RETURNING HOME IN THE TIME OF COVID

As a travel medicine doctor, preparing a person for safe travels used to be a usual consult for me in my outpatient practice. The assessment involved a detailed history of the itinerary, purpose for travel, describing the accommodations, and finally, the individual host factors which mean any comorbid conditions of the traveler. This discussion was never quick or straight forward because there are too many variables to consider and even something as simple as whether you were 'visiting a friend or relative' placed you on a higher level of risk – the dreaded 'VFR'- which in travel medicine means a person who underestimates their risk because they feel they are returning to a once-familiar environment.

With this, I thought I was prepared but traveling during a respiratory virus pandemic holds a whole new set of challenges. It seems that crossing borders with different case numbers while being in an enclosed space with strangers for several hours, breaks every public health rule in the book so it is not surprising that travel has taken a huge sucker punch this year.

As an Infectious diseases specialist, I was very fearful of air travel and would still recommend that most people limit their exposure to essential-only as much as possible, however as we understand this virus better we can learn to modify our behavior to resume activities in safer ways. I had to take an international flight recently and although I did it safely, I can tell you it was not without anxiety.

In my defense, I'd like to clarify that Infectious diseases doctors are a bit weird. We see the world in multi-layers. There are the buildings and solid stuff and then there's the living which comes in macro (humans, animals, plants) and micro (bacteria, virus, parasites, fungi). We walk around with these juxtaposed layers all the time. We don't see a bat cave we see histoplasmosis, we don't see a swimming pool we see cryptosporidium, and a cruise ship is just one giant norovirus on water. It probably isn't fun to go on vacation with us on a good year, this year it's nearly impossible to turn that switch off and let loose.

A plane looked to me as one giant container with locked-in air where every breath I would inhale was what the other person had just exhaled. You may say the air is exchanged often, 'OK, but how often is enough?' and 'how about staying in your seat vs walking up and down aisles, mister', Oh that's right! I forgot about the clots, UGH!. It's enough to put a damper even on the most avid of travelers.

The way to approach such an overwhelming situation is accepting that there is no such thing as ZERO RISK. EVER! From this mind frame, we can look at several points of risk and do our best to minimize exposure while not sacrificing the entire experience. Aside from the OBVIOUS GOLDEN RULES – DO NOT TRAVEL IF SICK AND IF YOU'RE AWAITING A TEST RESULT. After talking through scenarios with colleagues this is what I did.

Getting to The Airport:

Responsible commuting starts at your door.

▪ Wear masks when in taxis, ride-sharing, and public transportation. A big thank you to the Uber/ Lyft and yellow cab drivers who were taking full precautions. Including opening windows and placing screen dividers between front and back seats. Most even provided hand sanitizer when entering and exiting the vehicle.

If someone outside of your bubble is driving you to the airport, they should follow the same rules of mask use, open windows in the car, and limit the hugging goodbye. Don't be fooled that because someone is a friend or relative they cant infect you.

Airport: Hand sanitizers are available at all entrances. USE THEM!

Mask Usage is mandatory in all airports/lounges/kiosks/everywhere. So go prepared and BRING PLENTY.

I confess I did not wipe down the check-in kiosk but I did sanitize hands immediately after finishing the check-in process. Then on to Security, which hasn't changed- It's still a drag. Even though there are fewer people all around, lines are as lengthy due to the 6ft distance between each other. You will be asked to remove your mask briefly for an identity check.

Airport facilities are CLOSED. There is NOTHING TO DO. Duty-Free stores, high-end shops, the Sunglass Hut, and Whittakers in Auckland, all closed! An occasional shop for water and reading material is available but expect to feel the depressing thought that the fun perks of flying are on hold for a while. This goes for airport bars too. Although, I did notice a difference between August and October with few more options available in October indicating a gradual re-opening.

The Plane: Boarding the Plane was a bit more orderly. Jamming entrances one on top of each other is not something anyone wants to do anymore so DON'T BE THAT PERSON. Just wait for your group to be called, Respect the 6ft, and be mindful as ever about 'personal space'. Most travelers were very cautious, this gives everyone around a sense of relief. If you take care of yourself it speaks volumes of the type of risk-taker you are and thus how safe I can feel around you. Everyone is sizing you up these days. WE'RE WATCHING EVERYTHING.

AirNZ gives you a fresh mask upon boarding and then every 4 hours thereafter. They announce that per Ministry guidelines, masks should be changed frequently so they pass around to refresh your mask. No other airline did that. Don't expect them to, but that's KIWI Care for ya.

Wipes were handed out by United Airlines for wiping down your tray table and screen (probably to make up for the fact that they overbooked every single seat). I had my Janola/Clorox wipes and wiped everything around me including window, walls, seatbelt buckle, armrests, anything that I wanted to touch freely during my flight without having to hand gel each time, I wiped. I was determined to be a chain-blocker!

Eating was a tricky part because masks have to come off. This is where leaving that middle seat empty helps, in a region with community transmission of COVID-19 I don't feel comfortable sitting that close to another person without a mask yet.

The Bathroom. There is some risk here. I would say that mask on is mandatory. Flushing with the lid down and of course hand washing. I think we all try to minimize the times we use the bathroom anyway so that probably goes without saying. During the long flight, I would try to time the bathroom before exchanging my mask, that way I could discard the mask after potential contamination in the bathroom.

Any flight short enough, try to stay in your seat, limit movements around the cabin (which also will help later for contact tracing if needed), and limit eating to avoid removing the mask. The whole LA-NYC flight I kept thinking how mom's cooking was worth the fast and a better tradeoff anyways. I was right!

Disembarking the Plane: Be prepared to disembark BY ROWS. There is no need to rush up and clutter the hallways to get your overhead bag as you will be asked to sit back down anyway. Again, it is about minimizing risk and allowing for space between each other at all times, including the final part of the flight and baggage claim.

Public Health Checkpoints: Upon arrival at your destination: Checking in with information desks at your destination is key as some areas require you to register your accommodations or give information about isolation etc. Funny story, I walked right in because when I mentioned New Zealand, the DOH person in JFK said, " NEW ZEALAND! you guys have done a great job, you're GOOD, welcome home". 

Layovers: If you are allowed to GO OUTSIDE get some fresh air! Remember risk is less outdoors and depending on how crowded it is it may be possible to even remove your mask and 'feel normal' again with the sun in your face and nose to the wind.

Arriving home: No hugs mom. That was hard after so many months. I SHOWERED immediately. Dirty clothes off. Face, nares, and throat rinsed before I even came close to my mom who is in a VERY HIGH-RISK GROUP due to advanced asthma. From that point on and for the next 5 weeks, I had a new bubble.

Dalilah Restrepo, MD Travel Medicine/ Infectious Diseases Specialist