Family Planning: Unvaccinated Relatives

Two questions today, related but not identical, both related to relatives reluctant to be vaccinated and how to think about interactions. In both of these questions, I’m going to focus not on how to encourage them to be vaccinated, but on how to interact under the assumption that they will not be. I read, in a lot of these questions, frustration coming through. Why is this person making this vacation planning even more difficult than it is? And I get it! Believe me, I get it. But your decision making around these things will be better if you can put the frustrated (or angry) emotions aside. So: reserve some other time for yelling in anger into your pillow, and take this time for decision processes. My husband and I and our one-year-old twins are planning a trip with extended family we have not seen this past year. It will be 13 adults and 6 kids under 3 in a shared house. All but one adult with be fully vaccinated. That adult is unvaccinated by choice. We’re concerned about sharing the house because of the one unvaccinated adult. Can you help me access the actual risk he may pose to our kids by sharing a house for a week? Thank you! I’ll talk through the risk here, but in framing that I’d suggest starting by stepping back to what the choices are. These conversations — about risk, about mitigating risk — will be more productive if you outline what decision you’re making. It seems to me that your choices here are (1) Go with unvaccinated relative; (2) Not go; (3) make a huge stink and try to get the unvaccinated person uninvited. I’m going to assume you are choosing between (1) and (2) here, but of course (3) is a whole other ball game. The Risks The risk from the unvaccinated adult depends on several factors. The most notable is the case rate in the area they are coming from, and their overall risk factors. Several weeks ago, I did a post with a risk calculator, which might come in handy here (post, calculator). Given the current case rates in much of the US, the implied risk of the person bringing COVID to your gathering is very small, and the risk of transmitting to a kid is not 100% even if they did have COVID. I ran a few numbers through the calculator and came up with, perhaps, 1 in 7,600 as the risk of transmission in this scenario, if your unvaccinated relative comes from the average location in the US. And, of course, infections in children are often mild or asymptomatic, so serious illness risks are even lower. (Yes, the delta variant is a consideration. It’s more contagious and accounting for an increasingly large share of cases among unvaccinated people. In the calculator, I increased the transmission risk assumption from an earlier baseline. However, the broad way to think about this is unchanged. Kids are still low risk. Paying attention to case rates is still key. It’s a reason to encourage more vaccination but, as I said above, encouraging vaccination is not what this post is about). Beyond case rates, the other thing you want to take into account is whether the unvaccinated relative had COVID before. Most experts think that vaccination provides greater protection than previous infection but it is also clear that previous infection reduces the risk a lot (here is one study, in the Lancet, pointing to about an 80% reduction in infection risk.) This is an especially frustrating thing to consider if you’re upset at your relative’s choices, as it ends up seeming like you’re somehow rewarding them for getting COVID. But, again, this kind of frustration isn’t helpful for good decision-making. The fact is, if they had COVID before, their risk of having it is low. Putting this together: this activity right now, in most of the US, is quite low risk. It’s not no risk. And it’s also higher risk than if your relative got vaccinated. But reasonable people, in my view, could make either decision. The Mitigation If you do decide to go, I think it’s worth remembering the “Safety Turducken” of last winter. We’ve kind of put this aside, in many cases, now that we have the “Safety Lead Wall” of vaccines. But: whether it is the “unvaccinated by choice relative” or the “unvaccinated because too young children”, revisiting portions of the Safety Turducken may be a good idea. Most notably I would point to pre-visit testing as something to consider (I’m guessing asking the relative to quarantine is not helpful). Testing isn’t perfect, of course, but it detects a huge share of infections. Antigen tests — the rapid swabs — are now even available over the counter. The New York Times had a piece on the use of these here. If you decide to go to this event, it might be a good idea to ask the unvaccinated relative and all the unvaccinated kids to be tested a day or two in advance. My husband’s parents refuse to get vaccinated, but they still want to watch our two year old twice a week. We don’t necessarily need the child care, but obviously we want our son to have a relationship with his grandparents. Their argument is they are careful otherwise. Should I just draw the line here, or is it okay? This question shares similarities with the above, obviously. The difference is in the repeat nature of the interaction and the child care element. The reason this matters is that you probably do not want to be revisiting this decision twice a week and doing a full calculation. There is too much decision fatigue and, since they are providing child care, it will be harder to just change up what you are doing mid-stream. For this reason, I’d suggest you approach this by combining the calculation above with this idea from an earlier post on establishing case rate cutoffs to make frequent decisions faster. That is: run through the calculations and decide at what case rate you’d draw the line. Of course, you may decide to draw the line even at very low rates. And: if they’re up for it, I would still try to get them tested. It doesn’t have to be punitive, but it doesn’t seem unreasonable to ask them to do a weekly test if they’re unwilling to get the vaccine.

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