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

Feb 17
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
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
Dec 27, 2022
I appreciate all (or, at least most) of the feedback on yesterday’s post regarding how I make decisions about Covid risks and mitigations, including my 50% Rule.
A brief follow-up thread today, with a few additional thoughts and responses: (1/12)
a) First, of course we’re entering year 4 (!) of Covid (I mistakenly said year 3 in yesterday's first tweet). Sorry.
I was hoping that by now Twitter would have added an edit function, but the new management seems focused on other changes. Hopefully at some point. (2/12)
b) A few folks asked how masking fits into my risk mitigation algorithm.
Just as I’m comfortable doing anything OUTSIDE without a mask, I’m OK in ALL indoor spaces – incl. crowded theaters, subways, etc. – wearing a KN95. I’m also OK removing my mask briefly to eat/drink. (3/12)
Read 12 tweets
Dec 25, 2022
Covid (@UCSF) Chronicles, Day 1013
As we enter Covid Year 3, it’s clear we’ll be in our current predicament for the foreseeable future. This means we all need to find our own method to weigh & mitigate risks.
Today I’ll describe my “50% Rule” & how it governs my choices. (1/25)
All of us make risk choices daily, without much thought. What is the chance of rain above which I’ll bring an umbrella? Do I buy flood or earthquake insurance? Do I take a statin for my cholesterol? In making these choices, it’s rare there’s an unambiguously “right” answer.(2/25)
Instead, we weigh the odds & badness of the thing we’re trying to avoid; how unpleasant, risky, & expensive the mitigation is; & our own risk tolerance. Since the cognitive burden of doing this for myriad choices daily is onerous, we all develop rules of thumb to guide us. (3/25)
Read 25 tweets
Dec 19, 2022
Covid (@UCSF) Chronicles, Day 1006 (!)
There’s an awful lot of Covid confusion & misinformation out there, particularly around these three topics: masks, vaccines, and home tests. Let’s look at them in today's thread. (1/24)
To start, these statements are correct:
• Wearing the wrong mask, or wearing a mask incorrectly, doesn’t work
• Vaccination/boosters don’t work as well as they used to in preventing infection
• Home tests yield more false negative results than they used to.
But these statements are unambiguously wrong:
• Masks don’t work
• Vaccines/boosts don’t work
• Home tests don’t work
This is confusing enough that it’s an easy mark for those who want to spread misinformation. Here’s how I interpret the science to inform my decisions: (3/24)
Read 24 tweets
Nov 24, 2022
Covid (@UCSF) Chronicles, Day 982
Today – my Covid (as well as flu & RSV) plans for the Thanksgiving gathering. I’ll walk you through my current assessment of risks and risk mitigation strategies, and why I’m still being moderately careful. (1/25)
We’re having 12 family and friends over this afternoon. Our plan: while there will be some hanging out inside the house, the bulk of the festivities (including the meal) will be outside. And everybody will rapid test beforehand.
Here’s how we came to this strategy: (2/25)
First, case rates are up moderately, though not as high as I thought they’d be, given that the now-dominant BQ variants look to be fairly immune-evasive. But, for reasons we can’t completely fathom, our overall immunity (from vax & infections) is preventing major surges. (3/25)
Read 25 tweets

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