Trump’s age, immune system and underlying health problems will chart his battle against covid-19


The president, famously opposed to the medical guidance that Americans wear masks in most circumstances, may have left himself vulnerable to receiving a heavy dose of the coronavirus that has killed at least 207,000 people and infected more than 7.2 million in the United States, according to a Washington Post analysis.

People with underlying health problems also tend to have poorer outcomes. The 74-year-old president weighs 244 pounds, a total that makes him slightly obese, according to information released by the White House after his physical exam in June. He takes a statin for high cholesterol and his blood pressure is slightly elevated.

The most important factor is the president’s age. Human immune systems, which battle the virus, become less effective as we grow older. Even as the overall covid-19 death rate in the United States has declined during the eight months of the pandemic, nearly 80 percent of fatalities occur among people 65 and older. Older men die more frequently than older women.

Someone in Trump’s age group faces five times the risk of hospitalization as does an 18- to 29-year-old and a dramatically higher risk of death, said Graham Snyder, medical director of infection prevention and hospital epidemiology at the University of Pittsburgh Medical Center. The likelihood of Trump developing symptoms, and the severity of those symptoms, also increases with age.

“Age is very clearly the strongest predictor of not doing well with the virus,” Snyder said. “The likelihood of him developing symptoms, including death, is most strongly predicated on his age.”

Tom Frieden, director of the Centers for Disease Control and Prevention during the Obama administration, said Friday on Twitter that a 74-year-old “has approximately 3% chance of death [and a] 10-15% chance of severe illness.”

White House Chief of Staff Mark Meadows said Friday that Trump is experiencing “mild symptoms” of the disease.

Now that the virus has taken hold, doctors will closely monitor the response of Trump’s immune system. Many people who suffer the worst outcomes experience a “cytokine storm,” an overreaction of the body’s immune system that can ravage delicate blood vessels and lead to fluid build-up and pneumonia. Many of those patients require ventilators, typically in a medically induced coma, that essentially breathe for them.

The first five to seven days after Trump was infected — a date that may be impossible to determine — are critical. That is when he is most likely to develop the pneumonias, blood clots and bacterial infections that have made covid-19 so deadly.

“Usually, over the first week you get a sense of how severe this will be,” Snyder said. But another part of the disease’s unpredictability is the harm it causes a small number of people in the second week of their infection and beyond.

As the pandemic has made clear, the coronavirus can kill — or have almost no impact. As many as 40 percent of people may never develop symptoms. Some recover in a matter of days, while “long-haulers” suffer an array of symptoms — including shortness of breath, coughing, fatigue, pain and neurological problems — for months.

Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, said he has never seen a virus with such a wide range of outcomes.

For most people, symptoms are mild to moderate. They can recover at home, as Trump and first lady Melania Trump are doing.

It is possible the severity of the disease is affected by how the virus was contracted. Aerosol transmission involving tiny particles that float for a distance in the air could potentially lead to infection deep in the lungs and a more severe outcome, Columbia University epidemiologist Jeffrey Shaman said. Wearing a mask can help prevent that, research has shown.

Trump’s physicians will probably start him on supportive care to relieve any discomfort, said Amesh Adalja, an infectious disease expert at the Johns Hopkins University Center for Health Security. Those measures include hydration and acetaminophen for fever and aches and pains.

“We don’t reflexively treat patients, even ones who are 74 years old and overweight, if they have a mild case,” Adalja said.

Two former Food and Drug Administration commissioners said White House physicians might consider using remdesivir, an antiviral medication with modest benefits that is manufactured by Gilead Sciences. Even though the drug has been authorized by the FDA for serious cases, it has shown some promise for less serious cases, said Mark McClellan, FDA commissioner in the George W. Bush administration. He said it could be prescribed off label.

Scott Gottlieb, Trump’s first FDA commissioner, said he would recommend remdesivir even for a mild case. “It’s a bird in the hand,” he said. “You know it works.”

If Trump were to get much sicker and require hospitalization, he would probably get several treatments. Therapies for the disease are more available than they were when the pandemic began in January.

“We are seeing much better outcomes in severely ill people,” McClellan said.

Those treatments could include one or more of the following, depending on his condition: supplemental oxygen, remdesivir, the steroid dexamethasone and blood thinners to reduce the risk of clots.

Monoclonal antibodies, a treatment for covid-19 now being tested in clinical trials, might be available through a trial or expanded access program for unapproved medications.

If monoclonal antibodies were used, it should be in the context of a clinical trial, said Adalja. But in that case, Trump would also have the possibility of getting a placebo.

Gottlieb said he doesn’t think the antibody drugs should be used on Trump now because the data is too early. “It’s prudent not to give him antibodies right now,” Gottlieb said.

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