Traveling Safely During a Pandemic

Posted On January 11, 2021

So we did a thing this weekend: We actually booked a trip for 2021. (More on that later). Is it a hopeless gamble? Will travel in 2021 resume normalcy?

I highly doubt it. Vaccines will take a long time to roll out, especially to poorer countries. Masks will probably be in place for the forseeable future as long as a large number of the population remain unvaccinated. COVID19 testing will likely continue to be a requirement for travel to Hawaii and destinations outside the US – and I hope that testing will become more widespread particularly in the United States, where testing has continued to lag, and I hope testing protocols (such as the Hawaii Safe Travels program) will eventually replace the quarantine requirements imposed at some destinations, but that is not hard guarantee. Some airlines are in the process of testing protocols for international travel. Lastly, the pandemic hit the travel and leisure industry hard, and many hotels and restaurants may not be reopening any time soon, if ever.

On the other hand, I can make a case for our attempt to resume some normalcy. Both my husband and I received our second dose of Pfizer vaccine this week, hopefully providing us some degree of protection. We have access to PPE, purchased by us, and have a stock pile ready to go. We work in an environment that is high risk for COVID exposure, where every moment of the day is focused on maximizing ventilation, researching how often we can re-sterilize N95s, applying DIY to create the most protective yet comfortable face shield for an eight hour workday, etc…In comparison, the logistics of travel seems, quite frankly, less daunting for us. Furthermore, having to wear a mask outside of work isn’t quite as annoying when it has become so second nature at work. Funny how a cloth mask or a surgical mask on its own can seem so much more comfortable when you compare it to wearing an N95 for 8 hours straight! I am comfortable we can be responsible travelers. We both have many friends who work in the healthcare industry and have had to fly for their front-line jobs during the entire pandemic (think locums physicians, traveling nurses, medical device reps who assist with device implantation, etc), so we have been able to gather lots of advice and recommendations – and to date, no one we know of traveling frequently for work has acquired COVID19 from flying. The risk appears to be quite low.

The advice below is currently applicable to the SARS-CoV2 virus, a type of coronavirus that causes the illness COVID19, but is likely applicable to other viruses that spread through droplets and aerosols (think influenza, or other coronaviruses that cause the common cold).

Should I travel during a pandemic? And how dangerous is flying, really?

First of all, let me say that I do not endorse flying (or traveling in general) for everyone during a pandemic. Risks need to be well understood, including risks to you as well as risks to other people you may encounter in your journeys. You probably are safest remaining at home in isolation. However, what the public health world has learned from the HIV world is that abstinence is not effective…it is simply not realistic for everyone to adhere to, and it is impossible to prevent all human beings from engaging in risky behaviors. For those who choose to fly or travel because of work, because of family reasons (perhaps they have a family member not expected to live for much longer), or to get away for mental health reasons, I do not judge but would instead encourage taking every precaution possible to reduce the risk of spreading illness. And with vaccinations rolling out, it is getting safer.

It’s important to remember that everyone has their own individual risk calculator, of which activities for them might provide benefit enough to outweigh potential risk of themselves (or others). It’s quite striking, actually, how differently individuals perceive risk. For me, my perception of risk depends a lot on my personal access to personal protective equipment, whether or not others around me are taking adequate precautions (including personal protective equipment and social distancing), and the environment and ventilation of the space (important to consider for any airborne illnesses, such as COVID-19, influenza and others.) This is my personal risk-ranked activity list:

• Low risk: Eating outdoors at a restaurant or a park, going for a walk/run/hike outdoors with friends if socially distanced, walking through airports, grocery shopping (if I can avoid crowds and washing hands frequently), using a restroom at a gas station.
• Medium risk: airplanes, shopping at a more crowded store, sitting in a waiting room, or standing in line indoors.
• High risk (will not do): eating indoors at a restaurant, indoor concerts, going to a gym or yoga studio, going to a salon, getting nails done, attending an indoor meeting, having people over indoors.

Let’s discuss the various risks associated with travel:

1. You spread the disease to others you encounter during your travel or at your destinations. This to me is the greatest tragedy of irresponsible travelers. Never, ever travel if you are sick, and remember that travelers might not show symptoms of illness until they are already on their journey – asymptomatic spread is thought to account for over 50% of SARS-CoV2 spread. To minimize this possibility, there are strategies you can employ: quarantining yourself as much as possible for 10 days prior to travel (that means no to minimal contact with persons outside your household), in conjunction with testing, can substantially reduce your risk of spreading illness.
2. You acquire COVID-19 during your journey and then bring it back home to your community- spreading it to family, friends, or coworkers. Your risk acquiring COVID-19 while away from home is just like your risk of acquiring COVID-19 at home, and depends a lot on your personal behavior.
3. You become sick during your journey, putting stress on the healthcare system at your destination which may or may not have the resources for yet another ill patient. I would strongly recommend that people at risk for having a more severe case of COVID-19, which includes age, diabetes, underlying heart and lung conditions to name a few, should not really be traveling. As a younger person, who is healthy and does not have any risk factors, the chance of me being hospitalized for COVID is extremely low. But, it doesn’t mean I am free of risk of needing medical care while traveling. There is still a chance I could be hospitalized for injuries sustained in activities I might engage in while traveling, such as hiking, horseback riding, and swimming in the ocean…triple important for extreme sports enthusiasts. This should always be something in the back of your mind when you travel.

I also want to put risk in perspective. Airplanes and flying seem risky to most people. Think about people you know who are scared to fly or suffer extreme anxiety while flying because of fear of a crash, but do not hesitate to get into a car to drive. Yet, the number of motor vehicle accidents and deaths is astronomically higher than the number of people who die in an airplane crash. Similarly, I think an airplane to us seems like an enclosed, dirty confined place where we breathe stagnant air, we lack control over who is near us, and we can all think of times were probably gotten sick after traveling and blamed the plane. It’s probably not always the case – just as likely to be what got you sick was what you did in the days before you flew (including all the sleep deprivation and stress that wears down the immune system). With mask wearing enforced during flight, your risk is now even lower – with COVID, the cases known to be acquired during a flight all happened prior to the end of March 2020, when the airline imposed strict mask guidelines and other measures. With any disease spread by droplets or aerosol, ventilation is key to mitigating risk, and airlines have surprisingly excellent ventilation – and low COVID19 transmission rates….as opposed to your home, which was designed to be energy efficient and hence, has poor ventilation. To reduce COVID spread, the ideal ventilation turns over air 5 to 6 times per hour. The ventilation on a plane turns over air 20 times per hour, using HEPA filtration. The air in most commercial buildings turns over 2 to 3 times per hour. In your home? Since homes are designed to be energy efficient, the air might turn over only once every 2 to 3 hours. Yikes – no wonder COVID spreads so easily at house parties!

What if I have had COVID19? What if I have received the vaccine?

It is unclear at this time how long immunity lasts after having COVID19; current studies suggest at least 8 months. Reinfections to date have occurred, but are rare. Vaccination trials began in April 2020 and it is still unclear how long immunity will last or if a yearly vaccine might be necessary, similar to influenza. Neither a bout of COVID or the vaccine is 100% effective, as virus resistance depends on your immune system and underlying health conditions, but certainly your risk for becoming ill, and certainly for becoming seriously ill, is significantly less.

Factors to consider when planning pandemic travel:

So you’ve assessed your personal risk, and the risk you potentially pose to others, and have decided travel can be done safely….now what? In our “re-opening“ phases of travel, I are still taking a lot of factors under consideration when planning potential travel:

1. What is open: Our first requirement, of course, is that we can only travel to destinations who are currently open for tourism, which at this point is a very small proportion of the world. Pay close attention to current quarantine or testing requirements, and recheck often – Hawaii, for example, has changed entry requirements multiple times.
2. Scope out the COVID situation in that destination: I am still quite cautious, so I want to see that there are rules and testing in place wherever we might visit. What are the case positivity rates, how overwhelmed are the hospitals? Also keep an eye on closures or shutdowns that might affect your travel (think museums, beaches, parks, restaurants). Here is the world map and US map of coronavirus cases.
3. Outdoor activities prevail: It is unlikely to acquire COVID19 outdoors without very close contact. We are choosing locations where most activities during the day would be outdoors, and where there is the option of eating outdoors as well for most meals.
4. Have a flexible mindset. know that there is a very high chance that you may have to cancel or change your plans at the last minute. Try not to get your expectations too high. Have back up plans in case business is shut down, flights get canceled, or travel restrictions change. Remember that right now, airlines have generous cancellation and change policies.
5. All plans must be refundable: A lesson hard learned last year during the pandemic when I broke my usual rule against purchasing nonrefundable travel in order to save a few bucks. Big mistake. Thankfully airlines have joined Southwest in eliminated change fees, which makes it less risky to book flights. Book on a credit card that provides trip cancellation insurance, such as the Chase Sapphire Reserve. (last resort: If plans must be cancelled due to new restrictions/border closures and you aren’t able to get a refund from the vendor, dispute the charge on your credit card as soon as possible. It works beautifully.)
6. Do I fly or drive? it all depends on your comfort level. I think flying can be done just as safely as driving, as outlined below. With driving, your risks come from the stops you make. Our experience this summer: gas stations had a hit-or-miss masking rate, erring on the side of no masks, which means standing in line for the bathroom or to make a purchase could put you at risk if you aren’t wearing adequate protection. Eat your meals outdoors – or in your car. Check any hotels you might be staying at on the way to ensure they are taking precautions.
7. Minimize exposure during transportation: Pick airline routes with the fewest number of connections, and have a plan for keeping socially distanced at the airport (lounge access may be worth purchasing). Avoid trains, buses, or other modes of transportation where you would be in close proximity to others. If you use a taxi or ride share, keep the windows down to maximize ventilation.
8. Eating out: scope out the best local take out options. If you opt to dine at a restaurant, stick to outdoor seating – make meal reservations in advance so you can specifically request outdoor seating. If you are traveling in the US and you have a kitchen at your destination, have groceries delivered – you could even consider having meal kits delivered to avoid the hassle of stocking pantry basics

How to mitigate risk while traveling:

These are the steps I would take:

1. Self-quarantining before travel: Be incredibly careful what you do for the 10 days prior to traveling. Work from home; at work, live like everyone you come into contact with has COVID19. Minimize grocery store runs and errands down to the bare minimum. And for pete’s sake, this is NOT the time to get your hair cut, nails done, eat at a bar/restaurant indoors, or go to a gym. The only people you should be interacting with are those in your household, as much as possible – and, they should be adhering to the same rules.
2. COVID testing: If possible, test before you travel (if you aren’t already required to do so) and figure out a strategy to test at your destinations should you need to. Some airports (SFO, LAX) are offering rapid tests but appointments were booking out weeks in advance when the testing sites initially rolled out in the fall of 2020, putting some travelers in a bind. If testing is hard to come by, or you prefer to avoid the “brain biopsy” (nasal swab), I would recommend Vault Health saliva tests, if accepted (Hawaii does accept them – here is the current preferred testing list for Hawaii travel). We use these for work and found them to be quite convenient, and we were able to have the results within 48 hours. For destinations that require a negative test prior to arrival, make sure you have the capability of getting the test, and that the test is accepted at your destination (important for Hawaii!). UPDATE 1/12/21: the United States will begin requiring a negative COVID test prior to re-entry to the United States, so have a plan for your trip home (TBD if proof of vaccination will suffice. More to come, I am sure). For a presumed trip to Hawaii, I can outline how testing with Vault should be conducted:

• Order your test kit from Vault well in advance – they will arrive the next day, and are good for 12 to 18 months. Kits are linked to an individual by driver’s license so they must be ordered specifically for that individual – you cannot share. Certain states (Minnesota, Wyoming) offer the kit for free for their citizens (just order through the website, and based on your home address, you won’t be billed if the test is free). Otherwise, tests cost $125 at the time of this writing.
• Double check testing requirements: does the test need to be done within 72 hours of departure, or 72 hours of arrival? Reckeck requirements 5 days before you travel.
• Take your test. Of note, the Vault tests result with the date they were administered, but not the actual time, so you may have a bit more leeway than 72 hours – I would therefore take the test as early in the day as possible.  You must log into the link provided which will take you to a Zoom room where you may have a wait of anywhere from 5 minutes to 1 hour. Once a medical provider logs in, they will supervise you opening your test kit and watch you unceremoniously spit (it is a lot of spit!) into the test tube. Seal it up as they advise.
• Vault kits ordered for travel may or may not come with a sticker for quick processing. If not, we were advised to write HAWAII STAT in big letters on the test tube label and on the envelope to help expedite processing.
• Drop off the test kit at your nearest UPS overnight pickup location – I would chose the location with the earliest pickup.
• If nervous, and particularly if test kits are free or you have the resources to purchase multiple tests, consider taking 2 tests and dropping at different locations or on different days. If a trip is that important, it never hurts to have a back up test pending.
• You will have access to results on line, and will be notified by email. Open the PDF (in your Vault account, it will be attached as a link to the order number/date for that specific kit) and both print a hard copy and save it digitally.
• Example: For a Friday 11am flight to Maui, which at the time of this writing requires a negative test within 72 hours of your departing flight to Hawaii, you will want to take your test first thing Tuesday morning – and should have results Thursday, or worst case scenario, Friday morning.

3. Optimize your immune system: get plenty of sleep – aim for 8 hours per night – in the days before you travel. Optimize your vitamin D levels; ideally, your vitamin D level should be around 40-50, if you don’t know yours, 2,000-3,000 units per day is safe unless you have a history of vitamin D. toxicity. Zinc can be helpful short term, potentially for reducing your risk of getting sick, but also to help prevent severe illness from COVID19 (don’t over-supplement zinc long term, as it can deplete copper and cause a neuropathy). For zinc to actually help prevent of a severe case of COVID19, pair zinc with a zinc ionophore – a fat soluble substance which shuttles zinc across the cell membrane – we use a supplement called honokiol by Tailor Made. (hydroxycloroquine is also a zinc ionophore, which is probably why it initially appeared to be helpful).
4. Masks: Masks help to control the spread of droplets, protecting others, while certain masks such as N95s protect you the wearer as well. Masks will be required at many places, first and foremost at the airport and on the plane – and even with vaccines, this will not be changing any time soon. Make sure your masks are comfortable, fit well, and learn how to wear and remove them safely. Pack enough for the flight there and back, and pack additional masks to wear at your destination. Generally it is recommended to store masks in a brown paper bag, since the virus cannot survive for long on paper as compared to plastic, but for travel I would use a large ZipLock bag, one for clean and one for used masks (we wash cloth masks after each use, and re-sterilize N95s to reuse up to 4-5 times; surgical/droplet masks should be thrown once soiled). Which masks should you bring? I would recommend several different kinds:

• N95s: An N95 mask filters out airborne particles (by definition, 95% of very small particles up to 0.3 microns in size). On the plane and in the airport, an N95 will provide you the most protection in a small, enclosed space like a plane. KN95s are also effective, pack flat, and are soft and comfortable (the straps are not adjustable and some brands can fit too tight around the ears depending on your head size – try one before you stockpile a bunch). Remember – you are not fit tested for these, but in a well ventilated area, they should provide good protection – even better, cover with a cloth or surgical mask.
• Surgical (droplet) masks, which are the yellow or blue masks you see worn in hospitals, has an outer layer that repels large droplets; they very much have a limited life, but are probably more effective for protecting the user than cloth masks given that they repel droplets, unlike cloth masks (better yet – wear one over your N95). They are also lightweight and easy to talk with, and I find them the most comfortable for jogging (hopefully, you can find a place to jog where a mask isn’t required!).
• Cloth masks help prevent droplet spread, but do not provide the user with much protection. However, they have the advantage of being plentiful, are washable, and come in lots of styles – and as long as you are in an environment where everyone is wearing one, they can be fairly effective. I personally find droplet masks more breathable, but cloth masks are more durable and better if you are going to be taking them off/on a lot during the day (for example, while hiking). Pick tightly woven fiber, and I look for those with adjustable ear loops, moldable wire over the nose, and pockets for filters also probably add some benefit (ffilters can be purchased – or use coffee filters). Thin hiking buffs might be breathable, but do not provide any protection for you or the wearer – and if you cough or sneeze, it converts large droplets into smaller aerosols that might spread even easier.

4. Eye protection: yes, droplets infect mucous membranes –which includes your eyeballs!  Wearing some form of eye protection also prevents you from touching objects and accidentally rubbing your eyes. For best results, use goggles or something that covers your eyes completely – I have found foam lined “onion glasses” a very comfy lightweight option to wear and they fit easy inside a purse or carry-on. Face shields can also be an option, with the benefit of providing another barrier between droplets and your mask – find a comfortable one that wraps around as much of the side of your face as possible. Be aware that they are harder to pack, but might be more comfortable. Eye glasses or sunglasses offer some protection and are a better option than nothing at all.

5. Personal Air Purifier: my sister in law found us this device on Sharper Image. Similar to the surgical droplet masks, it repels viral particles via ions, and can be clipped onto your shirt/jacket or worn on a cord around your neck. Can’t hurt, right?

6. Hand sanitizer: current TSA guidelines allow 12 ounces per person. I recommend getting a small refillable bottle you can clip to the outside of your purse/backpack/carryon to quickly sanitize, and a larger stash in your carry-on. Gloves are not needed as long as you wash your hands as frequently as possible and use hand sanitizer.

7. Sanitizing wipes: I always have traveled with these – you never know what has touched those airline trays, and after our friends saw a couple stash a dirty diaper in the seat back pocket….bleh. The airlines are handing these out for you to sanitize your own seat, but bring some extra.

8. On the plane (and in the airport): Avoid taking off your PPE unless necessary (you will need to lower your mask at the TSA screening). Unless you are on a very long flight, avoid the urge to eat/drink if at all possible. If you do need to remove your mask to eat/drink, try to coordinate to do so when others around you have their mask on. In the airport, find a very isolated spot before removing your mask to eat or drink. And it should go without saying: if you have a coughing fit or have to sneeze, DO NOT remove your mask!! The whole point of the mask is to reduce droplet spread. If it grosses you out, change out your mask (somewhere socially distanced, of course).

9. Fly first class or business class if able – now that most airlines are doing away with blocking the middle seat, this is a great opportunity to take advantage of cheap fares or consider using those frequent flier miles that have been piling up! For example, United’s Polaris first class seats almost feel like being in an isolated pod, make a very safe, low risk way of getting to Hawaii.

10. On arrival: find out when your room was cleaned or when hotel staff were last in your room – generally a small droplet containing a viable virus is thought to remain in the air for only 8-14 minutes at most after an infected person leaves a space (many early reports of SARS-CoV2 lingering in a room for over a week were looking at fragments of the virus – like a fingerprint, but not the actual intact, contagious virus itself). On surfaces, the viral particles can linger longer, putting you at risk if you were to touch a surface and then touch your space. If hotel staff were recently in your room, consider using a disinfectant wipe to wipe down high touch surfaces like light switches, remote controls, and the bathroom counter. If your room was cleaned over 24-48 hours ago and has not been in use prior to you checking in, the risk of contracting virus from the room is quite low. I would change clothes on arrival, but it isn’t necessary to immediately wash those clothes – after 24 hours, it is unlikely any virus will remain on clothing, so just set those outer garments aside for a good day or two if possible.

Do you have other COVID-related travel questions? Comment below!