Bob Wachter Profile picture
Jan 8 25 tweets 7 min read
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)
...has also been quite careful, came over Monday night to watch a movie. She felt fine, as did he.
Wednesday am (~36 hours later), he woke up & felt awful. Sore throat, dry cough, muscle aches, chills. No taste/smell abnormalities. I told him to stay home, drink fluids…(4/25)
…and take Tylenol or Advil. Local pharmacies were all out of rapid tests, but I had one set stashed away. He came outside (I wore an N95) & we ran it, w/ a nasal swab. It was negative. I was a little reassured, though he was not – “Dad, it feels just like I felt after my…(5/25)
… vaccine,” he said. He seemed sick enough to be infectious; I wondered if he’d be an example of the newly reported problems with false-negative rapid tests in the first days of an Omicron infection. He called the @UCSFHospitals Covid hotline... (6/25)
medrxiv.org/content/10.110…
…(he’s a patient) to get a PCR or Color (PCR-like) test. 1st available: 4 days away, so no help. I heated up some chicken soup, bought an oximeter (97%, whew – though his heart rate was 120: concerning) & told him to call me if his symptoms changed or his O2 sat fell <95%.(7/25)
Next day, I called him at 9am – no answer. My brain knows the odds of a fully vaxxed young person dying are near-zero. Still, I wondered briefly if he’d survived the night: evidence-based medicine meets parental emotion. I tried again at 10, still no answer. I let myself… (8/25)
…into his place & found him sleeping… and breathing.
An hour or so later, he heard from the friend he saw Monday pm. She had tested pos. Of course, that increased my son’s odds of having Covid, but still the incubation time of <2 days seemed awfully short. It was time…(9/25)
… for another rapid test. This time, based on early reports that swabbing throat PLUS nose improves yield for Omicron (vs. nose alone), that’s what we did: a good rub around his tonsils & tongue, and then (same swab – a bit gross) both nostrils. washingtonpost.com/wellness/2022/… (10/25)
The 15-minute wait, and then...the pink line: he was positive. Like millions of other young people, my son had Covid. I felt a strange guilt – not entirely rational, but real – for not having protected him.
We cancelled the PCR test (now 3 days away) since the diagnosis...(11/25)
...seemed secure. So one more case omitted from the public #'s (which makes skyrocketing case counts even more amazing).
He called in sick to work, set himself up for at least 5d of strict isolation, & I set out to figure out his prognosis & if treatment was merited. I...(12/25)
...knew, deep down, that odds of a bad case were low. But when it’s your kid, you freak out a bit.
Re: prognosis, youth helps: compared to his 64 yo dad, he has 1/4 the hospitalization risk, & 1/25th the death risk. An on-line risk calculator (riskcalc.org)...(13/25)
…(which doesn't consider vax or Omicron but does consider age & risk factors) calculated risk of hospitalization at 2.3%. I figured that his 3x vax cuts that by ~80%, & Omicron’s "mildness" by another ~50%. So maybe a one-in-300 chance (~0.3%) of needing hospitalization. (14/25)
There are 4 main treatment options for a symptomatic outpatient. One: monoclonal antibodies. But the only one that works against Omicron, (I’m assuming he has Omicron, because it’s now dominant in the U.S. and because the lightning-fast incubation is an Omicron tell)… (15/25)
...Sotrovimab, is in exceptionally short supply – last wk, UCSF had none in stock. So that’s out. My fave, the Pfizer pill Paxlovid, which ⬇the chance of hospitalization by ~90%, is also hard to find. @UCSF, we’ll only use it in severely immuno-…(16/25)
pfizer.com/news/press-rel…
…-suppressed folks. 3rd choice: Remdesivir, an IV drug that we’ve long used in hospital, but recently shown to ⬇hospital & death rates by 87% in hi-risk outpatients. nejm.org/doi/full/10.10… Because it’s IV, its use is also limited to patients at much ⬆risk than my son…(17/25)
… Finally, Merck’s Molnupiravir. Like Paxlovid, it's a 5-day pill.merck.com/news/merck-and… It’s less effective (~30% benefit) than Paxlovid, but more available. Should my son go on it?
A 30% risk-reduction sounds OK. But when your risk is only 0.3% for hospitalization,...(18/25)
...a 30% benefit would translate into 0.3%⇾0.2%, or 1/300 going to 1/500. You’d need to treat about 1100 people like my son with 5 days of pills to prevent one hospitalization (“number needed to treat,” NNT). And chance of death is probably ~1/5000, with a NNT of 20,000. (19/25)
I called his doc, who noted that the pills have benefit when used before day 5. “I’d err on not treating,” he said wisely, but might reconsider if things worsened in the next couple of days.
It’s now day 4. Pulse ox is fine, heart rate has slowed, he's a bit less flu-ish(20/25)
..., but his throat still hurts like hell. When 5d are up, we’ll do another rapid (if I can find one) – if neg he’ll leave isolation (& wear an KN95). If pos, he’ll stay isolated until it’s neg, or day 10. He’ll still mask for 5d more. And that – we hope – will be that. (21/25)
Am I worried about Long Covid? A little. The literature is a mess: some studies show 50% of people have persistent (>1 month) symptoms. Other studies say it's more like 5%. It seems like vax lowers the risk. So it’s a concern, but there’s not much we can do but wait & see.(22/25)
Any lessons? First, thank God for vaccines! Yes, he had Covid, but his vax slashed the odds of a severe case, hospitalization & death. 2nd, concerns re: false neg rapid tests in Omi are real, as are shortages of tests & meds.
Omi's lesson: lower your guard & it'll pounce.(23/25)
Should he have watched movies with his friend? I think so – it seemed like a fairly safe encounter. But while Omi is surging, even low risk stuff – things that were safe last mth – may now be risky. Given how quickly this storm may pass, it seems wise to hunker down a bit.(24/25)
My son should do OK, but the illness & the anxiety it causes are miserable. Resigning ourselves to getting Omicron doesn’t seem right, especially since the surge may be short-lived. I still think it’s an experience best avoided – for you and your loved ones – if you can. (25/end)

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More from @Bob_Wachter

May 19
We're hearing lots of reports of Paxlovid rebound, but there are no good data about prevalence. Yesterday I polled my followers to learn more.

The results (next tweet) are striking. (Of course, keep in mind caveats regarding on-line polling results.)(1/13)
As of now, there've been 4846 responses. 93% either didn’t have Covid recently or hadn’t taken Pax.
Of the ~350 respondents who HAD taken Paxlovid for Covid, ~46% said they experienced rebound (new symptoms plus a test that went from – to +), vs. 54% who said they did not.(2/13) Image
In the Pax clinical trial, rebound was seen in 2%, so clearly we’re seeing a big difference in real-life use. If the poll results are even close to accurate, we need urgent study by @pfizer & @US_FDA to answer questions about a medication being Rx'ed 20K times a day in U.S.(3/13)
Read 13 tweets
May 18
If you follow me, you know that my wife @katiehafner had Covid last week, took Paxlovid, & is now testing negative.
In this 🧵(w/ a few polls to see your thoughts), I’ll discuss what to do in the post-Covid period, in light of the latest Covid curveball, Paxlovid rebound. (1/25)
To recap: Katie taught at a science writer’s workshop in Sante Fe, May 2-6. There were 50 attendees. Vax required; testing not. Masks were optional. Katie masked during sessions, but ate with the group indoors multiple times. Her symptoms began on Saturday May 7, and she… (2/25)
…tested positive Sunday May 8. She felt awful (terrible headache, congestion, fatigue) on Sunday and Monday; she began Paxlovid Monday, May 9. By Tuesday, she was feeling much better (which she attributed to the Paxlovid, though who really knows). She stayed in … (3/25)
Read 25 tweets
May 9
The latest Omicron variant (BA.2.12.1) is the most infectious yet, & it’s snagging tons of people who have avoided Covid for > 2 years. It’s hitting close to home for me, so tonight’s 🧵is about that…with a few poll questions to see how your thinking lines up with mine. (1/23)
My wife, @katiehafner, like me a healthy 64-year-old, has been quite careful but – with my encouragement – has re-engaged with the world, confident that her 2 vaccine shots and 2 boosters will protect her from serious illness, and reconciled to the fact that Covid may not…(2/23)
… get much better than it is now for the next several years. So last week (M-F), she taught at a writing workshop – there were about 45 attendees and 5 instructors. Course attendees had a vaccination requirement. Masks were optional. The attendees & instructors… (3/23)
Read 23 tweets
May 4
The steady drumbeat of cases, coupled w/ CDC’s finding that 60% of Americans have had Covid cdc.gov/mmwr/volumes/7…, naturally raises the inevitability question: Are we all destined to get Covid? And, is it worth remaining careful?
I’ll address these questions in this 🧵. (1/25)
It can certainly FEEL inevitable – especially when every day brings news of Covid+ friends & family, including many who are vaxxed/boosted & staying careful. Omicron sub-variant BA.2.12.1 is remarkably infectious, leading to a real (& underestimated) ⬆in U.S. cases (Fig). (2/25)
Nevertheless, I don’t think it’s inevitable that we’ll all get Covid in 2022-23. For folks (like me) who have dodged the bullet so far, I’m fairly – but not 100% – confident that we can remain Covid-free by acting prudently, adjusting behavior based on the current threat.(3/25)
Read 25 tweets
May 2
Covid case numbers less reliable than before (home testing, fewer test sites). Our @UCSF asymptomatic test pos rate (ATPR) remains a good proxy for community prevalence.
Bad news: in last few weeks, ATPR is⬆3-fold, now 3.4%. Implies ~1/30 asymptomatic folks in SF are pos. (1/4)
In last mth, SF has become far less mask-y. At this point, if you've decided you're OK getting Covid (which isn't crazy if vaxxed/boosted), then fine to keep mask off in crowded indoor spaces. If you'd prefer to avoid Covid & have become less cautious, it's time to re-think.(2/4)
I'd still like to avoid Covid (mostly worried about Long Covid symptoms & long-term risks (heart/neuro/diabetes); also disruption of daily life). I'd slipped a bit re: masking in non-crowded spaces, & gotten less careful re: restaurants. I'm resuming more cautious behavior. (3/4)
Read 4 tweets
Apr 17
I’ve been gratified hearing from many people who have said that they’ve followed my lead in deciding what they'll do, and not do, in various stages of the pandemic.
It’s a particularly confusing time now, so today’s 🧵 is a summary of the choices I'm making these days. (1/25)
I’ll get to these choices later (if this is TL;DR, skip to 15/25). But to understand them, you need to appreciate my own risk, risk tolerance, & synthesis of the evidence – since as rules melt away, choices will be increasingly personal, often without clear “right” answers.(2/25)
Here goes:
1) I’m 64, pretty healthy (mild asthma, mild high cholesterol). So I have a moderately ⬆risk of a bad outcome from a Covid case (compared w/ a younger person), but not super-high.
2) I live in San Francisco, which remains a careful city when it comes to Covid… (3/25)
Read 25 tweets

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