Important Holiday Travel/Gathering COVID-19 Update and Health Advice

Practical tips and information

We all are excited about the upcoming holidays and seeing friends and family, but are in the midst of high levels of RSV and influenza transmission and the beginning of a new COVID-19 surge. There is important new information you should keep in mind, and additional planning to be done in the event you are traveling.

Planning

1. Assess yours, your family’s and your guests’ risks. Important questions are:
   1. Where will you be gathering? This will be important when assessing ventilation. (See below) For most people, the answer is likely to be someone’s home.
   1. How many will be attending? The higher the number, the higher the risks.
   1. Will there be small children? If those children have been in school or day care or a nursery, then there are increased chances that they may have been exposed to a number of the circulating respiratory viruses, (as well as group A strep – more on this below) and early on in the illness, the child may not look sick or be able to report symptoms, but still be contagious. Thus, it may be helpful to check with the school or daycare to determine whether many children have been out sick lately and if so, with what.
   1. Will there be people in attendance who are ages 65 and older and/or people who are immunocompromised either by virtue of having an underlying immunodeficiency or by a disease that weakens their immune system or from treatments for a condition that weaken the immune system? These folks are at the highest risk for severe COVID-19, hospitalization and death. Further, unlike most adults, they will be at increased risk for severe disease from RSV.
   1. What risks of exposure have guests been incurring in the 3 – 5 days prior to the planned gathering? Obviously, the risks of someone bringing an infection to the gathering are greater in someone who has been traveling and attending meetings or conferences without wearing a high-quality mask than in someone who has been working from home and wore a high-quality mask for their travels to the gathering. I often hear people tell me that they feel safer because some of the intended guests had COVID-19 a month ago or two months ago. I understand their reasoning based on some data with variants that were circulating last year suggesting that those who were infected were likely protected from reinfection for a period of perhaps up to several months. However, I would caution that we do not have that kind of data for the variants circulating this year, that the current fast-increasing variants tend to be much more transmissible and immune evasive than prior variants, that people who were infected 1 – 2 months ago likely were infected with BA.4 or BA.5, and we do not have good data as to how protective, if at all, prior infection with BA.4 or BA.5 would be against these current new variants. BA.4 is largely gone and BA.5 continues to decline as it is overtaken by these new variants. The little data that we have could allow arguments both for and against some cross-immunity to new variants, but certainly we cannot feel confident in concluding that those previously infected individuals are protected from infection with more recent variants. In addition, I remind people that these persons may be of higher risk than others because (1) it is very likely that they continue to be involved in activities today that provided the opportunity 1 – 2 months ago for them to become infected and (2) in fact, they may be less cautious now than 1 – 2 months ago being under the impression that they have immunity from that prior infection.
2. Be sure to have an adequate supply of at-home COVID tests. Don’t forget that every household has the opportunity to order 4 free at-home rapid antigen tests (2 boxes each containing 2 tests) right now if you have not already ordered them this month. I have already requested and received mine. You can order these free tests at www.special.usps.com. I am not sure you will receive yours in time for your holiday gathering, but it is worth a try, and even if not, these can be used to replenish your supply. If you already have a supply of tests, check the expiration dates to make sure that the tests are current. However, the FDA has recently extended the expiration dates for a number of home tests based on more testing since the agency issued their authorization for the tests. So, before tossing any of your current tests in the trash, check the FDA’s website at https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/home-otc-covid-19-diagnostic-tests#list to see if your test’s expiration date has been extended. If you are out of tests and don’t receive your free tests in the mail in time, you can find tests at most pharmacies and many grocery stores. A certain number of tests per month is covered under many insurance plans, so if you go to the pharmacy itself to make the purchase, they can determine your insurance coverage for the tests https://www.cms.gov/how-to-get-your-at-home-OTC-COVID-19-test-for-free.

There is also an exciting new option. There have been some at-home PCR test options previously, but earlier versions allowed you to obtain the specimen at home, but you still had to send it off to a laboratory for testing and results. More recent versions have allowed the testing at home, but have required the additional purchase of parts for the testing, and still, these tests could take an hour to perform. Now, the FDA has extended authorization to an “all-in-one” single use testing device and supplies that allows PCR testing at home in 30 minutes without the need to closely examine for a faint line, such as happens with the rapid antigen tests. When testing is complete, a light appears next to “positive” or “negative” letting you know what the result is. The device can then be placed in a baggie and tossed in the trash for disposal. I ordered some of these tests and was able to purchase them for under $30 each. If you are interested, you can find out more at www.lucirahealth.com. See below for more information about testing.

If you do become ill and you are an adult over 50, you have underlying medical conditions that make you high risk, and especially for those who are elderly (>75), it is very important to get tested. First, if you do have COVID-19, you will have significantly improved chances of avoiding developing severe disease requiring hospitalization or potentially causing your death if you get started on Paxlovid, an antiviral medication, within 5 days of developing symptoms. Even if you don’t have COVID-19, your doctor can check to see if you have influenza. If so, starting an antiviral within 48 hours will lessen the severity of illness and shorten the duration of your illness. Finally, your doctor can also check to make sure you or your child don’t have a group A strep infection that would require antibiotics.

• Be sure you have a supply of over-the-counter fever-reducing medicines, cold-symptom relieving medicines, and high-quality masks. Be aware that there are shortages in many parts of the country of children’s over-the-counter medicines with many pharmacies and grocery stores reporting that their shelves are completely empty, so if you have children, make sure you spend the time now looking for where you can obtain your supply, rather having to search once your child is sick and perhaps many of the nearby pharmacies are closed or have reduced holiday hours.
• Make a plan. Check with your doctor and your children’s doctors’ offices about (1) what their holiday hours will be; (2) how you can get access to testing and antivirals if you get sick when the office is closed (beware if they advise going to the ER because currently, most if not all ERs are already very busy, many are reporting significant delays (many hours and in some parts of the country I have heard of delays of up to a couple of days for evaluation if people are not suffering a life-threatening emergency. In many places, hospitals are experiencing capacity constraints resulting in people who are admitted to the hospital having to remain in the ER for their care for days due to a lack of beds elsewhere in the hospital}; and (3) what over-the-counter medications and doses they recommend for your children based upon their age if they do get sick over the holidays. There are “test to treat” locations in some parts of the country where you can go to be tested and if positive, have your antiviral medication be filled right there. You can check to see if there is such a site near you by going to Test to Treat​ | HHS/ASPR.
• If you will be staying with someone else over the holidays, make a plan as to where you will go if you or your child becomes sick or tests positive so that you minimize the exposure to those you are staying with. Check out nearby hotels or rental homes that may have vacancies.
• Know where to go for medical attention. Given that it is likely that your doctor’s office will be closed on Christmas and New Year’s Eve and on Christmas and New Year’s Day, identify one or more urgent care centers near where you live or are visiting. Check their website to verify days and hours of operation and check to see if they post waiting times on their website. If yours or your child’s illness does not seem to be severe, urgent care centers will likely be your best bet in that wait times are generally shorter and co-pays through your insurance are likely to be less.
• Have a plan in the event of an emergency: In some parts of the country, the high volumes of illness, the increase in injuries that we see this time of year, and the reduced staffing due to illness and holiday scheduling has led to the overwhelming of ERs and to delays in EMS response times. Therefore, know where the nearest hospital is, and if you have small children, where the nearest pediatric hospital is. If you have more than one hospital nearby your home or where you will be visiting for the holidays and you are planning ahead, you can check with your doctor to see which hospital he or she recommends. There is no single source to identify the highest quality hospitals in your area, so I use a couple of websites. The first is the LeapFrog Hospital Safety Grades https://www.hospitalsafetygrade.org/search?findBy=state&zip_code=&city=&state_prov=ID&hospital=, which I use to get a sense of the hospital’s commitment and efforts towards ensuring patient safety. You can search hospitals by state to allow you to compare. I strongly prefer hospitals with an “A” grade for patient safety. I then look at quality scores and awards, and I like HealthGrades website for this: https://www.healthgrades.com/find-a-hospital. When you go to this webpage, type in hospitals and your city and state. The hospitals in your area should pop up in descending order of overall quality. When you click on the hospital, you will see recent quality awards, if any. Then, given that you most likely would need a hospital for a respiratory illness, you can click under the areas of pulmonary (lung diseases) and critical care (how well the hospital, its doctors, nurses and therapists perform in caring for patients in the intensive care unit) to see how that hospital’s quality outcomes are. Another indicator of the best hospitals that I use is Magnet status – a very difficult to achieve status to achieve for excellence in nursing that has been correlated with quality of care. You can go to https://www.nursingworld.org/organizational-programs/magnet/find-a-magnet-organization/ and scroll down to select the state you live in or are visiting, and the list of Magnet designated hospitals and the years in which they have been redesignated, if applicable, will appear. Of course, if you are not planning your choice of hospital in advance and you have an emergency, just go quickly to your nearest hospital.
• Be prepared for the rare, but increasingly common situation in which not only hospitals, but EMS services are backed up. Given the pressure on the EMS system in some parts of the country, have a plan for how you would get a family member to the hospital if the illness or injury is not life-threatening or requiring advanced first aid or medical interventions prior to arrival at the hospital (i.e., an ambulance or medical helicopter is not necessary).
• Plan for an extended wait time in the ER. Given the back-up in hospitals and the extraordinary time that you may have to spend in the ER with your child or family member, who will care for your other children in your home on short notice? Who will care for your pets if you are tied up in the ER for more than a day or if you are the sole care-taker of your pets and you have to be admitted to the hospital? Also, if you have vital medications that you have to take on a schedule that is shorter than the amount of time it may take for you to be seen and evaluated by a doctor, take those with you because a hospital cannot provide you with medications until after you are seen and evaluated by a physician and have physician orders for the medications. It is always good to have a list of medications with the dosage and frequency of the medicines noted. And, if you are in a foreign country, consider having a list of both the medical illnesses and the medications (use generic names of the medications along with doses and frequency) translated into the language used in that country if it is not English.
• If you are traveling to another country, be sure to do your research. Consider whether that country is having a surge of cases and whether its health care system may be getting overwhelmed. For example, Hong Kong, South Korea, New Zealand, Japan, France and China are all having new surges right now. Those countries will not only pose inherently more risks of exposing you to illness, but may also create problems for you in terms of access to care. And, in some countries, you must consider whether they might institute a lock-down if the government determines cases are out of control that might impair your ability to return to the US as scheduled. You likely will want to make sure that you take extra medications with you in case you do become ill and can’t travel, are put in mandatory isolation or quarantine, or unable to return on schedule due to a lockdown or testing positive. A warning – also be sure to check that country’s restrictions as to what medicines you can bring into the country. I was quite surprised when my research showed that a European country had a law prohibiting the possession of a common anti-diarrheal medicine that is over-the-counter in the US and an Asian country that made it illegal to possess a common antihistamine that is over-the-counter in the US except in a lower dose that, to my knowledge, is not even available in that low dosage form in the US. You can get helpful information from the US embassy in the country that you are traveling to.
• In addition, if traveling to another country, check to make sure what insurance coverage you will have in the event of illness. Many insurance companies will cover emergency care at a hospital, but they may not cover outpatient care, medications, oxygen or other services that might be needed. If that is the case, consider purchasing travel insurance. I am not aware of any US health insurance plans that would cover a medical evacuation if you are in a location where it is determined that the level of care you require can’t be met or if the hospital is overwhelmed and you can’t get all the care that you need. You can purchase insurance that will cover medical evacuation, but you need to ask questions such as (1) will the policy cover flying you home to the US or just to the nearest city or country that can provide the care (many provide only for the latter and even for a plan that will bring you back to the US, I had to search for one that wouldn’t just take me to the nearest medical center in the nearest state, but would bring me back home to a medical center here); (2) will the medical flight also carry your luggage back with you (I commonly see restrictions on the number of bags they will allow you to bring); and (3) will the medical evacuation flight allow your spouse or children fly back with you (many do not).
• Also, if traveling to another country, you especially need to do your research as to how you would access care if sick and you needed testing and treatment, but also where you would go and how you would get there if hospital care was necessary.

Measures you can take to reduce your exposures at a family gathering

1. Limit exposures in the several days leading up to the gathering and wear a high-quality mask whenever out in public for those 3 – 5 days prior to the gathering and on any public transportation taken to the gathering:  Family gatherings usually involve eating and drinking indoors, especially during the cold winter months, and this will increase risks of exposure due to the impracticability of wearing masks while eating or drinking. Nevertheless, wearing high-quality masks properly during any public transportation to the site of the gathering will considerably reduce exposure risks leading up to the family gathering. Contrary to many people’s impressions that travel by airplane is low risk, airports are crowded during the holidays, people are in close contact going through security and sitting at the gate or in airport restaurants and restrooms, and people from many distinct geographic regions are intermingled very possibly with variants that are common to that state or country of residence, but to which you have not yet been exposed. Further, while air circulation and filtration may be good when the flight is at cruising altitude, ventilation is usually poor when people are boarding or deplaning. There have been many well-documented outbreaks that have been connected to flights.

We also know from self-reporting and observations that many people will continue with their travel plans even if they realize they are sick. Many people are dismissive of the risks to others by transmission of whatever illness they have and many simply don’t want to cancel flights, hotel arrangements and other plans that they have been looking forward to.

In addition, limit your exposure in the week prior to your family gathering. Avoid large gatherings, work from home if you are able, wear a high-quality mask when you are out with others with whom you do not live (e.g., work or the grocery store).

• Do not show up to the family gathering if you feel ill, or even if you have new symptoms that are not particularly bothersome, but you did not have in the preceding days, such as allergy-type symptoms or unexplained fatigue, and especially not if you feel feverish or have a fever. Encourage and get agreement from others attending the gathering that they will not show up if they feel ill or have unexplained symptoms.
• Get the bivalent booster and encourage everyone else who will be in attendance to do so. If you don’t know where you can get the vaccine, open a text message and type in “438829” for the contact and then type in your zip code as the message. You will receive a text back that lists a couple of sites that are close by that have the vaccine. It will provide you with the name of the pharmacy or clinic, the address, and the phone number. It will also provide you with the email address http://www.vaccines.gov where you can find additional sites near you. If you need additional assistance, you can call 1-800-232-0233. While the booster is less effective in preventing infection and severe disease now that we have so many highly transmissible and immune evasive variants circulating around the world, studies have shown an advantage of the bivalent booster over the prior boosters you may have received, there is mounting evidence that if you have not received a booster within the past 6 months you have lost a significant part of its protection, and you still are less likely to be infected if everyone is boosted and based upon our latest studies, people of all ages have a 50% reduction in the potential for severe disease (i.e., illness that would cause you to need care at a hospital) with the bivalent booster, and that is especially important when our hospitals are already under significant capacity constraints. That reduction in severe disease for those over age 65 is actually 75%. Therefore, don’t put all your reliance on the vaccine to prevent you from getting infected (take the other measures I reference above and below), but this reduction in severe illness still makes the vaccine very worthwhile. While we would hope everyone has already received their bivalent booster, if you or someone else over the age of 5 hasn’t yet received it, please get it ASAP and recommend the others who have not yet received it to do so ASAP for whatever protection it will provide you in anticipation of your gathering.
• Get your Flu shot. It is not too late, but get it now if you haven’t already. This year’s match looks quite good. Again, there may not be enough time by the time of your planned gathering to get the full effect of the vaccine if you haven’t already received it, but get it ASAP because influenza is at quite high levels in most countries in the northern hemisphere. Remember, if you are over age 65, be sure that you get the high-dose version of the vaccine.
• If you are over age 65 and have not received your “pneumonia” shot, get that as soon as possible. This shot is to protect against one of the most common forms of bacterial pneumonia – one that can be quite serious in the elderly and individuals with certain underlying conditions (e.g., some cancers or if you don’t have your spleen or it is not functioning). The risk for bacterial infections increases after certain viral infections, and bacterial pneumonias have long been recognized as a serious complication of influenza. In fact, we are seeing evidence of a possible increase in invasive group A strep in children recently in the US that has been reported earlier this year in a number of other countries in Europe. Therefore, if your child develops fever and particularly, if it is accompanied by a rash, be sure that your child is evaluated for the many possible causes, including group A strep infection as antibiotic treatment is important to avoid some serious complications.
• Most gatherings during these upcoming holidays will be indoors due to the weather. However, if you are fortunate to be spending your holiday gathering in a part of the country or world that has nice weather, please consider having your gathering outdoors. If indoors, try to optimize the air handling to minimize transmission of viruses to the extent you can. Opening a door or window can be very helpful, but may be impractical due to the weather conditions. You can explore adding a HEPA filter or MERV-13 filter to your furnace to filter the air. You also can use air purifiers and filters if you have them, or alternatively, you can make Corsi-Rosenthal boxes fairly easily and inexpensively https://engineering.ucdavis.edu/news/science-action-how-build-corsi-rosenthal-box. I would put one in each room where people will be congregating or sleeping. A way that you can assess whether you have achieved adequate ventilation is to use a CO2 monitor. You can purchase these for less than $100. I turn mine on during my flight, in my hotel room, or in the room where the gathering will take place. CO2 accumulates as there are more people in the space for longer periods of time in the absence of adequate ventilation. If you turned your CO2 monitor on outdoors, you would generally get a reading of about 440 – 450. For indoors, there are differences of opinions, but I shoot for CO2 levels less than 800. Certainly, I would not remain in a room unmasked if the CO2 levels exceeded 1,000.
• Pre-event testing. Ideally, have every guest do a rapid antigen test upon arrival to town and the day of the gathering. If positive, they should not attend the gathering. Although most at-home COVID-19 tests indicate that they are for use in children over the age of 2, largely because they have not been tested in younger children, I can’t think of a reason that the tests wouldn’t work in all children, so check with your child’s primary care provider to see if they have any concerns about testing your child. If not, it may be particularly important to test these children with an at-home COVID-19 test before friends and family members come over since children under 2 are likely to have difficulties verbalizing symptoms to you. In addition, parents need to consider the risks that others will create for your children. After the age group of those over 65, children 0 – 6 months are the most commonly hospitalized group for COVID-19. Also, children under the age of 2, and especially those 0 – 6 months and even older children who have significant underlying health conditions such as asthma or neurodevelopmental disorders, are at the highest risks for severe RSV, which might result in hospitalization.

Unfortunately, the sensitivity of these at-home tests has declined with the emergence of these new variants. It is not that the variants are not detected by the tests, but rather, it may take testing two or three times over intervals of 48 hours each for the test to show up positive. So, a single pre-event test will give some assurance, but two negative tests over 48 hours will be much better assurance and three negative tests each spaced 48 hours apart will be the best possible assurance, though this is not likely to be feasible for all your guests. An alternative approach for those who have not had COVID-19 within the past 90 days is to do the at-home PCR test I mentioned above. This test needs only be done once and has a very high sensitivity rate of 98% (at least per the reports of the company to the FDA). PCR tests often are positive a day to two days before the rapid test becomes positive, so for those guests arriving in town the day of or day before the gathering, this approach may be the best.

I hope this is helpful. I wish you all happy and safe holidays!