Give Thanks
Last week I wrote about preparing for Thanksgiving by getting vaccinated, boosted, and tested as needed.
Today I’ll get into some specifics by unpacking an excellent question from one of my patients. Here’s to maintaining safety (and sanity) over this holiday week. Let’s go!
Hi Dr. McBride,
A friend of ours will be hosting an outdoor Thanksgiving dinner. The host had COVID-19 a year ago and is rejecting the idea of being vaccinated. Her family is vaccinated other than her and her 18-year-old son. My husband and I are boosted, but our kids who are flying in from college this weekend have only had two shots. Is this an event we should not attend? Or is it low risk since it’s outside? I’m trying to calculate the risk.
Thank you!
Let’s start with the basics.
First, don’t go anywhere if you have symptoms. Remember that COVID-19 can present as sniffles, a sore throat, and other mild symptoms that people often ignore, especially after we’ve been vaccinated, thinking “This can’t possibly be COVID!” It’s important to remember that symptomatic people can infect others.
So, what to do if you have symptoms? Call your doctor and/or get tested. A negative rapid antigen test (like Abbott’s BinaxNow) means that it’s unlikely you have COVID-19. However in symptomatic people I usually recommend taking a second rapid test to be sure. Two negative rapid antigen tests makes a diagnosis of COVID-19 extremely unlikely. What about PCR testing? A single negative PCR test in a symptomatic person means it’s highly unlikely that you have COVID-19.
Now let’s talk about my patient’s Thanksgiving, starting with the adult host who had COVID-19 a year ago. She certainly has some immunity to the virus as a result of her immune system “seeing,” fighting off, and winning the battle against a pre-Delta strain of coronavirus. Her immunity to SARS-CoV-2 somewhat reduces her risks for 1) reinfection and/or 2) transmitting the virus to others. But it’s difficult to know how durable that immunity is. In other words, because immune protection seems to wane with time and her infection was a year ago, it’s certainly possible for her to get COVID-19 again and also to unwittingly transmit the virus to other people at Thanksgiving.
Note that if I were her physician, I’d recommend she get vaccinated because the vaccine is an extraordinarily safe and effective way of reducing the risk of symptomatic COVID-19 and dropping the risk of infecting others. Even though it takes two weeks for the vaccine to take full effect, it’s never too late to get vaccinated.
Then there’s the 18-year-old unvaccinated son of the host. Without any known immunity to the virus, he is at highest risk, depending on his exposures, for getting COVID-19. He’s also at highest risk for asymptomatically carrying the virus and unwittingly infecting other people.
Next there’s my triple-vaccinated patient and her husband. By getting boosted, they both have topped off their antibody levels and have optimized their overall protection from COVID-19. The risk of infection isn’t zero (and it never will be), but after a booster shot, the risk of symptomatic infection is dramatically reduced.
What about the risk of transmission after being triple vaccinated? We don’t have definitive proof that transmission is reduced after three shots, but it would break our understanding of immunology if it didn’t! In other words, getting vaccinated and boosted gives you the strongest immunity against COVID and against transmitting the virus to others.
What about the college kids who’ve only had two shots? The risk of severe disease from COVID-19 in twice-vaccinated healthy young people is extremely small. The risk of transmission is also small—but not zero—and largely depends on their exposures. In other words, if these college kids are coming off a week of indoor gatherings in a state where viral transmission is high, I’d be worried about them carrying coronavirus without symptoms—but a lot less worried than if they were unvaccinated.
Now let’s talk about the setting for this shindig. It’s outside! The outdoors is pretty darn safe. Numerous studies find that <1% of cases are attributable to outdoor transmission. Is it possible to inhale the virus-laden breath-plume of someone who’s in the unlucky small percentage of people who are vaccinated and asymptomatically infected with coronavirus—and then to get infected while you’re close-talking by the bonfire? Sure! It’s just highly unlikely.
OK—now it’s time to play out the worst case scenario: you’re mingling outside, feeling protected by your own and others’ vaccination status—plus the natural ventilation of the outdoors—when suddenly the temperature drops and the host calls out, “It’s getting cold! Let’s eat inside!”
What to do? First, recall that poorly-ventilated and crowded indoor spaces are where coronavirus loves to spread. But also remember that if you are double-vaccinated and young—or healthy and triple-vaccinated at any age—your risk of transmitting the virus and of getting severely ill is low. (Though the risk of severe illness also depends on your underlying health conditions.)
Here are some ways to mitigate the risk of being indoors with people who may be carrying coronavirus and don’t know it:
Consider having everyone take a rapid antigen test (like Abbott’s BinaxNow) before going inside or, better yet, the morning of the event. A negative rapid test tells you that, at that moment, you’re not carrying enough virus in your nose to infect other people. The problem is that these tests are expensive. The upside is that they offer an added layer of protection for other people in your midst.
Crack windows and doors. The more you increase ventilation, the better chance of dispersing this aerosolized virus.
Limit the number of people in a room. Spread out if you can! There’s no perfect number here—it’s just that the fewer the number of people in a space, the smaller the chance of coronavirus’ invisible presence and potential spread.
Wear a mask inside if you’re unvaccinated. Consider wearing one if you’re vaccinated. Masks can help reduce transmission of the virus, but their relative utility drops after we’ve been vaccinated. In other words, the vaccines do a much better job of reducing viral spread than masks do! Particularly if you’re unvaccinated, it’s important to wear a well-fitting surgical, KN95, or N95 mask indoors.
So, should a fully-vaccinated person wear a mask indoors? I would argue that masking indoors should be optional and up to our personal risk tolerance of the (tiny) chance of getting a mild illness. I, for one, will go maskless because I have faith in my three shots and because my family are at low risk and/or are fully vaccinated, too. Plus, connecting with loved ones includes seeing faces!
What’s the upshot? Get vaccinated, get boosted if eligible, blanket your Thanksgiving group with rapid antigen tests if desired (and in your budget), and wear a well-fitting mask if you’re both indoors and unvaccinated.
MOST importantly, try to enjoy this holiday if you’re lucky enough to have time off work! After 20 months of unpredictability and uncertainty, political and social unrest, and a ubiquitous virus in our midst, we all need a break. We need time to rest and restore. We need time to connect with loved ones. We need to think about each other not as vectors of disease but rather vessels of love and compassion.
Want to know what I’m doing this Thanksgiving? I’ll spend the day with my parents, three teenage kids, husband, two brothers, uncle, two cousins, cousin-in-law, six young nieces, and three dogs. All of the adults and teens are vaccinated. The nieces are partially vaccinated. We’ll spend most of the day outside. We will dine indoors. We will drink and be merry.
We will celebrate family togetherness. We will pray for people we have lost and for people who are suffering. We will give thanks for the gift of family, the blessings of modern science, and the promise of a brighter tomorrow.
I will see you next week. Until then, be well.
P.S. Join me live at 6 pm ET (3 pm PT) tomorrow November 23 on “The Dr. Drew podcast” at https://drdrew.com/live/! We will talk about managing mental and physical health at this stage of the pandemic.