By Jennifer Couzin-Frankel

The White House released a statement regarding the treatment the president has received: “Following PCR-confirmation of the President’s diagnosis, as a precautionary measure he received a single 8 gram dose of Regeneron’s polyclonal antibody cocktail. He completed the infusion without incident. In addition to the polyclonal antibodies, the President has been taking zinc, vitamin D, famotidine [Pepcid], melatonin and a daily aspirin.”
The overnight bombshell that President Donald Trump tested positive for the pandemic coronavirus has prompted a flood of questions. Among them: What is his risk of severe illness? And how might he be treated? To learn more, ScienceInsider spoke with Neil Schluger, a pulmonary specialist who is chair of the Department of Medicine at New York Medical College. He was among many doctors who raced to treat patients when New York City suffered a massive surge of COVID-19 cases in the spring.
Schluger stresses that he has no direct knowledge of the details of Trump’s illness and is not in any way connected to his care. He commented generally on what we’ve learned about risk factors and treatment for mild and severe cases of COVID-19—as well as whether former Vice President Joe Biden, the Democratic nominee for president, might be at risk following Tuesday’s presidential debate.
This interview has been edited for clarity and length.
Let’s start with comorbidities, which we now know play a big role in the course of COVID-19. Trump’s age—74—as well as his weight and being male have all been shown to increase risk for more serious illness from this virus. He also reportedly has high cholesterol. What additional risk might these conditions pose, and can we tease them apart?
A: There is no question that the most significant risk factor for serious illness and a bad outcome is age. That, I think, has held up everywhere around the world. It almost swamps the other risk factors.
Men do seem to have a rougher time. When you look at serious illness and mortality, men seem to be affected more than women. And [being] overweight and obesity are very interesting. They have consistently shown up in many studies as being a common feature in people who are hospitalized. A study published in July in the Annals of Internal Medicine indicated that [being] overweight and obesity were bad prognostic factors mostly in younger people, which they defined it as anyone younger than 65. It may just be that as one gets older, age swamps other risk factors.
How much of an increase in risk does being older than 70 pose?
A: It’s important to remember that at 74, the age of the president, most people will recover. But when you look at the mortality curves related to age, it really starts to go up. Compared to 18- to 29-year-olds, people 65 to 74 have five times the rate of hospitalization and a 90 times higher risk of death.
If Trump is early in the course of disease how might you treat someone like him? Would the antiviral remdesivir or interferon drugs be indicated? Would it depend on what symptoms the patient has, if any?
A: I want to speak fairly generally. I don’t think it’s fair to comment over the shoulder of whoever might be taking care of the president.
With that caveat, the best evidence for therapeutic effectiveness is dexamethasone, but that’s only used and only needed in people with severe illness. In the next category down would be remdesivir. The general feeling about remdesivir is it has a modest benefit in people with moderate illness. It seems to shorten duration of symptoms a little bit, they feel better more quickly. We sort of compare it to the effectiveness of oseltamivir (Tamiflu) for influenza—not a huge lifesaver, but it seems to reduce symptoms.
Should you take remdesivir as soon as you know you have COVID? That’s obviously not a crazy idea. There haven’t really been any data about that because at the moment, the drug is given intravenously. Studies haven’t been done in people with mild illness. But obviously the president of the United States has access to everything.
The next therapy which has been given to a lot of people, and we don’t have great answers for, would be convalescent plasma. Just last week the NIH [National Institutes of Health] expert panel on COVID treatment said they’d make no recommendation for or against the use of convalescent plasma in anyone with COVID.
What about treatments that boost interferons, proteins that defend against viral invasions?
A: There have been a couple small studies that look promising, but I’m not sure I would just give it.
Another treatment that’s gotten a lot of attention is monoclonal antibodies. Would they be valuable?
A: The trials are really interesting and important. There’s been some efficacy of those drugs in Ebola. But I haven’t seen any definitive data for COVID. I personally—unless someone has access to data that hasn’t been published yet that really looks promising—I would say they’re not ready for prime time. In theory they could be made available to certain individuals, but that would seem to make most sense in sicker or high-risk patients.
Let’s talk about the course of disease in someone with Trump’s health and age profile. He is reportedly experiencing mild symptoms now. What are the different ways this could go?
A: As testing has become more widespread, we’ve learned that most people like him will have mild disease and recover without any specific treatment. The natural history of the disease is such that most people that are going to get very sick will generally get very sick in the first 7 to 10 days. There are always exceptions, but I think the next week or so is when there is going to be a tremendous amount of concern.
Why does the virus cause some people with mild symptoms to get much worse, whereas others quickly recover? What determines whether someone becomes seriously ill?
A: There are host factors and bug factors. Some bug factors might have to do with the initial exposure: Did you really receive a blast of coronavirus from someone who was highly infectious? Or did you just get infected with a small number of viral particles that your immune system can take care of? On the host side, it really has to do with the nature of their immune response, their age, and their other conditions.
When would hospitalization be recommended?
A: The reasons to hospitalize someone with COVID are the reasons you’d hospitalize anybody: Your vital signs are unstable and need to be monitored because we’re worried something bad is going to happen, or because you need a therapy that can’t be given as an outpatient. Certainly, if someone develops respiratory complications and needs supplemental oxygen, that’s a reason to be in the hospital. But the vast majority of people won’t need to be in the hospital.
One of the things that I think everyone has noticed—there’s a sense that we’re better at treating this than in March and April. We’ve gotten better at treating severe cases.
Q: There’s been discussion about whether Biden is at risk after Tuesday’s debate. The candidates were some distance apart, but of course maskless and speaking energetically for about 90 minutes. Would you worry about Biden? At what point would you stop worrying?
A: The incubation period seems to be 2 to 12 days, more or less. They seemed to be relatively far apart, so the risk should be relatively small. I’m sure the Biden campaign will be very cautious, given the circumstances. [Biden reported testing negative after this interview took place.]
What comes next?
A: I think we’ll have to wait and see. I’m sure he’s going to get very close medical attention. One worries about anybody in that age group, although President Trump still has a very good chance of having a mild course of disease. But there’s no way to really know.