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The Atlantic
The Atlantic
Lora Strum

A Guide to Mixed-Vaccination-Status Holidays

Getty; The Atlantic

This time last year, health officials were advising Americans to stay home for the holidays. The CDC cautioned against travel; Anthony Fauci announced that he would be spending Christmas apart from his children for the first time in 30 years. But that grim advice was accompanied by hope for a normal 2021 holiday season: Pfizer’s COVID-19 vaccine was authorized for emergency use in adults on December 11, 2020, with Moderna’s following close behind.

Now 61 percent of Americans are fully vaccinated, and more than 70 percent have received at least one dose of a vaccine. These numbers mean that millions of American families can feel a whole lot safer than they did last year about gathering for the holidays.

But U.S. vaccination rates still leave a lot of room for unprotected family members or friends at celebrations, unwrapping gifts or ringing in the new year together—including children under 5, who still aren’t eligible for any COVID-19 vaccine. While vaccinated people tend to live with other vaccinated people, and unvaccinated people with other unvaccinated people, “I think once you start adding in extended families … mixed vaccination status would become pretty common,” Jennifer Beam Dowd, a demography and population-health professor at the University of Oxford, told us.

[Read: America is getting unvaccinated people all wrong]

Those families will have to face the tough question of how normal their gathering can really be if some attendees are not vaccinated. We spoke with Dowd and several other experts about how to weigh the risks of getting together with unvaccinated loved ones and make the holidays as safe as possible.

The safest holiday table this year will be the one where everyone present is fully vaccinated and, if eligible, boosted. If that’s the case, and no one at your gathering is at high risk of severe illness from COVID-19, everyone can remove their mask and celebrate with cautious optimism, Rachael Piltch-Loeb, a researcher at the Harvard T. H. Chan School of Public Health, told us via email.

Anyone at this hypothetical party still has a chance of contracting a breakthrough infection. How big that chance is will depend in part on whether the Omicron variant is circulating in your area. The variant has been shown to be more transmissible than Delta, and the risk of getting a breakthrough infection is higher. The good news is, booster shots seem to help stave off Omicron infections. COVID-19 cases among the vaccinated have been overwhelmingly mild, but we don’t yet know whether that will be true in the long run for Omicron, and the logistical headache of a positive test is still worth considering before you sit down for an unmasked, indoor meal.

[Read: Omicron’s explosive growth is a warning sign]

For many Americans, being in a room with unvaccinated loved ones while case numbers are high and a new variant looms constitutes unacceptable risk. “​​I personally am not comfortable gathering with unvaccinated adults,” Joshua Barocas, an infectious-disease researcher at the University of Colorado School of Medicine, told us. But if you’ve thought about the risk that such a gathering poses to yourself and others, and decided that you’re willing to go anyway, know that not all mixed-vaccination-status gatherings are created equal.

To help you better understand the risks associated with various scenarios, we’ve broken down the chances of transmission at a gathering with one unvaccinated adult, multiple unvaccinated adults, and unvaccinated or semi-vaccinated kids, who add another layer of complexity to already tricky situations.

If your gathering includes only one unvaccinated adult—say, Cousin Paula—she is roughly three times more likely to become infected than anyone else. Paula’s exact risk of infection depends on how widely the coronavirus is circulating in her community, the possibility that the vaccinated people present could be experiencing breakthrough infections, whether everyone wears a mask indoors, and what the ventilation situation is like, Barocas said. And if she does catch the virus, Paula’s risk of hospitalization is roughly twice as high, and her risk of death seven times as high, as if she were vaccinated.

According to Piltch-Loeb, exactly how much of a threat Cousin Paula poses to her vaccinated friends and family depends on a few factors: her behavior prior to attending the event, the precautions that the entire group takes, and where she’s coming from. (The CDC still recommends that unvaccinated Americans not travel until they are fully vaccinated.) If Paula has tested negative before the gathering and lives in a community with relatively low transmission, the other attendees won’t be as significant, Piltch-Loeb said. But keep in mind that the CDC currently classifies transmission as substantial or high in more than 90 percent of U.S. counties.

[Read: We’re not at endemicity yet]

If Paula isn’t the only unvaccinated adult coming over for Christmas, the riskiness of your gathering will be higher, and more complicated to assess. Dowd said the chance of COVID exposure is additive: If about one in 100 people in your community is testing positive each day, then one unvaccinated guest would mean a 1 percent risk of exposure, two unvaccinated guests would mean a 2 percent risk, and so on. In other words, when caseloads are high, each unvaccinated person at a gathering raises everyone’s risk by a greater factor than when caseloads are low.

Children add yet another layer of complexity. Kids 12 and older have been eligible for vaccination since May, but the 5-to-11 group was given the green light only at the end of October. Only those who got their first shot within the first two weeks of eligibility stand a chance of being fully vaccinated by Christmas Eve. Meanwhile, the nation’s 23 million or so under-5-year-olds still don’t have access to vaccination. And no one under 16 is eligible for a booster shot. That means plenty of American children going through the holidays without the full protection of vaccination.

Kids are not likely to become severely ill or die if they do get infected with the coronavirus, but more than 600 children have died of COVID-19 in the United States so far, and this summer’s Delta wave led to huge numbers of kids being hospitalized. Even in the best-case scenario, testing positive can wreak havoc on a household. “There are life events that go with quarantining: missed school, missed work. It's a tough choice for parents,” says Larry Corey, a virologist at Seattle’s Fred Hutchinson Cancer Research Center.

[Read: COVID parenting is reaching a breaking point]

To protect unvaccinated ​​and half-vaccinated kids during the holidays, Barocas recommends keeping them away from unvaccinated adults, especially in areas with high transmission. The safest gathering for kids, he said, is one where all adults present are vaccinated. We don’t yet know for sure how Omicron changes the risk landscape for children. The number of young patients testing positive for the coronavirus in South African hospitals has increased over the past few weeks, but doctors there told The New York Times last week that they have not seen a spike in kids being hospitalized for COVID and that few children have required oxygen.

Even if they’re relatively safe in a room full of vaccinated grown-ups, unvaccinated kids might pose some danger to those around them: Studies have shown that children can infect others in their household, as well as in schools and other group settings. For this reason, Dowd recommends limiting the amount of time that unvaccinated kids spend in close proximity to their more vulnerable loved ones, such as their grandparents.

[Read: Why are we microdosing vaccines for kids?]

Vaccination remains the best way to protect yourself and the people around you from the coronavirus, but it’s not the only way. If you decide to attend a holiday gathering of people with mixed vaccination statuses, Barocas recommends that everyone, even if they’re vaccinated, gets a rapid test the day they plan to get together. Cousin Paula should take a (slower, more reliable) PCR test too, Corey adds. If you can’t find enough rapid tests to cover everyone, Dowd recommends prioritizing unvaccinated folks, then people who work in high-risk industries, such as health care and food services, and anyone with a known recent exposure.

As our colleague Katherine J. Wu has reported, rapid tests are most likely to catch you when you are infectious—they aren’t very good at ruling out infection in an asymptomatic person. It’s a tricky distinction, Barocas said: “A negative test says that you could still be infected but, as best we can tell, you’re unlikely at that particular moment to transmit the virus to another person—you’re not so infectious.” A positive rapid test, whether you’re vaccinated or unvaccinated, symptomatic or asymptomatic, indicates that you’re most likely infected and infectious. If you do test positive on a rapid test, Barocas said, you should get a PCR test to confirm, skip any gatherings, and self-isolate.

[Read: The wrong way to test yourself for the coronavirus]

In addition to testing, Dowd recommends being extra careful about possible exposure in the week prior to the holidays by avoiding large gatherings and crowded indoor spaces and wearing a mask if you can’t avoid them. The more layers of risk involved in your holiday plans—in the form of unvaccinated attendees or possible prior exposure—the more layers of protection you should add. Though they might not make for the carefree holiday of your dreams, additional safety measures such as opening windows and doors for ventilation, dining outside if the weather permits, and masking while you’re not eating can reduce, though not erase, the risk of mixed-vaccination gatherings.

Of course, all of this advice is useful only if you know whether your friends and family are fully vaccinated. Tara Kirk Sell, a senior scholar at the Johns Hopkins Center for Health Security, told us that before you initiate that conversation with a loved one, you should know what level of risk you’re willing to accept. “It’s good to figure out first what your ground rules are before you start trying to find information,” she said. Then explain why you’re so interested in knowing their vaccination status: Maybe you have an unvaccinated child at home; maybe you’re concerned about your life being disrupted by a breakthrough infection.

[Read: Getting back to normal is only possible until you test positive]

Lizzie Post, a co-president of the Emily Post Institute and a co-host of the Awesome Etiquette podcast, suggests another option if asking for someone’s vaccination status directly could cause conflict. You can let your loved one know your COVID safety measures—such as requiring everyone opening presents on Christmas morning to be vaccinated—and ask whether they’re able to accommodate that. If they say they can’t, Post says, you can offer an alternative, such as joining via Zoom, wearing a mask, or gathering outside.

If the conversation gets heated, Amanda Craig, a licensed marriage and family therapist practicing in New York City and Connecticut, recommends letting your family member or friend know that you appreciate where they’re coming from, but you won’t back down on your own safety. The ability to express ourselves, especially to our loved ones, is crucial for our health too, Craig told us. Family are the people who are supposed to care about us. “If we can’t be honest with them,” she said, “that’s a whole different problem.”

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