“Wear a condom!”

Asking loved ones not to be together for the holidays is like asking teens not to have sex.  People will do it no matter what we say, so we should help them do it as safely as possible.  Let’s talk about COVID condom-equivalents!  Below are my thoughts, here at the end of August, about how we can make holiday gatherings hotbeds for communion and connection, rather than infection and transmission. These are my own recommendations and do not represent the advice or policies of my employer:

Talk About It Now

If your family is anything like mine, people have varying degrees of comfort and anxiety about COVID, and these levels may themselves oscillate and evolve over time.  Before we even talk about gathering for the holidays, we need to know how people feel and what they think about it all, as much as possible.  Talk to your nuclear family.  How important is it for each of you to be with extended family?  What trade-offs are people willing and not willing to make in order to do so?  What are the deal breakers?  What are the must-haves?  Starting these conversations today gives everybody time to reconcile differing opinions and make the most accommodating and collaborative plans.

Contact your extended families.  What’s everybody thinking?   Who’s on the same page?  For those who are not, what will need to happen?  How can we all work it out so that these holidays bring joy and connection, however we can get it, rather than more separation and loneliness?

Isolate for 14 days in advance

The most effective method for preventing infection and transmission is isolation. The incubation period for SARS-CoV-2 is 2 to 14 days. If we have no contacts outside of our household in that time, the chances of us getting infected, and then passing the virus onto others, is very low. I know this is not possible for many, but if we really want to be together safely, this is what we should aim for. Everybody who will be together in the extended family needs to minimize contact with people who will not be with us, in order for us not to spread the virus rapidly between us.

Merge Bubbles SAFELY

Once we have decided to gather, we should follow precautions obsessively:

1. DO NO PARTICIPATE IF WE HAVE SYMPTOMS.
2. Check temperature daily; stay away/isolate if over 100.0 degrees Fahrenheit.
3. Wash hands and sanitize surfaces like our lives depend on it—20 seconds with soap and water, or enough 60+% ethanol-based hand sanitizer to take many seconds to dry, no exceptions, early and often.
4. DO NOT share anything: utensils, drinking vessels, implements, etc.  When it doubt, throw it out and get a new/clean one.
5. Minimize close contact–consider masks if close contact is prolonged.
6. Optimize ventilation.
7. Spread out whenever possible.
8. Mask up if it helps us feel safer—especially if anyone was not able to isolate.  Respect one another’s decisions on this—be kind and generous.  Nothing ruins a gathering, holiday or otherwise, faster than snide comments and passive-aggression.

Know the Risks

So many statistics abound, and depending on our particular perspective on the pandemic, we will focus on certain facts more than others.  The bottom line is this:  Populational statistics are not easily applied to individuals.  Nothing can predict your or your family’s outcome if exposed.  Some things to keep in mind:

1. None of us, not even veteran infectious diseases and public health expert Dr. Anthony Fauci, have seen a disease with such a spectacularly wide spectrum of illness—from asymptomatic to rapid multisystem organ failure and death, and everything in between.
2. Any person, regardless of demographic, could have any course.
3. There is no way to predict what any given individual will have, and virtually no way to influence it, other than preventing infection in the first place.  Maybe you can increase your vitamin D level and decrease your risk (talk to your doctor about it).  But unless you’re in the hospital (which means you are very sick), where remdesivir and dexamethasone may shorten your hospital course, there is nothing you can take or do to make you better.  You could be ill for many weeks with symptoms that involve your lungs, gut, brain/nervous system, heart, and blood vessels.  And all you will be able to do is wait it out.
4. If you get infected, even if you recover, we still don’t know whether and what long term effects the virus and the disease will have on your body and/or your immune system.  It’s simply too new.
5. The local positivity rate where we are can help us assess the risk we pose to others.  Where are we and our relatives coming from, and what does the pandemic look like t/here?  Find out here. 

Stay vigilant

Let’s say Thanksgiving goes well and nobody gets (too) sick in the weeks following.  Are we getting together again in December or over the New Year?  If so, we will all need to follow the same preparations and precautions before and during all gatherings to make it into 2021 unscathed.  The good news is, if we have already merged bubbles and we all steer clear of contacts outside of this new cohort, we may continue to commune safely all through the season.

I may update this post as the holidays get closer. Maybe everything will get better and we will have much less to worry about… I seriously doubt it. The best thing that could happen is that we all draw closer, physically and/or otherwise, to take care of each other and appreciate all that we have; that we live more mindfully, kindly, and inclusively in all domains; that we pull together in every way and keep each other safe and healthy.

What will be your COVID condom-equivalents this holiday season?  How willing are you to wear them every time, no question, without fail, to protect yourself and your loved ones?

***

Coda:  On Testing

Below is a draft of information I have written for patients.  It reviews what constitutes an exposure, and guides decision making about testing.  Bottom line:  Negative testing does NOT guarantee the absence of infection or risk of transmission.  Know what the information means and how to use it before getting tested.  These are also my own recommendations and do not represent the advice or policies of my employer:

Definition and Degree of Exposure

Known exposure

–You spent more than 15 minutes within 6 feet of someone who was symptomatic with COVID-19 illness and/or tested positive ​within the two weeks prior or 48 hours after the time you were with them.

Possible exposure

–Same situation as above, but you and/or the other person were masked​.  ​Some would still consider this an exposure​, others would not.  If you were both masked for the entire encounter, the risk of transmission ​is significantly lower.

— You spent less than 15 minutes unmasked with someone who was symptomatic or tested positive within the two weeks prior to or 48 hours after the time you were with them.

–You attended a large gathering, flew on an airplane, rode a train, etc. where someone in the vicinity recently or subsequently tested positive. The risk in this situation is higher if anyone was unmasked and/or if it was indoors and/or in a small, poorly ventilated space. Avoid these activities if possible.

–Prolonged outdoor contact, unmasked, inconsistently distanced at 6 feet or more, eg outdoor dining.

Not an exposure

–Outdoors, consistently masked and/or distanced from other people at least 6 feet apart

Statistics of Infection

–Incubation period is 2-14 days

–Average time to symptom onset is 5 days

–By 10-11 days, 90% of infected people will have developed symptoms

–Viral load peaks 1-2 days before and after symptom onset—this is when the test is most likely to be accurate

Reasons for Testing

–Required for return to work/school, participation in structured activity, etc.

–Known exposure

–Symptoms:

• fever
• cough
• any new shortness of breath or difficulty breathing
• chills
• shaking with chills
• muscle pain or body aches
• headache
• sore throat
• new loss of taste or smell
• diarrhea
• nausea or vomiting
• congestion or runny nose
• fatigue

–I do not recommend testing in the absence of symptoms, exposures, or a requirement. 

Timing of Testing

–After a known or possible exposure, the best thing to do is self-isolate ​for 14 days.

–If you develop symptoms, seek testing.

–If you do not develop symptoms, consider testing around day 5-10 and continue to isolate

–Check the turnaround time at your designated testing site.  Results can take anywhere from hours to weeks.  Note that if a result is reported many days after the test date, that result may not reflect real time infection status.  Thus testing may not be useful and 14 day self-isolation is the best course of action.

​-A negative test does NOT ‘clear’ you. Testing can be negative in up to 30% of people who have symptoms, and may be higher in those who are asymptomatic or early in infection. Therefore, you MUST continue to isolate for a full 14 days after a known exposure, even if you test negative.