal lungs, breathing air at sea level, will have an arterial oxygen saturation of 95% – 100%. His tongue and lip should appear pink.
If the oxygen saturation is 94% or lower, oxygen needs to be given. A saturation of less than 90% is a clinical emergency. The hypoxic patient may not appear “blue” until the saturation is less than 90%. Likewise, it is difficult to detect cyanosis in a dark-skinned patient or one who is severely anaemic. The pulse oximeter detects hypoxia sooner and is a life-saving early-warning system in the intensive care and operation theatre.
The key is to diagnose Covid-19 pneumonia early by detecting the initial drop in oxygen saturation to promptly put out a treatment plan. Early detection prevents patients from getting worse and having to be intubated and mechanically ventilated, which still results in a 50-80% mortality rate. This risk is greater among males and those above 70 years-of-age.
One in five hospitalised Covid-19 cases in Germany (Feb 26 – Apr 19) succumbed to the disease. The death rate rose to 53 percent for those who needed ventilation. Hospitalised male patients had a higher mortality rate (25 percent) than women (19 percent). Older patients were also more vulnerable. 27 percent of patients in the 70s and 38 percent above 80 died.
In Malaysia, all Covid-19 positive cases are admitted to low-risk treatment centres for medical monitoring, regardless of how they feel, so that early and pre-emptive treatment can be given well before patients develop severe symptoms.
This, I believe, is the secret recipe behind our low death rates. In many countries, cases are asked to stay home, and to call only when they feel “sick enough”. This delay has proven to be a tragic death sentence, even for young, previously healthy people.
Issue 3. Risk of hospitalisation, severe illness and death for seniors
Eight out of 10 Covid-19 deaths reported in the United States are among adults 65 years and older. Among adults, the risk for severe illness from Covid-19 increases with age, with older adults aged 85 and older at the highest risk. Severe illness means that the person may require hospitalisation, intensive care, or a ventilator to help them breathe, or death.
Black and ethnic minority groups are also at higher risk. These underlying medical conditions increase the risk for severe illness: cancer, chronic kidney disease, chronic obstructive pulmonary disease (COPD), heart conditions, for example heart failure, coronary artery disease, or cardiomyopathies, weakened immune system, Obesity (BMI of 30 kg/m2 or higher), sickle cell disease, smoking and Type 2 diabetes mellitus.
The following comorbidities increase hospitalisation risks: asthma by 1.5x, obesity 3x, diabetes 3x, hypertension 3x, severe obesity (BMI>40) 4.5x. Chronic kidney disease, coronary artery disease, history of stroke, and COPD by 4x each. Those with three or more conditions have 5X increased risk.
The US CDC (Aug 2020) revealed the Covid-19 hospitalisation rates for the 65-74 year-age group to be 5X more than those aged 18-29. The rate for the 75-84 year group is more than 8x.
The CDC Morbidity and Mortality Weekly Report (March 2020) confirmed the following: (I could not find more recent data):
• ages 85 and older, 31%-70% were hospitalised and 10%-27% died.
• ages 75-84, 30.5%-59% were hospitalised and 4%-10.5%% died.
• ages 65-74, 29%-43.5% were hospitalised and 3%-5% died.
• ages 55-64, 20.5%-30% were hospitalised and 1%-3% died.
• ages 45-54, 21%-28% were hospitalised and 0.5%-0.8% died.
• ages 20-44, 14%-21% were hospitalised and 0.1%-0.2% died.
• ages 0-19, 2%-2.5% were hospitalised and none died.
The death rates for age group 65-74 is 90X and for age 75-84 is 220X more than for age 18-29 year age group (18 Aug).
Issue 4: Post discharge – was he tested (before starting his rally on 12 Oct)?
On 12 October, a memo from the White House physician announced Trump had tested negative with the Abbott BinaxNOW rapid antigen test “on consecutive days”.
Since 9 July, WHO said the test-based strategy (two negative RT-PCR tests before discharge) is no longer recommended in the majority of cases, because of the prolonged isolation of patients who may continue to shed detectable SARS-CoV-2 RNA (persistently positive on RT-PCR), but are no longer infectious. The prolonged isolation affects individual well-being, society and (other patients’) access to healthcare. Also, there is insufficient testing capacity to comply with this test-based discharge criteria in many parts of the world.
The US CDC Guideline (10 August, updated 10 September), “Symptom-Based Strategy for Discontinuing Transmission-Based Precautions”, supported WHO in the use of duration of symptoms from onset, rather than pre-discharge testing, to avoid prolonged isolation and the unnecessary use of laboratory testing resources.
The latest CDC recommendations for the “Duration of Isolation and Precautions for Adults with Covid-19” (10 September) are as follows:
- For patients who are asymptomatic throughout their infection: transmission-based precautions may be discontinued when at least 10 days have passed since the date of their first positive viral diagnostic test.
- For patients with mild to moderate illness: At least 10 days have passed since symptoms first appeared and at least 24 hours have passed since last fever without the use of fever-reducing medications and symptoms (e.g., cough, shortness of breath) have improved.
- For persons with severe illness or the severely immunosuppressed who may produce replication-competent virus beyond 10 days that may warrant extending duration of isolation and precautions for up to 20 days after symptom onset; consider consultation with infection control experts.
Role of PCR testing to discontinue isolation or precautions
For persons who are severely immunocompromised, a test-based strategy could be considered in consultation with infectious diseases experts. For all others, a test-based strategy is no longer recommended, except to discontinue isolation or precautions earlier than ten days.
This is based on the finding that RT-PCR tests may remain positive for up to 12 weeks in recovered patients, although viable virus has not been isolated 3 weeks after symptom onset. (Korea CDC; Li et al; Xiao et al; 2020). Investigation of 285 persistently positive cases, which included 126 persons who had developed recurrent symptoms, found no secondary infections among their 790 contacts. Efforts to isolate replication-competent (viable) virus from 108 of these cases were unsuccessful (Korea CDC, 2020).
A large contact tracing study reported that high-risk household and hospital contacts did not develop infection if their exposure to a case patient started 6 days or more after the case patient’s illness onset (Cheng et al 2020).
As described in the Decision Memo, an estimated 95% of severely or critically ill patients, including some who were severely immunocompromised, no longer had replication-competent virus 15 days after onset of symptoms. No patients had replication-competent virus more than 20 days after onset of symptoms.
This means that even in the severe cases, within 15-20 days of onset of symptoms, doctors were unable to grow viable viruses from the patients, i.e. they were essentially no longer infectious. The ability of a virus to multiply in cultured cells serves as a surrogate marker of infectivity.
Issue 5 – Duration of infectiousness post Covid-19 – 10 days
Both WHO and CDC conclude that available data indicate that persons with mild to moderate Covid-19 are no longer infectious more than 10 days after symptom onset.
Persons with more severe to critical illness, or who are severely immunocompromised are likely to remain infectious, no longer than 20 days after symptom onset.
Pre-discharge negative RT-PCR or rapid antigen tests the recovering patients are reassuring, but are no longer required for discharge from isolation.
Issue 6 – Is he immune? Role of serologic (antibody) testing?
WHO and CDC both stated that serologic testing should not be used to establish the presence or absence of SARS-CoV-2 infection or reinfection. The increasing number of reported laboratory confirmed re-infection cases has raised some doubt about one’s immune status post Covid-19.
A few cases seem to be clinically more severe the second time around. The correlation of infection or vaccination with the duration of antibody test positivity or protective immunity (or worse disease) need more study. Until more is known, Covid-19 survivors should still avoid unnecessary re-exposure.
Issue 7 – Trump’s treatment cocktail –“reckless negligence” or “miracle cure”?
The giving of remdesivir, monoclonal antibodies, and dexamethasone within the first two days of diagnosis has caused some doctors to extrapolate that his condition must have been quite severe.
They used the current practice of only giving these in the more severe stages to back their “expert” opinion that he falls into the severe category, hence that he might still be infectious, even after 10 days.
On the other hand, could it be possible that Trump, an inveterate risk-taker, was a willing guinea-pig, and wanted his doctors to give him everything that might possibly work, ASAP (as soon as possible)?
To me, as a paediatrician with 31 years of experience, it makes a lot of sense to give exposed patients specific antibodies as soon as exposed, rather than wait till the viruses multiply and really cause havoc.
Paediatricians are familiar with the use of Hepatitis B immunoglobulin (antibodies) given simultaneously at birth with the HB vaccine to babies of HBsAg positive mothers. This drops maternal to child transmission by 90% and is hugely better than HB vaccine alone.
HBIG provides instant passive protection, mopping up any HB virus that may have invaded the neonate during birth. This passive immunisation protects the baby in the first two to four weeks while his immune system is being “kick-started” by the HB vaccine.
Perhaps SARS-CoV-2 monoclonal antibodies may work in the same way in blocking Covid-19, better, given early than late. Perhaps Trump’s willingness to take risks allowed his physicians to go against the current timing preferences. His rapid, almost miraculous recovery is a turning point for reviewing Covid-19 treatment protocols before interest groups and the litigious set them in stone.
In their Brutus-like obsession and politicised grandstanding, the miracle of a possible Covid-19 cure with a concoction of available treatment options given very early, is missed. What if, all the weapons to defeat this virus are already in our hands, but our timing is all wrong?
A fusion opinion from a Sarawakian public health specialist, paediatrician, ex-associate professor, disaster relief and medical volunteer, passionate about helping people learn.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.