POST 263. July 24, 2022. CORONAVIRUS. “Inside the West Wing, there was never much doubt that Mr. Biden would eventually contract the disease.”…”The president’s access to healthcare started even before he got sick. He receives full time medical care from the White House Medical Unit, a part of the military located on the first floor of 1600 Pennsylvania Avenue.”

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“President Biden has tested positive for COVID-19, the White House announced on Thursday.

He is fully vaccinated and twice boosted and, according to White House press secretary Karine Jean-Pierre, “experiencing very mild symptoms.” She said he has begun taking Paxlovid, a standard course of treatment for people who are considered to be at higher risk of adverse affects of COVID, including anyone over 50.

Biden “will isolate at the White House and will continue to carry out all of his duties fully during that time,” Jean-Pierre said in a statement. “He has been in contact with members of the White House staff by phone this morning, and will participate in his planned meetings at the White House this morning via phone and Zoom from the residence.” (B)

“In the early days, Mr. Biden was a president in a bubble, governing the country mostly by Zoom inside the Oval Office. He rarely traveled. He held few in-person meetings. And most of the ceremonial trappings of the office — like the medal ceremony — were canceled or postponed, victims of the lockdowns that were deemed necessary to stop the spread.

But like many other Americans, Mr. Biden has loosened up in recent months. Protected by multiple doses of the vaccine, the president and his aides have changed their risk assessments and have begun to live with the coronavirus.

“Whatever your thing is — whether it’s being the president of the United States, going to school, going to work, doing the things you enjoy, being with who we love — it can’t be put off forever,” said Andy Slavitt, who advised the White House on its Covid-19 response early in the Biden administration.

Mr. Slavitt said Covid-19 has become a disease that “comes around as frequently as a common cold but with much more severe consequences. It’s a much more uncomfortable middle state for people to adjust to.”…

But the pandemic is not over.

According to the C.D.C., most of the country is now classified as areas with high community transmission. The latest Omicron subvariant to become dominant, BA.5, is vastly more contagious than the original coronavirus, though doctors say the vaccines remain effective at preventing hospitalization and death.

So Mr. Biden has to walk a careful line, demonstrating that he is just like every other American eager to be done with Covid-19, even as he keeps his eye on the possibility that the pandemic could come roaring back.

Inside the West Wing, there was never much doubt that Mr. Biden would eventually contract the disease. By this week, many of the people around him already had: Vice President Kamala Harris; Jen O’Malley Dillon, his deputy chief of staff; Karine Jean-Pierre, his press secretary; several cabinet members, including the attorney general; Doug Emhoff, the second gentleman; and Jen Psaki, his former press secretary — twice…

“We’re in a much, much better place than where we were 18 months ago, when the president took office,” Dr. Jha said, adding that the current level of about 400 Covid-19 deaths per day was “unacceptable.” He also added a grim warning.“This virus,” he said, “is going to be with us forever.”  (A)

“1. What are the important risk factors for Biden?

The most important risk factor for developing severe COVID-19 is age. If you are 79 years old when you become infected with COVID-19, like President Biden, you are eight times more likely to become hospitalized and 140 times more likely to die compared with someone who gets COVID-19 at age 20. Preexisting health conditions – like obesity, cancer and chronic kidney or lung disease – also increase the risk of severe illness. But Biden is reported to be fairly healthy.

Fortunately, preexisting immunity from vaccination or from a previous episode of COVID-19 is highly protective against severe disease. Researchers only have limited data on the BA.5 variant that is responsible for most recent COVID-19 cases in the U.S. – and likely Biden’s, too – but the level of protection from vaccines is likely similar to that of the previous strains BA.1 and BA.2…

2. What is the first line of treatment for someone like Biden, and why?

Current best medical practice is to give antiviral treatments to patients who have recently developed mild to moderate COVID-19 symptoms and are at higher risk of severe illness. The goal of antivirals is to stop the virus from replicating in the body in order to prevent hospitalization or death.

Currently there are four antiviral drugs available in the U.S. for the treatment of COVID-19 in outpatients: nirmatrelvir-ritonavir, better known by the brand name Paxlovid, remdesivir, bebtelovimab and molnupiravir. The best drug for a particular patient depends on preexisting health conditions, accessibility and drug interactions with other medications. Paxlovid is widely used because it was shown to be highly effective in a clinical trial and is available in pill form…

3. How does Paxlovid work, and what are its shortcomings?

Paxlovid is an oral antiviral drug that is used to treat some patients with mild to moderate COVID-19 who do not require hospitalization. Paxlovid is a combination of two medications. One is nirmatrelvir, a drug that works by disrupting the coronavirus’ ability to make functioning proteins. The other is ritonavir, an HIV drug that boosts the level of nirmatrelvir in the blood by blocking an enzyme in the liver that breaks down nirmatrelvir…

Paxlovid is not a panacea. It cannot be used for some patients who have significant kidney or liver problems, and it interacts negatively with a large number of other medications. Some patients cannot take Paxlovid because of the other drugs they use, but physicians can sometimes manage these interactions.

4. What will Biden’s health care team be on the lookout for?

Biden’s doctors will be monitoring his symptoms and checking his blood oxygen level. If Biden’s symptoms – like cough, shortness of breath or fever – worsen or he needs supplemental oxygen, it is possible he would be hospitalized where he may get treated with additional drugs, including steroids.

Some patients experience an initial improvement followed by a “rebound” of their COVID-19 symptoms. It is not clear how often rebounds happen or if they are associated with COVID-19 treatment. Rebounds appear to be generally mild and not associated with hospitalization or death, though they can prolong the required period of isolation.

It is still too early to tell how mild or severe Biden’s bout of COVID-19 will be. With most mild cases only lasting around a week, the U.S. should only need to wait a few days to get a sense of what kind of fight the president is facing.” (E)

“The president’s access to healthcare started even before he got sick. He receives full time medical care from the White House Medical Unit, a part of the military located on the first floor of 1600 Pennsylvania Avenue.

It’s staffed by doctors, nurses, physician assistants, and medics, and operates similar to an urgent care center. As part of the job, presidents always have a doctor traveling with them. 

One former senior official in the Trump administration who spoke to Insider on condition of anonymity said the White House can also bring in outside physicians, such as specialists in infectious disease.

Arthur Caplan, a leading bioethicist who teaches at NYU Langone, said the president has immediate access to primary care, regular testing, and any medication doctors determine are needed.

“Obviously you have excellent rapid access to whatever drugs you might need,” Caplan said. “Many Americans do not.”

On top of that, the president can quarantine while still doing his job in a way many US workers cannot, particularly if they don’t receive paid sick days that will help them support their families.

“The president doesn’t have this problem,” Caplan said. “He can Zoom 24/7 and do things that CEOs and other people in fortunate positions can do in isolation.”

Should the president’s condition worsen, he’d be transferred to Walter Reed National Military Medical Center, a world-class facility about 16 miles north of the White House in Bethesda, Maryland. It’s the same place where presidents receive their annual physicals and screenings such as colonoscopies.

Biden can travel to Walter Reed either through a motorcade or by helicopter. And he wouldn’t have to wait hours in the emergency department like most regular patients.

If Biden were to go to Walter Reed then he’d stay at the presidential suite. According to the former Trump administration official, the space is similar to an apartment and includes both a bedroom and a Cabinet room so “you can keep being president even while you’re in the hospital.”

“Think of it like a very deluxe hospital setting,” the person said.”It’s the size of what you would imagine the leader of the free world to run the government from if he should need to be in the hospital.”

On top of that, Walter Reed doctors can call on specialists at the nearby National Institutes of Health, such as Dr. Anthony Fauci, the federal government’s top infectious disease expert, or another clinical expert.

Open questions remain about whether the president could get what has been called “long COVID,” meaning symptoms of the illness that persist for months including fatigue and headache. Caplan said the best healthcare in the world won’t matter if doctors find themselves unable to treat serious, persistent symptoms.

It’s too early in Biden’s diagnosis to know whether he’ll have long COVID, and it’s still not clear what proportion of people who get COVID have these extended symptoms.

“I’m not aware of data that age is a significant risk factor for long COVID,” Jha said. “He gets excellent care from his physician and if he has persistent symptoms they will get addressed.” (F)

“President Biden’s coronavirus infection is a stark illustration that the Covid vaccines, powerful as they are, are far from the bulletproof shields that scientists once hoped for.

Mr. Biden has received multiple doses of the Pfizer-BioNTech vaccine; his most recent shot, a second booster, was on March 30. Studies suggest that those doses will provide a powerful bulwark against severe illness — and indeed, the president has only mild symptoms so far after testing positive on Thursday, according to the White House.

But even booster doses offer little defense against infection, particularly with the most recent versions of the virus. What protection they do offer wanes sharply and quickly, several studies have shown. In the president’s case, the booster shot he received nearly four months ago is likely to have lost most of its potency at preventing infection.

Earlier in the pandemic, experts believed that the vaccines would be enough to forestall not just severe disease, but also the vast majority of infections. And that was true when earlier versions of the virus, including the Delta variant, swept the globe.

But the Omicron variant upended those hopes. As more of the population gained some immunity, whether from infection or vaccines, the virus evolved to dodge those defenses. BA.1, the subvariant of Omicron that circulated over the winter, was adept at causing infections even in those who had received a booster dose just weeks earlier.

Each subsequent avatar of the virus has become still better at sidestepping immunity. BA.5, which now accounts for nearly 80 percent of cases in the United States, is the most wily yet. Detailed data collected in Qatar suggests that immunity from previous infection and vaccines is weakest against BA.5 compared with its predecessors.

BA.5 is also highly contagious. The nation is recording roughly 130,000 cases per day on average; that number is likely to be a huge underestimate, because most people test at home or do not test at all.

The number of hospitalizations has also spiked over the past few weeks, although BA.5 does not appear to cause more severe disease than other forms of Omicron.

Given how much the virus has changed, the administration has been debating the value of authorizing additional shots of the original vaccine in the fall and offering second boosters to adults younger than age 50. An advisory panel of the Food and Drug Administration said last month that vaccine manufacturers should tailor shots to the newest variants.

But it’s unclear whether those shots will arrive in time to forestall a fall surge, and whether the virus will have once again evolved beyond their reach.” (C)

“When all 50 states, the District of Columbia and United States territories declared public health emergencies in response to the coronavirus pandemic in March 2020, those declarations allowed state officials to lift limits on hospital capacity, expand access to telehealth services and even allow highway weight limits to be exceeded, in case the National Guard needed to quickly move in.

By Monday, fewer than a dozen states will have emergency declarations in place, according to the National Academy for State Health Policy. States have let the declarations expire even though the Omicron subvariant known as BA.5, perhaps the most transmissible coronavirus subvariant yet, is pushing up positive tests, hospitalizations and intensive care admissions across the country.

The wider latitude conferred by a state’s public health emergency, like making it easier for out-of-state medical providers to help with in-person and telehealth care and for retired health care workers to return to work, was critical to states’ responses to earlier waves of coronavirus cases.

But as Americans adjust to living with the virus, the country’s governors have increasingly had to justify the extension of such declarations to legislators who consider them an unnecessary use of executive power. On Wednesday, Gov. Kathy Hochul of New York said that she needed to extend her pandemic emergency powers into the fall in case serious disease and hospitalizations spike higher.

At the same time, the Biden administration last week again extended the federal coronavirus public health emergency, which was first set in January 2020. The declaration means the emergency period will last at least through mid-October.

The federal designation allows millions of low-income Americans expanded access to Medicaid coverage; adds flexibility for telehealth; and grants states access to pandemic-related funds.

Additionally, private insurers and Medicare will continue to cover the cost of at-home virus tests as long as the public health emergency remains in effect…

In some cases, the state must have a declaration in place to receive funding from the federal government. Though Connecticut’s public health emergency ended last month, the state kept a limited version in place so that it can receive more federal money for food assistance for low-income families.

The pandemic has prompted some states to change the regulations surrounding emergency orders during the pandemic, said Andy Baker-White, senior director of state health policy at the Association of State and Territorial Health Officials. Legislatures have amended the process for declaring an emergency, shortened the maximum length of each emergency and reduced the number of times that a governor can renew an emergency declaration. In Arizona, beginning next January, the governor cannot declare a public health emergency without the legislature’s approval.

“With the backlash to the exercise of this authority, there has to be political will, as well as the expense of political capital to bring back a declaration,” Mr. Baker-White said. “Some states have taken things that they were only able to do in an emergency and put that action into the law, so they don’t need the emergency trigger.”..

But one effect of the pandemic — the improved access to telehealth — is at risk, since many waivers that allow such care across state borders have expired. And in states that no longer have emergencies declared, hospitals have once again instated capacity limits. Lifting those in the event of another surge would require issuing another declaration.”  (D)

UPDATES

“The World Health Organization on Saturday declared the unprecedented monkeypox outbreak that has spread around the world a public health emergency, a decision that will empower the agency to take additional measures to try to curb the virus’s spread.

In an unusual move, WHO Director-General Tedros Adhanom Ghebreyesus made the declaration even though a committee of experts he had convened to study the issue did not advise him to do so, having failed to reach a consensus. The same committee met just one month ago and declined to declare a public health emergency of international concern, or PHEIC…

“Nine and six is very, very close,” Tedros said in a news conference called to announce the decision. “Since the role of the committee is to advise, I then had to act as a tie-breaker.” (G)

“Two cases of monkeypox have been identified in children in the United States, the US Centers for Disease Control and Prevention said Friday.

The two cases are unrelated and probably the result of household transmission, the CDC said.

One case is a toddler who is a resident of California. The other is an infant who is not a US resident. Public health officials are investigating how the children were infected.

Both have symptoms but are in good health and receiving treatment with an antiviral medication named tecovirimat or TPOXX, which the CDC recommends for children under the age of 8 because they are considered to be at higher risk from infection.

Since the monkeypox outbreak began in May, most of the cases have happened among men who have sex with men. However, anyone can catch the virus through close skin-to-skin contact. In the case of children, the agency said this could include “holding, cuddling, feeding, as well as through shared items such as towels, bedding, cups, and utensils.”

The CDC says the Jynneos monkeypox vaccine is being made available for children through special expanded use protocols. The agency has also developed new guidance for health care providers about identifying, treating and preventing monkeypox in children and teens…

The US government has shipped 300,000 monkeypox vaccines to US states and territories as of Friday afternoon.

“That means hundreds of thousands of Americans are going to be getting vaccinated in a matter of days or weeks,” Dr. Ashish Jha, the White House Covid-19 response coordinator, said Friday. “Jurisdictions, states territories, cities are getting their vaccines typically about 30 hours after ordering them.”

Jha said Friday that New York City had received enough monkeypox vaccine to provide at least one dose to about half its eligible population, while DC had gotten enough to provide one dose to 70% of its eligible population.

The newly released doses increase available supply, but they cover just a small portion of the eligible population. The CDC estimates that more than 1.5 million people are eligible for the monkeypox vaccine.

The prescribing information for the Jynneos vaccine says a full course is two shots given four weeks apart. The CDC and the US Food and Drug Administration have said that people need both doses to fully prevent disease.

But in New York City and some other places seeing a high degree of viral spread, officials have been giving out a first shot to as many people as they can, even before second doses are available.”  (H)

“The New York State Department of Health and its Rockland County counterpart confirmed that the infection was transmitted from someone who received the oral polio vaccine, which has not been administered in the United States since 2000. Officials said in a news release that the virus may have originated outside the United States, where the oral vaccine is still administered.

“I want to stress that this individual is no longer contagious,” said Ed Day, the Rockland County executive, in a news conference Thursday afternoon. “Our efforts now are focused on two issues: vaccinations and figuring out if anyone else has been impacted by this disease.”

Those who are unvaccinated or haven’t completed their vaccination series should get vaccinated, officials said. The current polio case presents a very low risk to those who are already vaccinated against polio: Those who have had all three shots have close to 100 percent protection.

The person’s symptoms began about a month ago, said Dr. Patricia Schnabel Ruppert, Rockland County’s health commissioner, at the news conference. The patient presented with “weakness and paralysis,” she said, and the department was notified on Monday about the confirmed case…

The highly contagious virus was one of the most feared diseases until the 1950s, when the first vaccine was developed…

The last case of polio in the United States was in 2013, in someone who brought the disease in from abroad. There has not been a case originating in the United States since 1979, according to the Centers for Disease Control and Prevention.

The disease was one of the most feared in the country until the 1950s, when the first vaccine was developed.

Sixty percent of Rockland County’s 2-year-olds have received all three doses of the polio vaccine, according to state data — a considerably lower rate than the 80 percent rate in the rest of the state excluding New York City.

To achieve herd immunity for polio, the target vaccination rate is 80 percent, according to the World Health Organization.” (I)

“It was still not clear exactly when or where the patient had contracted the disease, though health officials believe the person was infected by someone who had received the oral polio vaccine, which contains weakened live virus.

Such vaccines have not been administered in the United States since 2000, suggesting that the virus may have “originated in a location outside of the U.S. where O.P.V. is administered,” according to county officials. The oral vaccine is safe, but people who are unvaccinated can become infected if vaccine-derived virus is circulating in a community.” (J)

• A.Like the Rest of Us, Biden Learns to Live With the Risks of the Virus, By Michael D. Shear and Zolan Kanno-Youngs, https://www.nytimes.com/2022/07/22/us/politics/biden-covid-health.html?referringSource=articleShare
• B.Biden tests positive for COVID and shows mild symptoms, White House says, by Andrew Harnik, https://www.npr.org/2022/07/21/1061864203/biden-test-positive-covid-19
• C.Biden had received a second booster. Here’s why it wasn’t enough to prevent infection., By Apoorva Mandavilli, https://www.nytimes.com/2022/07/21/health/biden-covid-booster.html?referringSource=articleShare
• D.The pandemic isn’t over, but most U.S. states formally say that it’s no longer a health emergency., By Adeel Hassan, https://www.nytimes.com/live/2022/07/22/world/covid-19-biden-news?referringSource=articleShare#covid-state-health-emergency
• E.Biden tests positive for COVID-19: An infectious disease doctor explains the risks and treatments available for the 79-year-old president, by Patrick Jackson, https://theconversation.com/biden-tests-positive-for-covid-19-an-infectious-disease-doctor-explains-the-risks-and-treatments-available-for-the-79-year-old-president-187496
• F.If President Joe Biden gets severely ill from COVID, then he’ll have access to superior medical care including an army of doctors and his own medical suite, by Kimberly Leonard, https://www.businessinsider.com/medical-care-president-joe-biden-white-house-2022-7
• G.WHO declares monkeypox outbreak a public health emergency, By Helen Branswell, https://www.statnews.com/2022/07/23/who-declares-monkeypox-outbreak-a-public-health-emergency/
• H.CDC reports the first two monkeypox cases in children in the US, By Brenda Goodman and Deidre McPhillips, https://www.cnn.com/2022/07/22/health/monkeypox-children-vaccine/index.html
• I.First Polio Case in Nearly a Decade Is Detected in New York State. By Hurubie Meko, https://www.nytimes.com/2022/07/21/nyregion/polio-case-new-york.html?referringSource=articleShare
• J.Rare Case of Polio Prompts Alarm and an Urgent Investigation in New York, By Jesse McKinley and Nate Schweber, https://www.nytimes.com/2022/07/22/nyregion/rockland-county-polio-unvaccinated.html?referringSource=articleShare
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