Bob Wachter Profile picture
Dec 29, 2021 24 tweets 6 min read Read on X
My latest tweets have mostly been bad news, which saddens me, particularly during holiday season.
Today I’ll take you to my Happy Place, with some thoughts on why we could be in good shape – and maybe even great shape – in 6-8 weeks.

A 🧵(1/24)
Let’s start by agreeing that the current state is awful, and likely to get worse. Case rates are skyrocketing (Fig L), hospitalizations are going up fast (but not nearly as fast as cases; R), it feels like everybody's infected or recently exposed, & there are shortages of…(2/24) ImageImage
…key tools, including testing (both PCR & antigen) & therapies (mostly Sotrovimab [the monoclonal Ab that works vs. Omicron] & Paxlovid, the Pfizer oral antiviral with outstanding efficacy in preventing serious illness in outpatients with Covid).(3/24)…
But there are some positive trends peeking out from behind the fog of gloom. Let's explore them...
(4/24) Image
First, the case-hospitalization dissociation is now solid. Omicron’s relative mildness is both due to inherent properties of the virus (increasingly shown thru animal studies and epidemiologic data) and fact that high levels of vax-induced immunity –(5/24)
– while less protective vs. mild Covid – are quite protective vs. severe cases. Sadly, unvaxxed are sitting ducks, wholly dependent on inherent “mildness” of the variant, which'll protect them a little but not a lot. But the vaxxed/boosted should feel good about their odds.(6/24)
This means that those hospitalized for Covid are mostly those who have made a (bad) choice to remain unvaccinated. They deserve our compassion and care (and, in my experience, they're getting it), but it was a choice for which they should have appreciated the risks.(7/24)
With Omicron this infectious, many vaxxed people will get mild breakthrough cases…, which should leave them even more protected vs. another infection.
And virtually all unvaxxed people, unless they’re being uber-careful, will get infected shortly.(8/24)
Most of the unvaxxed who get Covid will get lucky and have a relatively mild case, others will have a more serious case but survive (& be left w/ a measure of immunity), & a few will die. In any case, society’s overall immunity to Omicron should be far higher in 4-6 weeks…(9/24)
… than it is today – both from additional people getting vaccinated and the consequences of having had Omicron, both in vaccinated (where the infection will act like another booster) and unvaxxed individuals.(10/24)
We’ll have to see how well a case of Omicron protects vs. recurrence, but I’m quite hopeful that it will offer major protection.
(Protection may decay over time, which may lead to a resurgent threat by winter 2022. But this is my Happy Place, so let’s stick to the spring).(11/24)
More good news: by late January, I expect two of the key bottlenecks will have eased: the testing bottleneck (particularly as the feds ramp up free rapid testing). And the supply of Paxlovid will grow so that the pill is available, at least for high-risk Covid outpatients.(12/24)
It’s looking like Paxlovid will work as well on Omicron as it did on Delta. Assuming this, & that it’s available, in a month we could find ourselves with an outpatient pill that lowers hospitalization & mortality rate of high-risk patients by ~90%.(13/24)…
So we may be in a position where most high-risk pts have strong immunologic protection (via vax, & some from a breakthru), and newly infected high-risk patients can get rapid dx via testing & a pill that lowers chance of a severe case to 1/10th of what it would have been.(14/24)
And vaxxed and boosted people who have managed to avoid infection with Omicron will be protected by falling numbers of cases (as the immunity wall grows) and reassured by solid evidence that they are quite well protected against severe cases by their vax/booster combo. (15/24)
One final bit of good news: adding to the experience in South Africa, where cases peaked & began falling after ~2 months, we may now be seeing a rapid plateau in London (Fig), one of the hardest hit cities in Europe. As usual, it’s hard to tell how much of this is… (16/24) Image
… from increased population-level immunity vs. more careful behaviors (likely it’s both). In any case, the early evidence of a London plateau – if it persists – may portend a similarly early plateau in U.S. cases and the possibility of falling case numbers in 6-8 weeks.(17/24)
Let’s be clear: I'm NOT in my Happy Place now, given the potential for overwhelmed hospitals & some ongoing uncertainty re: Omicron’s risks. It's time to be more careful – to avoid crowded indoor spaces (sorry, New Year’s Eve), & wear N95s. The current threat is very real.(18/24)
But by early February, we could be in a place where Covid is, in fact, “like the flu” – with the vast majority of the U.S. protected through vaccines or recent infections, folks at higher risk having ready access to an oral treatment that markedly lowers their risk, and…(19/24)
… a healthcare system no longer stressed to the point of perilousness – for both Covid patients & others needing our services. At that point, allowing folks to go “back to normal” might be a reasonable posture – while recognizing that higher risk people – or those… (20/24)
who have contact with them (eg, parents of unvaxxed toddlers, people who live or work with the immunosuppressed) – may logically choose to continue their cautious behavior, such as masking and avoiding crowded indoor spaces.(21/24)
Am I SURE that we’ll end up in my Happy Place in February? Sadly, no – there’s no guarantee that our pattern will mirror South Africa’s or London’s. We might still face big shortages of Paxlovid or testing, or we may learn that Long Covid is a real threat after Omicron.(22/24)
But these risks feel like fairly low probability events. As dire as things look now, I think the likeliest outcome is a pretty good situation in February which – if we’re lucky (and there hasn’t been much luck in 2020-21) – will be our durable state by 2nd quarter, 2022.(23/24)
At that point, “I’m over this!” might no longer be a sign of exhaustion, confusion, or political affiliation, but rather a perfectly rational and evidence-based way of approaching Covid, and life.
Fingers crossed.

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More from @Bob_Wachter

Dec 18, 2023
Covid (@UCSF) Chronicles, Day 1371
I haven’t X'ed much about Covid lately, mostly because things are fairly stable. But a lot of folks have asked me what I’m doing, Covid-wise.
So today: how I’m acting, & why. Graphic below shows my general approach; more details follow. (1/25) Image
How am I acting currently? Given a moderate uptick in Covid over the past two months, I’m back to masking in crowded and poorly ventilated places, particularly when I don’t need to talk. When I do mask, I always use an N95; I see no reason to wear a less effective mask. (2/25)
Examples of where I currently mask: crowded stores, airplanes or trains; elevators; and theaters. But given that today’s uptick is only moderate, I’m still OK with indoor dining (though will opt for outdoor if conditions allow) and for going maskless at holiday parties. (3/25)
Read 25 tweets
Aug 18, 2023
Covid (@UCSF) Chronicles, Day 1249
While good data are far harder to come by than in the past, it’s clear that we’re experiencing another Covid uptick. Today: what that means and how you might choose to alter your behavior in response. (1/25)
First, the evidence for the uptick (I don’t say “surge” since I associate that with the massive surges of the past):
This curve of hospitalizations (a reasonable proxy for the amount of Covid in the community) shows a definite, but relatively mild, upward trend. (2/25) Image
Alas, one can't look at any single measure to quantify an uptick anymore. But all arrows now point in the same direction: up (⬆ wastewater,⬆ hospitalizations,⬆ deaths,⬆test positivity). Even my fave measure, @UCSFHospitals’ asymptomatic test positivity rate, is no… (3/25)
Read 25 tweets
Jul 13, 2023
Until this week, I remained a NoVid, which I chalked up to being fairly cautious, fully vaxxed & a bit lucky.
This week my luck ran out. My case is a cautionary tale, particularly for the “just a cold” folks. Mine definitely was not...I literally have scars to show for it. (1/22)
I’ve got my 2nd bivalent in April, so my protection against a severe case was still strong, but the 2-3 month window of protection vs. getting Covid had passed. I've let down my guard a bit: still masking on planes & in crowded rooms, but I do now eat and drink indoors. (2/22)
This week, I was on clinical duty @UCSFHospitals. We are still required to mask in patient areas (good!). I felt fine until Sunday afternoon when, after leaving the hospital, I noticed a dry cough. By Sunday night, I felt flu-ish, with a sore throat, fever, and chills. (3/22)
Read 22 tweets
May 23, 2023
Covid (@UCSF) Chronicles, Day 1161
With the Pub Health Emergency over, it's a good time to update you on my view of Covid & my current approach to Covid behavior – which is now based on 2 principles:
1) Is the risk worth it?
2) Can I live w/ the behavior for the long haul? (1/25)
First, let’s review today's situation. Since Omicron's emergence in 11/21, the biggest surprise has been the absence of surprises. Yes, we’ve seen a few variants that led to mild surges, but we haven’t had to interrogate our Greek dictionary for a new letter for 18 months. (2/25)
mRNAs still work great in preventing severe infection, and Paxlovid, home tests, & ventilation still work well too. Long Covid remains a concern, but we know that both vax & Pax lower its frequency, that most (though definitely not all) folks… (3/25)…
Read 25 tweets
Feb 17, 2023
Important @TheLancet systematic review finds Covid infection confers robust & long-lasting (good at 40 weeks) protection vs both symptomatic & severe Covid infection.(Weaker w/ Omicron, but still good.)…
How will results influence my behavior/thinking?(1/7)
a) I've been considering a Covid infection to be the equivalent of a booster in terms of protection against reinfection & severe disease (hospitalization/death). These study results indicate that it is at least that good, maybe even a bit better... (2/7)
b) We've been headscratching about why XBB variant didn't cause more of a surge, despite low uptake of the bivalent booster. It may be that immunity from all those 2022 Omicron infections kept it at bay (that's informed speculation – Lancet study ended before XBB spike)... (3/7)
Read 7 tweets
Jan 19, 2023
Covid (@UCSF) Chronicles, Day 1038
Some folks continue asking what I'm doing viz Covid behavior...
Answer: I'm changing my behavior. In the Bay Area, I'm now OK with indoor dining & removing my mask for small group gatherings.
I haven't changed, the risk has. Here's how: (1/25)
Specifically, I haven't changed my perspective on balancing prudent caution with everyone's (including my) desire for "normal."
But, in the Bay Area at least, the Covid risk has come down considerably, and, by my way of thinking, this allows for a more permissive approach.(2/25)
Where I'm coming from:
1) I'm 65 & haven't had Covid
2) I want to live as fully as I can, but am comfortable taking reasonable steps to avoid infection
3) I'm fully vaxxed & had bivalent in Sept
4) My main fear is Long Covid, which I peg at ~5% probability per Covid case. (3/25)
Read 25 tweets

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