We are now two years into the COVID-19 pandemic and there is a lot of pent-up demand for travel. Canceled vacations are being rescheduled. Postponed weddings are being booked. Grandparents want to see grandchildren who live in distance cities. People just want to get out. But the pandemic is far from over and travel precautions are as important now as ever. So, how should we advise our patients, families, and co-workers who plan travel?
First… the obvious
There are some travel precautions that can apply to anyone. Travel advice that should be universal includes:
- Delay traveling until you are vaccinated
- If you are vaccinated, get a booster before traveling
- Make sure that your traveling companions are vaccinated
- If you or your traveling companions have COVID-related symptoms, do not travel
What should you pack?
Since the pandemic began, I’ve made several driving trips to North Carolina, Maryland, and Virginia. I flew to Bar Harbor, Maine for a week of hiking. I flew to northern California for a week at the coast. I flew to San Francisco to visit with a new grandchild for several weeks. Here is my COVID packing list:
- Rapid COVID tests. You never know whether test kits will be available at your travel destination. You may need one because of symptoms or because it will be prudent to test prior to visiting a relative with risk factors for severe COVID.
- Extra face masks. Face masks get stuffed into pockets, get left on kitchen counters, and fall off into the mud. The elastic ear loops on surgical masks tend to break. Always carry extras with you.
- Hand sanitizer. A good idea for travel before COVID and an even better idea during COVID. TSA now allows passengers to carry up to 12 ounces of alcohol hand sanitizers on aircraft. Keep a bottle in your car or in your purse.
- Clorox wipes. Did a snotty nosed kid grab the door knob to the gas station two minutes before you did? Keeping sanitizing wipes in your car or hotel room can bring piece of mind.
- Thermometer. Jet lag and sunburn can cause symptoms that can resemble COVID. You keep a thermometer at home in case you get a febrile illness – take it with you on vacation.
- Oximeter. OK, admittedly I’m biased by being a pulmonologist. But I’ve seen too many “happy hypoxemic” COVID patients in the hospital who had oxygen saturations in the 80’s without any shortness of breath. If you do get COVID, checking your oxygen saturation is just as important as checking your temperature (and maybe more important).
- Acetaminophen and/or NSAID. If you do get COVID while traveling, you are going to need to isolate yourself. That means not going to the local pharmacy to buy Tylenol so carry some with you.
- Vaccine card. Here in Ohio, the idea of requiring a vaccine card is about as socially acceptable as laws about gun restriction. However, many communities require documentation of vaccination to go into a restaurant or bar. Even when not required by local ordinances, some restaurants and venues require evidence of documentation because it brings in otherwise wary customers. Take a picture of your card and keep it on your phone.
- Extra medications. If you take prescription medications, bring enough to get you through a quarantine period in case you or a travel companion have to extend your travel time due to a COVID infection.
Travel within the U.S.
Check the websites first! The CDC’s COVID data website can give you up to date information about the prevalence of COVID at your travel destination and about percent of the county that is vaccinated. In addition, each state’s department of health website can give you even more data. City department of health websites can tell you about local indoor masking and vaccination documentation requirements. Current COVID-related hospital occupancy data can tell you whether or not you will have available healthcare if you fall and break your leg.
Car travel. Keep hand sanitizer, Clorox wipes, and extra masks in your car. Wear masks at all times when indoors at restaurants, rest stops, and gas stations. When driving from Ohio to North Carolina, we no longer stop at restaurants – we pack a lunch and eat it in the safety of our car. If you have to go through toll roads, EZpass allows you to skip the toll both attendants.
Restaurants. Check restaurant websites to find out if they require employees and/or customers to be vaccinated – if nothing else, these restaurants attract customers who take COVID seriously and consequently are less likely to be infected. Eat at off hours – instead of eating dinner at 6:00 PM, consider eating at 4:30 or 9:30 when the building will be less crowded. Consider carry-out – In Bar Harbor, we ate all of our dinners as carry out on the balcony of our hotel room overlooking the ocean – better scenery and no worrying whether the anti-masker at the table next to you is going to cough in your direction while you are eating your sandwich. In cities like New York and San Francisco, you must show your vaccine card to enter.
Minimizing risks during air travel
The airport is often riskier than the plane. Modern aircraft have very advanced air filtration systems. Cabin HEPA filters remove 99.9% of airborne viruses and the volume of air in the cabin is exchanged every 2-3 minutes. Air enters the cabin through the ceiling and exits the cabin through floor vents in the seat rows. In addition, each passenger can adjust their own personal overhead air vent for additional comfort and air flow. So, even though passengers are seated close together, the airflow systems provide a lot more safety than in a building, such as the airport. Furthermore, people tend to be less attentive to masking and social distancing in the terminals than once they get on the plane
In the airport: Avoid traveling on busy travel days – Tuesdays and Wednesdays tend to be the least busy. Use hand sanitizer liberally – as noted above, TSA currently allows you to carry 12 ounces of alcohol hand sanitizer, rather than the 3 ounce limit on other liquids. Maintain social distancing whenever possible – TSA precheck lines are generally less congested than the regular TSA lines; if you have layover, find the least busy gate to sit and wait until your aircraft boarding time. Avoid airport restaurants and bars – eat a meal before you leave home.
In the plane: Turn on your overhead air vent to increase the filtered air that you are breathing. Avoid or minimize eating and drinking during the flight – when the flight attendants pass out beverages and snacks, everyone tends to take their masks off to eat/drink at the same time so wait to eat or drink until after everyone else has finished and re-masked. When eating or drinking on the plane, try not to take your mask off for any longer than you can hold your breath. Wear a mask at all times – the greater the filtration of the mask the better; I am fortunate that I was fit-tested for an N-95 mask (with a beard) and that is the mask I wear.
Travel outside of the U.S.
Check the websites first! COVID travel restrictions are constantly changing and each country is very different. Some countries are not currently permitting non-essential travelers to enter. Check the government websites of any country you plan to visit to find out their specific travel requirements. Next, check the U.S. state department website for travel safety information about the country you will be traveling to. Finally, check the CDC website that stratifies the COVID risk of each country. Don’t go to countries that are classified as level 4 risks and if you can, select from those that are level 1 risks.
You may need COVID travel insurance. Although many commercial health insurance policies will provide at least some coverage for illness-related expenses abroad, most do not cover the cost of medical evacuation or quarantine housing. Many countries now require documentation of a COVID-specific travel insurance policy. These can be purchased on-line and typically run about $500 per person, depending on one’s age and duration of travel.
COVID testing prior to arrival. Most countries currently require travelers to have a negative COVID test prior to entry. Some require a PCR test while others will accept a rapid COVID test. Some require the test to be done within 24 hours prior to arrival, others require it within 48 hours, and others require testing to be done in the immigration area of the airport at the time of arrival. In all cases, some form of documentation of the test is required. For this reason, the self-read home test kits sold at your local pharmacy will not be sufficient. Many pharmacies and U.S. airports will do travel COVID testing with advance scheduling. If the country that you will be traveling to requires testing to be done in their immigration area, they will likely require payment in cash at the time of testing.
Will you need a COVID certificate? Some countries (for example, member of the European Union) require you to have a COVID certificate in order to go just about anywhere in that country. These can be obtained on-line from the each government’s website.
Returning to the U.S.
Check the websites first! The CDC travel website provides up to date information about entry requirements to get into the U.S., including requirement for U.S. citizens returning from travel abroad. These requirements can change so check this website when first planning a trip and again shortly before departing.
You will need a COVID test. The U.S. requires documentation of a negative COVID test (rapid or PCR) within 1 day prior to arrival. This is slightly different than the 24 or 48-hour requirement of most other countries. The test can be done anytime the day before arrival in the U.S. Many hotels and airports in other countries will perform testing and provide documentation for a fee. You can also do an at-home test that has telehealth proctoring. Importantly, most of the commercial test kits sold at pharmacies are self-read and do not have a telehealth component. Because you have to present documentation of a negative COVID test to get into the U.S., these self-read tests will not suffice. Examples of acceptable at-home tests include:
- Abbott BinaxNOW
Note that there are two versions of the Abbott BinaxNOW test – one that is sold at retail pharmacies and does not have a telehealth component and a second version that is sold on-line that does have a telehealth component. Only the second version is accepted for entry into the U.S. can can be ordered online at emed or optum. It is a good idea to pack at least one of these tests for each traveler, even if you plan to get your pre-U.S. entry COVID test at a hotel or airport at your travel destination – you just can predict if the hotel will run out of tests or if the airport has staffing issues on the day that you plan to fly back to the U.S.
Weighing the risks of travel
Patients would often ask me “Is it OK for me to travel?” Sometimes, the answer was a flat-out ‘no’ but more often, it was varying degrees of ‘maybe’. There are two considerations: the traveler’s personal risk factors and the risks associated with the travel destination. The good news is that people who have been vaccinated and boosted are at relatively low risk of getting so sick that they require hospitalization or die if they do get COVID while traveling. However, risk factors for severe infection such as advanced age, obesity, diabetes, hypertension, or immunosuppression must be factored in, even for those who are fully vaccinated. The travel destination is at least, if not more important. Locations where there is a culture of masking and vaccination are lower risk than areas dominated by anti-maskers and anti-vaxxers. Destinations where you won’t encounter crowds and where you will mostly be outdoors are lower risk than destinations where there will be crowded indoor areas. A vacation rental home where you will be eating your own meals is less risky than a hotel. Cruises are probably among the highest risk travel options.
Just being a human poses some degree of risk in this COVID pandemic. Traveling incurs some additional risk but the good news is that most people can minimize that risk by careful planning and taking the right precautions.
January 5, 2022