President Donald Trump’s COVID-19 diagnosis has stoked political anxiety and raised a flurry of questions about what happens next, especially about contact tracing and treatment options.

Trump and his family members have spent considerable time on the campaign trial in Arizona in recent weeks.

His son, Donald Trump Jr., was in metro Phoenix as recently as Thursday for a fundraiser. Hours later, Trump announced on Twitter that he and first lady Melania Trump had tested positive for COVID-19, the disease caused by the new coronavirus.

Trump’s multiple Arizona events this year — in some cases, indoor speeches with large crowds — have drawn supporters together, sometimes in tight quarters with few masks or social distancing. Before his diagnosis, Trump had been scheduled to return to Arizona to campaign in person in Tucson on Monday and in Flagstaff on Tuesday.

For a president who has been active and social across the country and at White House events, a big question is what impact his infection could have on not just him, but his close circle and even more broadly, people nationwide who have attended rallies or interacted with him and crowds he’s assembled.

Two Republican senators — Mike Lee of Utah and Thom Tillis of North Carolina  — who attended Trump’s Saturday announcement of Amy Coney Barrett as his Supreme Court nominee have since tested positive for COVID-19, as has the president of the University of Notre Dame. Melania Trump also was there.

By late Friday, the number of infected people who attended the event had grown to seven, including former White House Counselor Kellyanne Conway.

Experts have begun weighing in on best practices for contact tracing to prevent further spread of the virus from Trump and those with whom he’s been in contact.

The president’s infection was “not inevitable, but this was the likely outcome,” Dr. Michael Mina, assistant professor of epidemiology at the Harvard T.H. Chan School of Public Health, said Friday on a call with reporters.

“He’s as susceptible as anyone else is in the country or in the world, and many of us are taking precautions that greatly exceed the precautions that he tends to take,” Mina said.

With symptoms initially described as mild, Trump went Friday to Walter Reed National Military Medical Center, where he is expected to stay at least for a few days.

The U.S. Centers for Disease Control and Prevention recommend that infected individuals remain in isolation for 10 days after the onset of symptoms and once their symptoms have improved.

Contact tracing for the president and public

In addition to monitoring the president’s health, an essential next step is what public health officials call contact tracing. That means identifying contacts who could have been infected by the president and encouraging them to monitor their symptoms, get tested and ideally quarantine to prevent further spread.

Beyond Trump’s inner circle, his infection raises the question of spread among any of the thousands at his campaign events and how contact tracing should work for them. 

The president’s large public events often have had limited mask-wearing and social distancing, making them ripe environments for spread of the virus from anyone in the crowd who might be carrying it.

Trump and his family members have hosted several such events in Arizona in recent weeks.

Indoor rallies are the worst for the spreading the virus.

“These kinds of rallies are actually the worst possible setting to become super-spreader events, because what are people doing at rallies? They’re yelling and screaming and talking loudly, singing, chanting — all of these things increase the amount of virus that we excrete,” said Dr. Priya Sampathkumar, an infectious disease specialist at Mayo Clinic.

Full contact tracing would mean if an individual tests positive after attending a rally, public health officials would call everyone that person came into close contact with at the event. Many of them would be strangers, and contact tracing would not be possible. And contact tracing needs to be done quickly so people can quarantine before unknowingly spreading the infection. 

“Because there are so many people gathering without wearing masks, it just makes it a lot more complex to try to figure out. You really can’t do effective contact tracing, which is why we don’t have large scale gatherings like that,” said Dr. Farshad Fani Marvasti, a public health expert, physician and associate professor at the UA College of Medicine — Phoenix.

Marvasti said anyone who attends a rally or large gathering in Arizona or elsewhere is at high risk for carrying the virus. 

Arizona contact tracing criticized as insufficient

Trump rallies notwithstanding, Arizona has been criticized for its contact tracing, which has often fallen short of the ideal standard.

Even in May, Maricopa County and Pima County, the state’s largest counties, were not conducting full contact tracing and reaching out to all of an individual’s contacts.

By July, as cases were spiking and Arizona was becoming a national hotspot, Maricopa County was not meeting federal guidelines for case investigations and contact tracing.

At that point, contact tracing was very difficult because of the significant number of new daily cases, but better tracing earlier on might have mitigated some of the state’s spike. 

The state health department has worked to add people and funding to boost county efforts at contact tracing, which should be more feasible now that the state’s new daily cases are lower.

Marvasti said Arizona’s contact tracing has not been effective.

To get there, the state needs a comprehensive testing strategy so that people in public-facing jobs, schools and other essential places can have routine testing as a requirement for staying open, he said.

Contact tracing is effective when there’s widespread and quick testing. The federal government is sending Arizona more than two million rapid COVID-19 tests, and schools will be among those prioritized for using them.

Sheer number of cases a challenge

Contact tracing has at times been a national stumbling block, too, hindered by the challenges of the sheer numbers of infected individuals, problems with people not picking up their phones to talk to public health officials, and the difficulty of remembering everyone with whom they’ve been in contact. 

Mina said contract tracing has only been able to capture maybe 5% of those infected in time to prevent them from spreading the virus to others. One thing that’s needed is more frequent testing to detect the index cases who are spreading infection, he said. 

“Our surveillance systems are failing, and that is just a fact,” Mina said. “It’s why we’re not able to keep this under control. It’s why we’re having to shut down economies in order to control it.”

On a smaller scale, contact tracing from Trump’s positive test should involve identifying the president’s contacts and those he interacted with closely at meetings, events or political rallies. Any of those people could be infected and could be spreading the virus, whether they have symptoms. 

“Certainly people like Hope Hicks and Donald Trump are ripe for being the index cases that can lead to super-spreading events because they have really large networks and they are often amongst large crowds,” Mina said.

For White House aides and other close contacts of Trump, Mina said, frequent and rapid testing will be essential to stop more widespread transmission.

They also should be wearing face masks all the time, he said.

The fact that Trump’s infection was detected early prevented him from spreading the virus to many others, Mina said.

Trump likely was infected between Saturday — the day of Trump’s Supreme Court announcement in the White House Rose Garden —  and Monday, according to Ashish Jha, a prominent public health expert, who explained the timeline on Twitter.

Jha said everyone who has been near the president since at least Saturday should be tested to try to find the source. 

Reach the reporter at [email protected] or at 602-444-4282. Follow her on Twitter @alisteinbach.

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