Immunocompromised? A Guide for Staying Safe from COVID-19 During the 2021 Holiday Season

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With the holidays quickly approaching, there is a whirlwind of decisions to make about what you’re comfortable with. Will you visit with family and friends? If so, should you ask everyone if they’re vaccinated? And if you’re fully vaccinated, will you still take the same precautions you did last holiday season?

All of these scenarios are even more complicated if you’re immunocompromised and at high-risk for severe COVID-19.

In a recent poll of the Global Healthy Living Foundation’s COVID-19 Patient Support Program, only 11 percent of respondents — who are immunocompromised or high-risk — said they plan to spend the holidays like they did before the pandemic. Most plan to make some modifications to plans, such as having smaller gatherings or being only with others who are fully vaccinated.

Unlike last year, where many people spent the holidays only with members of their immediate household or alone, we are now in a phase of the pandemic that is centered around minimizing risk. If you’re immunocompromised, that means evaluating how safe and comfortable you will feel in a given situation, based on who else will be attending, everyone’s vaccination status, local rates of COVID-19, and more.

There are a number of steps you can take to stay safer from COVID-19 during the 2021 holiday season, some of which you’ll recognize from last holiday season. Of course, there’s one major difference between this year and last year: There are now very effective vaccines.

The Impact of Vaccines on Holiday Plans

Being fully vaccinated and around others who are fully vaccinated is the safest scenario for the holidays, but people who are immunocompromised should likely take some extra precautions too.

First, make sure to get a third dose or booster dose of the vaccine.

“This year, we are in a much better position because of the vaccine availability,” says gastroenterologist Inessa Khaykis, MD, of Vanguard Gastroenterology in New York City. “Last year, we were not in the best place before the holiday season. I encourage my patients to get the vaccine, take advantage of the third shot that is available, and obviously continue to use social distancing, masking, and other precautions in crowded places.”

If you’re immunocompromised, you may need an additional third dose of an mRNA vaccine for protection. For instance, the American College of Rheumatology recommends that those with inflammatory or autoimmune rheumatic conditions who are on immunosuppressive or immunomodulatory medication get a third dose of the Pfizer or Moderna vaccine at least 28 days after the completion of the vaccine series.

Booster shots are available for people at high risk for severe COVID-19 because of age, other chronic conditions, or occupation. These boosters are meant to increase immunity when antibody levels wane over time. The Pfizer and Moderna boosters are recommended six months after you’ve received the second dose.

And everyone — regardless of whether they are immunocompromised or high-risk — who received the Johnson & Johnson COVID-19 vaccine is eligible for a booster at least two months after the initial dose. (Read more on what you need to know about COVID-19 vaccine boosters for people at high risk.)

All of that said, the U.S. Centers for Disease Control and Prevention (CDC) notes that people who have a condition or are on medications that weaken their immune system may not be fully protected against COVID-19, even if they are fully vaccinated and have received an additional vaccine dose.

If this applies to you, the CDC recommends that you continue to follow its recommendations for unvaccinated people — including wearing a well-fitted mask during holiday celebrations — until otherwise advised by a doctor.

Data suggests that some immunocompromised people may have a reduced immune response to COVID-19 vaccination, including those receiving chemotherapy for cancer, people receiving stem cells or organ transplants, and those using immunosuppressive medications like rituximab.

The more protection you can get through immunization before the holiday season, the better. But whether or not you’ve received a third dose or booster shot of the vaccine, experts urge caution if you’re immunocompromised and gathering with others for the holidays.

“We’re not out of the woods yet, so I still think people should be cautious,” says clinical rheumatologist Magdalena Cadet, MD, Associate Attending Physician at NYU Langone Health in New York City. “We are on a decline, so we don’t want a spike to start at this point. I would probably still avoid large gatherings.”

Here are more top tips from experts for celebrating safely this year.

Carefully consider where you’ll be traveling

Rates of COVID-19 infection vary based on location. The CDC recommends that fully vaccinated people (even those who are not immunocompromised) wear a mask indoors in public if they are in an area of substantial or high transmission. You can determine community transmission by using this CDC tracker.

The CDC notes that fully vaccinated people might also choose to mask regardless of the level of transmission in their community, especially if someone they live with is immunocompromised or at increased risk for severe disease — or if they live with someone who’s unvaccinated.

As of press time, most of the United States is experiencing high or substantial community transmission, as noted in red and orange in the image below.

This goes to show that although the summer surge of COVID-19 cases has receded, we’re not yet through the pandemic.

“As much as we’d like to think the pandemic crisis is behind us, we can’t be completely lax about that,” says Dr. Khaykis. “At this point, pick your destination very carefully.”

Ask if unvaccinated people will be present

Experts agree that it’s a best practice to avoid spending long periods of time with unvaccinated folks if you’re immunocompromised, even if you’re fully vaccinated.

“If you know that everyone at the dinner table is going to be vaccinated, then it’s a little safer,” says Dr. Khaykis. “Talk to the host ahead of time to make sure that you’re not walking into an uncertain situation.”

You likely won’t be alone in asking. A recent Harris Poll of 2,055 American adults — including 1,454 vaccinated adults — found that 50 percent of vaccinated respondents were either “extremely” or “considerably” hesitant to spend the holidays with family members or friends who are unvaccinated.

In fact, 42 percent of vaccinated respondents said they had canceled at least one event or travel plan with people because those individuals were unvaccinated.

“If not everyone is vaccinated at the gathering and you’re immunocompromised, you might want to consider changing your plans to a more intimate environment where you can feel more secure,” says Dr. Khaykis.

And if you’re at a gathering where everyone who is eligible for a vaccine is immunized, but children under the age of 5 (who are not yet eligible) or children under the age of 12 (who may be partially but not fully vaccinated) are present, take steps to create some distance between yourself and the kids — as difficult as that may be.

“I would keep your mask on unless you’re eating, and try to maintain social distance with the children,” says Dr. Cadet.

In general, even if you’re fully vaccinated (and have a third dose or booster) as an immunocompromised individual, a key way to stay safe is by surrounding yourself with people who are also protected.

“One of the biggest benefits of immunizing against COVID-19 is this concept of herd immunity, the idea that we can create what in effect are human shields, protecting our most vulnerable community members,” says David Aronoff, MD, Director of the Division of Infectious Diseases at Vanderbilt University School of Medicine in Nashville, Tennessee. “For immunocompromised individuals, they can think of protection from infection in terms of layers of protection — one layer is doing the things they can do to protect themselves, including getting vaccinated and any additional doses or boosters that are recommended.”

An additional layer of protection is ensuring those around you are also vaccinated.

Consider requesting COVID-19 testing as a back-up plan

Although it’s not recommended, if it’s absolutely inevitable that you’ll come across unvaccinated individuals during your holiday celebrations, you may recommend COVID-19 testing for guests.

“Do all you can to get everyone who’s going to be gathering vaccinated before the gathering,” says Dr. Aronoff. “For those people who are either ineligible for vaccination or unable to complete vaccination, ask them to consider getting tested for COVID-19 prior to arrival.”

The closer testing takes place to the event, the better. You may even consider having rapid antigen tests available on site if somebody’s not feeling well or wasn’t able to get tested. These tests can determine if someone is contagious with COVID-19 within minutes. Many rapid antigen tests cost about $24 for a pack of two.

“The combination of immunization and access to testing are important one-two punches to improving safety around the holidays,” says Dr. Aronoff.

Continue wearing a mask indoors

In its holiday guidance, the CDC advises that fully vaccinated immunocompromised individuals continue to take all precautions that unvaccinated people should, including wearing a well-fitted mask in indoor public places or in crowded outdoor settings in areas with high numbers of COVID-19 cases.

“I still think that mask wearing is really important indoors, especially with people who are outside of your bubble or not vaccinated,” says Dr. Cadet.

Even if you’re in one of the few areas of the country with low community transmission, wearing a mask can help protect you.

“If you don’t know the vaccination status of the other people gathering, masks should be worn indoors,” says Dr. Cadet.

Evidence shows that wearing a mask can also lower your risk of catching other infections like the flu. It may feel disheartening to think about spending another holiday masked up, but keep in mind that the more people who get vaccinated against COVID-19, the less necessary these measures will be in the future.

“Hopefully, we’ll see a time in the future where disease activity is controlled or low enough and people are vaccinated enough that some of these non-pharmaceutical interventions, like social distancing or wearing masks, can become truly optional,” says Dr. Aronoff.

Consider the number of households you gather with

Think of each household that you’re meeting with as a bubble. The more bubbles you socialize with, the higher your risk becomes.

“Having more households together versus one household together is a little more risky for disease transmission to occur, if the number of people at said gathering is the same,” says Dr. Aronoff. “So there’s probably an incremental increase in risk with, say, two people each from five different households versus ten people from one household.”

The most important thing, however, is to make sure any number of people gathering are vaccinated if eligible (or that they provide a negative COVID-19 test).

And of course, anyone who has respiratory symptoms or fever should not be participating in family gatherings — regardless of what’s causing the symptoms.

“It’s not good to come to a family gathering when you’re sick, but particularly not during a pandemic,” says Dr. Aronoff. “I would certainly encourage anybody who’s feeling under the weather to get tested not only for COVID-19, but also increasingly thinking about other infections like influenza.”

Ensure your space has good ventilation

Even in the age of COVID-19 vaccines, being outdoors is safer than being indoors — and you should avoid crowded, poorly ventilated spaces, per the CDC.

“If the weather is great, then the outdoor gatherings can proceed,” says Dr. Cadet. “That would be the best scenario. Otherwise, open the windows and make sure there is ventilation.”

When it’s too cold or otherwise impossible to gather outdoors, your next best bet is to have small family gatherings (read: not large events) indoors under safe conditions.

“For average family get-togethers, as long as people are fully vaccinated or recently tested as negative for COVID-19, then I think it’s reasonable to have gatherings indoors and take it one situation at a time,” says Dr. Aronoff. “It’s hard to make a blanket statement about family gatherings needing to be outside, because I don’t think we’re there right now. Many people are vaccinated, and it’s very clear that the vaccines are helping reduce the risk of disease.”

In addition to getting vaccinated against COVID-19 (including the third dose or booster shot if you’re eligible), make sure you also get your flu shot and other vaccines recommended by your doctor. By following vaccination recommendations and other mitigation efforts, we may be able to avoid the winter surge that occurred last year.

“We’re optimistic that disease activity won’t be peaking the way that it was last year during the holiday season,” says Dr. Aronoff. “We’re entering the winter months with disease activity falling to some extent and many, many more people now having some immune protection — mostly through immunization, but also some through infection or the combination of infection and immunization. I think that is putting us in a little better footing for this winter.”

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