Watching national data

And being in the hospital this week

I see two things that appear contradictory

But both are true

1. Link between cases & hospitalizations is much weaker with Omicron than in the past

2. Our healthcare system is in trouble

Thread: the moment we are in
Let's talk about I'm seeing in the hospital first

In the hospital, seeing lots of COVID patients

Some admitted due to COVID

They are all either:

1. Unvaccinated

2. Very high risk folks not boosted

And some admitted "with" COVID as incidental

Almost all not boosted

Haven't seen a single boosted person admitted for COVID

And in the national data

Risk of hospitalizations is still those two groups

High risk not boosted

And that pool of people is still very, very large

And that is driving the surge of hospitalizations

But first,

Let's look at the link between cases and hospitalizations

We're admitting 15K-20K COVID patients a day!

If you use NY data, may be half are incidental "with COVID"

So 7.5K-10K every day

That's still a lot

But... way less than what we'd have seen in prior waves
In prior waves, you could look at cases today

And reliably predict 6%-9% of them would be hospitalized a week later

Now, closer to 2%-3%

And since we're missing a LOT of cases now because folks testing + at home

Hospitalization rate is even lower

But we still have a problem
Because those getting hospitalized are from the "at risk for hospitalizations if infected" group

And there are a lot of Americans in that group

My estimate? At least 40 million

Though in reality, probably more

And I'm only focusing on adults

So let's do some math

There are about 6 million Americans >65 who are not yet even vaccinated

They are VERY high risk for getting severe disease

There are 20 million people >65 who are vaccinated but not boosted

They remain at risk of getting severe disease if infected

There are 60M adults (<65) who aren't vaccinated

And 30M adults 50-64 vaccinated but not boosted

If 25% have high risk conditions

And if 30% have some protection from prior infection

That's still at least 15M people <65 at risk for bad outcomes

Though likely more

So at least 40M Americans vulnerable to severe disease if infected

A quarter could easily get infected in Omicron wave

And 10% of them hospitalized

That's 1M+ hospitalizations

There is no way our healthcare system can handle that in the next month or 6 weeks

So we have two things happening

Many "very low risk of bad outcomes" people are getting infected

The young/vaccinated/maybe boosted or older but boosted

Those cases are not turning into severe illness


That's the uncoupling of cases and hospitalizations

But we still have at least 40M Americans, likely more

Who are vulnerable

And when they get infected

Many are landing in the hospital

It may be a "milder" disease

But let me assure you

Omicron not milder enough to protect unvaccinated folks or un-boosted high risk folks
So how do we get through the next month or so?

We can still get more vulnerable people protected

First shot of vaccine begins to provide some protection within 10-14 days

Boosters begin to work within a week

That will help reduce number of vulnerable folks

But also..

We have to reduce the sheer volume of infections

Using public health approaches like more testing, avoiding indoor crowds, and more indoor mask wearing

I remain very worried about our hospitals' ability to care for everyone who needs care over next 6 weeks

So on the debate of whether cases matter or not?

Among protected people, they matter way less

Among vulnerable people, they matter a lot

But because we all live in one country

We have to reduce infections overall even as we protect more people via vaccines and boosters


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More from @ashishkjha

10 Jan
Given the immense value of in person schooling for America's kids,

Lets talk about how every school can be in person safely today

Not under ideal conditions

But under real-world conditions

First, let's start with "ideal", which LOTS of school districts have done

What is ideal?

1. Teachers vaxxed/boosted
2. Kids vaxxed
3. Everyone masked w/good masks
4. Ventilation
5. Testing

Billions of $ available for ventilation and testing
Vaccines free, widely available

I get it, some places chose not to do it

But $ is not the barrier

So lots of school districts chose not to do these things

What if a school doesn't have testing and systemic upgrades in ventilation?

Can schools still be safe?


If folks vaxxed/boosted
And we have masking (compliance doesn't have to be 100%)

Still very safe
Read 7 tweets
4 Jan
Day 2 of hospital service

A few observations about the whole "hospitalized for COVID" versus "hospitalized with COVID"

This distinction matters

But may be not in the way people think

First, we have a few patients in the hospital for COVID

But not many, thank goodness

Not many because RI is highly vaccinated state

More common on our service is folks admitted with COVID

That is, they came to hospital for something else and found to have COVID

Its tempting to say that COVID here incidental and therefore, doesn't matter

Not quite right

There are two types of "with COVID" patients and they both have an impact on care, utilization, stress to the system

The first type is: had COVID -- was "mild" -- but now have complications

Example (changing details for confidentiality)

The 86 y.o. man with kidney disease

Read 7 tweets
3 Jan
We know how to keep people safe in schools during COVID

For an airborne virus

Masking and ventilation/filtration substantially slow spread

As does regular testing

And vaccines protect from bad outcomes

So I've been puzzling over why this isn't happening everywhere

If key strategies include masking, ventilation, testing, vaccines

Masks became widely available late 2020

By early 2021, there was lots of $ from Feds for improving vent/filtration as well as testing

By fall 2021, every adult & school-aged kid was eligible for vaccines

So barriers are now primarily not money or availability (though testing is currently a challenge)

So what are the main barriers?

First, misinformation

Like schools are always safe (you have to make them safe)

Or masks don't work (they do, some more than others)

Read 6 tweets
29 Dec 21
.@ezraklein asks a great question

What is the goal at this point?

I think it needs another element

What costs we are willing to pay to achieve that goal?

My goals?

Save lives, prevent hospitals getting overwhelmed, keep essential things (schools) open

In that order


Let's talk about other goals and costs we're willing to bear

Reduce infections? Yes!

Low cost things like encouraging indoor masks will help

But to really suppress infections? We likely need hard lockdowns

Which makes no sense at this point in pandemic

So the other goals...
Saving lives, keeping hospitals functional, schools open?

We know how to do that

1. Vaccines & boosters for all but especially high risk folks

2. Lots of rapid tests in key settings (nursing homes, schools, etc)

3. More ventilation/filtration

This all feels doable

Read 4 tweets
28 Dec 21
While new CDC isolation guidelines are reasonable, here's what I would have done differently

1. Required a neg antigen test after 5 days

2. Had different guidelines for vaccinated (contagious for shorter time) versus unvaccinated

3. Specified higher quality masks

Short thread
So why are CDC guidelines still reasonable?

Because if you actually follow what CDC says,

They require people be asymptomatic

And wear a mask for 5 more days

And if people actually followed the guidelines

I can't come up with how they aren't quite reasonable

The critique appears to be that people won't follow CDC guidelines

That they'll stop isolating after 5 days even with symptoms and/or not wear a mask

Yes. That'll happen for some

But shorter isolation means lower barrier to test/isolate

Which will motivate others to test

Read 5 tweets
26 Dec 21
As Omicron cases explode

We need a strategy for isolating folks who test positive

We need to think about the purpose of isolation clearly

Because if we don't get it right,

It'll both be hugely disruptive and won't keep us safe

So let's discuss what we need to do

First principles:

Why ask people to isolate at all?

Well, that’s obvious

We don’t want them spreading

So what we care about is CONTAGIOUSNESS

We want folks to isolate when they're contagious

So when are people contagious?

Well, it varies. A lot

OK, so what to do?

How long folks are contagious depends on two things

1. When they test positive (i.e. early in the phase of infection vs. late)

2. Their immune system's ability to clear the virus

Take the average person who tests PCR+ today

How long will they be contagious?

Read 15 tweets

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