Reflections: A Year Of COVID-19

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Dr. Howard Leibrand, Skagit County Health Officer 

Today is the first of several heavy anniversaries for Skagit County. On March 10, 2020, the first case of COVID-19 was reported in Skagit County. On March 13, Governor Inslee closed schools in order to protect students, staff and the community at large from COVID-19 spread. On March 17, Skagit County first became aware of the Chorale outbreak, which would lead to the loss of 2 Skagitonians- some of the first known casualties from COVID-19 in Washington State. On March 23, the first ‘Stay Home, Stay Healthy order’ began.

Since then, we’ve learned a lot. The science has come a long way- we now know how effective masks are at preventing spread of COVID-19; we know that surface transmission is pretty unlikely (so wiping down groceries isn’t really necessary), and we have three vaccines that are highly effective against the wild coronavirus.  All of this is a testament to human innovation and resiliency. 

We’ve also worked incredibly hard. Skagit Public Health, Department of Emergency Management and Unified Command have put in long, hard hours and accomplished so much. Skagit operated the longest continuously running COVID-19 mass testing site and has opened one of the largest mass vaccination clinics in the region. This clinic has administered over 6,000 doses of vaccine so far and has the capacity to do up to 940 total doses per day.

Residents and friends of Skagit County have also made huge efforts. Beyond everyone taking precautions to keep the community safe, individuals have donated thousands of masks, volunteered over 14,000 hours at the test site, vaccine clinic and staffing the hotline, and given $700,000 dollars to the Skagit Community Foundation’s COVID-19 fund which helped families in need through this difficult year. I am continuously in awe of my colleagues and the community that I serve. 

Unfortunately, the work is not yet over. While I look forward to further reopening of Skagit businesses and activities, now is not the time to let up on our basic precautionary measures. The B117 variant was confirmed in Skagit County two weeks ago, and it is likely that this more contagious version of the virus is circulating at large in the Community. Because it spreads more quickly and easily, if we don’t continue to observe precautions we risk a large fourth wave of illness. We also risk the B117 or the wild virus potentially mutating further and lessening vaccine efficacy; something that we have seen early evidence of in places like Brazil (P1) and South Africa (B1351). I encourage the community to double down their precautionary efforts. Wear masks- two if you can- at all times in public or during private social gatherings. Stay six feet apart from anyone you don’t live with, continue to practice good hand hygiene and please, stay home if you feel ill. 

I promise you, spring is coming. We will further reopen, and learn to live with COVID-19. You will see loved ones in unmasked social gatherings again. Vaccines will protect us. But we cannot get there without everyone’s help. Over the last year, I’ve said this many times but it bears repeating: wear a mask, wash your hands, and stay safe, stay healthy. 


Updated Quarantine Requirements for Vaccinated Persons

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On February 10th, the Centers for Disease Control (CDC) announced some recent changes to quarantine requirements for those who are fully vaccinated. This update comes at a perfect time as more people are getting vaccinated and as many are beginning to wonder what life will look like post-vaccine.

If you have been following the news, or if you have been recently vaccinated, you have most likely heard the recommendations: Vaccinated persons should continue to follow current guidance to protect themselves and others, including wearing a mask, staying at least 6 feet away from others, and avoiding crowds.

But why must those who have received both doses of vaccine continue to practice these safety precautions? Shouldn’t we be able to go back to normal once vaccines are more readily available?

Well…the science just isn’t there quite yet to tell us otherwise!

What we know—and don’t know just yet

We know that the currently approved COVID-19 vaccines are highly effective at preventing symptomatic COVID-19, meaning that those who have received a full vaccine series have protection against developing symptoms and are especially protected against severe illness related to COVID-19. The evidence also shows that symptomatic and pre-symptomatic transmission has a greater role in transmission that purely asymptomatic transmission.

While mRNA COVID-19 vaccines (like Pfizer and Moderna) have demonstrated high efficacy at preventing severe and symptomatic COVID-19, there is limited information on how effective the vaccines are at reducing transmission and how long protection lasts. The efficacy of the vaccines against emerging SARS-CoV-2 variants is also not yet known.

As we wait to learn more about how much vaccines are able to reduce transition, it is best to be cautious. Counties across Washington State have shown reductions in COVID-19 cases in the past several weeks, and it is best to keep doing what we know works best against the virus.

If you are like me though, you may be looking for a glimmer of hope for the coming months. The updated CDC quarantine guidelines is a promising example of the benefits that vaccinated individuals will begin to see.

Updated Guidance for Vaccinated Persons

The CDC states that vaccinated persons with an exposure to someone with suspected or confirmed COVID-19 are not required to quarantine if they meet all of the following criteria. Persons who do not meet all three of the below criteria should continue to follow current quarantine guidance after exposure to someone with suspected or confirmed COVID-19:

1. Are fully vaccinated (i.e. it has been longer than two weeks following receipt of the second dose in a two-dose series, or it has been longer than two weeks following receipt of one dose of a single-dose vaccine).

2. Have remained asymptomatic since the current COVID-19 exposure.

3. Are within three months following receipt of the last dose in the series (meaning that an individual is no more than three months out from their last vaccine dose).

Experts are currently gathering data about the duration of immunity to COVID-19 post-vaccination. At present, we have good data confidence to say that immunity lasts for 90 days (or three months). This may change as more data is gathered and analyzed.

Vaccinated healthcare personnel, patients, and residents in healthcare settings

If you are a healthcare worker, patient, or resident of a healthcare setting, these new updates will not apply to you. This exception is due to the unknown vaccine effectiveness in this population, the higher risk of severe disease and death, and challenges with social distancing in healthcare settings. These individuals must continue to follow current quarantine guidance.

Exposed and feeling sick. Now what?

Fully vaccinated persons who do not quarantine should still watch for symptoms of COVID-19 for 14 days following an exposure. If they experience symptoms, they should be clinically evaluated for COVID-19. In addition, vaccinated persons should continue to follow current guidance to protect themselves and others, including all other SARS-CoV-2 testing recommendations and requirements, and state, territorial, tribal, and local travel recommendations or requirements. For local information, visit: https://www.skagitcounty.net/Departments/HealthDiseases/coronavirus.htm.

More to come

The CDC quarantine recommendations for vaccinated persons, including the criteria above, will be updated when more data becomes available and additional COVID-19 vaccines are authorized.

To find out if you are currently eligible for vaccine in Washington State, visit www.findyourphasewa.org. If eligible, people can register for an appointment at one of the many vaccine provider locations: https://www.doh.wa.gov/YouandYourFamily/Immunization/VaccineLocations. Please know that vaccine supply is still quite limited at this time, and it will take several months for all currently eligible individuals to receive vaccine.

For information about Skagit County Public Health’s vaccination clinic at the Skagit County Fairgrounds, visit www.skagitcounty.net/COVIDvaccine or call the Vaccine Hotline at (360) 416-1500.


Looking Toward the Finish Line: Precautions Post Vaccine

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We are at the point in this COVID-19 marathon where the muscles in our legs are burning and our feet are begging for a rest. We have been dealing with this “new normal” for so long, and sometimes it has felt like there will never be an end to it all.

With vaccines now becoming more widely available (though still quite limited, due to supply), many people may feel that the finish line is just within their grasp. And what a wonderful feeling this is!

As more and more people receive the vaccine and as Washington State moves through the Governor’s new Roadmap to Recovery re-opening plan, it is important to remember that the race isn’t over. While we are absolutely looking toward the finish line, it isn’t the time to stop just yet.

There are still precautions to take, even once someone receives the vaccine. We are all tired of these safety measures, but they will continue to be necessary (at least for now). So why do we need to keep taking precautions? Here are some things to consider:

The vaccine is highly effective–but not foolproof.

At present, both vaccines available in the U.S. (Moderna and Pfizer) require two doses. These vaccines have proven to be extremely effective; the first dose gives 50 percent protection against COVID-19, while the second dose raises the effectiveness to about 95 percent. Of course, that means that there is a 5% chance that someone may still contract COVID-19 after receiving both doses.

And while the hope is that most—if not all—people receive the vaccine over the next several months, we know that there are some limitations. Both Moderna and Pfizer have not yet been approved for children (though Pfizer has been approved for people 16 and older). It may be some time until either a new brand of vaccine is approved that is recommended for children, or until Moderna and Pfizer finish clinical trials for minors and are granted approval for this population. So, until this time, children are still at risk of contracting the virus.

We do not yet know how long immunity lasts.

At this stage, experts do not yet know how long people are immune to COVID-19 after receiving the vaccine. Long-term effectiveness will depend on two factors: the duration of one’s immune response and changes in the virus over time. There is a chance that people will need to receive the COVID vaccine yearly, just like the flu, in order to account for any changes. Experts just do not know yet because the vaccine is so new.

That said, some research has indicated that the current vaccines are effective for at least 6 to 12 months. We will become informed in the coming months as more people receive the vaccine and as scientists track long-term effectiveness.

Experts do not yet know whether people can still spread COVID-19 after getting vaccinated.

The COVID-19 vaccines that are currently available are designed to keep people from getting sick. Clinical trials did not test whether those vaccinated could still spread SARS-CoV2, the virus that causes COVID-19.

This means that someone who has received the vaccine is approximately 95 percent protected against getting sick but could still contract the virus and infect a friend or loved one who has not been fully vaccinated.

Everyone should still wear masks and social distance—even after getting the COVID-19 vaccine.

For all the above reasons, it remains crucial that people continue to take pre-cautions—even after receiving the vaccine. Continue to wear your mask when in public, continue to keep gatherings small and keep your distance, and stay home when you are sick. Yes, these precautions aren’t fun. And yes, we are tired and we want so desperately to stop.

The finish line is in sight and we are getting closer. In the meantime, continue to take precautions and make sure to get vaccinated when you are eligible. If you don’t know your phase of eligibility for the vaccine, visit: www.findyourphasewa.org. You can also call Skagit County Public Health’s Vaccine Hotline at (360) 416-1500, Mondays-Saturdays from 7:30 a.m. to 6:00 p.m.

We will continue to update our webpage when new vaccine developments are available. Go to www.skagitcounty.net/COVIDvaccine for updates.

Keep Going! You’ve Got This!


Are playgrounds re-opening? What you need to know.

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I was scrolling through my social media newsfeed on a recent Saturday morning, when a particular post caught my eye: Mount Vernon playgrounds have re-opened. As a mom of a toddler who has been shut out of all playgrounds and splash-pads this summer, I nearly jumped for joy. My first thought was, “FINALLY! Shoes on! Let’s go!” … But then reality set in. Is it too soon? Is it safe? All the anxieties of the past six months flooded my brain and I spent the rest of the morning debating about our next move.

After quickly scoping out our nearest park, I decided that we would give it a try. My daughter couldn’t put her shoes on fast enough when I told her we could go. Before I knew it, we were walking up to her favorite twisty slide, and she looked back at me with reservation in her eyes. It felt so alien to be at a playground again, and even weirder to encourage her to climb onto the steps.  

All in all, it was a wonderful morning. She had a blast! But I was glad that I’d talked to my daughter about my expectations before we went, and about how we had to continue to be careful about keeping our distance when around others. Here are some things that I took into account before we left the house that may be helpful for you and your family.

Talk to your child about keeping their distance

Even though playgrounds may be reopening, we should be trying our best to keep a six-foot distance from others, and this can be really hard to accomplish between children at a playground! Talk to your child before you leave the house about what your expectations are, and even practice what six feet looks like. Discuss some things that your child can say if another child is getting too close, and reassure them that you will be there to help them.

Note: While you may be able to control what your own child is doing, it may be difficult to make sure other children are keeping their distance. Stay close to your child and discuss any concerns that you may have with the parents/caregivers of the other children at the playground (if it becomes problematic). If it is too difficult to keep distance, be prepared to leave.

Go during “non-peak” hours

Go to the playground when it isn’t busy, and leave (or take a snack break and come back) if it gets crowded. Though the park was empty when we arrived in mid-morning, within several minutes we were greeted by two other families. I think if we went again, I’d make a point to go earlier (since it was a sunny Saturday, after all) or maybe even a bit later in the afternoon. Keeping your distance—as mentioned above—is much easier to achieve if the playground isn’t crowded.

Take the usual health precautions

This is nothing new, but it is important to keep in mind regardless! Adults and children must wear masks when at the playground (exception being children younger than two  years old and those with health exemptions), and sanitize your hands often. Bring some hand sanitizer with you to have in your pocket, and talk to your child about avoiding touching their eyes, nose, and mouth.

Be sure to follow the signs!

Some parks may not have opened their restroom facilities yet, so make alternate plans for going to the restroom. If the facilities are open, be sure to wear your mask and try to avoid congregating in big crowds. When you are using the restroom families, take the opportunity to wash everyone’s hands! Hand sanitizer is great, but nothing beats good, old-fashioned soap and water.

Weigh the pros and cons

I had to wrestle with the pros and cons of going back to the playground and even made a few false starts before we actually made it there that morning. Even though being outdoors lowers the risks of infection, there are absolutely some risks associated with crowding and contaminated surfaces. In the end, I trust the benefits to our mental health outweigh the potential risks. That being said, I made sure to follow instructions on all posted signage, and practiced safe distancing and proper hygiene throughout our trip. I also don’t know if we will continue to go if the parks begin to get crowded. I guess I’ll make that judgment call when and if the time comes.  

Take care of yourself, and take care of others. Oh, and don’t forget the sunscreen!


Phase 3 Progress

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June 27, 2020

Please note: Phases of the Roadmap to Recovery have since changed! For updated information, go to: https://coronavirus.wa.gov/what-you-need-know/roadmap-recovery-metrics.

It’s been three weeks since Skagit County moved to Phase 2 of the governor’s Safe Start plan. Three weeks is the minimum amount of time a county has to wait before applying for the next phase. During this time, the county has to meet several metrics—the most important of which is positive case numbers—showing that it has the COVID-19 outbreak under control. Friday, the Skagit County Board of Health met with Skagit County Public Health and decided not to apply to move forward to Phase 3, because the County does not meet all the metrics.

“Of course, this is disappointing,” Public Health Director Jennifer Johnson said in a press release. “But unfortunately, we’ve seen an uptick in positive cases over the past several weeks that have prevented us from being able to move forward, per the Safe Start—Reopening Washington plan.”

In this post, we’ll take a look at the metrics the state is using and see how Skagit County measures up.

METRIC: Fewer than 25 positive cases per 100,000 people (32 Skagitonians) in the last 14 days

In order to meet this metric, Skagit County would need to see no more than 32 positive cases over the last 14 days. We’ve had 36 positive cases over the last two weeks. While we recently saw a decrease in cases, which helped get us to Phase 2 of the governor’s Safe Start plan, since then we’ve experienced a disturbing increase in the rate of positive cases.

Right now, most of our current cases are linked to extended family gatherings and celebrations, people traveling to visit family or friends both in and out of state, and we continue to see workplace transmission from worksites within Skagit County and adjoining counties. For many weeks now, most people becoming infected are of working age, born between 1970 and 2000. Positive cases usually show up about two to three weeks after exposure, and you can see the increase in cases three weeks after Memorial Day, indicating that people gathered against state and local health guidance.

“We have primarily seen cases tied to unauthorized gatherings, travel outside of the immediate community and workplaces,” said Dr. Leibrand. “It’s disappointing to see so many cases tied to activities not authorized under Phase 2. We hope the community will view this as a wakeup call and start taking the guidance more seriously.”

Below is a graph showing our County case data based on the numbers you can find on the Skagit County website. These numbers differ slightly from the state data, as Skagit County bases its case data on when the positive test result comes in, and the State bases its data on when the positive test was collected. The state also has a 6-day lag time to ensure it has all positive test results in before it publicizes its data. The state is using its own data when determining whether a county has met the metrics to move forward. While the data may differ slightly, the story told is the same: Our cases continue to rise faster than we’d like. The state shows that we have a positive rate of 27.1 cases per 100,000 Skagit County residents. Public Health expects this number to rise to 29.4 percent by June 29th and 30th, due to the six-day delay in the state data.

Skagit County COVID-19 positive case data.
Data as of June 26, 2020

Is Skagit County meeting the metric? NO

What can you do to help the County meet this metric? Minimize your risk of infection so you (and your close contacts!) don’t add to the case count. It’s not fun, but the best thing you can do is continue to stay home as much as possible. If you do go out, there are ways you can protect yourself:

  • Wear a mask (now required whenever you’re in indoors in public or if you’re outdoors in public and can’t maintain six feet of physical distancing)
  • Stay as far away from non-household members as possible (six feet minimum)
  • Wash your hands or use hand sanitizer often
  • Don’t touch your face
  • Limit the number of non-household members you come into close contact with to five or fewer per week. Any single gathering of more than five people (who don’t all live together) are prohibited during Phase 2.
  • Stay home if you’re feeling unwell, even just a little unwell, except to get tested. The drive-thru testing site in the Skagit Valley College parking lot is open Monday-Friday, 9am-4pm. Please bring your insurance card or the information from your card (plan name, group number, and individual identification number). With this information, insurance covers the cost of the test with no co-pay from you. If you don’t have insurance, the state will cover the cost.

METRIC: COVID-19 hospitalizations is flat or decreasing

Skagit County has been seeing a relatively flat hospitalization rate, between zero and three people hospitalized at any given time over the last few weeks.

Is Skagit County meeting the metric? YES

METRIC: Health care system readiness

The state defines health care system readiness as having less than 80% of the licensed beds full, and less than 10% of licensed beds occupied by suspected and confirmed COVID-19 cases. According to the state’s Risk Assessment Dashboard, 75.7% of Skagit County’s hospital beds are occupied, and only 0.6% of them are occupied by COVID-19 patients.

Is Skagit County meeting the metric? YES

METRIC: Average number of tests performed per day during the past week is 50 times the number of positive cases (maximum of 2% positive test rate)

According to the state’s Risk Assessment Dashboard, Skagit County is testing 56.8 people per positive case reported, a positive rate of 1.8%. It’s important that the county continues to test a lot of people to keep the ratio of positive test results low. Also, testing is the only way to find asymptomatic or presymptomatic people and have them isolate in order to stop them from spreading the virus to others in the community.

Is Skagit County meeting the metric? YES

METRIC: 90% of cases reached by phone or in person within 24 hours of a positive lab report

Skagit County Public Health contact tracers attempt to contact 100% of all positive cases within 24 hours of their notification of the case. Last week, they were able to successfully reach every single positive case within this time frame.

Is Skagit County meeting the metric? YES

METRIC: 80% of contacts reached by phone or in person within 48 hours of receipt of a positive test report on a case

Skagit County Public Health contact tracers attempt to contact 100% of close contacts of positive cases within 48 hours of notification of the case. Last week, they were able to successfully reach 92% of close contacts within this time frame.

Is Skagit County meeting the metric? YES

METRIC: 80% of cases are contacted daily during their isolation period

Is Skagit County meeting the metric? YES

METRIC: 80% of contacts are contacted daily during their quarantine period

Is Skagit County meeting the metric? YES

METRIC: Maximum of one outbreak (defined as two or more non-household cases epidemiologically linked within 14 days in a workplace, congregate living or institutional setting) per week

In June, Skagit County Public Health has investigated about one outbreak per week among employees at workplaces.

Is Skagit County meeting the metric? YES

Determining whether it’s safe to reopen is not something Skagit County leadership takes lightly. We’re all eager to open back up fully and return to some sense of normalcy. Skagit County is meeting most metrics—our healthcare system is prepared, our contact tracing team is absolutely incredible—but our case counts are too high for us to proceed.

“We want to reopen, but as the metrics show us, it’s just not safe right now,” said Board of Health Chair Commissioner Ron Wesen. “My colleagues and I will continue to watch the metrics closely, and consult with Public Health. As soon as we are able to do so safely, we will apply to move forward.”

It’s up to all Skagit County residents to do their part to help the county reach Phase 3. We need everyone to practice social distancing and good hand washing; we need everyone who is medically able to wear a mask, even if you find them uncomfortable (we all do!); we need everyone to limit their contact with people they don’t live with. This isn’t easy for anyone. But the more consistent we all are, the sooner we’ll be able to move on. Help us get there.


Flying during the Pandemic

Flying during the Pandemic

Reading Time: 4 minutes

Stay Home and Stay Healthy, the Washington State’s COVID-19 emergency order, began a little over two months ago. But it seems like it was a completely different time—a time without Zoom and face masks, and when five feet did not seem like an unsafe intrusion on personal space. While it has been frustrating to build new routines and redefine our “normal,” the Stay Home and Stay Healthy order is working; it is keeping us, and our community, safe. Being a Public Health employee, and knowing the importance of Stay Home and Stay Healthy, made my decision to KEEP my Memorial Day travel plans incredibly tough.

Like many others, I booked airfare and solidified travel plans in early fall of 2019. And then COVID-19 happened. Unlike many others, my flight did not get canceled. It did get rescheduled several times, but never canceled.

Picture me singing Should I Stay or Should I Go by The Clash in my head. Because that is exactly what I did. “It would be wrong of me to go,” I thought to myself. “This trip isn’t technically essential…I could risk getting others sick.” I worried and I felt guilty. However, after weighing the pros and cons, and speaking with family and co-workers, I decided that going was the right decision for me.

I knew that my travel destination/plans were fairly low risk. I would be visiting two national parks, both of which had protocols in place to keep visitors safe during the pandemic. But getting to and from my destination—spending time in an airport and on an airplane—made me nervous.

My Experience in the Airport and Beyond:

I was pleasantly surprised! When I first arrived at the airport, it was empty…or almost empty. There were a couple of people but not many. It was very easy to maintain a six-foot distance from everyone. Also, almost immediately upon entering the airport, an announcement coming from the PA system stated that “masks are required.” I took a couple more steps and saw visual signs mirroring the same message. I looked around and sure enough, most people were wearing masks. I let out a sigh of relief and kept walking.

I walked up to one of the Alaska Airlines kiosks with the intention of printing my boarding pass. It was closed, and so were the surrounding kiosks. Experiencing some confusion, I asked for assistance and was directed to a specific section of kiosks that were open and being wiped down between users. After I printed my boarding pass, I walked straight through security. Literally, there was no line. A TSA agent did confirm my identity and in doing so, I had to remove my mask. Given that there was no one around me and my mask was off for less than five seconds, I felt safe.

While sitting at the gate, an Alaska Airlines agent announced that masks are required on all Alaska flights. This message was reaffirmed by the flight attendants and we were asked to keep our masks on during the entire flight unless eating or drinking. Bottled water and a snack mix were distributed. However, no beverage or snack cart services occurred. To help with social distancing, all passengers were given an entire row to themselves unless traveling with a family member. Therefore, I stretched out, watched some Netflix and before I knew it, arrived at my destination. My experience flying back to Seattle was nearly identical.

Tips or Things to Think About when Flying/Traveling during COVID-19

  1. Plan Ahead.

While airports may have implemented strict protocol for keeping passengers safe during COVID-19, not all states have. Some states are still “open” which means people may not be taking the same safety precautions you are used to.  Research your destination and the state’s current COVID-19 plan/order. The CDC provides a list of questions to reflect on, that may help you decide if traveling is the right choice for you and your family.

If you decide to travel, protect yourself and others during your trip. Use your best judgement—social distance (keep six feet of physical distance from other), wear a mask, practice hand hygiene and cleanliness, even when others are not!

  • Be Flexible.

Airlines are doing their best to keep everyone safe during this difficult time. This may result in flights being canceled or changed. So, it is extremely important to be flexible, check your email and flight reservation regularly. My flight departure time changed three times and reduced the length of my trip by seven hours.  

Depending on the airline and your desire, you may be able to cancel your flight and be refunded, given a voucher or simply change your day/time of flight without paying any additional fees. However, this is not guaranteed.

  • Come Prepared.

Airports and airlines have implemented protocol for keeping passengers safe during COVID-19. But this does not mean that your risk of exposure is zero. Come prepared and stay safe with hand sanitizer and disinfectant wipes, a water bottle and snacks.

  • Wearing a mask was required in the airport and during my flight. Bring a mask/face covering! If you do not have a mask, come prepared to ask for one once you arrive at the airport.
  • Airport bathrooms are often spread out and hand washing stations are not always close by. Try not to touch your face. But if you are like me, and not touching your face is nearly impossible, make sure you have hand sanitizer and use it frequently! You may also find yourself sitting in a seat, or touching surfaces that have not been recently cleaned. Along with hand sanitizing, bringing and using disinfectant wipes may be beneficial.
  • Do not assume that all stores and restaurants within the airport will be open. From my observation, about 50% of them were closed. Also, the airline you are flying with may not providing in-flight beverage and snack services. So, fill up your water bottle after going through security, and bring snacks if you think you’ll be hungry.

Find more advice and Travel FAQ’s here  

Please remember:

If you feel sick prior to traveling, stay home. From my observation, airlines are being more accommodating than normal regarding cancelations, refunds, vouchers, and flight changes.

If you feel sick during or after traveling, self-isolate and get tested. If you are experiencing severe symptoms, please consult your primary care physician for advice on next steps.