As the holiday season approaches and the COVID-19 pandemic worsens, it is crucial to understand that there is no way to gather in person in a way that completely guarantees you will not catch or spread COVID-19. The CDC has strongly cautioned Americans against traveling or gathering in-person this holiday season [1]. OSMS does not condone gathering in-person against this guidance, but has compiled this guide so that people understand, and can act to minimize, the risks associated with gathering if they still choose to do so.

OSMS has compiled guidance from 27 resources to help you understand the risks associated with in-person gatherings this holiday season, as well as examples of specific risk-level scenarios and precautions for each scenario.

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Millions of people around the world look forward to the holiday season every year. It is a time for families, friends, and communities to come together and celebrate traditions. While these traditions may vary, there is a common theme of sharing and togetherness. Due to the way COVID-19 spreads and the timeline in which symptoms appear, there are many risks associated with celebrating together in person during the pandemic [2]. Understanding these risks and taking certain precautions can keep your family, friends, and communities safer this holiday season.

People who are sick with COVID-19 are contagious for several days before they feel sick. Some people who are contagious with COVID-19 never feel sick, or never show symptoms of being sick, but can infect other people anyway. These facts, combined with how easily COVID-19 is transmitted indoors and how many sick people require hospitalization is what makes gathering for the holidays so dangerous. Across multiple states like Massachusetts, New Hampshire, and Ohio, an average of almost 1 in 20 COVID-19 patients require hospitalization [27].

A large number of COVID-19 infections in a given area increases the risk of people becoming infected and subsequently spreading the virus [3], and is a critical factor to consider when making plans for this holiday season. This includes the number of COVID-19 cases in your location, as well as in the locations where attendees are traveling from. Family and friends should be encouraged to monitor the number of cases in their community, and in the community where they plan to celebrate when deciding whether to attend or host a gathering [4].

Any form of travel increases the risk of getting and spreading COVID-19 [5]. Public transit is particularly risky due to spending long periods of time in an enclosed space with others, often in circumstances where adequate ventilation and social distancing may not be possible. There are likely to be long lines and crowded conditions at ticketing counters, security checkpoints, and while boarding [6]. Pre-screening travelers is not fool-proof as some people contract the virus but do not develop detectable symptoms (asymptomatic) and then unknowingly spread it to others [7].

Air travel is generally thought to be lower-risk [8]; however, an increase in passenger volume due to holiday travel means that airports and flights are more likely to be crowded and empty seats between passengers to facilitate distancing would be unlikely. Even with filtered cabin air and mask use among passengers, travelers would still be spending an extended amount of time in an enclosed space and one infectious passenger can sicken many others [9].

Train and bus travel also includes the potential for crowded conditions. Air filtration and ventilation systems in buses and trains are not as efficient as those used in aircraft so the risk of transmission via aerosols is higher [10]. Additionally, bus stations, train stations, and rest stops are all places travelers can be exposed to COVID-19 from other travelers via aerosols or shared surface contact [11].

Driving to your destination may be less risky if you are traveling alone or if all passengers are from the same household and you take precautions in public areas like gas stations and rest stops [12]. If you are not from the same household, spending time within an enclosed vehicle greatly increases the risk of catching or spreading COVID-19 from other travelers due to spending a long period of time in a small space where social distancing is not possible. Keep in mind that it is possible for a passenger to contract the virus before or during the trip, and then spread it to other passengers without showing symptoms [13].

Anyone traveling on a plane, train, bus, or in a car (with passengers who are not from their household) should plan on wearing a mask [PPE USE GUIDE] for the duration of their travels. If you are driving alone or with members of your household, plan on wearing a mask any time you are not inside your vehicle. Bringing additional masks in a clean plastic bag is recommended in case your mask breaks or becomes soiled [14]. If you are traveling with children, bring extra masks for them as well. Note that younger children may need reminders about keeping their masks on and not touching their eyes and face [15]. 

Travelers should also carry hand sanitizer with at least 60% alcohol content at all times, and use it after touching any shared surface or objects, before and after removing your mask, as well as before and after eating or drinking [16]. Offer hand sanitizer to children during the same circumstances and supervise them to ensure safe and effective use. Consider packing sanitizing wipes in your carry-on bag in order to disinfect surfaces like tray tables, armrests, and any personal objects like your cell phone or tablet, and toys if you are traveling with children [17]. 

Gathering with people outside your household increases your chances of catching or spreading COVID-19. The level of risk associated with hosting or attending an in-person gathering is highly variable and depends on the number of guests in attendance, whether or not the guests are from the same household, if the gathering is held indoors or outdoors, what sort of activities or behaviors the guests are engaging in, and the duration of the gathering [2].

The more people interacting at a gathering and the longer these people interact, the more likely an infectious person will spread COVID-19. [17]. While CDC (US) does not suggest a specific limit for the number of attendees for gatherings, they recommend that the size of a holiday gathering should be determined based on the ability of attendees from different households to stay a minimum of 6 feet apart, wear masks, and practice good hand hygiene [17]. In the US, many states have recommendations or restrictions around how many people may gather in groups outside of their household in an effort to reduce the likeliness of attendees spreading the virus if they are infected [18].

In-person gatherings with safety measures in place, such as mask-wearing, social distancing, and handwashing, are less risky compared to gatherings where fewer or no preventive measures are being implemented. Activities that increase the risk of spreading aerosols or respiratory droplets like talking loudly and singing should be avoided, especially indoors [17]. Dining as a group with people seated less than 6 feet apart is risky, especially if conversations are occurring, and consumption of alcohol at a gathering may impair judgment and make it difficult to practice COVID-19 precautions. Individuals who do not consistently adhere to social distancing (staying at least 6 feet apart), mask-wearing, handwashing, and other preventive behaviors, pose more risk than those who consistently practice these safety measures in their daily lives[19].

Indoor gatherings pose more of a risk than outdoor gatherings because COVID-19 spreads through exposure to infectious respiratory droplets and aerosols [20]. Poorly ventilated spaces allow for aerosols to remain suspended in the air where they can be inhaled by people who then become infected [21]. Good ventilation greatly reduces transmission and is easier to achieve in an outdoor environment. If gathering outdoors is not feasible, indoor spaces must be modified to allow for proper ventilation. Windows and doors should be opened for outdoor air to move through the space; if this is not possible, portable HEPA air purifiers can be used to filter indoor air, and high-performance filters (MERV-13 or greater) can be installed in residential HVAC systems [22]. If a gathering is held in an outdoor tent, the sides should be at least partly rolled up to allow for the circulation of fresh air. Space heaters can be used to keep attendees comfortable during outside air circulation in a cold climate [17]. 

There are circumstances where people absolutely must not attend an in-person gathering. Anyone who currently has COVID or symptoms of COVID, anyone awaiting COVID test results, and anyone who has or may have been recently exposed to someone with COVID should not attend an in-person gathering [23]. People who are considered at risk for severe complications from COVID should strongly consider not gathering in person [24].

Risks/Mitigations Scenarios

The following examples of holiday scenarios outline the risk associated with each type of gathering as well as suggestions for making the gathering safer, given the underlying risk factors.

Scenario: Gathering virtually

This is the safest way to celebrate the holidays during the COVID-19 pandemic. There is no risk of contracting or spreading COVID since you are not gathering with anyone in-person and you are not traveling. Even if someone is sick or has to quarantine, they can still participate in a virtual gathering. Consider this type of gathering for anyone who is at risk of severe complications of COVID-19 and cannot gather in person.   

Suggestions

• Using video chat to gather virtually for a meal [Zoom- Free Promo]
• Holding a virtual gift swap as a family/group
• Sharing family recipes and cooking together over video
• Creating slideshows or online photo albums to share with family/friends

Scenario: Gathering with your household members in your home

In this type of gathering you will be celebrating with the people you already live with. The risk of this type of gathering should be comparable to the daily risk of exposure from living with the same people and will depend on the daily preventive COVID behaviors of your household members when they are out in public or away from home. If one member of your household has COVID, it is likely that others could become sick from exposure to respiratory droplets or aerosols and contact with contaminated surfaces.

Suggestions

• Gathering of household members only- no guests from outside the home are present
• Ensure that members of the household already follow COVID protocols outside of the home (masks, social distancing, hand hygeine, etc.)
• Keep common areas inside the home clean and regularly disinfect surfaces and high touch objects (door handles, light switches, cooking and dining areas, etc.)
• Prepare food at home and do not share eating or drinking utensils
• Any household member who has symptoms of COVID-19, or may have been exposed to an infectious person should not gather with other household members and should quarantine in their own room or designated sick room [HOME CARE FOR COVID-19]
• Consider joining other households for a holiday meal over video or phone chat

Scenario: Gathering with members from outside your household with masks and social distancing

There is a plausible risk of spreading COVID-19 to multiple people at this type of gathering. The risk of infection increases with the amount of time spent at this type of event, especially if indoors with inadequate ventilation. Activities that generate aerosols and respiratory droplets like loud talking, laughing, and singing further increase this risk. There is more risk of contacting potentially contaminated shared surfaces, and risks associated with food serving and eating. Additionally, you cannot be entirely certain of other guests’ COVID-19 precautions in their daily lives. If one person at this type of gathering has COVID-19 it is likely that many other attendees will become infected.

Suggestions

• All attendees should wear masks when not eating or drinking
• The gathering should be outdoors or in a very well-ventilated area such as a garage with the doors kept open. If the gathering must take place indoors, then ventilation should be addressed by means such as windows and doors being kept open to allow for adequate airflow, or using air purifiers to filter the air
• Remind guests to refrain from physical greetings like handshakes or hugs
• Guests from different households should be seated a minimum of 6 feet away from one another and maintain social distance at all times
• Food should be served by only one person- avoid sharing or passing serving utensils or plates and do not allow guests to crowd at food and beverage service areas
• Hand sanitizer or handwashing stations should be available for all attendees and bathrooms should be kept open and ventilated when not in use
• Keep music low enough so people refrain from shouting in order to participate in conversations
• Avoid singing, which projects respiratory droplets and aerosols
• Gather the names and phone numbers of all guests in the event that contact tracing becomes necessary if one or more guests get COVID

Scenario: Gathering indoors with other members outside of your household while following minimum to no COVID protocols

This type of gathering is significantly risky and discouraged across many county and state recommendations (in the US). This type of gathering may not allow for social distancing and attendees may not be wearing masks. There is a major risk of spreading or contracting COVID via personal interactions like non-socially distanced talking, laughing, singing, hugs, and handshakes. Potentially contaminated surfaces and crowded dining areas increase this risk. If one person has COVID, it is likely that most attendees will be exposed and possibly infected. The more people infected at an event, the more at risk the community will be and the communities where the guests are from.

Suggestions

• Strongly consider revising your plans to incorporate strategies which are less risky (see previous risk scenarios)
• Attendees get tested and get test results back before gathering and have maintained quarantine while awaiting test results
• Attendees have quarantined for 14 days before and will quarantine 14 days after gathering
• Collect names and phone numbers for all attendees for contact tracing

Conclusion

Testing and quarantining are not fool-proof strategies for gathering safely. The RT-PCR test is more sensitive at detecting an active COVID-19 infection, though results may take longer. The accuracy of rapid-testing has received scrutiny and the test can generate false negative [25]. A person may be infected with COVID-19 but still have a negative test if they are very early in the course of the illness. They may not have symptoms yet, but they can still infect others. Even if a person has quarantined for 14 days leading up to the event, there is still a risk of contracting the virus during travel and transmitting it to other attendees [26]. 

Gathering virtually is the safest way to celebrate this holiday season. By not gathering in person, you will keep yourself, your family and friends, and your communities safer as the world continues to fight the COVID-19 pandemic.