Thread by @Bob_Wachter

This thing has rapidly become the world’s exasperating good news/bad news story. If your head isn’t spinning, you’re not paying attention.

A 🧵on my take on both the good news & the bad, with an emphasis on the things that have changed in the past few days... or minutes.(1/25)

Bad news: Omicron has exploded in the U.S., weeks before we thought it would. As recently as 2 weeks ago, most experts thought this would be a January issue, not a December one. The rapid uptick nationally, particularly in cities like NYC, Miami, & Houston, is jaw-dropping.(2/25)

Even here in SF, the nation’s most vaccinated (and likely boosted) city – and a city where masking is still the norm – we’re now seeing the familiar northward-facing curve (Figure). It’s now clear that no place in the U.S. will be spared a direct hit from Omicron.(3/25)

Good news: What goes up must come down, in life & Covid. The new data that Omicron cases in South Africa have peaked and are now falling is comforting. thehill.com/changing-ameri… Omicron may turn out to be a 6-8 week hurricane, doing a lot of damage but moving through quickly.(4/25)

More good news: evidence for lower severity is increasingly persuasive, incl. new data from UK. reuters.com/business/healt…
How much less severe is not yet clear – I’m going with a 30-50% lower rate of hospitalization as my governing assumption, subject to change w/ more data.(5/25)

Bad news: as has been said ad nauseam, if there are 3 times more cases & severity/case is 40% lower, that’ll still result in far more hospitalizations & deaths than w/ Delta (which was truly awful). Moreover, after two years, just hearing “less severe” will be enough for…(6/25)

… many people to avoid taking extra precautions, whether masks or vax/boosters. Since so much of Covid is determined by behavior rather than biology & physics, a lack of behavioral modification could lead to far more cases than if there was no “less severe” narrative.(7/25)

Good news: we don’t have to worry about mask supply –there are plenty of reasonably comfy N95’s around. Given Omi's increased infectivity, I'm nearly always choosing an N95 if it's a mask-up situation. The virus has upped its game; we need to up our protection.(8/25)

More good news: In late '21, we have tools to “rescue” people, particularly those at-risk, if they get Covid. The main evidence-based tools are monoclonal antibodies and, as of today, the Pfizer drug Paxlovid. The MAbs reduce hospitalization by ~70%, Paxlovid by nearly 90%.(9/25)

Bad news: The MAbs that your hospital has stocked (likely Regeneron or Lilly) no longer work against Omicron. The one that will work (GSK's Sotrovimab) is in massively short supply. Moreover, lab tests show some loss in GSK's efficacy as well. nature.com/articles/d4158….(10/25)

So, while MAbs might have lowered Delta risk by 2/3rds, we can't ensure access to an effective MAb for Omi.
Note the symmetry here: for hi-risk unvaxxed people, Omicron might be milder, but one of the key tools we had (w/ a similar risk reduction) might not be available.(11/25)

Paxlovid, which got EUA today, is a true game-changer: a 5d pill that reduces risk of hospitalization by 89%. cnbc.com/2021/12/22/fda… But here too there are problems: you’ll need to get diagnosed quickly, & tests (whether PCR or antigen) are incredibly hard to come by…(12/25)

…and then you’ll need access to the drug. Pfizer anticipates having 180K doses by January 1 – there were 190,000 Americans dxed w/ Covid YESTERDAY! So as Covid cases soar, we'll see real bottlenecks in access to the meds (MAbs & Paxlovid mostly) that can truly lower risk.(13/25)

Good news: our tests – both PCR & antigen – still work fine w/ Omicron. Bad news: these too will be in enormously short supply when we need them most – both to trigger a prescription for Paxlovid (which may not be in stock anyway) or, as we’ve been touting, to use...(14/25)

…as a tool to create a safe space for a get-together or in workplace/school. Biden's announcement of 500M tests in Jan, while welcome, is too little & too late. We should've been working on making these tests free & accessible for months, as many other nations have done.(15/25)

Bad news: old incubation period rules (5d) aren’t right anymore. At least from Norway X-Mas party study, it looks shorter than that: 2-3d. eurosurveillance.org/content/10.280… This’ll put a premium on earlier testing & faster tracing, both hard to do. We still don’t know what Omicron…(16/25)

… does to the infectious period – maybe you get sick sooner but clear it faster? Dunno. We need to sort this out stat – if every infected MD/RN is forced to stay home for 7-10 days, I don’t see how we can staff our hospitals & clinics. By report, @nyulangone has gone to…(17/25)

… 5 days of isolation for asymptomatic vaccinated healthcare workers (w/ neg rapid tests days 4-5), which seems logical to me, though many will wait for CDC to bless this strategy. Fauci raised this yesterday as a crucial issue, and he’s right.
beckershospitalreview.com/infection-cont… (18/25)

Good news: vax (& booster) still works for Omi. Bad news: you really need boost for real protection – 1 or 2 shots won’t cut it, & prior infection is of limited help. And we may end up needing a 4th shot, as Israel has begun for high-risk people. nytimes.com/2021/12/22/wor… (19/25)

And more bad news: 40% of our fellow citizens have made the foolish choice not to get a remarkably effective and safe vaccine that has saved hundreds of thousands of lives in the U.S. And if they haven’t taken it yet, I can’t imagine many will do it now, particularly…(20/25)

… as the “less severe” narrative takes hold (largely without the nuance and caveats it requires). These unvaccinated folks will almost certainly get Omicron. Luckily, the vast majority will survive. But tens of thousands will die unnecessarily, compounding the tragedy.(21/25)

More bad news: After 2 yrs, we don’t understand much about Long Covid, & don’t know its prevalence w/ Omicron, after vax, etc. It remains a hardship for millions, and a lingering concern for me as I think about the prospect of getting even a “mild” case of Omicron.(22/25)

Good news: it's possible that – when dust settles from this Omicron surge – we’ll find ourselves in a fairly good place: with a dominant virus that is, in fact, milder than Delta, with virtually everybody having some immunity from either infection or vaccination,…(23/25)

… and with ready access to testing and oral antivirals to help us manage a small number of ongoing cases – leading to lower rates of transmission and fewer bad outcomes.(24/25)

The bad news: virtually every piece of good news in the two years of this damn pandemic has been followed by bad news.
(25/end)