Welcoming family into your home for Thanksgiving? Here's how to keep COVID out

The holidays are upon us. Here's your toolkit for how to keep COVID out of your festivities and keep your most vulnerable family members safe this year. — Chanelle Nibbelink for NPR

Here's one thing to be thankful for this year: It's not Thanksgiving 2020. A year ago vaccines had not yet been approved, daily deaths were rising sharply — surging to more than 2,000 a day by December — and many Americans hunkered down and skipped holiday celebrations to reduce their risks.

This year, 80 percent of people 12 and up are now vaccinated with at least one shot, and about half of Americans are planning to gather in groups of 10 or more for the holidays, a recent survey shows.

While many of us are ready to reboot our holiday traditions, COVID cases are once again rapidly climbing — with nearly 95,000 new cases a day. Experts warn we still need to keep COVID risk-reduction in mind. Even if your family is fully vaccinated, remember your most vulnerable family members, particularly people over 80 or the immunocompromised, are still at higher risk of severe COVID.

Nearly two years into this pandemic, we've learned a lot about how to reduce the risks of catching and spreading this virus, including the simple steps of masking and hand-washing. Let's not forget now.

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Here are some reminders for how to keep your family gatherings safe.

If you're gathering with grandparents or other elders, realize: They're still at risk

Reality check: People over 80 have an elevated risk of dying from COVID, even if they're vaccinated

While the vaccines offer strong protection against hospitalization and death, breakthrough infections are a reality. Often, a coronavirus infection following vaccination leads to only mild illness, and sometimes people test positive but show no symptoms at all. However, older people and those with compromised immune systems are at higher risk of getting a severe breakthrough COVID case.

Though it's rare for breakthroughs to lead to hospitalization or death, the chances for one group are higher. As NPR reported, CDC data from August showed that fully vaccinated people aged 80 or older were about 13 times more likely to die from COVID, compared to the general vaccinated population (of all ages). That's one reason getting boosters is especially important for older adults.

"This is something that we must be conscious of as people are gathering across generations," says physician and public health epidemiologist William Miller of The Ohio State University. "Grandpa and Grandma are protected relative to if they hadn't been vaccinated, but they are still at risk," he says.

That's why it makes sense to take precautions during travel and in the week leading up to any celebration where older friends and relatives will be present.

"I would absolutely encourage people to continue to wear masks," in crowded, indoor places such as grocery stores, Miller says, even if it's not mandatory. This will reduce the risk of being exposed and passing on the virus. And remember, the TSA's face mask requirement remains in effect through Jan. 18, 2022, requiring masking in airports, aboard commercial airline flights, and on commuter bus and rail systems.

So, bottom line, even if everyone invited to your holiday gathering is vaccinated, it's still important to protect loved ones who are older or immune-compromised.

Get a booster shot if you're eligible

Federal health agencies now recommend COVID vaccine boosters for all adults, six months after their last shot — and they may be especially important for adults over 50 or any adult with underlying conditions or a high-risk job. Getting one before holiday travel and gatherings could increase your immunity against COVID.

The agencies' decision was based on emerging evidence that immunity can diminish over time and evidence that shows a booster dose can, just as the name implies, boost protection.

Some of the most recent real-world data come from the U.K. Back in September, the U.K. government introduced a booster program targeting people 50 and older.

White House medical adviser Dr. Anthony Fauci said the new analysis points to a significant increase in protection (against symptomatic infection) from a booster dose. "If you look at the third dose in people whose protection has drifted down to about 63 percent, you boost it back up to at least 94 percent, which is really quite impressive," he says. "That's exactly the kind of thing you want boosters to do."

Fauci says immunity begins to rebound within days after getting a booster shot, though you don't get the peak of protection for two to four weeks. He says before joining indoor holiday gatherings, especially in places with high viral transmission, "I would recommend if you are eligible for a boost, go get boosted right now."

Rapid tests can protect your guests. Here's how to time taking them

As a risk-reduction measure, you might want to ask your guests to take a COVID test before a large holiday get together. A year ago, it was hard to get real-time information from COVID testing due to delays in test results and a lack of rapid test options. Now, there are plenty of over-the-counter rapid antigen tests, such as the Abbott BinaxNOW or Orasure InteliSwab, available online and in pharmacies.

"A rapid antigen test is an added layer of protection for everyone," says Judy Guzman-Cottrill, a pediatric infectious disease expert at Oregon Health and Sciences University.

"The antigen tests are a quick snapshot to see if the viral proteins are present in that person's nose that day," explains Guzman-Cottrill. So, if a person was just exposed and the virus is still incubating, they could get a negative result one day followed by a positive result the next day.

The tests are not 100 percent reliable if someone has just been exposed, explains Emily Landon, an infectious disease physician at the University of Chicago. "The test really doesn't pick up really low levels of the virus in your nose, and so it's not going to pick up a really early infection," she says. So she recommends taking the test the morning of the gathering, or as close to the start of the gathering as possible.

Some families test before they travel, and then again when they get to their destination, depending on the level of risk of people they're staying with. (Note: depending on which test you buy, instructions vary. For instance BinaxNOW instructs that people should be tested twice over three days with at least 24 hours between tests for most accurate results.)

William Miller is on board with a test-to-be-safe strategy, too. "It's kind of a mindset," Miller says. It's a way to signal: Let's make the visit as safe as it can be.

Think carefully about how to include unvaccinated family members

Deciding who to invite to your home is a matter of personal discretion, but experts say at this point in the pandemic, it's pretty clear that a fully vaccinated group is the safest scenario.

"I think it's reasonable for people to require their guests to be immunized," says Guzman-Cottrill, especially if guests include kids too young to be vaccinated (or who have only received their first shot) or people less likely to have a strong immune response to the vaccine, like the immunocompromised. "Those are the people who we still really need to make sure we keep as safe as possible because this pandemic is not over," she adds.

A vaccine requirement could lead to some hurt feelings or conflict, but Miller suggests framing the decision as a way to protect elderly loved ones. "I really do think that it's perfectly acceptable to say, 'I'm sorry you're not vaccinated. You know, Grandma's here, and by you coming, that increases her risk substantially,' " he says.

An alternative option is to ask an unvaccinated guest to do a lab-based PCR test 24 to 48 hours before the event (as long as they're able to get the results back in time) or a rapid antigen test COVID test just before their arrival. In addition, Landon recommends asking unvaccinated guests to take extra precautions in the week leading up to the event, including wearing masks in public places and limiting exposure to other unvaccinated people.

"We think with the delta variant, most people are getting sick a few days after exposure, but it can take up to a week, maybe a little longer," explains Landon. "I think it makes the most sense to take precautions for one week prior to having close, unmasked contact with someone who's at high risk," she says.

Take precautions if your young child is unvaccinated or has only had one shot

Many children ages 5 to 11 have received their first of two recommended doses, but won't be eligible for a second dose until after the Thanksgiving holiday. Immunity builds gradually after vaccination, but it's not known exactly how much protection just one dose of the COVID vaccine provides to kids, says Guzman-Cottrill.

"I know many families find themselves in this annoying state of limbo right now because their kids will not be fully vaccinated by Thanksgiving," she says. Given this "limbo" state, "it's really important to just keep in mind that this is not the time for those families to let their guard down," she says. It's not a reason to cancel multi-generational gatherings, but it's a reminder to take precautions.

So, which precautions are recommended? It kind of depends on the health and age of the relatives who will be attending. "If Grandma is a spry 70-year-old woman who has no medical problems and has two doses of vaccine plus a booster, I don't think these kids are going to pose a ton of risk," Landon says.

But if the grandparent is over 80 and has medical problems, the risk of a bad outcome is much higher.

An easy step to take if you're concerned about your unvaccinated kids passing the virus to grandparents is to mask up, not only during the visit, but also for a week in advance when in public, especially avoiding crowded, indoor spaces, even if mask mandates are not in effect.

She says she would not recommend keeping kids out of school to avoid exposure, unless there are extra risks associated with your kids' school — such as an outbreak of cases or a lack of masking. If the circumstances warrant missing school in order to protect a high-risk relative, "then that may be a layer you want to add," Landon says.

Another option: if you live in a temperate climate, stay outdoors as much as possible for mixed-generation social events, and maybe choose to not sleep over in the same house with the grandparents.

"Just come during the day for the big event and stay at a hotel," Landon suggests. Or have the grandparents sleep in a hotel, she adds.

Bottom line: "You have to think about the risk of the individuals involved — about what would happen if they got COVID," say Landon. And better to err on the side of caution.