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This story was updated Oct. 8 at 9:25 a.m.

Oct. 6, 2020 -- President Donald Trump returned to the White House on Monday after a 3-day hospital stay for COVID-19, promptly removed his mask, and entered a room full of similarly unmasked staff.

With the coronavirus spreading through the top levels of his campaign and administration, and reports that the White House is not doing recommended levels of contact tracing, fear for what comes next in U.S. government grows. According to an internal memo dated Wednesday from FEMA, more than 34 White House staffers and other contacts have been infected in recent days, ABC News reported.

The White House situation, with that many infections and at least two hospitalizations, is already a superspreader issue, says Amesh Adalja, MD, a senior scholar at the Johns Hopkins Center for Health Security.

“There are clearly multiple infections,” he says. “You can expect to see more.”

It’s also led to a temporary shutdown of U.S. Senate floor activity after several members tested positive. And in a separate outbreak, members of the Joint Chiefs of Staff are in quarantine after Adm. Charles Ray, the vice commandant of the Coast Guard, tested positive.

Health experts have pointed to the Sept. 26 White House event to introduce Trump’s Supreme Court nominee, Amy Coney Barrett, as the catalyst for the cases.

Images of the outside ceremony for Barrett in the White House Rose Garden showed guests seated close together, often without masks, with many hugging afterward. While that has been given a lot of attention, “the scarier scenario is the inside shot [showing a meeting of the nominee and family inside the White House] in terms of aerosol transmission,” says William D. Ristenpart, PhD, a professor of chemical engineering at the University of California, Davis, who studies COVID transmission.

Besides the event itself, Ristenpart says he is concerned that steps are not being taken to prevent future cases. "I was not reassured that the president took his mask off [upon returning to the White House on Monday] and then went inside. He absolutely should not be walking into an indoor space with his mask off."

Adalja says anyone who attended the Barrett event “should consider themselves infected and quarantine for 14 days. A lot of people [who were at that event] are D.C. residents, and it's important that the D.C. public health [department] have the data to see who is infected."

The president and first lady Melania Trump have tested positive for coronavirus, as has White House press secretary Kayleigh McEnany, White House senior advisers Hope Hicks and Stephen Miller, and Nicholas Luna, personal assistant to the president. The New York Timesreported that  three White House employees in the housekeeping department have also tested positive, as have at least two White House press aides who work for McEnany.

They are in addition to at least three U.S. senators, Trump’s campaign manager, the chairwoman of the Republican National Committee, former senior adviser Kellyanne Conway, and former New Jersey Gov. Chris Christie, who has also been hospitalized.

“We still don’t know key elements about the COVID outbreak affecting the White House,” former CDC Director Tom Frieden, CEO of Resolve to Save Lives, said on Twitter.

In a series of tweets, he laid out a six-step course of action he said needs to happen at the White House. It includes identifying anyone who had contact with anyone in the White House after Sept. 18 and has tested positive or has COVID-like symptoms.

Next, he said, is to track cases by time of onset of symptoms, analyze risk factors for infection, and explore ways people may have spread the virus. Finally, the White House should take action to limit further spread and determine if the process worked. “Outbreak control works, if done quickly and well,” Frieden said.

Without more detailed information, it is difficult to say what impact these cases related to White House events might have on the functioning of the government, overall, says Alex Becker, PhD, a postdoctoral scholar in biology at Stanford University  who has studied super spreading of COVID-19.  "However, given the infectious period and quarantine guidelines from the CDC, it's possible that the WH staff could remain under its full capacity for two weeks, depending on the current and future rate of infection."

Becker said it's still unclear if there was just one event that caused the outbreak. It could be the Rose Gardeen cremony for Amy Coney Barrett, or it could something else. "We don't actually have contact tracing data so we can't pinpoint a single day, event, or index case," he said. "Without such data, it's hard to fully understand where these infections, and potential outbreak, are heading."

Revised Rules on Face Masks

After Trump tested positive for the coronavirus on Friday, the White House revised some of its rules regarding the use of face masks inside the building.

As of late June 2020, 412 people worked for Trump at the White House, as well as another 96 full-time domestic workers, including maids, chefs, and maintenance personnel. There are 132 rooms, 35 bathrooms, and about 55,000 square feet of floor space.

National Security Council staff are now required to wear masks, while for other White House employees, they remain voluntary. But residence staff are required to wear masks at all times and have been since April, according to a White House statement. Since Trump’s positive test, they are required to wear full PPE.

Dan Zak, a reporter for The Washington Post, posted a video on Twitter early Tuesday of workers spraying areas of the White House, including the press room. Zak said no one would say what was being sprayed or why, but the workers are seen wearing full personal protection equipment.

But the fact that some people are working inside the same building with a mask-optional policy appears to run contrary to what the CDC recommends. Just this week, the agency reaffirmed its guidance that the virus spreads not just through respiratory droplets released from coughing and sneezing, but through much smaller aerosol particles released from talking and singing.

Those who regularly surround Trump at the White House are now being tested regularly. So far, many more have tested negative than otherwise.

It’s not clear with whom Trump has met since returning to Pennsylvania Avenue on Monday night. Attorney General Bill Barr, who has tested negative, has been quarantining nonetheless.

The New York Times reports that many White House employees were not at work on Tuesday. Many presumably were teleworking from home. With live cases confirmed in the White House and the U.S. Senate, many are watching how the virus spreads in Washington, D.C. The district reported 105 new cases Tuesday, the most since June 3.

Now, the White House is home to a contagious COVID patient. While Trump’s doctor, Cmdr. Sean Conley, DO, said Tuesday that the president continues to do well, “had a restful first night at home, and today he reports no symptoms,” he remains ensconced in the White House, surrounded by staff.

Trump will not be required to remain in the third-floor residence for the first family. Conley told reporters on Monday, “We're going to do whatever it takes for the president to safely conduct business wherever it is he needs to do within the residence and White House.”

But he did say it will not be business as usual.

“We've worked with our infectious disease experts to make some recommendations for how to keep everything safe down at the White House, for the president and those around him,” Conley said.

He declined to provide more details.

‘The Key Letter There Is the Ventilation’

Ristenpart says the environment inside the White House is all the more important in preventing the virus from spreading further.

"The key letter there is the ventilatiion," he says. "For aerosol transmission [of COVID], the thing that really, really counts is how quickly you get the aerosol particles out of the room." The ventilation rate, or air changes per hour, is very important to reduce spread, he says.

According to The Associated Press, the White House installed a new HVAC (heating, ventilation and air conditioning) system in recent years. The HVAC improvements from 2017 cost nearly $2 million, during another renovation. In addition, other filtration systems were installed in the executive mansion in March, according to the White House statement.

The CDC has recommendations on ventilation rates. A poor rate, Ristenpart says, would be one per hour, meaning it takes an hour for air to completely turn over in a room. For an operating room, 15 air changes an hour is recommended. Other things that govern how quickly and how much the coronavirus is spread involve the maximum occupancy of a room and how good the air system is.

Experts talk about "plume" vs. "room," he says. The plume refers to the respiratory plume -- what you exhale while facing someone and the exhalations go right into their face. "The longer-range threat, the room, is that these expiratory particles get carried. They are more dilute, but if you have a poorly ventilated room, they linger, and that maximizes the chance someone will inhale them."

Show Sources

Executive Office of the President: “Annual Report to Congress on White House Office Personnel.”

Twitter: @maggieNYT, @DrTomFrieden, Oct. 5, 2020. “Here's who has tested positive and negative for Covid-19 in Trump's circle.”

Forbes: “National Security Council Staff Told To Wear Masks, White House Rules Still Make Them Optional.”

Business Insider: “There are over 300 staffers Trump doesn't choose when he enters the White House -- and they're the ones he'll see every day.” “The White House Building.”

Ben’s Guide to the U.S. Government: “White House: 1792 (construction began).” “Scientific Brief: SARS-CoV-2 and Potential Airborne Transmission.”

The New York Times: “Many White House officials stay home as outbreak grows, and concerns rise for spread of cases in Washington, D.C.,” “Contact tracing efforts are restricted to the two days before Trump’s diagnosis.”

Amesh Adalja, MD, senior scholar, Johns Hopkins Center for Health Security.

William D. Ristenpart, PhD, professor of chemical engineering, University of California, Davis.

 Alex Becker, PhD, postdoctoral scholar, Stanford University.

ABC News: "34 people connected to White House, more than previously known, infected by coronavirus: Internal FEMA memo."


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