Thread by @Bob_Wachter

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)