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Scott Webb: Welcome to Right Beside you, a Reid Health Podcast. I'm Scott Webb. And today, we're discussing RSV, COVID and flu, what we're calling the triple-demic of 2022. And I'm here with Dr. Samuel Iden. He's the Medical Director of Emergency Medicine at Reid Health. He's also board-certified and fellowship-trained in emergency medicine.

So doctor, thanks so much for your time today. We're going to talk about the triple-demic of 2022, which for those who don't know, is RSV, flu and COVID. So as we get rolling here, why are increased cases of RSV, flu and COVID a concern? Because they're being reported nationally. We're hearing a lot about it. So from your perspective, why is the triple-demic a concern?

Dr. Samuel Iden: Lots of reasons why it's concerning. The first that comes to mind right away is obviously the ability of the healthcare system to manage large volumes of ill people that we have when you have not just one pandemic ongoing, but when you have three different disease processes that seem to storm together in a period of time so that you're battling not just one virus, you're not just battling COVID now, you're battling three viruses at the same time; influenza, which there's a couple different types of influenza within that, and COVID and RSV. The interesting thing about during the peak of the COVID pandemic, initially it seemed like everything else just disappeared. And we even commented on, "Wow, where'd all the strokes go? Where'd all the heart attacks go?" They were still there, but it seemed like COVID just dominated. And now, we have COVID plus we have really a high volume of influenza and especially RSV.

Scott Webb: Yeah, you're so right. And you would know best as someone who's on the front lines, but we found that because of COVID, maybe folks weren't going to the emergency department. They weren't going to the hospital for things like heart attack and stroke and those kinds of things. So, it seems like everything is back in full force, if you will. Plus we have these concerns over RSV, flu and COVID, and it's being reported a lot and also being reported that there's an increase specifically in pediatric patients, pediatric cases, if you will. So, why is RSV particularly dangerous for children?

Dr. Samuel Iden: So, the reason for the high volumes of RSV this year, nobody exactly knows. We'll go from year to year with sort of fluctuations in the severity of the RSV season, heavy years, light years, that sort of thing. They think, the scientists are thinking that it's possible that we've got a heavier than usual season this year because there were so many children that were sort of protected by the isolation that we had with COVID. So, you can get RSV at any age, but it is the very young children that are hit the hardest with RSV. And a lot of it has to do with just simply their small airways, their small bodies, their small lungs, being able to handle the virus and the infection and the secretions that come along with it. But the children very most at risk are those that are really essentially less than six months, less than three months, particularly those that are less than three months and who were premature. Those are the children that we worry the most about with RSV. But like all of these diseases, at any age, depending on your immunosuppression status can cause problems, but RSV is the biggest problem in small children.

Scott Webb: Yeah. And so with that in mind, for those of us parents, my children are older, 14 and 19, but for those of us with three-month olds, six-month olds, little ones with the little airways and all of that, what symptoms should we be on the lookout for? How can we tell if a child is struggling?

Dr. Samuel Iden: Put simply, it looks like they've got a cold. Initially, you'll see runny nose. They may have a decreased appetite. If we're talking about the smallest children here, those that are less than six months of age, you know, they can't tell you, "My body hurts. I've got body aches," right? But what you can tell is that they're fussier than usual. They're grumpy. They don't want to eat as much. Maybe they've got a fever. They've got a little bit of a cough. But certainly, they've got that runny nose and congestion. It seems like when they're trying to take that bottle, they're struggling with the secretions in their nose, coughing for sure. And then if it gets a little more severe, you'll notice a worsening cough and wheezing. Those are the most common things that you'll see. And it should be remembered that most children will do fine with this. But those are the symptoms that you're going to see initially.

Scott Webb: Yeah. And I think that's one of the complicating factors here for us as parents and as adults, is RSV, COVID, flu, they can all sort of manifest or present in a similar way, or they share symptoms. Is that one of the difficulties for us and also for providers, is to figure out which one is which?

Dr. Samuel Iden: Oh, absolutely. If a child presents with those symptoms I just rattled off, it could be any one of the three. And that does pose somewhat of a challenge, sort of the silver lining of that, however, is that really the management upfront for most children and adults is going to be very similar. There are some medical treatments that we can get to later that may vary a little bit. But for the most part, for most children, whether it's influenza or whether it is COVID or whether it's RSV, it's mainly supportive care, the old grandma's chicken noodle soup and pushing the fluids and controlling the fevers and these types of things. But you are exactly right, it can be very challenging to know which disease you're dealing with. Even more challenging though, regardless of the disease is the question of how sick is this particular child going to be? Knowing that the vast majority of children do fine with RSV. It is still true that one to two children out of a hundred will end up hospitalized. So, I mean, one to two out of a hundred, that's a real number, right? That will end up getting sick enough to where they have to be in the hospital. So, that's the real challenge, whether it's COVID or whether it's influenza or RSV, is looking at a patient and trying to figure out is this one of the patients that's going to do great and fly through this without any trouble? Or is this going to be a child that in 48 hours from now is going to be struggling ?

Scott Webb: I certainly don't envy you and other providers, because it sounds, as you say, the management is pretty much the same for all of them. But you're also being asked to look into a crystal ball and say "Hmm, is this going to be the one or two out of a hundred that ends up in the hospital or not?" That's really challenging for you, I'm sure.

Dr. Samuel Iden: It can be. The thing for parents to remember is if your child is very young, if they're under two months, or your child was a premature baby, those are high risk kids. If your child has known lung disease or known heart disease or if you are a patient who is a transplant patient or undergoing chemotherapy, you automatically go into different categorization of concern.

Scott Webb: Right. I've got a really loaded question for you, doctor. And it's one, I think, that's still on all of our minds. You know, I got my booster shot recently and I sort of walk around and I see some people with masks, other people not, I'm still using sanitizer like it's my job. I guess really boil it down, is COVID still dangerous? Is it something we still need to be, you know, hypervigilant about?

Dr. Samuel Iden: Yes, it's still dangerous. I don't know that hypervigilant is the right word. I do think vigilance is called for. I think all of these have potential to be dangerous. And it really frustrates most of us in the healthcare field that this all became so politicized. To get a little more specific, we at our hospital, and most hospitals, have adopted a sort of a three-level masking policy depending on the prevalence of COVID in the community. Inside of that, so if we have a lower community prevalence, then we'll be without masks. And we get into a yellow area, then we'll wear masks in patient-facing areas only. And then, red is all masks all the time. Inside of that, we will have individuals who choose to wear a mask all the time, and it's become more accepted that people are walking around with masks on.

Certainly, I'm battling a little bit of a cold right now. When I go back to work, I'll follow the policy, I'll make sure I'm 24 hours without a fever and my symptoms are improving. But for the next week, even though we are not an all mask all the time policy, I personally will be wearing a mask to protect others because, even though I'm feeling better and I don't have a fever and the CDC says I can go back to work, the CDC also recommends you should probably wear a mask for the next several days. So yes, we should be wearing masks when appropriate. But I don't think we're at a place where we should be scowling at that person who's not wearing a mask.

And I would say the same is true for vaccination. The nice thing about both influenza and COVID is we have a vaccine for both of those, and I would strongly encourage those who are able and willing to get your flu shot and to definitely get your COVID booster. There's still this common misconception that floats around out there. Grandma got a flu shot and she got the flu the next week, and it's because they gave her that shot. And I will reassure folks that does not happen. You do not get the flu from the flu shot. It is a safe vaccine. The COVID vaccine has proven to be safe in over millions and millions of people. So, these are safe vaccines. And unlike RSV, we have some prevention for both of them.

Scott Webb: Yeah. And unfortunately, doctor, I'm old enough now to start thinking about whether or not I should get the shingles vaccination. You know, I'm in my 50s now, and I've never thought about shingles before. I'm like, "Geez, how many vaccinations can one person get?" But that's perhaps a different podcast. But you mentioned the CDC and recommendations and things. So, maybe you could just kind of go over this, how long should we or children stay home if we're sick, so that we can do our part to reduce the spread?

Dr. Samuel Iden: Great question. Generally speaking, the CDC has pulled back considerably from when we were in the throes of the COVID epidemic. Initially, there for a while, you had to stay home for two weeks. We're not there anymore. We're more now in a five to seven-day isolation recommendation. The main thing is that you need to be at least five days removed to seven days removed from the first onset of your symptoms, and your symptoms have to be getting better, and you have to be at least 24 hours without a fever without using fever-reducing medication. So, it doesn't count if you took some Motrin and you didn't have a fever all day. Well, that may have been suppressed by the ibuprofen that you took. So, you need to go at least a full 24-hour period without having a fever. And you need to be about seven days out from the onset of your symptoms.

One thing that frustrated individuals during the COVID pandemic is there was so much press put on it and so much of a microscope that the general public is not used to the way medicine and science works where these things get changed frequently because we get more information and we get more data. So, I would encourage individuals what I say today may be different, you know, in a few weeks as we learn more about the virus and about it, how it acts. So, try to stay a little bit up-to-date with credible resources such as the CDC and what their recommendations are.

Scott Webb: Yeah, that's great advice from an expert. None of us have ever lived through, or most of us anyway, have never lived through something like this, a pandemic with masking and all of that. And things change. Sometimes at times during COVID, it seems like they were changing minute by minute, day by day. And hopefully, we've all learned to just be a little bit more flexible, you know, and understand that we have to rely on the expertise of experts and the CDC and so on. You touched on earlier the difference in treatment. So, we talked about management is similar, but maybe you could talk about the different treatment options for RSV, COVID and the flu.

Dr. Samuel Iden: So again, primarily for all three of them, care and treatment is relatively supportive. That is for fevers and body aches, we're using ibuprofen or acetaminophen as needed. Let me take RSV first for small children. For there, you just want to make sure that the child is staying well hydrated. For smaller babies, a bulb suction to get the mucus out of the nose, so they're better able to breathe, especially while they're feeding. Pushing the fluids.

The fever itself shouldn't be a huge concern. They will have a fever, but that's the natural course of things. Oftentimes, I'll have mothers who are worried to death about that number, and we don't worry so much about that number as we do how the child is looking and how the child acts, and is the child feeding, is the child wetting diapers and doing all the things that little babies do. So, a fever of 102 shouldn't cause a mom or dad to totally freak out. And a little bit of children's acetaminophen, and if it comes down a little bit and the child acts a little better, that's great. But mainly, it's rest, hydrate, give it some time.

Now with RSV, there is one medicine for very high risk babies. Babies who were premature. And I would encourage folks, if you have a very young infant, less than a couple months old, who is premature, you talk to your primary care, your pediatrician, about whether or not your baby is one that would be a candidate for this medication that can help prevent. It has not been clear to use in everybody, but it's something to talk about to your primary care, your pediatrician.

Influenza, very much the same as far as care. It's supportive care. You know, you stay home and you don't give it to other people,

Scott Webb: We hope, yeah. Right.

Dr. Samuel Iden: And you know, that's coming from someone who has struggled with that, with COVID and with influenza, I've always been a person who'd go to work, right? And that's the way I grew up. I know that's the way a lot of people grew up. It's a cold, you go to work. Well, yes and no. If you got to think about that coworker that you have, if they have a family member at home that's immunosuppressed, what are you doing for them? So, be smart going back to work too early and not spreading it around to others. But as far as the actual care at home, it's fever-reducing medicines like acetaminophen or ibuprofen along with pushing fluids to stay hydrated. Rest, get plenty of rest and just keep an eye on respiratory symptoms and making sure that everything is flowing in and flowing out the way it should be.

COVID, very much the same. Obviously with COVID, the thing we're looking for most of the time with COVID is respiratory complications. Same supportive care, but what you're watching for am I starting to have more trouble breathing? Am I short of breath when I shouldn't be short of breath, sort of above and beyond the norm? That's when you should be seeking care.

A common question I get in RSV with babies, is when do I know when to go to the emergency department? And that's tough. It's important to know with RSV that usually children get worse on day three or day four of illness. So, be ready for that. And certainly, if it seems like your child is struggling to breathe and they have what are called retractions, that's when sort of the skin and tissue pulls in between the ribs with every breath, or it seems like they have what you call seasaw respirations where, as the stomach rises with the baby trying to breathe, the chest sinks in. Or if you see above their clavicles or collarbones, it's pulling in with every breath, that's a sign that a child is in some distress and, absolutely, you should seek medical care. And those are kids, you don't wait, you go to the emergency department for something like that. If they're retracting and they're really working hard to breathe, hey, I hope you come to the emergency department and we say, "No, it's fine." But don't sit at home with a child that looks sick like that.

Scott Webb: Yeah. It definitely falls under the better safe than sorry. So yeah, if we go to the emergency department and we get the all clear, great. No problem. Absolutely just great advice today and I really appreciate your time and your expertise. And again, another one of these sort of million-dollar questions, and we've touched on some of it here, but from your perspective, any tips on preventing RSV, COVID and the flu?

Dr. Samuel Iden: Wash your hands.

Scott Webb: I like it.

Dr. Samuel Iden: Yeah, I think what we were just talking about primarily is, hey, if you're sick, don't go to work. And be understanding of coworkers who call in with a viral illness. We want to try to control all of these All of these are shared through sharing utensils. You know, I have a busy family. I'll leave my glass of tea on the countertop and my son will come by and grab my glass of tea and drink after me. I mean, these are the ways that viruses are spread. So, hand washing is hugely important.

I would encourage, this is kind of getting out there a little bit, but if you've got a brand new baby, the fall and the winter is not the time to take that baby out to show everybody and pass around at church and that sort of thing. I think you're just asking for trouble. And I'm not trying to be a sort of a buzzkill with that. I think it's so exciting to bring home a new baby. But in the fall and the winter is the time just maybe to be a little selective about what kind of exposure you're putting your children in front of. Just be wise. Be smart about that. Hand washing, I can't say that enough.

Most of these things, all three of the ones we're talking about today, you do a good hand washing and that gets it off of your hands. Avoid contact with sick people the best you can. That's hard when you have little children. If you've got a newborn at home and then a three-year-old, if that three-year-old has a snotty nose, the three-year-old shouldn't be giving the newborn a big kiss on the cheek. You know what I mean? That's just common sense things.

Scott Webb: Yeah.

Dr. Samuel Iden: In the moment, you feel bad about putting a stop to, but it happens.

Scott Webb: Yeah, it definitely happens. Well, this has been great today, doctor. You know, we prefaced this by talking about the tripledemic of 2022 and I don't want to scare anybody, but these things are real. They're happening, the RSV, flu, COVID and there are things that we can do to try, as you say, wash our hands to prevent the spread. Also, if anyone in our home, children or otherwise get sick, obviously there's, you know, recommendations for that as well. So, great to have your time. You stay well. Thanks so much

Dr. Samuel Iden: Thank you very much.

Scott Webb: And if you have additional questions or concerns, as always, contact your family doctor. And if you found this podcast helpful, please do share it on your social media. And thanks for listening to Right Beside You, a Reid Health podcast. Hoping your health is good health. I'm Scott Webb.