Consider This Approach to Your Behaviour As Omicron and Christmas Approach

As the holiday family gatherings and celebrations approach we are in a very confusing time, bombarded with daily news of increasing COVID-19 cases, of the rapid rise of a new viral mutation, Omicron and struggling with decisions on booster vaccinations.

Where I live in St. Louis County 70% of individuals have received at least 1 shot of vaccine but cases and hospitalizations have surged again, most likely related to more indoor gatherings.

Percent with at least one COVID vaccination shot is slowly climbing in St. Louis County but lags the national average
Hospitalizations related to COVID-19 in St. Louis County and the St. Louis metro area have surged considerably in the last month, exceeding overall US numbers.

The skeptical cardiologist has found Bob Wachter’s tweetorials throughout the pandemic to be useful summaries of the current situation with advice for everyman that is science-based, yet easy to read. Dr. Wachter is the chief of medicine at UCSF. . Yesterday he posted a helpful tweetorial on how the new information is changing his thinking and behavior.

Here are his words with some of mine in between:


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…(2/25)

E…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.(3/25)

The risk of our behaviors is not binary but nuanced and affects those we come into contact with.

Prior to Omicron I, like Wachter, had become comfortable taking some calculated risks but Omicron has changed that calculus for us and “hunkering down” may again be wise in the short term

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…(7/25)

.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?…(8/25)

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…(9/25)

… 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).(10/25)

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.(11/25)

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.(12/25)

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?…(13/25)

What factors should go into calculating our risk of certain behaviors?

9) We all should have paid more attention in 4th grade when we were taught to calculate 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/y/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.

Such calculations are exhausting. What has Wachter calculated for himself?

I find myself struggling with many of the same decisions.

I (long three-time vaxxed) am traveling (flying) to visit my wife’s relatives for Christmas and I will wear my new (Kimberly-Clark PROFESSIONAL N95 Pouch Respirator (53358), NIOSH-Approved, Made in U.S.A) N-95 masks for the trip. We will test ourselves prior to leaving. My wife will have received her booster before we leave.

We dined indoors in a restaurant last night but after more thought I wish we hadn’t. Outdoor dining in St. Louis in the winter is rarely a possibility, unfortunately.

Whatever decisions you make I hope you have a COVID-free holiday and remain safe, sane and sassy.

Superlatively Yours,

-ACP

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9 thoughts on “Consider This Approach to Your Behaviour As Omicron and Christmas Approach”

  1. I am interested to hear your thought process analysis of risk to benefit of this new type of vaccine given we do not have data on the effects of it long term.. or even relatively short term since it has only been used for a relatively short time.

    Reply
    • Kathy,
      In Israel (https://www.nejm.org/doi/full/10.1056/nejmoa2110475) they looked at over 800,000 patients who were vaccinated compared to a similar number not vaccinated and found
      n the vaccination analysis, the vaccinated and control groups each included a mean of 884,828 persons. Vaccination was most strongly associated with an elevated risk of myocarditis (risk ratio, 3.24; 95% confidence interval [CI], 1.55 to 12.44; risk difference, 2.7 events per 100,000 persons; 95% CI, 1.0 to 4.6), lymphadenopathy (risk ratio, 2.43; 95% CI, 2.05 to 2.78; risk difference, 78.4 events per 100,000 persons; 95% CI, 64.1 to 89.3), appendicitis (risk ratio, 1.40; 95% CI, 1.02 to 2.01; risk difference, 5.0 events per 100,000 persons; 95% CI, 0.3 to 9.9), and herpes zoster infection (risk ratio, 1.43; 95% CI, 1.20 to 1.73; risk difference, 15.8 events per 100,000 persons; 95% CI, 8.2 to 24.2).

      Of most concern has been the signal of increased risk of myocarditis which is in males ages 12-26. The authors compared patients with and without COVID for comparison purposes and saw an 18 fold increased risk of myocarditis in those infected versus those not. Plus, there were many other adverse events in the infected group.

      SARS-CoV-2 infection was associated with a substantially increased risk of myocarditis (risk ratio, 18.28; 95% CI, 3.95 to 25.12; risk difference, 11.0 events per 100,000 persons; 95% CI, 5.6 to 15.8) and of additional serious adverse events, including pericarditis, arrhythmia, deep-vein thrombosis, pulmonary embolism, myocardial infarction, intracranial hemorrhage, and thrombocytopenia.

      given the marked effectiveness of the mRNA vaccines in reducing infection, hospitalizations and death related to COVID-19 it makes sense for most individuals to get vaccinated.
      Until the vaccine has been in use for many years we can’t know the answer to potential long term consequences.

      Reply
      • “Until the vaccine has been in use for many years we can’t know the answer to potential long term consequences.”

        Isn’t it also worth mentioning the same situation applies to being infected with Covid? Because people that are opposed to vaccination always cite the uncertainty about long term effects of vaccines, but completely overlook the unknown long term effects of Covid ( as well as the minor short-term effects, like hospitalization and dying )

        Reply
        • Mike,
          Excellent point.
          For me (major risk factor of age>65) , the vaccine dramatically reduces my risk of long COVID or any of those serious adverse events (beyond hospitalization, intubation and death) mentioned in my comment on the Israeli paper including pericarditis, DVT, PE, MI, ICH.
          Dr P

          Reply
  2. Thank you for your thoughts and those thoughts of Dr. Wachter, I find his/your thoughts and conclusions are helpful. I am in a decision making role for our church and appreciate the well reasoned and science based thoughts about gatherings. In this time of uncertainty and frustration, it is good to be reminded that Covid doesn’t care if we are tired of taking precautions, they are essential – especially with an older and compromised population. Thanks for doing the mental crunching and summarizing this confusing issue.

    Reply
  3. Thoughts on elective surgery (knee replacement) 12 Jan for 78yo female with pacemaker, stent and recent ablation for atrial flutter. Postpone the hospital procedure with overnight stay in Doylestown PA or not?

    Reply
    • Thank you for your informative comments. Do you foresee in the future a multi purpose one shot flu shot that will address many of the variants?

      Reply
  4. Thanks for the tip on the N95 masks. The dual-strap design is a good choice for my sweeheart who is a verterinarian and has to meet with owners as well as her patients… she hates the ear loop models.

    Have a merry Christmas (or the holiday of your choosing)…

    Dan

    Reply

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