Opinion | How to Not Kill Grandma This Thanksgiving and Holiday Season

Last year, I wrote a piece called “How to not kill Grandma (or anyone, including yourself) this Thanksgiving.” People seemed to find it useful. So I decided I would republish it this year, with some updates.

The basic idea: people travel great distances to see relatives during the holiday. In doing that, they interact with a lot of people — which gives respiratory viruses opportunities to spread rapidly. And who are these travelers often going to see? Older relatives, many of whom might be vulnerable to serious consequences from seemingly mild illnesses. What can take a kid out of school for a few days could land a grandparent in a hospital, ICU, or worse.

So, this piece is designed to say, “Hey! You! Traveler! Don’t inadvertently kill your relatives this holiday season.”

Now, it is 2023. Which is to say, not 2022, 2021, or 2020 (a year in which we had COVID-19 circulating, but no vaccines, if you can fathom that hellscape). I realize that at this point, many people are just not going to do anything to stop the spread of viruses.

My argument has always been that harm reduction is worthwhile. Do whatever you are willing to do for others, but please, not less. If you’re willing to take a COVID test before you see a high-risk relative, do that. If you’re willing to wear a mask while you travel so that you don’t transfer influenza from the airport to the assisted living facility where your relatives live, do that.

So, what happened during Thanksgiving 2022? I took a look at the Inside Medicine Respiratory Virus Dashboard. Last year, there was a clear surge in respiratory syncytial virus (RSV)-related hospitalizations the week after Thanksgiving in adults ages 85 and older, but not in children or working-age adults. In fact, RSV was declining in kids by then, but still remained at high levels; put another way, RSV levels changed drastically enough that we can see that rates slowed down after kids left school, but levels remained high enough to bring to their older families during the break often enough that we see the population-level effect. This indicates — or at least strongly hints — that the non-geriatric population introduced RSV to the geriatric population over the Thanksgiving holiday last year.

The picture for influenza and COVID was similar, but not quite as crystal clear. In kids, flu peaked the week of Thanksgiving and fell from there while COVID reached a local peak and leveled off for a bit; for older folks (ages 85+), the flu peak came the week right after Thanksgiving while COVID had a local peak then as well — a peak that was actually topped by hospitalizations (wait for it) the week after Christmas.

Do we really want to be a part of this?

No. But there are simple things we can do to decrease the odds of being viral vectors, without ruining the holidays.

With that in mind, here’s the rest of the piece, first published a year ago…

The holiday season is upon us. Cold and flu season is in full swing. COVID isn’t gone. It’s a lot.

I love Thanksgiving, and so it pains me to say that it has long been known that Thanksgiving is, well, kind of a killer. I know that’s awful, but it’s true! Here’s what we can expect:

• More respiratory viruses (respiratory viruses prefer cold conditions).
• An expected uptick in deaths from a surprising array of causes as we get deeper into the fall.
• Higher motor vehicle fatalities on Thanksgiving Day (dangerous driving conditions, both natural and, especially, man-made).

Indeed, in terms of when we are collectively the sickest and face the highest mortality rates, winter is coming.

And, of course, there’s COVID. This Thanksgiving will be our fourth with COVID. In 2020, COVID was still working its way through the country, so the holiday data are hard to interpret. But in 2021, something important seems to have happened:

The week after Thanksgiving, the percent of new COVID-19 cases requiring hospitalization went up rather suddenly, especially among older people, from the high-30% to low-40% range before Turkey Day, to north of 50% the week after. Now, it’s possible that this was an artifact of reduced testing among healthy people during the holidays (i.e., the number of hospitalizations didn’t go up, but the testing among healthy people went down). But that seems unlikely, looking only at people ages 80 and older. The weekly case rate and new hospitalizations in that age group also increased somewhat a week or two after Thanksgiving 2021.

This says to me that the average 80-year-old who contracted COVID during Thanksgiving was less healthy than the typical 80-year-old getting infected during normal days. That makes sense. People on the vulnerable end of the spectrum tend to be more isolated normally. So, Thanksgiving is a time when those at the most risk take the most risk, either by welcoming visitors or traveling to see family. Last year, a week after Thanksgiving, we saw what looks to be the downstream results of that.

However, Thanksgiving is but a prelude. The data for Christmas look worse. Again this makes sense, with longer visits and even colder weather. Last year, the percent of new COVID cases requiring hospitalization went up right after Christmas, and that was despite the emergence of Omicron, which infected droves of young people, driving down the overall rate of hospitalization on a per-case basis (even as overall new hospitalizations rose). In fact, you can see that after the post-Christmas bump in the percent of cases requiring hospitalization among people ages 80 and up (peaking at above 55% the week after Christmas), that figure dropped to the 20% to 30% range by mid-January, where it stayed through the late winter, spring, summer, and even the early fall 2022.

Now, these observations are just that — observations. To get a fuller understanding of these effects, epidemiologists and disease modelers will have to apply complicated techniques (like “difference in difference,” which measures the changes in the context of existing trends).

Where does this leave us?

Here’s what you should do — what I will be doing — if you’re potentially visiting anyone for whom COVID (or any serious respiratory illness) could be devastating.

• Bring rapid tests. If you’re positive for COVID, isolate (i.e., stay home). Test yourself prior to your first interaction with someone you’re worried about spreading any virus to, and again a day or two later. (If you have the tests, use them daily until you’re 5 or 6 days from your last substantial exposure.)
• If you have a cold (like I currently do, after a nearly 3-year run without so much as the mildest of viral illnesses), wear a good mask. My seasonal rhinovirus or adenovirus could land a vulnerable person in the intensive care unit.
• Air the place out, especially in tight spaces. If you’re driving for an hour with a person who can’t afford to get COVID, RSV, or any other serious virus, keep the air moving. You’d be surprised how simply opening the window occasionally for a couple of minutes (even just part way), can make a tremendous impact on ventilation and air quality. I recently checked the carbon dioxide levels in my car (using a portable monitor) before and after opening the window for just a couple of minutes. The difference was as immediate as it was remarkable. While we tend to think of COVID exposure as all-or-none, the reality is that even people who live together don’t always catch COVID from each other. An hour of exposure does not necessarily spell an infection. So “harm reduction” like leaving the car (or living room) windows open even for a little while can make a marked difference.
• Don’t get infected en route. Wear a mask and bring hand sanitizer. (We seem to have forgotten how many viruses actually do spread the way we initially thought COVID spread — via droplets on surfaces.) Last year, a friend of mine described a family gathering in which everyone tested before driving or flying to a family reunion. The eventual outbreak that happened a few days later at the reunion would have been averted if people had tested both upon arrival and 2 to 3 days after travel (where exposure risks can be high).
• Do not drink and drive. Ever.

This piece originally appeared in Inside Medicine.

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