COVER STORY
ZOOMING HOME: Host a virtual holiday meal with friends and family who don't live with you. Schedule a time to share a meal together virtually, and have people share recipes and show the dishes that they prepared.
SEASON'S GREETINGS FROM THE PANDEMIC
'TIS THE SEASON TO SOCIAL DISTANCE AND DON A MASK!
BY ELIZABETH J. LUCAS, MD, CARA COLEMAN AND MALLORY CYR
As families approach the holidays, many are looking to adopt old traditions or create new ones to cultivate the joy associated with the holiday season while maintaining a reasonable degree of safety. Here, we hope to present some strategies that can help everyone stay safe.
As we near the most wonderful time of the year, families with adults and children with complex medical conditions are thinking about how to enjoy the holidays amid the worldwide severe acute respiratory syndrome coronavirus2 (COVID-19) pandemic. Individuals with complex medical conditions are considered high risk for severe disease with infection with COVID-19, so families have already witnessed dramatic shifts in their day-to-day lives.
For all of us, this holiday season will look different than previous years. At the time of writing this article, several European countries are resuming rigid lock downs, rolling back the opening of restaurants, bars, and other spaces where large groups of people can gather.1 The number of new cases in the US are similarly on the rise, with the last week of October reporting the highest rate of new cases of COVID-19 among children and adolescents.2 Over the past two weeks, Governors from several states have stepped up to implement and/or tighten a variety of restrictions on activities such as gatherings and wearing masks. We know from data collected here in the US that holidays observed during the summer led to peaks in new cases, driving more hospitalizations and unfortunately, COVID-19 related deaths (CDC).
Many health care providers are concerned that the upcoming winter holidays could lead to even higher numbers of cases as families engage in travel and participate in large gatherings.
As families approach the holidays, many are looking to adopt old traditions or create new ones to cultivate the joy associated with the holiday season while maintaining a reasonable degree of safety. Here, we hope to present some strategies that can help everyone stay safe. The CDC ( cdc.gov/coronavirus/2019-ncov/daily-life-coping/holidays/thanksgiving.html ) just released guidance as to how to approach Thanksgiving planning during the surge.
One theme that will consistently resurface throughout these recommendations is that this year will require more planning and attention than years past to reduce the risk of spread of COVID-19. Other strategies will be familiar, with an emphasis on maintaining social distance wherever possible, wearing personal protective gear, and practicing frequent hand hygiene. Families of children and adults with special healthcare needs and disabilities can always reach out to their health care providers to have honest discussions about the risk for their loved one, and to use shared decision making to develop creative, flexible and responsive accommodations to holiday traditions that minimize risk of COVID-19 transmission and balance the need for love, laughter and life!
Travel: Should we go over the hills and through the woods to grandmother's house in 2020?
The gold standard of protection from risk is to forgo travel altogether. Before making any travel plans, it is suggested that you review the guidelines and COVD-19 cases at your destination ( c dc.gov/coron- avirus/2019ncov/travelers/how-level-is-determined.html). Every state is in a different phase of shut down, that may further restrict you from gathering with people other than those in your household, or even traveling to that state.
If travel cannot be avoided by families, be sure everyone has their flu shots and plan for the most direct route. If driving, choose the shortest distance and plan your route carefully. Where possible, avoid stopping for food or gas along the way to minimize contact with other travelers. Packing meals along with plenty of hand-washing, sanitizing and cleaning supplies for the trip is one strategy to reduce potential exposures. If flying or taking another form of mass transit, look for flights with the fewest seats sold or flights at less desirable travel times. Airports and transportation centers tend to be less crowded during the early morning and later evening, allowing for more effective social distancing. When on the plane, remaining seated for the duration of the flight, wearing a cloth facial covering or a facial mask, and relying on food brought with you will reduce potential exposures.
If you plan to travel on any form of mass transit, wearing a cloth facial covering or a facial mask is essential for minimizing the risk of COVID-19 infection transmission. Despite the socio-political controversy around wearing masks, the scientific evidence is clear.3 Masks primarily reduce infections by capturing respiratory and aerosol droplets that disperse from breathing, talking, or coughing.4 COVID-19 virus particles hitchhike rides on droplets to spread successfully and it has been demonstrated that cloth facial coverings greatly reduce the number of droplets that can scatter. Masks do not reduce blood oxygen levels in people, including vulnerable populations, and allow for the normal exhalation of carbon dioxide.5
When all measures are strictly followed, travel is made safer and so far, the numbers of infections related to air travel have been small (CDC). Most important, if you or anyone in your family feels sick or starts showing any symptoms consistent with COVID-19, then the best way to help your extended family, community, city, state, and country is to cancel planned travel and stay home.
The Holidays are NOT cancelled… just adapted:
Outside of travel, families with adults and children with complex medical conditions likely look forward to holiday traditions that may need adjusting during the COVID-19 pandemic.
DURING YOUR TRIP : PROTECT YOURSELF & OTHERS FROM COVID-19
• Wear a mask to keep your nose and mouth covered when in public settings, including on public transportation and in transportation hubs such as airports and stations.
• Avoid close contact by staying at least 6 feet apart (about 2 arms' length) from anyone who is not from your household.
• Wash your hands often or use hand sanitizer (with at least 60% alcohol).
• Avoid contact with anyone who is sick.
• Avoid touching your eyes, nose, and mouth.
CDC Travel guidance: cdc.gov/coronavirus/2019-ncov/travelers/travel-during-covid19.html
COMING TOGETHER : PRECAUTIONS FOR HOSTING AND GATHERINGS
• Limit number of guests (10 or less) and have clear conversations with guests ahead of time as to expectations.
• Gather outside or in very well-ventilated areas and sit 6 feet apart.
• Bring your own food, drinks, plates, cups, utensils.
• Use single-use items, such as condiments or sauces, and disposable food containers.
• Limit people in food preparation area.
• Disinfect surfaces often.
CDC Holiday guidance: cdc.gov/coronavirus/2019-ncov/daily-life-coping/holidays.html
Some festive fun like touring neighborhood light displays in a private vehicle, holiday tree shopping, and holiday home decorating can be done without any changes. Depending on the climate in which you live, moving some activities outdoors can also help.
These risk assessments are not absolute and do not take into account differences in vulnerability between certain complex children and adults; so, families must still use their judgement about how much risk is acceptable. You can work with your child's healthcare provider, using the shared decision-making process to determine what the safest options are for your family to continue your favorite holiday traditions.
It has been a long year, and it is understandable, the strain that social distancing has had on the mental and emotional health of many people. It is difficult to think of not spending the holidays with loved ones. However, making these sacrifices for one year, may lead to the ability to have future holidays with those who may be more at risk.
For families looking to keep their risk for COVID-19 transmission as low as possible, but maximize their fun potential, now is the time to tap into one's creativity. Many families with adults and children with complex medical conditions are long-term innovators as they have found solutions to their unique child's needs.
As eventful as 2020 has been, we have learned a lot that can help us move forward and out of the pandemic. Uncertainty swirls all around us as if we are in the middle of a snow storm and the landscape seems to change daily. Hold on to your skills as families of children with health care needs; you know how to adjust, make accommodations, be flexible and nimble. Lean in to your experience balancing risk, health and living life this Holiday season. We wish all of our readers a joyous and safe holiday season! •
FLEX TIME : TIPS FOR ADAPTING HOLIDAY TRADITIONS
• Leave a surprise — flowers, homemade cookies, a nice note — on a neighbor's doorstep.
• Pick out and donate a toy for a holiday gift drive.
• Record a happy song or dance and send it to friends or family who need a pick-me-up.
• Cook a meal together, and video-chat a family member who can't be with you.
PBS: pbs.org/parents/thrive/adapting-holiday-traditions-during-coronavirus
TEAM EFFORT : GUIDELINES FOR SHARED DECISION MAKING
Shared Decision making to resolve difficult decisions in health care, education, child care, and community life, balancing risk reduction with other ongoing needs, specific to the needs of the child and caregivers (especially, but not limited to, families), respecting and valuing the concerns of multiple stakeholders (health care providers, educators, school nurses, and others) to achieve consensus for needed accommodations. Practical steps include:
• Develop shared goals and objectives.
• Identify personal and cultural preferences, priorities, and concerns of all parties actively involved.
• Collaboratively review risk-reduction strategies and creative, flexible, and responsive accommodations under consideration, specific to the needs and risks of the child and contacts.
• Determine which individual(s) are responsible for carrying out the actions required to achieve the shared goals.
• Acknowledge that evidence to inform these decisions during the pandemic is limited, evolving, and often subject to multiple interpretations.
• Continue to re-evaluate decisions as new data become available.
American Academy of Pediatrics: Caring for Children with Special Health Care Needs During the COVID-19 Pandemic:
ABOUT THE AUTHORS:
Elizabeth J Lucas, MD is a Complex Healthcare provider at Nationwide Children's Hospital in Columbus, Ohio. She has board certifications in Internal Medicine, General Pediatrics, and Pediatric Infectious Diseases. She plans to spend this holiday season eating holiday cookies, mostly, but is open to including holiday donuts in this diet. Cara Coleman is the mother of four (one of whom, Justice, had disabilities and medical complexity until she died in 2017) and Program Manager at Family Voices National. The Coleman family will spend their holidays in cozy pajamas, playing games inside and out, watching movies and eating way too much food! Mallory Cyr is the Project and Communications Coordinator for Family Voices National, a subject matter expert on healthcare transition for CYSHCN, and navigates life as an adult with medical complexities. Mallory will be spending the holidays with her husband and dog, using Zoom to share her favorite traditions with her family in New England!
References
1. Kupferschmidt, K., Europe is locking down a second time. But what is its long-term plan?, in Science. 2020: sciencemag.org.
2. American Academy of Pediatrics reports highest one week increase in child cases of Covid-19 since onset of pandemic, in Children and Covid-19: State-Level Data Report. 2020: aap.org.
3. Gandhi, M. and G.W. Rutherford, Facial Masking for Covid-19 - Potential for "Variolation" as We Await a Vaccine. N Engl J Med, 2020. 383(18): p. e101.
4. Chu, D.K., et al., Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet, 2020. 395(10242): p. 1973-1987.
5. Chan, N.C., K. Li, and J. Hirsh, Peripheral Oxygen Saturation in Older Persons Wearing Nonmedical Face Masks in Community Settings. JAMA, 2020.