The holiday season is upon us. Cold and flu season is in full swing. Covid isn’t gone. It’s a lot.

I love Thanksgiving, and so it pains me to say that it has long been known that Thanksgiving is, well, kind of a killer. I know that’s awful, but it’s true! Here’s what we can expect:

•More respiratory viruses (respiratory viruses prefer cold conditions).

•An expected uptick in deaths from a surprising array of causes as we get deeper into the fall.

•Higher motor vehicle fatalities on Thanksgiving Day (dangerous driving conditions, both natural and, especially, manmade).

Indeed, in terms of when we are collectively the sickest and face the highest mortality rates, winter is coming.

And, of course, there’s Covid. This Thanksgiving will be our 3rd with Covid. In 2020, Covid was still working its way through the country, so the holiday data are hard to interpret. But in 2021, something important seems to have happened:

Case hospitalization rates, cases, hospitalizations in people ages 80+ — Image by Benjy Renton for *Inside Medicine.*

The week after Thanksgiving, the percent of new Covid-19 cases requiring hospitalization went up rather suddenly, especially among older people, from the high-30%-low 40% range before Turkey Day, to north of 50% the week after. Now, it’s possible that this was an artifact of reduced testing among healthy people during the holidays (i.e. the number of hospitalizations didn’t go up, but the testing among healthy people went down). But that seems unlikely, looking only at people ages 80 and older. The weekly case rate and new hospitalizations in that age group also increased somewhat a week or two after Thanksgiving of 2021.

This says to me that the average 80-year-old who contracted Covid during Thanksgiving was less healthy than the typical 80-year-old getting infected during normal days. That makes sense. People on the vulnerable end of the spectrum tend to be more isolated normally. So, Thanksgiving is a time when those at the most risk take the most risk, either by welcoming visitors or traveling to see family. Last year, a week after Thanksgiving, we saw what looks to be the downstream results of that.

However, Thanksgiving is but a prelude. The data for Christmas look worse. Again this makes sense, with longer visits and even colder weather. Last year, the percent of new Covid cases requiring hospitalization went up right after Christmas, and that was despite the emergence of Omicron, which infected droves of young people, driving down the overall rate of hospitalization on a per-case basis (even as overall new hospitalizations rose). In fact, you can see that after the post-Christmas bump in the percent of cases requiring hospitalization among people ages 80 and up (peaking at above 55% the week after Christmas), that figure dropped to the 20%-30% range by mid-January, where it stay through the late winter, spring, summer, and even the early fall of 2022.

Now, these observations are just that—observations. To get a fuller understanding of these effects, epidemiologists and disease modelers will have to apply complicated techniques (like “difference in difference,” which measures the changes in the context of existing trends).

Where does this leave us?

Here’s what you should do—what I will be doing—if you’re potentially visiting anyone for whom Covid (or any serious respiratory illness) could be devastating.

•Bring rapid tests. If you’re positive for Covid, isolate (i.e., stay home). Test yourself prior to your first interaction with someone you’re worried about spreading any virus to, and again a day or two later. (If you have the tests, use them daily until you’re 5 or 6 days from your last substantial exposure.)

•If you have a cold (like I currently do, after a nearly 3-year run without so much as the mildest of viral illnesses), wear a good mask. My seasonal rhinovirus or adenovirus could land a vulnerable person in the intensive care unit.

•Air the place out, especially in tight spaces. If you’re driving for an hour with a person who can’t afford to get Covid, RSV, or any other serious virus, keep the air moving. You’d be surprised how simply opening the window occasionally for a couple of minutes (even just part way), can make a tremendous impact on ventilation and air quality. I recently checked the carbon dioxide levels in my car (using a portable monitor) before and after opening the window for just a couple of minutes. The difference was as immediate as it was remarkable. While we tend to think of Covid exposure as all-or-none, the reality is that even people who live together don’t always catch Covid from each other. An hour of exposure does not necessarily spell an infection. So “harm reduction” like leaving the car (or living room) windows open even for a little while can make a marked difference.

•Don’t get infected en route. Wear a mask and bring hand sanitizer. (We seem to have forgotten how many viruses actually do spread the way we initially thought Covid spread—via droplets on surfaces). Last year, a friend of mine described a family gathering in which everyone tested before driving or flying to a family reunion. The eventual outbreak that happened a few days later at the reunion would have been averted if people had tested both upon arrival and 2-3 days after travel (where exposure risks can be high).

•Do not drink and drive. Ever.

•Find more good advice here, including information on the contagious periods for flu, RSV, and Covid.

Inside Medicine

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