Thread by Bob Wachter

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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)
…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)
www.bmj.com/content/375/bmj.n2713
But there are some positive trends peeking out from behind the fog of gloom. Let's explore them...
(4/24)
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 www.nytimes.com/2021/12/28/world/europe/omicron.html?searchResultPosition=1, 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)
www.pfizer.com/news/press-release/press-release-detail/pfizer-announces-additional-phase-23-study-res...
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)
… 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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