Yesterday’s @WashingtonPost piece on flying-after-vaccination, in which I said I won’t eat on an airplane, created a bit of a kerfuffle.… Even @natesilver538 weighed in today.

Let me explain my thinking. (A 🧵) (1/25)
I am fully vaccinated (2 doses of Pfizer in Dec/Jan). As such, I consider myself exceedingly unlikely to get very sick and die from Covid, though as the number of vaccinated people grows, we are beginning to hear about a few breakthrough infections.… (2/25)
Most breakthrough infections are mild but there are rare ones that are serious. Of >75M people fully vaxxed as of 4/13, CDC has logged 5814 breakthrough infctns (documented Covid post-full vaccination). That’s not surprising. As we know, the vaccines aren't 100% protective.(3/25)
Of these 5814, 396 pts (7%) were hospitalized & 74 (1%) died. Of the hospitalized pts, 34% were hospitalized for non-Covid reasons, but as far as we can tell from the report, the rest were Covid-related. It’s vital to put this in context: these are tiny, tiny numbers of… (4/25)
… breakthrough infections, & minuscule numbers of hospitalizations & deaths. If 2/3 of the 74 deaths were also Covid-related, we’re talking 50 deaths from Covid in 75M fully vaccinated people, or a chance of dying from Covid after full vaccination of 1 in 1.5 million.(5/25)
So my mantra that “there is essentially no chance that you will die of Covid after full vaccination” remains correct.

Note that the chance is probably not zero, it's just infinitesimally small. (6/25)
(You may have observed that this risk is similar to the risk of one of these unusual blood clots after the J&J. The essential point is that both of these odds are massively lower than the chances of an unvaccinated person dying of Covid. Please get vaccinated!)(7/25)
Then there's the matter of long Covid. I consider it unlikely that a post-vaccine breakthrough case could lead to long Covid (I have not seen a study addressing this issue) but my guess is that it also can happen, rarely.

So here’s my bottom line, which guides many of... (8/25)
... my decisions these days: I feel great being vaccinated, I’m doing many things I wouldn’t have done before vaccination, and I no longer worry about getting very sick and dying of Covid.

But – and here’s the key point – I still don’t want to get Covid if I can avoid it.(9/25)
This means that I still weigh my risk of being exposed to Covid when I make “safer/not safe?” choices. I completely understand why some people would take a different view: “I’m vaccinated & I don't want to think about risk anymore.” That position will likely work out fine.(10/25)
But for me, while I mostly feel liberated after vaccination, when there’s a somewhat risky situation that I have control over – particularly if it's an activity that isn’t all that important to me – I may make a different choice. Which gets us back to flying & restaurants.(11/25)
I’m happy to get together in San Francisco in a home w/ vaccinated & even unvaccinated friends/family. Why? The activity is meaningful to me, & SF is a pretty “cool” (Covid-wise) place: test positivity rate 1%, the prevalence of the UK variant is low (West coast variant…(12/25)
…is around, but it doesn’t seem to be as nasty), and there are only a handful of reported cases of variants with potential vaccine resistance.

That said, I still won’t eat indoors at a restaurant yet, though it’s a close call. Why not? (13/25)
Per CDC, indoor dining has been among highest risk activities. Masks are off most of the time. And, while I know my tablemates, I don’t know the folks at other tables. I like eating in restaurants, but it’s just not that important to me. Ergo: outdoor dining OK, no indoor.(14/25)
Then there's flying. As @washingtonpost piece pointed out, I'm comfortable flying, & have flown 2-3 times in 2021. I won’t take a frivolous trip, but will fly to visit family or for an important work-related event. I consider flying while masked to be exceptionally safe… (15/25)
… for a vaccinated person. And, even for an unvaccinated person, flying while everyone is masked is relatively safe – particularly if neither originating nor destination city (one assumes they're the source of most of the passengers) is particularly “hot”, Covid-wise. (16/25)
But here’s the rub about flying – it is really two different experiences: 1) a 100% masked experience in a clean environment with frequent air exchanges, and 2) an indoor restaurant in the sky.

It's #2 that worries me, even more so than indoor restaurant dining in SF.(17/25)
Why? First, studies have shown that flights are safer w/ middle seats open, but most flights now are packed (they’ve been full on every flight I’ve taken in '21).… If you fly, you need to assume you’ll be surrounded by strangers at very close range. (18/25)
Second, whereas I’m fairly comfortable that a SF restaurant has a Covid likelihood similar to the city's, I’m far less certain about my fellow flyers. Maybe there’s somebody from MI, where test positivity rate isn’t CA’s 1.5%, it’s 16%. Or from Florida, where it’s 10%. (19/25)
And folks may be coming from places where variants are common. I just don’t know. I’m not even sure no one on the plane has a fever or feels sick. (I’d guess that someone feeling ill would cancel a restaurant reservation before they'd cancel a planned flight). (20/25)
Finally, maybe most importantly, I don’t NEED to eat on a plane. And I certainly don’t need to eat while others eat. So my practice on short flights is not to eat at all, taking off my mask briefly (<1 min) at least 30 minutes after meal service to chug a bottle of water. (21/25)
On a longer (eg x-country) flight, I’ll also wait 30 minutes after everybody's done & then quickly eat something. I’ll keep my mask off for the least amount of time necessary.

Neither of these choices seem like that big a deal, and they certainly cause me no hardship.(22/25)
Having received Pfizer, I know that the chances of getting infected on a plane are at least 90% lower than the baseline rate, which is ~1/5000 (for unvaccinated people).…

I’m not at all dogmatic on this; I can understand why someone would make… (23/25)
… a different choice – either because they really love airline food (that's a joke), or, more likely, because they like the feeling of acting “normally” and are sick of playing the 3-dimensional Covid Risk chess game. If that's how someone feels, they should go for it. (24/25)
As for me, while you'll see me on the plane, I'll be the guy with his mask on during meal service. It just makes sense to me. (25/25; end)

• • •

Missing some Tweet in this thread? You can try to force a refresh

Keep Current with Bob Wachter

Bob Wachter Profile picture

Stay in touch and get notified when new unrolls are available from this author!

Read all threads

This Thread may be Removed Anytime!


Twitter may remove this content at anytime! Save it as PDF for later use!

Try unrolling a thread yourself!

how to unroll video
  1. Follow @ThreadReaderApp to mention us!

  2. From a Twitter thread mention us with a keyword "unroll"
@threadreaderapp unroll

Practice here first or read more on our help page!

More from @Bob_Wachter

4 Apr
1/ Covid (@UCSF) Chronicles, Day 383

Perhaps the most confusing time since the start of the pandemic – its easy to be overwhelmed. I’ll try to make sense of some of the key trends, particularly the “4th surge” & vaccines vs variants.

Bottom line: I’m still leaning optimistic.
2/ Part of my optimism stems from where I live: Covid stats in San Francisco are excellent. Let’s start w/ @UCSFHospitals, where there are 7 Covid pts (vs. ~100 in January), & only one on a vent (Fig L). Test positivity is 0.9%; 0.4% in asymptomatic patients (R). Pretty darn low. ImageImage
3/ SF overall is also good: 37 cases/day in city of 875K, maybe a tiny uptick in past few days (Fig L). Only 21 Covid pts in all SF hospitals (vs. 259 in January; R). And only 6 Covid deaths in SF in past 4 weeks; total deaths remain <500 for pandemic. Test positivity also 0.9%. ImageImage
Read 25 tweets
19 Mar
1/ Covid (@UCSF) Chronicles, Day 366

My first "Chronicle” was March 18 2020. Today, I've chosen to look back on the early days of this singular year, both terribly saddened by the incalculable losses – especially since so many were preventable – yet optimistic about the future.
2/ And not just optimistic about Covid. I think we’ll emerge as a better, stronger society, with more attention being paid to people in need, a broader set of tools for and approaches to attacking important problems, and a far higher chance of being prepared for the next threat.
3/ My March 18 2020 tweets are here: For many folks – scared & stuck at home – it was the first pandemic look inside a big hospital. @UCSF, to its credit, allowed a level of transparency that served our community well in coming mths. It was the right call.
Read 25 tweets
10 Mar
1/ Covid (@UCSF) Chronicles, Day 357

I’ve taken a little break from my threads – Covid is slowing down (yippee!) & I’ve gotten busy hosting @inthebubblepod. Thanks for your patience.

Today, I’ll update numbers, take a deeper dive into new CDC recs, & cover a few odds & ends.
2/ @ucsfhospitals, marked improvement. Today, 18 pts, 4 on vents (Fig L). (On 1/12, #s were 102/24.) Test positivity also way down: now 0.7% overall – 3% in pts w/ symptoms, 0. 4 in pts w/ no symptoms (Fig R). Thus, asymptomatic person in SF has ~1-in-250 chance of having Covid.
3/ Keep this low prevalence in mind in considering safety of activities. Remember, chance of catching Covid not only relates to riskiness of activity (eating inside, going to gym, etc) but also to odds that nearby person has Covid. Based on UCSF, it’s pretty low in SF right now.
Read 25 tweets
23 Feb
1/ Covid (UCSF) Chronicles, Day 342

A confusing time, with dueling narratives – one optimistic (Vaccines! Falling cases! @ASlavitt! Warmer weather!); the other pessimistic (Variants! Letting guard down!).

First a review of local scene. Then, why I mostly side w/ the optimists.
2/ Improvement in numbers is truly striking, w/ cases, test positivity & hospitalizations all plummeting. @UCSFHospitals: 42 cases, 11 vented (Fig L). Better yet: test positivity=1.7%: 6.2% in symptomatic pts, 1.1% in asymptomatics (Fig R). While these # s are much better than…
3/ …last mth, they still mean an asymptomatic person in SF has ~1/100 chance of having Covid (based on the 1.1% rate in our patients w/o symptoms).

So don’t let your guard down, particularly since – if you haven’t been vaccinated yet – you’ll get a chance in the next 3 months.
Read 25 tweets
19 Feb
In early January, @ashishkjha & I made case for delayed 2nd dose in @washingtonpost In last few weeks, @mtosterholm, Stanley Plotkin, & now @ZekeEmanuel have come out in support of this strategy. To be clear, we appreciate the counterarguments,... (1/4)
...particularly the messaging challenges (will some people forego 2nd dose?). But with the rapid spread of B117, the case for calling an audible for next 2 months & getting more people their 1st dose of Pfizer or Moderna has grown stronger. And this case is now bolstered (2/4)... real-world data from Israel @thelancet (1st dose 85% effective in preventing symptomatic Covid) & @NEJM (review of original @US_FDA data: 1st dose 92.6% effective)

Time's a wasting – increasingly clear that...(3/4)
Read 4 tweets
12 Feb
1/ Covid (@UCSF) Chronicles, Day 331

Today, UCSF Medicine Grand Rounds. I'll start w/ quick update on local scene & then review the terrific presentation on vaccines and masks by @monicagandhi9. The entire 75 minute conference is here – worth watching:
2/ While I’ll cover Monica’s presentation in this thread, there's more. At 39:30 Marguerita Lightfoot, chief of Division of Prevention Sciences, discussed vaccine hesitancy in communities of color. At 52:00, Robert Rodriguez, @UCSF Prof. of Emergency Medicine, & @DrEricGoosby
3/ @UCSF Professor of Medicine & former UN Special Envoy on TB, discussed their experience on President Biden’s Covid-19 Advisory Board. Just as @Atul_Gawande told me @inthebubblepod, Rob & Eric were impressed by the Biden team,….
Read 25 tweets

Did Thread Reader help you today?

Support us! We are indie developers!

This site is made by just two indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3/month or $30/year) and get exclusive features!

Become Premium

Too expensive? Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal Become our Patreon

Thank you for your support!

Follow Us on Twitter!