How can family safely get together for the holidays (Thanksgiving, Christmas)?

Coming up to the 8-month mark of vigilance against COVID-19 transmission, how much do we miss spending cozy hang-out time with friends and family outside our households?  For those who love the holidays, how much do you look forward to that family time – catching up over long meals, laughing, singing, hugging.  This year will be a challenge for so many as we navigate a very different holiday season, balancing our very real need for connection with each other’s safety.

On Tuesday, October 27, during a call with the nation’s governors, CDC Director Robert Redfield confirmed, “…what we’re seeing as the increasing threat right now is actually acquisition of infection through small household gatherings. Particularly with Thanksgiving coming up, we think it’s really important to stress the vigilance of…continued mitigation steps in the household setting.”

Many public health experts agree it is safest to skip this year’s holiday family gatherings, if possible.  It is also important, however, to recognize this risk-benefit calculation and decision is a personal one.  If the costs of celebrating the holiday over Zoom or with a phone call rather than in-person feel greater than the benefits to all involved, there are ways to minimize risk of COVID-19 transmission as you embark on an in-person gathering.

On October 19th the CDC issued detailed guidance for hosting, attending and traveling to holiday celebrations this season – the page is worth a read.  Noting that virtual celebrations or festivities held among members of the same household pose very low risk compared to the varying levels of risk of in-person gatherings combining households, the page then lists risk factors to consider in planning an in-person gathering, including: the level of community spread of COVID-19 in the area, the location (indoor/outdoor/ventilation) and duration of the gathering, the number of attendees and where they’re traveling from and the attendees’ behaviors for the 2 weeks before and during the gathering.  Several helpful charts also exist to aid in decision-making, comparing various environments and behaviors categorized as low-, medium- and high-risk of transmission, such as this one from the British Medical Journal, August 2020.

While there is no straight-forward answer to whether you should travel for the holidays and each person’s risk/benefit calculations will look different, this MarketWatch article highlighted a number of helpful questions to ask yourself, including:

Are you at higher risk for COVID-19 complications? What about the people you’re visiting?

• If you or a family member are in a high-risk group, including those over age 65 or those with underlying health conditions, you should be more vigilant

Where are you coming from? And where are you going?

• Be aware of the COVID-19 infection rate in your area as well as in the area you’re traveling to.  Make sure you are aware of which states require virus testing or have quarantine requirements.

Can you get tested, self-isolate and get your flu shot before traveling?

• Getting a COVID-19 test, especially if you’ve been in a variety of environments at higher risk for transmission to have occurred, can provide some extra reassurance.  But be aware that COVID-19 tests, especially rapid tests, are often quite poor at picking up asymptomatic infection.  If you have relatively easy access to testing, you might consider testing before leaving, after arriving and again on arrival home, to increase your ability to detect infection.  And while a positive test means, of course, that you will need to skip your holiday plans and self-isolate, a negative test isn’t a license to abandon other precautions.  Testing too early can lead to a false negative and give a false sense of security.  It is important to continue to wear a mask, wash your hands and practice social distancing.  
• Self-isolating as much as possible for at least two weeks prior to the trip can decrease risk to others considerably

Who else is going?  How many people will be there?

• Large gatherings are associated with higher COVID transmission levels.  Ideally fewer people than usual will be in attendance, and it is better if they’re already in your “bubble.” 
• When combining households, gathering two groups of people who completely self-isolated in their homes for two weeks is much lower risk than hosting family members from all over the country who have kids in school and traveled by train or plane to come visit.
• Finally, staying with family for several days generates multiple indoor encounters that increases risk considerably.  If out-of-town family do need to stay, having them stay in a separate room with a separate bathroom can decrease risk.

Is it warm enough to gather outdoors?  If not, can you improve ventilation?  

• At the gathering, maximizing distance between people and minimizing density and duration of time is helpful.  If people can’t eat outdoors, spreading out throughout the house to eat can be helpful.  Try to improve indoor air flow by opening windows or using air purifiers.

Will everyone be wearing a mask?  What will you do at meal time?

• Wearing a mask, particularly if density makes 6-foot social distancing difficult and/or if the gathering will not be outdoors, is important.  Making the most social part of the gathering the non-eating (mask-wearing) time and having a more silent eating time, spread apart from others not in your “bubble,” can also decrease risk.  You can try staggering eating times so that people from the same household eat together at the same table.  

Set boundaries and expectations ahead of time

• Come up with a plan that all attendees are comfortable with, keeping in mind public-health precautions.
• It’s ok to ask family members how they’ve been protecting themselves from infection.  If they haven’t, it’s ok to say you’re not visiting.

And what about the hug?

• Certainly it would be the lowest risk not to hug.  But there are many benefits derived from hugging.  A hug between two mask wearers carries less risk than a hug between two unmasked people.  Turning your head the opposite direction and minimizing time spent hugging can also help.

In summary, the safest thing for ourselves, our families and our communities this year is to spend the holidays celebrating within our own households.  As Dr. Kit Delgado, an Assistant Professor of emergency medicine and epidemiology at the University of Pennsylvania put it, “Unfortunately, the merriment we crave — eating, drinking and singing together in a cozy room — are among the highest-risk scenarios for transmitting COVID-19. I’m optimistic that things will be different next year, and we can give up this year as an act of charity to our friends, family and community.”  But if this year is of particular importance to spend with those outside of your household, the above list can be helpful in how you can best minimize risk.  

(Jennifer Abrams, MD, November 2, 2020)