Thread by @Bob_Wachter

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)

… This means that the average SF person is more likely to be vaxxed than in many other places. It also means that masking in a store or concert in SF is seen as normal. I’ve been to other parts of the U.S. where masking gets you funny looks, which makes it harder to do. (4/25)

3) In my household, I don’t have any small kids, immunosuppressed folks, or elders (unless you count mid-60s, which would be depressing).
4) I lean a bit cautious in my personal choices. I don’t hang glide. I used to scuba but don’t anymore. I drive 72 MPH in a 65 zone.... (5/25)

… Your own risk preferences will influence your Covid choices.
5) I’ve made it >2 yrs without getting Covid; I’d like to keep it that way. But today's risk-level may be as good as it'll get for the next few years, so we all have to find a set of behaviors we can live with.(6/25)

6) Given my age, fully vaxxed status, & Omicron’s relative “mildness,” I no longer fear getting super-sick from Covid. It’s not impossible that I could land in the hospital or die; it’s just that the risk is now at a level that doesn’t dominate my thinking about Covid… (7/25)

7) Instead, my biggest worry is that of Long Covid (LC), which I now think of in two fairly distinct buckets:
a. Prolonged symptoms, including fatigue and brain fog, that last for many months. From the (confusing) literature, I estimate the probability of symptomatic… (8/25)

…LC from an Omicron infection in a fully vaxxed person is ~5%.
b. Increasing the risk of bad non-Covid outcomes over time. Recent studies have shown ⬆risk of heart attacks & strokes, of diabetes, of brain shrinkage, and of blood clots. It’s hard to translate that to my… (9/25)

…own personal risk, since there are no long-term studies of 1-year outcomes of Omicron infections in fully vaxxed people (Omicron hasn’t been around long enough). But it is this long-term and uncertain LC risk that is my main motivation to try to avoid infection, even… (10/25)

… if the likelihood of a severe outcome from an acute case isn’t very high, and the likelihood of symptomatic LC in a fully vaxxed person is real but fairly low.
(If I’d already had Covid, these concerns about LC would also motivate me to try to avoid another infection.)(11/25)

8) I don’t find wearing a mask onerous, although of course I’d prefer not to. If I’m going to mask, I figure I might as well wear one that works. So I carry a KN95, which I use when I perceive high risk, & a comfier surgical/cloth combo, which I use in less risky settings.(12/25)

9) I’m lucky enough to be able to work from home much of the time; I now come to my office @UCSFHospitals ~2-3 days a week. It’s a pretty low-risk workplace, given >99% vax/boost rate of our workers. When I take care of patients, it’s all masks (mostly N95), all the time. (13/25)

10) I like eating in restaurants, and SF is often too chilly to do that outside. I also like to travel for fun and work. I don’t go to many concerts or indoor sporting events, and I’m happy watching most movies on a TV set.

OK, with that as background, here's what I'm ...(14/25)

...now doing. When I do something risky, I try to ask myself, “How will I feel if I get Covid?” If the answer is, “I’d kick myself because it wasn’t worth the risk,” then I try not to do it. If it’s, “It would've been worth it,” then I try to forget about C & enjoy myself.(15/25)

Boosters: I got my 2nd booster 2 wks ago. I chose to do Moderna after 3 Pfizers, on mostly theoretical evidence that protection is a bit better. Given the short period of protection from booster #2, if I were lower risk I think I would have waited for signs of a big surge.(16/25)

Travel: I have no hesitation flying, or taking a train, bus, or subway. I wear my N95 the entire time, only taking it down briefly (<1 minute) to eat or drink. I’ll continue doing this even if the mask mandate for travel is ended, as I think it likely will be next month. (17/25)

Indoor Dining: I will eat outdoors if feasible but am willing to dine indoors in a region with low case and test positivity rates (recognizing that the former rate is now an underestimate). How low? Now that I’ve had my 2nd booster, <~20 cases/100K/d and <~5-7%. (18/25)

Indoor Hangout With Friends (food, poker): no mask if I’m confident that everybody is fully vaxxed & the city has low Covid rates. If there’s going to be someone vulnerable there (baby, immunosuppressed, very old), I favor doing rapid tests on everyone before the event. (19/25)

Other Indoor Activities: I went to a large conference in Nashville last week. I wore my mask in sessions, though (to my surprise) ~80-90% of the MDs there did not. I did go to a few big indoor dinners/receptions with no mask, accepting it was probably the riskiest thing… (20/25)

… I was going to do. To me, it passed the “it’s worth it” test. (Luckily, no Covid.)
Movie/Theater/Concert: I’d be willing, wearing an N95 the whole time. For movies, I’d tend to wait for it to come to my TV.

Outdoor Activities: no mask unless super-crowded & no breeze. (21/25)

Got Exposed to Someone With Covid: depends on the exposure. If high level (hugged or long conversation), I’d isolate & mask, home test daily starting on day 2, and consider myself in the clear if negative on day 5.

Had Any New Covid-Like Symptoms (sore throat, cough...(22/25)

... fever, new GI symptoms): would consider myself potentially infected, rapid test for 2 days in a row, and relax if neg x 2.

Actually Got Covid: Try to get on Paxlovid ASAP, thinking it would decrease the (already low) odds of a very bad outcome, and potentially... (23/25)

... (though this isn't proven) lower the odds of both kinds of Long Covid problems: persistent symptoms and ⬆risk of non-infectious problems down the road. I'd isolate from others, including my wife, until I was asymptomatic AND my rapid test turned negative. (24/25)

So that’s how I'm choosing to live life given the current conditions. Your choices may well be different based on your personal situation, the Covid prevalence in your region, and your own risk tolerance. Hope this helps as you try to navigate today’s confusing landscape.(25/end)