Some advice from experts follow. The first is Bob Wachter from the University of San Francisco:
This is one of the most confusing times of the pandemic, w/ a firehose of new Omicron data (lots of fab work on #medtwitter putting it into context). In this (long) 🧵, I’ll offer my take on how the new information is changing my thinking & behavior.
I’ll start with a few general principles & observations (to save space & time I’m largely going to omit primary data – it’s out there; follow @EricTopol to keep up):
1) Things are uber-dynamic. We have far more clarity now than we had 3 wks ago, but many unknowns remain. More infectious: yes, not sure by how much. Immune evasion: definitely. Severity: conflicting data from UK & So. Africa, even today. Could mean it’s same as Delta, could mean it’s moderately less. Doubt it’s more severe or massively less severe. We’ll learn more soon.2) If you’re looking for “this is safe” or “this is unsafe” advice, you won’t get it here – the situation is too nuanced for that. There’s safER & LESS safe. And context matters: what might be safe for a healthy 30-year-old could be way too unsafe for a frail octogenarian.
3) It’s not about you alone. That healthy 30-year-old can spread Covid unwittingly to someone at high risk, including a loved one. So decisions about risk need to account for risk to others.
4) We’re all exhausted and sick of living this bizarre and diminished life. Quite naturally, this will influence many people’s decision-making and risk tolerance. But it doesn’t change the risks of those choices one iota. The virus is chipper and ready to go. It continues to deserve our respect, and appropriate caution based on the science.5) Speaking of calibrating behavior, a few mnths ago, I shifted my attitude – Covid will be with us for the long haul, & thus I was personally more comfortable taking calculated risks (ie, visiting family over holidays), in part because “if not now, when?” In other words in my risk/benefit calculation, I removed my “Remain Extra Careful; Covid Will Go Away” temporal factor. But now, w/ Omicron cases skyrocketing, I’ve added back that “hunker down” variable – I see the next few months as a time to fortify one’s safety behaviors. Why?
1st, Omicron looks to have peaked in So Africa; we’ll likely see a familiar surge-then-plunge pattern, just with a much steeper upslope. Second, I’m quite worried about an overwhelmed healthcare system – we’ll rapidly hit capacity limits in meds, beds, ICUs, testing and most importantly people (many MDs/RNs out sick too). Trust me, you want to avoid getting sick when the system is stressed. Third, I see the Pfizer oral anti-viral as a very big deal, and it won’t be available for 4-6 weeks (even then it’ll be in short supply).
6) Hunkering down means trying to limit risky activities. We now appreciate the negative impact of shutting schools. We need to do everything humanly possible (vaxxing, ventilation, testing, incl. test-to-stay) to keep schools open even in the face of a large surge.
7) Even if Omicron proves to be less severe, don’t get lulled: it’s unlikely to be massively less severe. If (let’s say) Omcrn is 30% less severe but cases go up 5-10x (both plausible), that’s still awful, w/ far more hospitalizations & deaths than comparable Delta surge.
8) In your own decision making, on top of weighing personal risk (age, comorbidities) & risk of exposure (activities, masking, case rates in your community, incl. fraction of Omicron), we now need to be more nuanced about level of immunity. It’s no longer Immune: Y/N?
Immunity is now (best>worst):
a) 3 mRNAs + infection (super-immune)
b) 3 mRNAs (very immune)
c) 2 mRNAs OR J&J + mRNA (modestly immune)
d) 1 mRNA or J&J alone, or infection alone (minimally immune)
e) No shots AND no infection (totally vulnerable)(14/25)9) We all should have paid more attention in 4th grade when we were taught to multiple fractions. Why? Because thoughtful decision making now requires you to multiple (brace yourself):
Personal risk (age, comorbidity) x activity (indoor, crowded?) x # of Covid cases in the region (cases/d/100K) x risk-reduction by you & others (masking, ventilation, etc) x fraction of Omicron in region x your level of immunity (zero to super) x how important activity is to you (visiting kids/grandparents vs. seeing a movie.
Exhausting, right?10) While some will say “I’m over this,” taking no precautions seems too risky. Yes, most Om cases will be mild, some severe (especially if hi risk), small # fatal, unknown % will get Long Covid. My vote: try to stay safe until threat passes or we’re more sure of severity.
So what am I doing now? (Context: I’m fairly healthy, mildly overweight 64 yo, 3 Pfizers, no small kids or elders at home, moderately risk-averse. I can work from home most days except when on clinical duty, as I am next week).
Would I travel for X-mas? In US, yes. Om still minority of cases in most places, planes safe, no guarantee next X-mas will be safer. Wear N95 for whole flight, minimize eat/drink time. To Europe: no, risk of Om is too high, and bureaucratic nightmare to return if positive.
Would I dine indoors? Not anymore, even tho SF has v. low case rate and 80% 2-shot vax rate. But cases will start climbing soon (& fast) & indoor dining not worth risk to me. Outdoor dining: fine for now. Crowded event (sports/concert): not for me at this point.
Would I do indoor shopping or work? Yes, but my rule is to wear N95 (or equivalent) in all indoor spaces unless it’s a small group that I’m certain is fully (3 shot) vaxxed, & I know all would stay home if feeling sick. Otherwise, mask stays on in indoor spaces.
Testing? I test myself & family with any compatible symptom (URI, headache, fever, GI). Note Omicron less likely to cause loss of taste/smell. At $12/rapid test (ouch), tests aren’t as accessible as they need to be. Testing before an encounter makes it far safer so it’s reasonable to test before visiting elderly or other high-risk folks, though I don’t test if I’m sure everybody is 3x vaxxed. If I was visiting immunosuppressed or unvaxxed person (incl. a young child), I’d test everybody before gathering.
I hope this is helpful. We’re all overwhelmed, exhausted and frustrated by yet another Covid Curveball. I hope you stay safe and sane, and let’s hope for a quick surge, a milder illness, and that lots of folks choose now to get vaxxed and boosted.
Originally tweeted by Bob Wachter (@Bob_Wachter) on December 17, 2021.
This from Andy Slavitt as well:
COVID Update: A setback is a setback. And we’ve had 3 setbacks with vaccine testing this week.
But all of those setbacks remind me of how blessed we have been so far by science and the people who monitor safety.
One setback, announced yesterday, is the change of position from the CDC on Johnson & Johnson’s vaccine.
J&J’s vaccine was flagged and pulled from the market temporarily in the Spring when reports of several blood clotting issues arose.
Many criticized the decision for causing doubt & disruption of vaccines at a critical moment after it was ultimately put back on the market.
Having been in the WH at the time, there were 2 incontrovertible reasons the vaccine was temporarily pulled.
One was the standard treatment for w blood clot turned out to be the wrong clinical response. Flagging the vaccine was the only way to be sure docs treated it right.
There were 2 deaths at the time & the FDA wanted to see if more reporting would come in if people hunted for the problem. Not much was there.
But today the death toll = 9, enough for the recommendation to say people are better off w Pfizer or Moderna.
A setback? Yes. We need more safe & effective vaccines, not fewer.
But this should be massively comforting as well. Vaccines have been used over 8.5 BILLION times. Thee safety profile is extraordinary. And the safety regulators are monitoring closely.
And only 9 deaths, considering the millions of times it has been given, means that in places where mRNA vaccines are not available, makes J&J still a very safe vaccine.
But this call is exactly right. It’s not as safe as the others given a choice.
The bigger concern- and a real one— is how J&J holds up in effectiveness against Omicron. And it appears not very well.
Which is why people w J&J are being encouraged to revaccinate & boost.
The second setback that was announced today was the lack of a response in Pfizer’s testing of the dose given to 2 to 5 year olds (it had a good response on 6 Mo to 2 year olds).
For many parents this is incredibly frustrating & disappointing. Small kids are at risk to Omicron.
The latest thinking is that it will be 6 months before a dosing can be approved now for kids under 5. And then it may be 3 doses— also disappointing for parents.
This creates barriers & inequities for the many parents who will find that very difficult.
We’re not used to reading disappointing news about vaccine trials. We’ve had a streak of successful first trials from the original vaccines to teens to kids that it’s easy enough to forget that the vast majority of trials fail.
Getting the dosing right in children is obviously something to test & roll out carefully. Too much vaccine in a 25 pound healthy child is something people who make vaccines are expert at preventing.
So it is smarter to test smaller doses than bigger.
But this means of you err, this is what happens. A safe bit ineffective dose is far better than an unsafe effective one.
Just imagine if we were reading today that a vaccine trial hospitalized toddlers. It would be a long time before parents trusted the vaccine.
Thanks to the safety regulators & people who conduct these trials, we are not in that situation.
There’s no denying how worrying it is to go into 2022 without a vaccine for pre-school age kids in the face of Omicron. As a baseline parents & parents need to boost.
On that note Pfizer filed to extend boosters down to age 12.
More in the “the news isn’t always good” front is early signs from the UK that the booster may wane over the first few months with Omicron.
This would be another setback. But like the others not one we can’t deal with.
Vaccine makers can adjust the vaccine to target the variant better. Two & three doses seem to do a great job protecting against severe disease.
The reality is the virus is highly adaptable & fit. But I still think science is better.
It’s not always as fast as we want. Doesn’t always get us what we need in time. And every day feels costly. But our ability to prevail isn’t in doubt.
There are many at risk while science adjusts. People who can’t be vaccinated & boosted. Older people & those with chronic conditions or immuno-compromised. Our policies & our resources should protect them.
Our policies, including disability policies & health coverage policies, should also be cognizant of long-term COVID effects.
Where science has temporary shortcomings, our policies should fill the gap.
And so should our behavior. A very opinionated news anchor read me what he considered to be his tough common sense wisdom.
“Nobody’s going to alter their plans over Christmas so Biden better do something else.”
Aside from being classic gaslighting, believe me the president doesn’t expect people to be safe on his account.
But if you’re going to be around kids under 5, older people or sick people, if science won’t protect them, that means we have to.
Our will ought to harden in the face of setbacks. Their presence makes me appreciate or progress I’ve taken for granted.
But no matter how good science gets, we won’t be able to science away indifference.
Originally tweeted by Andy Slavitt 🇺🇸💉 (@ASlavitt) on December 18, 2021.
I assume most of you are boosted. Rational people are or are planning to as soon as they are eligible.
I hadn’t thought of looking at it this way but it does make you think:
We’ve known that for a very long time. Recall the Obamacare wars. Or gun violence. But this time they are personally playing Russian Roulette with half the chambers loaded and it’s simply astonishing.
It’s Happy Hollandaise time here at Hullabaloo. If you’d like to drop a little something in the old Christmas stocking you can do so here. And thank you!