A year and a half ago, I wrote a post called Covid-19: My Current Model. Since then things have often changed, and we have learned a lot. It seems like high time for a new post of this type.

Note that this post mostly does not justify and explain its statements. I document my thinking, sources and analysis extensively elsewhere, little of this should be new.

This post combines the basic principles from my original post, which mostly still stand, with my core model for Omicron. I’ll summarize and update the first post, then share my current principles for Omicron and how to deal with and think about it.

There’s a lot of different things going on, so this will likely be incomplete, but hopefully it will prove useful. The personally useful executive summary version first.

  1. Omicron has already taken over, most cases are being missed, crunch time is now. Crunch time will likely last 1-2 months.
  2. First two shots don’t protect against infection, boosters do somewhat (60%?).
  3. Vaccination and natural infection protect against severe disease, hospitalization and death (best guess ~80% reduction in death for double vaccination, 95%+ reduction in death for boosters but too soon to know).
  4. Tests work, but when delayed are mostly useless for preventing infection especially when delayed, as Omicron can spread within 1-2 days after exposure. Rapid tests mostly test for infectiousness, not being positive.
  5. Omicron probably milder than Delta (~50%) so baseline IFR likely ~0.3% unless hospitals overload, lower for vaccinated or reinfected.
  6. Being young and healthy is robust protection against severe disease and death, being not that means a lot more risk. Long Covid risk small but real for all age groups, vaccination likely helps a lot.
  7. Medical system is under strain, could be overwhelmed soon, should be better again in a few months at most if it gets bad. Delaying infection has value but stopping it fully is likely not worth the cost. If you care about real prevention, the tools that matter are vaccination, good masks (N95 or even better P100+), social distancing and air ventilation.
  8. Vitamin D and Zinc, and if possible Fluvoxamine, are worth it if you get infected, also Vitamin D is worth taking now anyway (I take 5k IUs/day). Paxlovid is great (~88%) if available right after you test positive, but in very limited supply for now.
  9. Default action on positive test is 5 days isolation at home as per new CDC guidelines, if possible is good to get a negative rapid test before ending isolation. If things get bad, especially if you have trouble breathing, call your doctor, seek treatment and so on.

Here are the old principles that still apply, with adjustments as appropriate:

  1. Risks follow Power Laws. Focus on reducing your biggest risks.
  2. Sacrifices to the Gods are demanded everywhere. Most intervention effort treats Covid-19 as a morality in which the wicked must be punished, rather than aiming physical interventions to achieve physical results.
  3. Governments Most Places Are Lying Liars With No Ability To Plan or Physically Reason. They Can’t Even Stop Interfering and Killing People. There is a War, and the WHO, FDA and CDC, and most similar agencies abroad, and most elected officials, are not on our side of it. Instead they focus mostly on getting in the way, protecting their power and seeking to avoid blame on a two week time horizon.
  4. Silence is Golden. Talking or singing greatly increases infection risk, and the directions people face matter too. You’re still not safe or anything, but it helps.
  5. Surfaces are Mostly Harmless. Mostly don’t worry about them.
  6. Food is Mostly Harmless. Mostly don’t worry about it.
  7. Outdoor Activity Is Relatively Harmless. It’s a huge relative risk reduction.
  8. Masks Are Effective. I’m less excited about cloth masks than I used to be, but I remain confident in N95s, and if you actually need to not get Covid-19 you can step up and use P100s or other heavy-duty options at the cost of social awkwardness. My rule of thumb at this point: Cloth masks are for satisfying mask requirements. N95s are for reducing Covid-19 risk. P100s are for actually attempting to prevent Covid-19. Choose your fighter.
  9. Six Feet Is An Arbitrary Number. There’s still nothing better than an inverse square law, so by default I presume 12 feet is a quarter of the risk of 6 feet, and 3 feet is quadruple the risk, there is no magic number. No one seems to care about distancing much anymore. If there was one big omission last time, it was not focusing on air ventilation and flow.
  10. Partial Herd Immunity Matters. 75% immunity no longer cuts it under Omicron, but every little bit helps. This isn’t an all-or-nothing situation. Every person that is immune, or even partially immune, slows the spread.
  11. Yes, We Know People Who Have Been Infected Are (Largely) Immune. This is less absolute than it used to be. Infection by Delta or earlier strains provides strong protection against severe disease, hospitalization and death, but not total protection, and it provides far less protection against infection.
  12. Our Lack of Experimentation Is Still Completely Insane. Yes.
  13. We Should Be Spending Vastly More on Vaccines, Testing and Other Medical Solutions. Yes.
  14. R0 Defaults In Medium-Term To Just Under One. This is true because case rates and behaviors and rates of previous infection adjust until it becomes true. It’s importantly not true if pushed past its breaking point, and the question is whether or not this happened with Omicron. But in a few months, it will be true again either way.
  15. The Default Infection Fatality Rate (IFR) Is At Most 1%. Still true, but my estimates are now doubly lower for better treatments and Omicron being milder, see the new section.
  16. Many Deaths and Infections are missed. The numbers I put here no longer apply, and the rate at which cases are missed varies a lot based on conditions. My guess is that most deaths are now identified in the United States, but that most cases are once again being missed under Omicron because they’re milder and testing is once again in short supply.
  17. People Don’t Modify Behavior Much In Response To Rules. Most of the reaction to conditions is private choices on how to react. Private reaction to Omicron happened despite not much public imposition of new rules. Vaccine mandates are the one big exception.
  18. It’s Out of Our Hands. Almost entirely true at this point. It’s on individuals to react wisely.
  19. Support Longevity Research. If you think that people dying is bad, maybe we should do something about it.

Next, how to personally think about Omicron beyond the above.

First, infection.

  1. Importance of air ventilation is the biggest thing I didn’t talk about before. It makes a huge difference to risk of infection whether or not there is good air flow. The glass barriers in restaurants are probably counterproductive (and my not realizing this early on was a mistake on my part).
  2. You are probably going to get Omicron, if you haven’t had it already. The level of precaution necessary to change this assessment is very high, and you probably don’t want to pay that price.
  3. You can probably guard against Omicron if you want to do so badly enough and don’t need to work outside the home, either short term or entirely. This means a P100-style or better mask, if you’re actually trying. It means extreme social distancing and isolation and caring about ventilation. It also means getting vaccinated and boosted. For those who are immunocompromised or otherwise at extremely high risk, this is a reasonable option.
  4. There are a ton more cases out there than are being reported. Hard to tell exactly how many, but it’s a lot more. In addition to missing a lot of cases, being several days behind can mean you’re at several times more risk than it otherwise looks like at any given time, until things stabilize. So looking at current positive tests can be an order of magnitude or more too low.
  5. Omicron spreads easier than Delta even among the unvaccinated. We don’t know this for a pure fact yet but it seems very likely to be a large effect. Assume the amount of exposure it takes to reach critical mass has gone down.
  6. Vaccination with one or two doses of current vaccines is minimally protective against infection by Omicron. The data isn’t fully in, but this seems clear. If you haven’t been boosted, your protection is mostly against severe disease, hospitalization and death, rather than infection, although you’re somewhat less likely to spread the disease further because you’ll recover faster.
  7. Vaccination with three doses is protective against infection by Omicron, but less protective than vaccines were against Delta. As a rule of thumb I am currently acting as if a booster shot is something like 60%-70% protective against infection but I don’t have confidence in that number. The main protection is still against severe disease, hospitalization and death.
  8. The generation time (serial interval) of Omicron is lower than Delta. Someone who is infected today will often be highly contagious the day after tomorrow, and may be infectious tomorrow. Much of infectiousness proceeds symptoms.

Next, testing and isolation.

  1. PCR tests are useful and accurate, but don’t mean you’re not infectious, and if they are delayed they become useless. The ideal is getting it back in 24 hours, but even that is a lot of the window before someone is infectious, so this doesn’t provide that big a risk reduction against Omicron. If it takes 48+ hours, use other than for treatment is greatly reduced.
  2. Rapid tests are useful and mostly tell you if you’re currently infectious. They can have ‘false’ negatives, and actual false negatives, mostly because you can be infected but not infectious, and then you’ll mostly come back negative. Also user error is always an issue. Rapid tests are the more useful way to identify who is infectious and prevent spread, but far from foolproof.
  3. All rapid and PCR tests detect Omicron. I include this because I know of people who aren’t confident on that and are freaking out a bit.
  4. A negative rapid test should be necessary before ending isolation. The CDC’s new guidelines don’t say this but this seems overdetermined and obvious to me. If you care about not being infectious, you should check on that before exposing others.
  5. The majority of infectiousness is within the first five days, and CDC guidelines now only require five days of isolation. That doesn’t mean five days is suddenly safe instead of unsafe, but the show must go on, so the rules have changed. Five days plus a negative test seems fine in general, but I still wouldn’t visit any grandparents that soon.

Next, vaccination, prognosis and treatment.

  1. Omicron is probably substantially milder than Delta. My guess is something like 50% milder, so half the risks. How much comfort that provides is your call.
  2. Being young is still the best defense. Everyone please stop being terrified about what might happen to young children. Most deaths will still be among the old and unhealthy. Remember that these are orders of magnitude differences.
  3. Being healthy still helps a lot. If you are at a healthy weight and don’t have diabetes, and aren’t immunocompromised, those are also big games. If you do have these issues, that’s a problem. See my old post on comorbidity.
  4. Vaccination is highly protective against severe disease, hospitalization and death. The vaccines are likely somewhat less effective against Omicron than Delta here, but still highly effective. Protection against hospitalization is probably something like 80%, with likely additional protection above that against severe disease, and then even more protection against death.
  5. Booster shots are even more protective. I urge everyone to get their booster shots.
  6. Previous infection, including by Delta, is highly protective as well. It’s at least similar to being vaccinated normally. Unclear if it’s better than that.
  7. The risks of Covid-19 prevented by vaccination greatly exceed the risks of vaccination. Even the specific ‘risks’ of vaccination are net decreased by vaccination, because it prevents Covid-19 and makes Covid-19 more mild. If you are worried about unknown risks, get vaccinated. There are a few exceptions for specific medical situations, if you think you’re one of those exceptions talk to your doctor.
  8. Most cases will be asymptomatic or mild, even if you are unvaccinated. It’s important not to forget this, or pretend otherwise in order to scare people.
  9. If you do have symptoms or test positive, take at least Zinc and Vitamin D. You should be taking Vitamin D regardless. This isn’t a statement that you shouldn’t take anything else, but there’s nothing else that I know rises to this level.
  10. If you test positive, consider Fluvoxamine. It is an SSRI, so it’s not something one should take lightly or proactively, only when you know you’ve been infected. Again, I’m not saying not to take anything else that I’m not listing, I’m merely saying I don’t have this level of confidence in anything else that’s available. Merck’s pill increases risk of mutations and I now believe it should not have been approved, but it likely is good for your personal health outcomes if you can get it in time and adhere to the protocol. If you do take it, you really really really need to follow the full protocol exactly.
  11. If you test positive and can get it in time, take Paxlovid. Paxlovid reduces hospitalization and severe disease by about 88%. If you’re young and in good health and don’t want to take from the currently limited supply, I applaud that decision until there’s sufficient supply.
  12. By default, recover while isolating at home. The medical system is there if you need it, but most of the time you will not need it. Trouble breathing is the biggest ‘seek treatment now’ sign, but I am not a doctor, this is not medical advice, and when in doubt call a real doctor.
  13. Once you go to the hospital or otherwise seek treatment, I don’t have anything for you beyond wishing you luck. If I get sick, I will follow my wife’s advice, as she is a doctor. Can only focus on so many questions at once.
  14. If the hospitals get overloaded things get much worse. A lot of patients that would otherwise live, will die without treatments the hospitals can give, especially oxygen.
  15. Getting Omicron in January (or late December) is worse than getting it in February, which is worse than getting it in March. At some point in January (or maybe February, but probably January) there will be a turning point where strain on hospitals and the testing system begins to decline. If you get sick during the period when things are bad, then your prospects are worse. A small amount worse if the system is merely under strain, but much worse if things start to collapse and capacity runs out. Also Paxlovid is coming.
  16. Long Covid is real but rare and risk scales with severity. This is not something we can be confident in, and there are big unknowns to be sure, but my baseline continues to be that Long Covid risks are mostly proportional to short-term serious Covid risks aside from not scaling as much with age, and other things that reduce one reduce the other. Long Covid is still the biggest downside to getting Covid if one is young. I wish I could put a magnitude on this risk, but my best guess continues to be that this is not that much worse or different than e.g. Long Flu or Long Lyme, sometimes getting diseases does longer term damage than we realize and curing and preventing disease is therefore even more valuable than we think. But to extent you worry, Paxlovid probably does a lot to prevent this, so holding out until it is available would help you here.

Other modeling observations and general prognosis.

  1. Omicron is already the dominant strain. Delta will not go away entirely, but is unlikely to be a substantial presence going forward.
  2. Things will peak in January, or perhaps February (or possibly the last few days of December). This is overdetermined.
  3. After the peak things will probably decline rapidly, then stabilize at a new normal level. Fluctuations will happen as before, but there won’t be another Omicron peak like this one. If there is sufficient overshoot on immunity things might collapse further.
  4. There might be another strain in the future. I don’t know how likely this is, but that’s the most likely way that things ‘don’t mostly end’ after this wave.
  5. Once this wave is over and Paxlovid is widely available, restrictions don’t make sense. Continuing to require distancing or masks, or pushing hard on further vaccinations, isn’t justified by the levels of risk we will face, and there’s no collective risk justification either.
  6. Taking action to ‘stop the spread’ mostly no longer makes sense. The spread isn’t going to be stopped, that ship has very much sailed. Slowing it down a bit has some value, but ‘pandemic ethics’ no longer apply.
  7. Modifying how you live your life also won’t make sense. Covid-19 will be one more disease among many, and life will be marginally worse, but by about April you shouldn’t act substantially differently than if it no longer existed.
  8. We’ll have to fight to end many restrictions. They will by default continue long past the point when they stop making any sense. Various forces will fight to use these restrictions to expand their powers permanently.

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Covid-19 will be one more disease among many, and life will be marginally worse, but by about April you shouldn’t act substantially differently than if it no longer existed.

This seems quite bold given our history of variants emerging. And if Omicron infects billions, then prima facie there's great opportunity for mutation. I'd be interested to hear your credence in the following proposition:

From 1 May 2021 to 1 Jan 2030, Zvi won't act substantially differently due to risk of SARS-CoV-2 infection.

Additionally, "one more disease among many" suggests (to me) that it won't cause 100K+ more deaths in the following few years, which also seems bold. [edit: American deaths, see replies for more]

Perhaps I should have explicitly put 'barring another major variant that disrupts this' there, but if Omicron infects most people on top of the vaccines, the damage a new variant does next time should be pretty low, and someone like me should be able to shrug it off and not care. 

4TurnTrout5mo
I don't see the reasoning for this. Why would the damage be low, rather than simply lower than it would have been with less herd immunity (in the world where people hadn't first gotten omicron)?
1adamzerner5mo
My guess is that it's because previous infection seems to provide significant (rather than weak or moderate) protection, and there will be a lot more people who have been previously infected next time a new variant roles around.
2Richard1215mo
It is absolutely certain that there will be more "variants of interest". This is basically the evolutionary modelling that pretty much all Governments have ignored, every time - Delta and Omicron were predicted by all eviolutionary biologists. The open questions are: * Whether there will be a new variant of interest that is notably more infectious, and thus becomes dominant after Omicron. In the UK, Delta completely outcompeted all other variants in around 3-4 months (>95% of all sequenced cases were Delta). Omicron is expected to do the same by Feb if not earlier. USA is likely similar, albeit delayed by a few weeks. * Whether future variants cause more or less serious disease than Omicron. * When this will occur. To me, it seems most likely this will be Feb/March 2022 or Fall 2022 If the answer to the first question is Yes, and the second question is "far less serious", then the pandemic is over When it occurs - it has become another 'common cold' and is unlikely to mutate further to produce more serious disease (because it didn't). However, if it is Yes and The Same Or More Serious, then we will certainly need further booster jabs in Fall/Winter 2022, perhaps tailored more closely.
4jaspax5mo
"One more disease among many" -- this Wikipedia graphic [https://en.wikipedia.org/wiki/File:Leading_cause_of_death_world.png] suggests that respiratory diseases already kill about 3.6M people/year, and pre-COVID I barely spent even a thought on them, nor did I expend extraordinary efforts avoiding them. We could add COVID to the mix and bump the number up to 3.7M people/year, and neither of the above would change.
3Zach Stein-Perlman5mo
Good point; I was imprecise. Thanks. I meant 100K+ deaths in America, which is 4% of the global population, so millions of deaths globally, and I was implicitly thinking of "disease" as contagious disease that exists in rich countries too. I haven't looked for numbers but I suspect that COVID is a quite large fraction of American deaths from contagious disease, such that even in April it will not merely be one such disease among many.
2Razied5mo
But this number of deaths from covid won't last, immunity from vaccines and past infections will get in equilibrium with some immune escape from perpetual new variants and declining immunity over time, just like it happens for flu strains. The finite number of very vulnerable old people will all die out, and over time the only people who will die of covid are the people who age into vulnerability, just like it happens with the flu.

Could you do readers an enormous favor and put references in when you say stuff like this:

"Vitamin D and Zinc, and if possible Fluvoxamine, are worth it if you get infected, also Vitamin D is worth taking now anyway (I take 5k IUs/day)."

3MondSemmel5mo
In case it helps, here [https://www.lesswrong.com/posts/pCbSJBtWTp5tLhc8e/covid-12-16-on-your-marks?commentId=KadT2Gwuvv6uGD4Hy] is a brief discussion of this topic.
  1. First two shots don’t protect against infection, boosters do somewhat (60%?).

 

I'm guessing you mean "first shots obtained in spring or summer are likely to have declined by now"? Or do you mean the third shot gives you more immunity than you ever had with only 2?

3Zvi5mo
I mean the second one, but 'new' two shots is going to do something in between. Three is better than a fresh two.

I had the same reaction as Elizabeth.  The data I've seen suggests that the key variable is "time since last dose".  Vaccines protect against severe disease and death very well, possibly for years.  But protection against infection specifically appears to peak about a month after your last dose, and drop to (around) zero about six months after your last dose.

Are you sure you're not confusing a time sequence here, with quantity or quality?  Your sentence suggests that there is something "different" about getting a booster (but it's the same physical entity as the first two doses!).  And even now, you say "three is better than a fresh two".  Do you have a reference for that, in particular to distinguish recency from quantity?

To be concrete, I would strongly suspect that, six months after these latest boosters, you AGAIN have very little protection against infection.

This chart was from before omicron (Aug 2021), but I'm not aware of any major changes in the data: https://www.medrxiv.org/content/medrxiv/early/2021/08/27/2021.08.25.21262584/F2.large.jpg

(From: https://www.medrxiv.org/content/10.1101/2021.08.25.21262584v1.full )

I'm skimmed mostly all of your covid posts, so in theory this shouldn't really be teaching me anything new, but I found it to be a very useful compilation. Thank you!

Budesonide?

2Zvi5mo
On my stack for investigation. Again, not saying no, simply not saying yes.

I was wondering if you had updated your thoughts on how much viral loads matter since your April 2020 post on it. I live in a co-living space of over 60 people with poor ventilation. I'm wondering if that means I should worry about getting covid more than the average healthy 30 year old man.

Also, I wanted to more enthusiastically thank you for your feedback on my fantasy sports poker card game in July.  You saved me a lot of time! I decided not to continue doing it.

6Zvi5mo
Happy I could help. My guess is that viral load does matter, but it's on the lower end of levels of importance I would have considered.

What form of zinc are you suggesting people take?

5Suna5mo
On https://www.lesswrong.com/posts/5DKqK3hEzzBoGF47C/consider-taking-zinc-every-time-you-travel [https://www.lesswrong.com/posts/5DKqK3hEzzBoGF47C/consider-taking-zinc-every-time-you-travel] Elizabeth mentions the brand she [https://www.amazon.com/Life-Extension-Enhanced-Lozenges-Count/dp/B01BKURF1A/ref=sr_1_4?crid=V59JWQ7302L6&dchild=1&keywords=life+extension+zinc+lozenges&qid=1632715140&sprefix=life+extension+zinc+loz%2Caps%2C216&sr=8-4&pldnSite=1] uses to prevent infections when traveling and explains some of her reasoning.
2Tom5mo
If you look at the 'ETA' paragraph at the end I would say she is effectively retracting that post. Also, that Amazon link is long and confusing so readers won't know if it may be an affiliate link. Better to use a bare version such as https://www.amazon.com/Life-Extension-Enhanced-Lozenges-Count/dp/B01BKURF1A/ [https://www.amazon.com/Life-Extension-Enhanced-Lozenges-Count/dp/B01BKURF1A/] or even just https://www.amazon.com/dp/B01BKURF1A/ Note that I'm not saying the link was an affiliate link (I don't know) and I'm certainly not suggesting that anyone here intentionally used one - often they get picked up and reused without the author even realizing it. I'm also not suggesting that they are always wrong: they have a place when disclosed - but they are becoming so common that readers and writers should be wary of them.
2philh5mo
Though that's about the common cold, not covid. She does mention covid in a comment:
3CraigMichael5mo
It’s thought that it applies to coronaviruses in general.

Omnicron probably milder than Delta (~50%) so baseline IFR likely ~0.3% unless hospitals overload, lower for vaccinated or reinfected.

Protection against hospitalization is probably something like 80%, with likely additional protection above that against severe disease, and then even more protection against death.

From some quick googling vaccination seems to provides about 10x reduction in IFR, so we are looking at ~ 0.03% IFR for the vaccinated, or about ~ 0.14% overall (0.6 * 0.03 + 0.4 * 0.3), and in practice perhaps lower if we factor in natural i... (read more)

Zvi, what are the chances that Paxlovid ends up having way more side-effects than the trials showed? I heard David Friedberg on the all-in podcast mention that he was pretty nervous about it because the drug messed with some pretty fundamental biological machinery, and that under non-covid circumstances it would be tested for a lot longer. I don't doubt that for people that end up at the ICU the benefits will overwhelm whatever side-effects end up happening, but how would the risk evaluation go for people with mild or mild-to-severe illness?

8AllAmericanBreakfast5mo
These are good questions. The following is not medical advice. It’s just framing the situation you’re describing in a little more detail. The Paxlovid trial had about 1,000 participants. Soon, we’ll be giving it to tens or hundreds of thousands of people who are seriously ill. This will give us more data about safety. For an individual patient over the next couple months, one challenge is that Paxlovid must be taken so early that you can’t be sure about the trajectory of your illness. More severe symptoms tend to kick in after Paxlovid’s window of efficacy expires. You have to infer your likelihood of severe illness from your risk category and the severity of your symptoms vs. the number of days you’ve been sick. If you are in a low-risk category, it’s unlikely you’ll have the opportunity to take Paxlovid before we have a lot more data. If you do, you’ll be weighing the risk of rare unknown side effects against the low chance of developing a more serious illness. At that point, I can only say to consult with your doctor.
4Zvi5mo
Law of Large Numbers should attach, shouldn't it? In Bayesian terms we should have enough information unless we expect fraud/suppression to be taking place. And their incentives are not to make that happen, it would not go well for Pfizer.
2CraigMichael5mo
Just heard that episode today and was thinking the samething. The scuttlebutt I’ve heard elsewhere is that paxlovid has several mechanisms to prevent viral replication. One of those mechanisms is similar to an HIV medication that has some known contraindications. OTOH HIV meds you take for life, Paxlovid you take for a few weeks. So my guess is that in the given the timespan you’re taking it, the risk is much lower.

There is a War, and the WHO, FDA and CDC, and most similar agencies abroad, and most elected officials, are not on our side of it. Instead they focus mostly on getting in the way, protecting their power and seeking to avoid blame on a two week time horizon.

Can I get an explanation of this? This is my first time reading about Covid on LessWrong (I'm new). My general impression (with no investigation or research) was that the WHO and CDC were doing a reasonable job in trying to figure out what was going on and giving reasonable advice on how to reduce the negative impacts of Covid. Am I under the wrong impression?

3Zvi5mo
You are under the wrong impression. They are doing neither of these things (although many of the individual things CDC says are reasonable). The explanation is mostly example after example over the course of two years, as documented in weekly posts. There are definitely some big highlights. I think it would be a good exercise to let others summarize the case here rather than me.
5velcro5mo
Could you (or others) provide one or two particularly egregious examples where "Governments Most Places Are Lying Liars With No Ability To Plan or Physically Reason. They Can’t Even Stop Interfering and Killing People"? Maybe just one or two weekly posts to look at? Clearly these organizations made mistakes, some significant. I think even if 50% of their decisions were mistakes, the wording here is not really supported. You claim these organizations "Can't Stop Killing People" Exceptional claims require exceptional evidence. Other than that, great post.

These are a couple posts I came up with in a quick search, so not necessarily the best examples:

Covid 9/23: There Is a War

"The FDA, having observed and accepted conclusive evidence that booster shots are highly effective, has rejected allowing people to get those booster shots unless they are over the age of 65, are immunocompromised or high risk, or are willing to lie on a form. The CDC will probably concur.  I think we all know what this means. It means war! ..."

Covid 11/18: Paxlovid Remains Illegal

"It seems to continue to be the official position that:

  1. Paxlovid is safe and effective.
  2. Paxlovid has proven this sufficiently that it isn’t ‘ethical’ to continue running a clinical trial on it.
  3. Paxlovid will be approved by the FDA in December.
  4. Until then, Paxlovid must remain illegal.
    [...]
    Washington Examiner points out the obvious, that the FDA is killing thousands of people by delaying Pfizer’s and Merck’s Covid treatments. It’s good to state simple things simply:

"So, set Merck aside for now and consider Pfizer’s Paxlovid. In the past 30 days, more than 37,000 people died of COVID in the United States, according to the CDC . Over the next 35 days, Paxlovid could prevent tens of thous

... (read more)
1Sherrinford5mo
What do you mean by "it would be a good exercise"?

Curated. This is another unusual curation, in that this is not a timeless post, but it does just seem pretty important for many readers.

I do encourage people to check claims for themselves and comment with counterarguments or additional research where appropriate.

This post explicitly says that its aim is not to explain what it states. Instead, the author says that people can check sources etc "elsewhere". Among the large number of claims and "principles" are, effectively, a call to "war" against US and international institutions, and a nonsensical claim about "governments most places". And when curating the post, you tell people to "check claims for themselves". We have discussed these or similar points with respect to previous covid-19 posts, so these norms on lesswrong are not surprising anymore, but they are disconcerting.

2Ruby5mo
That's a misleading rephrase. The author that they have detailed their sources and reasoning extensively elsewhere in their own other writing, which I'll add isn't hard to find if you just click on the author's profile. This post doesn't repeat the reasoning and sources since it's more of a summary post. Do you mean it's disconcerting that this post was curated, or that the contents of the post are more broadly disconcerting just for appearing on LessWrong?
5Sherrinford5mo
So effectively, you say: These are not just claims, but you have to search for sources and other justifications somewhere in the author's writings. This puts the burden completely on people who would dispute the claims or are skeptical about them. However, in his other writing, the author also makes several claims that are just claims without sources, in particular when they are claims about what some perceived other people (?) / "everyone" / the media (?) / "we" / [I can't always say who he is referring to] thinks, says or does: "Naturally, the public-facing articles all seem to quote the 83%, and ignore the 95% and 99%." [https://www.lesswrong.com/posts/msNB8MdQ2oh2o3Com/?commentId=zc4eQ7hcyDyLeqTmB#zc4eQ7hcyDyLeqTmB] ,"because again everyone is on the 'make the vaccines look unsafe' team" [https://www.lesswrong.com/posts/82kxkCdHeSb8smZZq/covid-3-18-an-expected-quantity-of-blood-clots?commentId=AzeosyGB4smEy9EqT] , "The second we is also everyone collectively, inside the belief system of those who hold this religious model, which I think is roughly half the country [https://www.lesswrong.com/posts/ZKPJm2GMuhyG5ni8o/?commentId=45Cc42cpgfQGKzRyk#45Cc42cpgfQGKzRyk] ". There are also other misleading or exaggerated claims like "Certainly our vaccine policy has given little or no thought to getting doses for the third world". [https://www.lesswrong.com/posts/4PTstS4Kt5hBMJTRL/covid-4-22-crisis-in-india?commentId=txdQgeNZLkvApLwvb#txdQgeNZLkvApLwvb] Asking for sources or explanations of claims leads to [https://www.lesswrong.com/posts/zFhhDCxz87yKwqYQf/omicron-my-current-model?commentId=CAxpzwksLf6qiKEHX] non-answers [https://www.lesswrong.com/posts/P7crAscAzftdE7ffv/covid-19-my-current-model?commentId=jHZ6S2CbxkmeLPQqr] . And no, I do not claim that I read all the posts or that I am representing all of Zvi's posts or all of his answers to comments here. I read several of them, found that they contain useful assessments of the situation along with claims without sou
5Ruby5mo
Thanks for the elaboration, I think I know understand better where you're coming from. Your quote from Rob Bensinger is well taken. We (the mods) should perhaps be much more explicit and upfront about this, but Zvi's Covid posts have been frontpaged and curated notwithstanding the harder-to-justify political content, because they have regularly been the best summary advice content available, and with Covid it's seemed best to provide information to people that helps them orient as quickly as possible rather than wait for advice factored out from political opinion. There's actually a double suspension of regular norms here in that although usually Curation is for posts we think are exemplary and should be widely read for their timeless content, we've deemed it worth it during Covid times to broadcast certain information we think many readers would be grateful to have, e.g. guidance on how to relate to Omicron.
2Sherrinford5mo
Thank you for your reply, Ruby. What would being explicit and upfront about this category of curated content look like? To me it seems like that would require something like a disclaimer box at the top of the post: "Note: Lesswrong usually curates posts that embody the virtue of scholarship. This implies balanced, fact-based arguments in which the authors make their line of reasoning transparent, understandable and open to discussion. It excludes referring to the author's authority as a substitute for an argument. It avoids the use of unnecessarily aggressive rhetoric, in particular based on false statements. This is particularly important in the context of politics discussions, not because these discussions need different rules of analysis on a theoretical level, but because experience suggests that the discussion of politics may be prone to inducing behavior like the disregard of rules of discussion and truth-seeking for only one side of the debate. It is important for LessWrong not to cultivate bias. However, for the present post the mods make an explicit exception and curate it because they want to increase its visibility. They think it is the best summary advice content available on the topic of covid-19. Even though the advice is not verifiable based on the post alone, the mods either believe its statements to be true because they read other texts by the same author that they found convincing, or because they trust the author for other reasons. Moreover, the mods do not endorse the political claims and the obviously false generalizations made in the post." This would obviously seem strange, but it is my impression of the reactions to discussions under these posts.
4Ruby5mo
Yes, a disclaimer at the top is the kind of thing I was imagining. Yours is pretty good! Though I might personally refrain from evaluating the political content of the post. This post has likely already had the bulk of traffic pass through, but for the next one, assuming there is, I'll likely work on something like this.
2Sherrinford5mo
I'm glad that you like the draft! I'd like to point out two things, however: 1. You already did evaluate the political content of the post by curating it. To any outside visitor to this site, from curious people lost in hyperspace to journalists or scientists, the stance that most governments are "Lying Liars With No Ability To Plan or Physically Reason", that "we" are at "war" against WHO, CDC and FDA will be the political line of LessWrong, with all that this implies, in particular because you made an exception from curation criteria. 2. A curation is (also) intended to make sure that the curated post will continue to get traffic.

When I edited to fix an error in #9 it messed up the numbering system. Mods, please either fix or simply reimport. I continue to ask that this be fixed so we can start lists with numbers other than #1.

There might be another strain in the future. I don’t know how likely this is, but that’s the most likely way that things ‘don’t mostly end’ after this wave

I agree, and I also don't really have great mental handles to model this, but this seems like the most consequential question to predict post-Omicron life. My two biggest surprises of the pandemic have been Delta and Omicron, so sorting this out feels like a high VOI investment.

Here's a messy brain dump on this, mostly I'm just looking for a better framework for thinking about this.

  1. The amount of transmis
... (read more)

Six Feet Is An Arbitrary Number. There’s still nothing better than an inverse square law, so by default I presume 12 feet is a quarter of the risk of 6 feet, and 3 feet is double the risk, there is no magic number.

Should this say that 3 feet is quadruple the risk of 6 feet, if we're assuming an inverse square law?

4Zvi5mo
Fixed, thanks. Moving too fast, whoops, etc.

Vaccination with three doses is protective against infection by Omicron, but less protective than vaccines were against Delta. As a rule of thumb I am currently acting as if a booster shot is something like 60%-70% protective against infection but I don’t have confidence in that number. The main protection is still against severe disease, hospitalization and death.

Two questions about this:

  1. Do you mean that a booster is 60-70% effective relative to being "fully" vaccinated but not boosted, or do you mean that being boosted is 60-70% effective relative t
... (read more)

Typo:

Much of infectiousness proceeds symptoms.

Precedes?

3MondSemmel5mo
Also: delayed x2
5Zvi5mo
Yes on both.

"The risks of Covid-19 prevented by vaccination greatly exceed the risks of vaccination."

Is this true across all age groups?  I've been getting PO'ed at radio ads in NY encouraging moms to get their 3 year olds vaccinated.  But maybe this is my mistake.  

Regarding long COVID: Zvi, does your model above incorporate the following findings (published after your original deep dive in Sept)? (If anyone other than Zvi has thoughts on how these affect the model laid out above, would be curious to hear your thoughts as well.)

 

  • 9/29/21 NPR article recapping a study from around that time
    • Affects over 1/3 of COVID sufferers, 2x as high as for flu:
      • "In the study published Tuesday in the journal PLOS Medicine, researchers found that about 36% of those studied still reported COVID-like symptoms three and six months af
... (read more)
5Zvi5mo
I don't know if I've looked at those particular ones but I've looked at a bunch. At this point I'm convinced that any study with improper controls will find a lot of Long Covid, and it doesn't mean much, because people report everything as Long Covid. And that if a study claims that Long Covid isn't correlated with severity of Covid, it's not properly controlled. This was never plausible to me, and the recent finding that Germans who didn't know they had Covid didn't report any Long Covid symptoms either seems conclusive that it can't be right.
2Sameerishere5mo
Thanks for responding. The first study did find that severity is correlated with incidence of long COVID, and controlled as follows: "Propensity score 1:1 matching [19 [https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003773#pmed.1003773.ref019] ] (with greedy nearest neighbor matching, and a caliper distance of 0.1 pooled standard deviations of the logit of the propensity score) was used to create cohorts with matched baseline characteristics and carried out within the TriNetX network" My knowledge of statistical analysis is rather insufficient to evaluate the controls in that study, so hoping you or another commenter can chime in on that.

Is there a good write up of the case against rapid tests? I see Tom Frieden’s statement that rapid tests don’t correlate with infectivity, but I can’t imagine what that’s based on

In other words, there’s got to be a good reason why so many smart people oppose using rapid tests to make isolation decisions

I am confused about why it's better to get Omicron later rather than sooner. I understand that avoiding overloaded hospitals is a good idea, but the reports from people who have Omicron (understanding that first-hand reports are created by people well enough to report and/or by bad actors) suggest that getting Omicron right now is equivalent to a nasty cold. 

Even the data suggests that getting Omicron right now is much less likely to lead to hospitalization, regardless of whether you feel chipper enough to tweet about it.  

So... why do you assume... (read more)

2cistrane5mo
Consider that in March it is much more likely that Paxlovid will be widely available than in February.
2Measure5mo
I think this only matters if you happen to get an unusually severe case that requires hospitalization, but that still affects the expected value somewhat.

There are two points numbered "27", one above and one below "Next, testing and isolation."

53. Taking action to ‘stop the spread’ mostly no longer makes sense.

From the context, it sounds like this refers to the time after the current wave is over, but if you don't consider context, it could easily be interpreted to apply already. 

4jaspax5mo
It applies already; the naive reading is correct. A major theme of Zvi's recent covidposting has been to establish that Omicron is already everywhere, and the kinds of policies that might prevent that are already useless.

I am very suspicious about statement that I cannot avoid getting omicron, unless I take extreme measures. Why ? Because I have heard the same about delta and it was false.

I have a friend in Germany, she teaches at school, where rapid antigen testing 3 times a week prevented the school transmissions. They know it, because if a child is flagged as a contact, they test them daily, so they have this feedback.

I pulled away my children (3 yo and 6 yo) from school and kindergarten and they did not get delta. The delta peak in our town did happen already. The kid... (read more)

3Zvi5mo
I have adjusted for experiences in previous waves, but it is reasonable to think I did not adjust enough.

I presume 12 feet is a quarter of the risk of 6 feet [...] there is no magic number

 

My intuitive oversimplified model of this has been analogous to the direct sound vs reverberant sound in acoustics (in slow motion). 

 

I'd expect the risk from direct viruses to follow the inverse square law (at least to the extent that the risk is linear to the expected number of viruses around you, which can't be true for high risks). And maybe be even be reduced by cloth masks which stop big droplets (?).

But the reverberant viruses are supposed to be the ma... (read more)

Support Longevity Research. If you think that people dying is bad, maybe we should do something about it.

But not gain of function research?

8Zvi5mo
That would be doing something about NOT dying. Gain of function is fine so long as it's humans who get to gain the functioning.

A negative rapid test should be necessary before ending isolation. The CDC’s new guidelines don’t say this but this seems overdetermined and obvious to me. If you care about not being infectious, you should check on that before exposing others.

 

How common are false positives after infection?

Eg the CDC says that

Recovered patients: Patients who have recovered from COVID-19 can continue to have detectable SARS-CoV-2 RNA in upper respiratory specimens for up to 3 months after illness onset. However, replication-competent virus has not been reliably

... (read more)

I've asked https://www.lesswrong.com/users/connor_flexman, a person who has previously estimated the number of expected days of life lost from covid (see for example https://www.lesswrong.com/posts/GzzJZmqxcqg5KFf8r/covid-and-the-holidays), how to update his estimates for the assumption that 100% of covid is omicron. On december 27, he told me that covid means 10 expected weeks of life lost for an average 30 to 50 y.o. person. And that to update https://microcovid.org estimates, you should multiply by 3.5 because omicron is more infectious and divide by 3 ... (read more)

Note that this post mostly does not justify and explain its statements. I document my thinking, sources and analysis extensively elsewhere, little of this should be new.

This is my first encounter with your writing, could you or someone else recommend a starting point that does justify and explain these statements?

2Ruby5mo
If you view Zvi's profile [https://www.lesswrong.com/users/zvi], the recent series of Omicron posts (titled "Omicron Post #N") steadily build up the picture regarding Omicron.

I write to commend you on one of the more thoughtful blogs on COVID-19 that I have read. I've been modeling, and writing about, SARS-CoV-2 since March of 2020, and following the literature closely. Your assessment and practical advice seem spot on. Thank you.

I think my only criticism is your one sentence polemic about the FDA, the CDC, and WHO. While I don't know anyone at the WHO, I have many colleagues at both the FDA and the CDC. The FDA and the CDC respect science, respect data, and respect regulations. They were villified under the previous administra... (read more)

3CraigMichael5mo
I think no one is denying that good people with good intentions and ethics work at the FDA and CDC. But I’m not sure where to go with that? Support them no matter what? What incentive would they have to improve if we took that approach? Hopefully the kind of criticism here is valuable feedback about how their policies are playing out in the real world, even if it’s not optimized for charitability. There’s a lot of people with relevant experience and perspectives that feel unheard here, Tara Haelle (Zvi mentions elsewhere) is one excellent example. https://twitter.com/tarahaelle/status/1478531929351860225?s=20 [https://twitter.com/tarahaelle/status/1478531929351860225?s=20]

You are forgetting declining immunity. Next winter may very well have a similar wave again. In fact this is imho the central scenario (60%ish probability). Quite possibly with multiple strains.

I agree with most of your post, but this looks like wishful thinking to me.

Also, individual prevention should be way easier than you make it out to be. Wear a well fitting N95 or better mask when meeting people and you are mostly done if you live alone or with compliant housemates. Just look at Covid stations in hospitals. Staff there is wearing mostly N95, often poo... (read more)

2Andrew Currall5mo
There will definitely be another wave next winter- I don't think anyone disputes that. I think it's very likely to be somewhat lower in terms of case count- how much depends a lot on what new variants arise. I think it's almost certainly going to quite a bit less bad in terms of hospitilisations/deaths (and this winter will be a lot less bad than last). Masks definitely work. But I don't consider having to wear a mask whenever I'm in the company of another person to be remotely a price worth paying for a significantly reduced chance of getting a bit of a sniffle, which all covid really amounts to for a young tri-vaccinated person these days. So I don't wear masks, even when legally required to.