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The coronavirus might not be the worst of it
The Washington PostDemocracy Dies in Darkness

President Biden, double-boosted, is in a good position to fight covid

President Biden arrives July 20 at the White House, the day before he tested positive for the coronavirus. (Demetrius Freeman/The Washington Post)
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The second U.S. president infected by the coronavirus is in a much more favorable position to fight covid-19 than the first.

When President Donald Trump was sickened in October 2020 — before the rollout of vaccines — he experienced covid symptoms severe enough to send him to the hospital as doctors scrambled to administer an array of medicines for a patient whose oxygen level had dropped to dangerous levels.

But President Biden, who tested positive for the coronavirus Thursday, has been fully vaccinated and twice-boosted, as recommended for people his age, and has an excellent chance of avoiding the most severe outcomes from covid, according to doctors interviewed Thursday.

The president’s physician, Kevin C. O’Connor, said in a statement released by the White House that Biden has fatigue, a runny nose and an “occasional dry cough,” which the doctor framed as “mild” symptoms.

O’Connor has recommended that Biden take the anti-viral drug Paxlovid — a powerful therapeutic that was not available when Trump became ill.

The drug is considered most effective when given early in the course of the illness. Biden has been routinely tested for covid. On Thursday, a rapid test showed a positive result, which was quickly confirmed by a PCR test.

“The president is fully vaccinated and twice-boosted, so I anticipate that he will respond favorably, as most maximally protected patients do,” O’Connor said.

Other medical experts echoed that optimistic prognosis.

“Odds are very good that he’s going to do okay,” said Jeanne Marrazzo, director of infectious diseases at the University of Alabama at Birmingham School of Medicine. “He’s a healthy elderly man. He’s fully boosted, he’s fully vaccinated and he got prompt treatment. I think all indications are positive.”

The White House released a brief video in which Biden offered assurance that he is doing fine.

“Symptoms are mild,” Biden said. “I’m doing well, getting a lot of work done. Going to continue to get it done. And in the meantime, thanks for your concern. And keep the faith. It’s going to be okay.”

When Trump became sick nearly two years ago, it was the dominant news story for days, with the presidential election just a month away. Biden’s illness, though a thunderclap of news amid the swelter of summertime Washington, seems less likely to rattle the political world for the simple reason that the virus has become less deadly.

Biden got his first two shots of the vaccine in December 2020 and January 2021. He got his first booster last September and his second on March 30 of this year.

“We’re in a very different place in the pandemic right now, because we have the tools like the rapid tests, the vaccines, the antivirals,” Andrew Pekosz, a virologist at the Johns Hopkins Bloomberg School of Public Health, said. But we have to stick with what works, he said: “We have to continue to use [the tools] effectively to minimize the severe impacts of covid-19.”

Covid is far more likely to cause severe illness in older people, and for the 79-year-old president, age is a risk factor.

But he also has three things in his favor, said Albert Ko, an infectious-disease physician and epidemiologist at the Yale School of Public Health. He has had all his shots, he’s getting help from Paxlovid, and the omicron strain of the coronavirus now dominant in the United States is generally less virulent, meaning less likely to cause severe disease, compared with the strains that spread in 2020 and most of 2021, Ko said.

“The strain that we experienced back then had a higher infection-fatality rate,” Ko said. “Hopefully, the prognosis is good. No one can give 100 percent certainty, but he has three strong factors that mitigate against a severe outcome.”

Some covid patients find out they have the disease only after becoming extremely sick and realizing they may have something more than a case of the sniffles and ought to take a coronavirus test. By contrast, Biden’s infection was found through what the White House said was a regularly scheduled rapid test.

Even though doctors interviewed Thursday said they do not expect Biden to have a severe case, covid has always been an unpredictable disease, and continues to be so even among people who have been vaccinated.

“What they’re describing sounds like a cold. Certainly, these symptoms could get worse. Every case of covid or any other illness has to start somewhere,” said David Dowdy, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health.

But, like other experts, Dowdy thinks Biden will probably start to feel better in just a few days, even if he has some lingering symptoms, such as a cough, for longer. “If things are going to get worse, we will probably see that happen in the next 48 hours,” he said.

Coronavirus vaccines — in Biden’s case, the Pfizer-BioNTech product — have helped drive down the rate of death and severe illness from the virus since they were first rolled out in December 2020, a couple of months after Trump became sick.

But the vaccines, while priming multiple layers of the immune system to recognize and respond to the pathogen, do not form an impermeable barrier to the virus — as countless people who are fully vaccinated and boosted and wind up sick with covid can attest. Virus-neutralizing antibodies produced by vaccines (or prior infection) wane over the course of a few months. Deeper layers of the immune system have to kick into gear and clear the virus once it gains an initial foothold.

Infectious-disease specialists said they endorse the publicly announced treatment regimen for Biden, noting that while he appears to be healthy and fit, he is considered high risk for severe disease solely because of his age. Immediately starting him on Paxlovid, the five-day course of antiviral medication, is the correct course of action, they said.

Marrazzo said there is no downside to taking Paxlovid if a patient is symptomatic and potentially at increased risk — for example, because of age.

“Most people start to feel really better within 24 to 48 hours,” Marrazzo said.

Pekosz said of the president, “He’s doing everything the way you’re supposed to do it in order to minimize severe disease. He has a very good chance to recover without too many difficulties.”

Research shows Paxlovid reduces hospitalization and death substantially in unvaccinated patients, said Erin K. McCreary, director of infectious-disease improvement and clinical research innovation at the University of Pittsburgh Medical Center. The drug’s impact is less clear among vaccinated patients — Biden has received four shots — but it will have some effect for him, she said.

The pill was largely studied when the delta variant of the coronavirus was in wide circulation, she said, so its effect during the current surge of omicron subvariants is less well known. Though it helps with severity of illness and disease progression, it does not reduce the duration of symptoms, she said.

A common-sense approach to viral illness should also be part of the president’s treatment, said Richard A. Martinello, an infectious-disease specialist at the Yale School of Medicine.

“I think taking it easy, listening to our body, not overdoing it is probably good advice for anybody,” Martinello said. “As part of that, getting plenty of sleep, keeping hydrated, eating well but not too much.” Biden could even get some light exercise if he feels well enough, Martinello said.

He urged unvaccinated people to consider Biden’s illness a reason to get vaccinated — even though he has become infected — because the benefits have proven to be so substantial.

“This is probably the single-most studied vaccine that we have in use” for any disease, Martinello said. It is the “single-best thing” we have for covid, he added.

The virus has evolved in response to the greater immunity in the population. Mutations have changed the structure and chemistry of the spike protein on the surface of the virus, making it less easily recognized by the front-line defense of antibodies.

The most transmissible form of the coronavirus yet, the omicron subvariant BA.5 now accounts for almost 80 percent of new infections in the United States, according to the Centers for Disease Control and Prevention. An almost identical subvariant named BA.4 accounts for 13 percent. Neither subvariant is known to cause more severe illness than previous versions of omicron.

It is fundamentally the same virus that has been rolling across the country in a succession of mutated strains since omicron appeared late last year, according to Anthony S. Fauci, Biden’s chief medical adviser on the pandemic.

On the family tree of omicron, BA.5 “is just a little bit of a sub-twig,” Fauci said Thursday just before the announcement of the president’s infection.

“What we’ve been experiencing is a progressive evolution of viruses that have a transmission advantage over the prior variant which they bumped off the table,” he said.

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