Dear Members of the Baylor College of Medicine Community,

This week, we seem to be stranded in COVID-19 purgatory. In the Houston region, new community cases are slowly inching up, as are new hospitalizations. The trend is concerning enough that most TMC hospitals are dusting off their surge plans in the event our health system is once again stressed. We still do not know if we are in the early phase of another exponential growth cycle, or at a precarious equilibrium. Based on recent stressors in our community, I fear it is the former. Public schools reopened for face-to-face instruction this week in Houston and other areas, the shorter days are driving people indoors and many are experiencing mask fatigue. In addition, much of Europe is experiencing a surge rivaling the first one, and reinstituting lock-downs. Much of the US, particularly in cooler regions, is also surging. I think we must assume we are in the early phase of another regional battle with SARS-CoV-2.

I know this is demoralizing for many, especially as we approach the holiday season. Many have given up so much already. Our lives have been disrupted by the pandemic in ways large and small. Should we sacrifice time with family and close friends over the holidays as well?

For a little ray of hope, I look to the recent NBA season. The NBA created a “bubble” in Orlando, played all their games, and completed their post-season. Lots of comingling of people, plenty of close, mask-less physical contact. How many infections since the NBA resumed regular season play in August? Zero. None of us have the resources of the NBA, and we cannot replicate their bubble (they tested everyone daily and took over entire luxury hotels). However, I believe it is possible to create your own “holiday bubble” and have a relatively safe and responsible time with family. Following the lesson of the NBA, forming an effective bubble requires planning, commitment and attention to detail.

Before we dive into the details, I need to start with a couple of significant disclaimers.

First, you need to honestly assess your own risk tolerance. The only way to remain completely safe is to remain maximally isolated. If you are elderly, immunosuppressed or have a serious underlying medical condition, you need to weigh the risks of holiday celebrations against the potential benefits. Creating a holiday bubble will help to minimize those risks, but cannot eliminate them.

Second, creating a holiday bubble is possible, but it will not occur without real commitment of all participants. One weak link will breach your bubble. Half-hearted commitments will only lead to a dangerous false sense of security. If everyone is not committed, you are probably better off celebrating exclusively with members of your usual household, and not mixing with family and friends from down the street, or across the country.

With those disclaimers in mind, here is my suggested process to create your own holiday bubble. It has specific tasks that must be performed on schedule. Count backward from the day your family plans on entering your holiday bubble to establish your timeline.

Today

• Get your flu shot. This will decrease the likelihood of developing a flu-related illness around holiday time, which could disrupt your plans.
• Have a serious family conversation. Do we want to commit? Are we willing to create and maintain a safe environment? DO NOT SKIP THIS STEP. Obtaining real commitment to form your bubble is the single most important part of this process:
  • Who is at high medical risk in our family? What is our risk tolerance for exposing them in a family get-together? If your risk tolerance is low, even a bubble may be too risky for you.
  • Are we committed to doing the substantial work necessary to create a “holiday family bubble?”
  • There is variability in how seriously people are taking precautions. Beginning two weeks before you come together, is everyone willing to rigorously adopt good viral control practices? (mask, physically distance, avoid crowds). Your bubble will only maintain its integrity if everyone is fully committed. If you have a family member that cannot commit, they cannot be safely invited to your holiday bubble.
  • Have everyone print the Holiday Bubble Checklist. Or, view a Spanish version.
  • Assign a Family Bubble Commissioner, a single individual who will take responsibility for reminding bubble participants of key milestones and encouraging compliance.
  • Sign a family pledge. I know this may seem a bit overboard to some, but obtaining commitment is critical.
• Agree on a location. One of the best options is a private home where everyone will come and stay. It would be ideal if the location included some outdoor space, weather permitting. Keep in mind, this will be your bubble. Once everyone arrives, you are there to stay. No excursions, no visitors. Once in the bubble, you stay in the bubble.
• If flying, order face shields or goggles to protect your eyes, which are a potential portal of entry for the virus. Consider trying to obtain N95 facemasks. Cloth masks used in combination with eye protection afford an acceptable level of safety, equivalent to the protective equipment used by health care workers during routine hospital care. An N95 combined with a face shield or goggles would provide maximal protection, and is equivalent to the equipment used by health care workers when dealing directly with known or suspected COVID-19 patients. Regarding eye protection, either a plastic face shield or eye goggles are effective. Goggles must fit snugly. Air purification in many planes is excellent, but varies based on the airline and model of aircraft.
• If flying, take a direct flight if possible.
• Check any travel restrictions for the state that you will be visiting. Note many states have restrictions and quarantine requirements. Some international destinations have testing requirements. Remember to check the regulations for the state to which you are returning after the holiday as well.

Two weeks (14 days) prior to holiday:

• Everyone planning to enter the holiday bubble must make extra effort to limit contact with other individuals to reduce risk of exposure.
  • If your job duties permit, work from home. Self-quarantine. Important: Quarantine is more than being cautious. It means staying home and avoiding all contact with anyone outside your regular household, even if masked.
  • If self-quarantine is not possible, maintain scrupulous attention to distancing and cloth masking along with hand washing/sanitizing.
  • Add a plastic face-shield or goggles to your cloth mask when you are indoors and in contact with others. Note, the face shield is in addition to, not in the place of a cloth mask.
• Daily symptom and temperature monitoring. If you become symptomatic or have any fever (even low-grade), seek evaluation by a physician and tested with a PCR test (for this purpose, avoid rapid tests). If your test is positive, cancel your participation in the bubble, along with all others who live in your household.
• Decide who will be cooking during the holiday. Stock up on non-perishable food items in advance.

5-7 days prior to holiday:

• Get a diagnostic test (PCR, not a rapid test). If positive, cancel your participation in the bubble, along with all others who live in your household.
• Stock up on hand sanitizer and disinfectant wipes for travel.
• Complete your food shopping. If you plan to drive, buy travel food in advance. Purchase perishable items for your holiday meal(s). Remember, you are quarantined. Use a grocery service with touchless delivery to maintain your quarantine status.
• Recheck travel restrictions.

Traveling to the bubble:

• Drive if possible.
  • Make the trip in a single day if you can do so safely.
  • Bring your own travel snacks
  • Limit time in — or avoid altogether — crowded roadside fast food restaurants, truck stops, etc. Mask and distance when out of the car. Consider adding a plastic face shield in addition to a cloth mask.
• If you must fly:
  • Wear a cloth mask (or N95 for maximal protection) and a face shield or goggles. Remember, eye protection is in addition to your mask.
  • While on the plane, leave your mask and face shield/goggles on as much as possible. Ideally, they should stay in place for the entire flight.
  • Skip the snacks and drinks.
  • Use the restroom prior to boarding.
  • Limit fluid intake for 30 minutes prior to departure, and during relatively short flights (two hours and less).
  • Avoid use of the airplane lavatory. If you must use the lavatory, keep your mask on, and wash your hands thoroughly.

During the holiday

• If you are confident everyone has followed the above guidance, you are relatively safe in your bubble. Continue to use common sense. Play games, eat, sing songs, throw the football. Enjoy fellowship with (bubble compliant) friends and family. After all your hard work, planning and preparation, you can relax and enjoy the holiday.
• For high-risk family members (elderly, immunosuppressed) it is probably prudent to continue to follow good masking, hand hygiene and distancing practices.

This is not easy, but what in this pandemic has been easy? Decide who is in your holiday bubble, and start the conversation today. If people are committed, begin the process as outlined above. Do not skip steps.

Let us try and spread this message. If most of us create a bubble, we can minimize the risk that the holidays will become a super-spreader event, and we can keep our loved ones safe.

Take the pledge. If you are on Twitter, post when you have committed to creating your bubble using #HolidayBubbleBCM. Encourage others to do the same. Finally, please share this widely using the following link: https://bit.ly/31tBKNs.

I wish you all safe holiday season, and one filled with companionship and love.

James T McDeavitt, M.D.
Senior Vice President and Dean of Clinical Affairs

Here’s the Bubble List:https://www.bcm.edu/pdf/covid-19/Baylor-Holiday-Bubble-Checklist.pdf