Thursday, December 24, 2020
By Greta Fox, FNP-BC

Let us be thankful that unlike the beginning of the COVID-19 pandemic, we now have nearly a year’s worth of data about how the virus spreads, and that we know how to avoid an American replay of the Canadian post-holiday surge.

COVID-19 is an airborne virus, which as of this writing has caused over 18 million infections and claimed close to 326,000 lives in the U.S.  While contact with contaminated surfaces is a factor, it is primarily spread by respiratory transmission, from person to person, and through particles that linger in indoor air. Most people who are infected do develop symptoms, but they are contagious before symptoms appear, and an estimated 20 % remain asymptomatic, yet contagious, unknowingly spreading the virus in their communities. Mask wearing is proven to dramatically reduce transmission and deaths , but at this time it is not universally accepted by all communities, and mask mandates are inconsistent.

Most of us want to celebrate the holidays normally, with our families and friends, but cases are surging,  gatherings of different households, especially indoors, are proven spreaders of the virus. According to the CDC, the lowest risk holiday activities are small dinners limited to household members only, and virtual gatherings with others. As COVID pandemic fatigue sets in, the temptation to push boundaries and take chances can be strong. However, NYU epidemiologist Celine Gouder warns that “it’s really important to understand that the coronavirus hitches a ride on our trust and our love for our family and friends. It’s actually the people we trust most whom we’re most likely to infect and who are most likely to infect us, because we’re not going to take those same precautions.” And indeed, the post-Thanksgiving surge is here, with more than 200,000 new cases and 3,000 deaths per day in the US. That’s an American death every 48 seconds. Hospitals and health care workers are overwhelmed, with ICUs at and above 100% capacity in many areas. Many European countries are imposing strict restrictions or going into lockdown. Angela Merkel pleaded in Parliament that “If we have too many contacts now, in the run-up to Christmas, and it ends up being the last Christmas with our grandparents, then we will have done something wrong, we should not let this happen.”

Let us be thankful for Georgia Institute of Technology professors Joshua Weitz and Clio Andris, who developed a risk assessment tool for gauging the odds, by county and by gathering size, of a COVID-infected person being present at a given event. For example, in our county, there is an estimated 8% chance of someone having COVID at a gathering of ten people – that’s one out of every twelve to thirteen people - and going up to 20% for a gathering of 25 people, or one in five. These are not good odds.

In addition to factoring in the current rate of community spread, COVID PCR testing has the potential for helping to reduce the risk of disease transmission over the holidays, but only if used correctly, which can be challenging to accomplish, particularly for students returning home from college. The incubation period for COVID is up to 14 days, with an average of 4 – 5 days between exposure to the virus and the development of symptoms. The  probability of a false negative test the day after exposure is 100%, and there are many factors which affect the variable but significant false negative rates even several days after exposure in both symptomatic and asymptomatic people. It is important to understand that any given test is just a snapshot of the day that it was taken and doesn’t exclude an exposure that is too early to show up on a test, nor does it exclude exposure to infection after the test was taken- exposure can happen during travel, or at the destination if quarantine is not maintained.

The current recommendation is to fully quarantine for two weeks prior to travel, and to wait at least 4-5 days after the start of the quarantine before testing. Testing 72 hours prior to travel is required by some states, so planning ahead for a re-test at that time will reduce the odds of a missed asymptomatic infection. But this is still about risk reduction, not elimination. Precautions need to be taken during travel.  While I have not yet found this recommendation in the current posted guidelines, common sense suggests that host households should also quarantine and test, to protect their guests.  Precautions may still need to be taken during the visit, especially in the presence of particularly vulnerable household members, as the “six-foot rule” has been debunked as the gold standard for safe distancing, and gathering outdoors (safer than indoors, but still requiring masks and distancing), or ventilating indoor environments to reduce airborne/aerosol transmission can become more difficult as the weather gets colder. Even with distancing, the virus doesn’t care that you’re hungry - removing your mask indoors to eat is still removing your mask indoors. And clearly, a negative test result on its own is not a guarantee that one is not infected and is not reliable as an event screening tool, as evidenced by the (mainly outdoor) Rose Garden “superspreader” event of September 26, where negative rapid screening tests on site “cleared” guests to interact without PPE. The White House’s continued reliance on testing as a screening tool has resulted in ongoing outbreaks.  Let us be thankful that we have had the opportunity to witness these failures, which serve as cautionary tales.

At the end of the day, we need to keep current and informed, and communicate openly and frankly with our loved ones. We can mindfully decide together what level of risk is acceptable, and fully comply with the agreed-upon plans. We can also choose to play it as safe as possible, acknowledge the difficult reality that life and death are at stake, avoid the risk of making this holiday a loved one’s last, and follow the CDC’s recommendation this year to skip the trip this time to help get us all closer to the time when we don’t have to do this anymore. And while we’re at it, let’s be thankful to ZOOM for lifting its 40 minute time limit for free meetings on Thanksgiving and Christmas. Have a happy, healthy, safe holiday!