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)
bmj.com/content/375/bm…
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 nytimes.com/2021/12/28/wor…, 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)
pfizer.com/news/press-rel…
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.
(24/end)

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More from @Bob_Wachter

Jan 15
Some folks are a bit confused about why things are likely to be much safer in a month than now – not why virus will peak & fall (we don’t entirely know) but why the risk to individuals will plummet – & with that, why activities that are unsafe now will be much safer then.(1/20🧵)
There are about a dozen factors that go into a risk assessment, and only one of them will fundamentally change: the probability that a person near me is infectious.
Let’s go through the other factors to isolate the one that makes virtually all the difference.(2/20)
Will the virus I'm exposed to next month be the same?

Almost certainly. Omicron's now the dominant (>95%) virus in the U.S. (Fig) and it’s a near-certainty that it will be that way next month.
Given its relative "mildness," I hope that's true in 6 months; time will tell.(3/20)
Read 20 tweets
Jan 11
Covid (@UCSF) Chronicles, Day 665
I haven’t done a SF update for a week – it’s a good time to catch up. Any impact of holiday gatherings should now be baked in, we all know scores of people with Covid, & hospitals are getting overwhelmed. So is SF’s high vax rate helping? (1/20)
Let’s look first at data @UCSFHospitals before turning to SF. 10d ago, we saw a mini-plateau & I wondered if SF's “wall of immunity” would prevent a hospital surge. Answer: no such luck.
Today, we have 75 Covid patients at UCSF Medical Center, up from 22 one month ago. (2/20)
Issue of how many of them have “incidental Covid” (testing pos. but there for another reason) has become hot; @SaraMurrayMD, @RhiannonCroci & I wrote about this @washingtonpost. washingtonpost.com/outlook/2022/0… Using our method (combines diagnosis & use of antiviral Remdesivir)…(3/20)
Read 20 tweets
Jan 8
I’ve been tweeting about Covid for nearly 2 years. But this week it became personal when my 28-year-old younger son got it.
With his permission, I’ll describe his experience & how I approached his situation, given the realities of life and the rapidly changing evidence.(1/25)
My son, who lives in SF, is generally healthy but overweight, placing him in a moderately high-risk group. He’s been quite careful since March 2020, & has received 3 Modernas. He used to wear a 2-ply cloth mask; since Omi, he’s switched to an KN95 (with my “encouragement”).(2/25)
He works in downtown SF in customer service, so he has a lot of people contact. I’ve worried that he’d get it from work, or from the bus. But that’s not how it happened. Instead, one of the few friends he sometimes sees in person – another fully vaxxed young person who… (3/25)
Read 25 tweets
Dec 31, 2021
A brief San Francisco update. As always, SF is a key test case since it's so highly vaxxed (81% of people w/ ≥ 2 shots) & most still follow public health recs (incl. masking). Nevertheless, we see skyrocketing cases; hospitalizations more modest but starting to tick up.(1/12)
Let's look @UCSFHospitals first. Test positivity rates continue to climb, though if you squint you might see a hint of a plateau. As always, my key # is the asymptomatic test pos. rate, now 7d avg of 8.27% – implying 1 in 12 people in SF without Covid symptoms have Covid.(2/12) Image
With that prevalence, you have to assume that everybody you come in contact with might have Covid.(Cities experiencing greater surges probably have even higher asymptomatic %.)
This is why I haven't been too critical of the CDC's 5d isolation guideline – the risk of...(3/12)
Read 12 tweets
Dec 28, 2021
Today's update on SF/@UCSF numbers. Bottom line –huge increase in cases & test positivity. Hospitalizations still pretty benign (though early signs of an uptick). Most remarkable stat is our asymptomatic test positivity rate (ATPR) @UCSFHospitals – now ~7%, or ~1-in-14.(1/16)
You'll recall that ATPR is fraction of pts getting care (hospitalization, procedure) @UCSFHospitals who we test for Covid routinely, even tho they have no symptoms. I use this as a rough approximation of the prevalence of Covid in Bay Area people who have no Covid symptoms.(2/16)
The ATPR was as low as 1/500 (0.2%) a few mths ago. Today, our 7d ATPR is 6.9%, and last 3 days it's ~8% (going up fast).
If its 8%, it means 1-in-12 people in SF who feel fine would test positive for Covid.(Not all would be in their infectious period, but most would be.)(3/16)
Read 16 tweets
Dec 28, 2021
There are so many Omicron #'s floating around, it’s overwhelming. In today’s 🧵,I’ll try to simplify things with a couple of rules-of-thumb that I’ve found useful. I’ll be interested in hearing if this helps or confuses more – it might hinge on whether you’re a chess fan.(1/25)
Chess? We’ll get to that in a bit. For several of the big picture Omicron issues, my go-to is not a chess board, but rather the Number 2.
Why 2? Because many of Omicron’s key variables are either just about twice, or approximately half, of what they were with Delta.(2/25)
Two key variables for which “2” is a useful rule-of-thumb:
a) How much more infectious is Omicron than Delta? About twice. (And Delta was about twice as infectious as Alpha was.)
b) How much less serious (measured by hospitalizations) is Omicron than Delta? About half. (3/25)
Read 25 tweets

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