How to form a COVID-19 social bubble

After months of quarantine, Americans are inevitably craving social interaction.

Forming a COVID-19 social bubble, also known as a pod, or a "quaranteam," is a huge topic of conversation as we try to stay safe while simultaneously doing more.

"Caution fatigue or quarantine fatigue is real, so bubbles take into account what is reasonable, feasible and sustainable," explained Melissa Hawkins, an epidemiologist at American University. "Social bubbles are a middle-ground approach that expands social interaction and contains risk by limiting exposure."

It's a simple concept in theory. You agree to only have contact with a small group of others and practice social distancing with everyone else.

"The idea is to break transmission chains in the population, so that nobody within the bubble gets infected, or, importantly, if somebody within the bubble is infected the disease does not travel into the wider population," said Per Block, a research lecturer in Oxford’s sociology department, who published a study this month about the effect social bubbles have on flattening the curve.

In practice, social bubbles are complicated, experts say, and involve intimate and ongoing communication between bubble members.

Tara Kirk Sell, a professor at Johns Hopkins Bloomberg School of Public Health, is familiar with the delicate balance.

"It's basically impossible to live a zero-risk life," Sell said. "An appropriate response to COVID is about shaping our risks and the risks we bring to others around us, within the context of our priorities and life situations."

For Sell, that meant enrolling her son in a small outdoor camp and her daughter in a small day camp. It also meant forming a "quaranteam" with two other moms and their families, who similarly have outside contacts, mostly around childcare.

"My personal bubble is a bit 'leaky,'" she conceded. But for Sell, a leaky bubble was more sustainable than cutting off ties with the outside world.

"COVID-19 isn’t going away," she added. "We need to figure out how to manage the next year or more in responsible ways that still allow us to maintain the important components of our lives."

Those choices come with sacrifices. Having a leaky bubble means that Sell plans to refrain from some interactions she participated in pre-pandemic.

"Neither my husband nor I will get to see our families this summer because we don't want to get our parents sick," she said. "If my parents lived with us, I'd choose a different route."

Most importantly, social bubbles aren't impenetrable, experts say. You should still practice social distancing with those outside of your bubble, wear a mask when social distancing is not possible and wash your hands.

With those caveats in mind, here's how to start a social bubble, maintain it, and when the time comes to say good-bye, exit gracefully:

If I have children, can I "double bubble" with another household with kids?

Sell: Yes. As a parent myself, I think that getting together with a household of kids of similar age is a good idea for sanity as well as child social development. It’s best if everyone has a similar approach to protective measures like mask wearing, a comparable numbers of contacts and the same risk tolerance, so things don’t get awkward when someone wants to go on vacation for the weekend.

Carolyn Cannuscio, director of research at the Center for Public Health Initiatives at the University of Pennsylvania: Assuming your bubble limits outside contacts, ideally for two weeks before entering this arrangement, then it should be relatively safe to include people of various ages. But maintaining distance from the world outside the bubble will prove challenging for many people. Adults may have to report to the workplace, teenagers could be congregating with friends or people of any age may have to visit a doctor's office or hospital.

Hawkins: A double bubble can be a great approach to support child care needs for parents, especially now that school is out and camps aren’t happening in most areas. We choose to bubble with another family who have kids the same age as ours and the kids go between the houses. It’s important to think about parenting styles in this arrangement; you are essentially agreeing to co-parent.

Can I bubble with more than one household?

Cannuscio: Yes. In general, the fewer people involved, the easier it will be to manage the agreement, communicate and limit exposures to people outside the bubble. Smaller is therefore likely to prove safer.

Sell: Yes. The same rules as apply. And it’s important to remember that the more people in the bubble, the more opportunities there are for increases in contact outside the bubble. Those with lower risk tolerance might not want to do this.

Hawkins: It’s advisable to limit it to one other household, a double bubble, rather than multiple households. But it does depend on the number of people in the household. Three single households is not the same as three households of four people each. More people creates more links and opportunities for exposure rather than a closed loop.

Can my parents who are over 65 be in our bubble?

Sell: People who are forming a bubble that includes people over 65, or those at high risk, should consider a smaller-sized bubble with a very cautious approach to any possible outside contact. The risks are so much greater if these individuals become infected. The older the grandparent or the more institutional the living situation they are in, the more caution is required. Contact with grandparents in nursing homes seems pretty high risk to me.

Cannuscio: Some families may be able to limit their bubbles safely to include their immediate household, with children, plus grandparents. In order to do this, quarantine strictly for two weeks before linking your households and then remain diligent about limiting outside contacts. If the bubble should burst (for example, if a family member has to have a medical procedure), then I would recommend separating again, quarantining and starting over. Our family has opted for this model, of limiting all of our contacts with the outside world so that we can visit with my mother. Our lives have improved immeasurably as a result. But this would be unsustainable if our four children were to return to in-person schooling in the fall.

Is it safe to "bubble" with another household if a member of that other household is an essential worker?

Cannuscio: Our family struggles with this. Many of our dearest friends are health care workers. We look forward to summer walks outside with them to ease the pain of months apart. But it will be a long time before we return to the familiar comforts of meals cooked and enjoyed together in our homes. This is a painful loss for so many people.

Sell: This is a higher-risk bubble, especially if the essential worker expects to come in contact with people who are infected on a regular basis. This doesn’t mean that they should be excluded from social interaction, but households with high-risk members might decide that this isn’t the right situation for them. These essential workers may want to have a smaller bubble to lessen the number of people who would be affected if they were to become infected.

How do we establish guidelines for the bubble? Can we let common sense prevail instead of setting specific rules?

Sell: It’s best to be upfront about what level of contacts you expect to be having and share information on who your other contacts are. Transparency is key, as well as establishing shared expectations.

Block: Set ground rules together, since your idea of common sense might not be the same as my idea of common sense.

Hawkins: You are agreeing to enter a social contract. Some may want to write up a contract and have bubble members sign their agreement, others may prefer to have daily check-ins to keep communication open. It’s up to group members to agree on the "house rules." Bubbles are also about support, compassion and mutual understanding, so having those conversations, even if they are difficult, is important to do from the very beginning.

If I'm single, or don't have children, what's the safest number of people to have in the bubble?

Block: In principle, there is no precise number that is best, but the larger the bubble, the riskier it is that somebody contracts the disease outside of the bubble and could spread it inside. Three small households in a bubble can still work, if the bubble has exclusive membership. I would pay attention to official local health guidelines on the size of your bubble, if such a recommendation is available.

Cannuscio: Smaller numbers are better. We are trying to limit the number of people we come face-to-face with and limit the number of social connections across networks. Those are the bridges that allow the virus to travel from group to group.

Sell: If there was such a thing as a truly impenetrable bubble, then it wouldn’t matter how many people were in it. But realistically, there’s always at least a limited amount of outside contact. The fewer the number of people, the lower the risk. I think that the best thing to do is to create a bubble that is sustainable going forward – that size depends on the individual.

Hawkins: You want to have a total of 10 people or fewer. It needs to be feasible and agreed upon by all, so that bubble behaviors can be sustained over a longer period of time.

I live alone. Can I have a social bubble with people who aren't in my household?

Sell: Yes.

Cannuscio: Yes.

Hawkins: The idea is to create a closed bubble loop. Each individual in the bubble has contact with each other but no one has contact with people outside the bubble.

Can we share food and use each others' bathrooms? Can we get within 6 feet of each other? Spend time indoors? Hug?

Block: You can interact with the people in your bubble the same way you did before COVID.

Cannuscio: Within the bubble, assuming outside contacts are strictly limited, members of the bubble should be able to interact freely. Any illness? Dissolve the bubble and start over!

Hawkins: You still want to be mindful of good health and hygiene practices, but yes, you can hug and be indoors together and play games. Think of it more of an expansion of your household than an expansion of things you can do.

Which questions should I ask people in my bubble who I don't live with?

Hawkins: Start by talking about common activities like grocery shopping. Are they doing it all online or going to the grocery store? Are they comfortable with restaurant dining, only outdoor dining or only curbside pickup? How do they feel about outdoor activities? Then tackle more complex issues, like summer travel. You need to buy in from every member of the bubble in order for the bubble to be effective.

Cannuscio: Ask about face-to-face interactions with family members, friends and neighbors. Ask about whether they're required to work at the office or whether they can work from home. Ask about their views on masks and physical distancing. Ask what scares or concerns them in terms of their own risk of viral exposure or transmission. Ask how they will get necessities like food and medicines. Ask how they are tolerating so much time alone and whether they've been socializing. Ask what the country "reopening" means to them and how reopening might shift their behavior. Ask what would make them want to "break up." Most importantly, ask yourself these questions. Give transparent answers to your friends and loved ones. The bubble is too fragile to carry secrets.

What if I'm worried that someone in my bubble isn't adhering to the rules we set together?

Cannuscio: Then this is not the bubble for you.

Sell: If you don’t trust the people in your bubble and you think that the level of risk is too high for you or your family’s risk factors, then you should find a different situation.

Hawkins: Their behavior impacts your health and vice versa. If you don’t trust a person before joining a bubble, that's probably a red flag that you won’t feel comfortable trusting them in the bubble.

How do I say no to a bubble but preserve the relationship?

Cannuscio: Tell the person how much you love them and explain that you are focused on protecting a specific person. All of your decisions are guided by that right now. Make a plan to connect at a distance. Write an old-fashioned letter. Drop off a batch of cookies. Call.

Sell: Say that you aren’t at the point where you are comfortable increasing your contacts and you look forward to getting together when things settle down.

Hawkins: The same rules for good communication apply here. Be honest and direct and considerate of others' feelings. I think it’s better for the relationship in the longterm to acknowledge that a bubble may not be the best idea, instead of having it not work out and causing harm to the relationship.

What if I make a mistake and break social distancing? Do I have to come clean to my bubble?

Block: It's probably a good idea, since the whole system is built on trust to others in your bubble.

Sell: Definitely. Don’t be that jerk.

Cannuscio: Have you heard the expression, "You're only as sick as your secrets?" Your secrets can also make your bubble-mates sick. Presumably you bubbled with them because you love them. Show your love by talking openly and often.

Hawkins: This is an opportunity to talk about hard things. This is a shared experience. Talk about the challenges and any missteps.

Any additional tips for building an effective bubble?

Hawkins: It’s useful to think of an effective bubble in terms of risk management and supporting adherence to guidelines. You're moving from an all-or-nothing approach to a balanced approach. It’s also an opportunity to strengthen communication in relationships. I think an effective bubble needs to be framed within context of kindness and mutual respect.

Cannuscio: Establish routine check-ins. Set some dates to re-evaluate whether the bubble is working. Maybe even set a trial period of a week or two, so that you can exit gracefully if it's not working. If you have a feeling it's not right, be brave and get out before things fall apart.

What to know about the coronavirus:

• How it started and how to protect yourself: Coronavirus explained
• What to do if you have symptoms: Coronavirus symptoms
• Tracking the spread in the U.S. and worldwide: Coronavirus map

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