Scott Webb (Host): The viral trifecta of COVID, flu, and RSV are on the minds of many, especially medical providers, who are on the front lines, like Dr. Jaime Gonzalez. He's here today to share the latest on all three, their respective vaccines, and his hope that we can share kindness, not diseases.

 This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb. Today, we're going to talk about the viral trifecta, which, you know, sort of sounds like some sort of action film or something, but this is not a film we want to see. None of us want COVID, flu or RSV. So, it's good to have you on and talk through some of this stuff. And, you know, we're heading into the cold and flu season, as I was mentioning before we got going here, and we're also worried about COVID and RSV, so that trifecta, if you will. So, let's start with RSV. What is that? What can you tell us about the virus? Are some folks more at risk than others?

Dr. Jaime Gonzalez: As the name suggests, RSV or respiratory syncytial virus is a virus that, you know, primarily attacks the respiratory organs, such as the lungs, which often cause difficulty breathing, coughing, congestion, due to the blockage of the airways, as well as, you know, runny nose, pink eye, ear infections and most commonly occurs between October and April or May. It's usually the season for RSV, with a peak around January or February. And it used to be that almost all children were infected by the age of two, although that kind of changed during COVID because people were wearing masks. And so, those children weren't getting any RSV or any type of virus. But then, once we saw people relax a little bit, we saw a decrease in masking, all that stuff, all the protective factors, RSV has returned again.

The groups that are at risk of getting it, certainly everyone. But, you know, infants younger than six months of age, we want to be careful with, those attending daycare or those infants with older siblings who may have the virus but do not necessarily have symptoms. We also want to be especially careful with children and infants with underlying lung diseases, such as cystic fibrosis, asthma, et cetera; those with heart disease, Down syndrome, or any type of immune deficiency. And then, and this is personal, too, because, infants born before 35 weeks of age, and we just had two twin babies last year who were born at 34 weeks, so we were especially hunkered down.

Host: I'm sure.

Dr. Jaime Gonzalez: And then, individuals of any age, you know, that have lung disease, such as asthma, COPD, or those exposed to secondhand smoke or heart disease as well as older adults that live in nursing homes. Those are the groups that are most vulnerable to this virus.

Host: Yeah. So, a lot of folks at risk, especially babies, folks with preexisting conditions. So, a lot to take in there. Wondering how similar or different it is from influenza and COVID-19. It's one of the things that I envy the least about healthcare providers, is trying to diagnose these things because it feels like they all kind of have the same symptoms. So, maybe you can take us through that. How do you differentiate RSV from flu, from COVID and everything else everybody gets?

Dr. Jaime Gonzalez: Yeah, it's very difficult. All three can certainly, you know, as we know, cause severe lung disease, especially in vulnerable groups. As I mentioned earlier, all of them obviously are also transmitted from people to people. and it takes about a couple days for the symptoms to happen from the time of infection. But again, the symptoms can be very similar in terms of breathing issues, in terms of difficulty breathing or cough.

With COVID and the flu, really, it's more of a systemic type of illness. It affects more organs other than the lung, which is worse. RSV is primarily isolated to the lungs or the respiratory tract, so runny noses, breathing issues. And then, you know, COVID and flu cause more, you know, weakness, fevers, things affect more the body.

Major differences in terms of difference between RSV, COVID, influenza is the way that they get transmitted. COVID, as we've seen, is a lot more contagious in the fact that it's airborne. So, what that means is that the droplets are smaller. It can be suspended in the air for longer, so it's easier for people to get it versus both influenza and RSV are more larger droplets. And what that means is that it doesn't get suspended in the air as much. So usually, you get it from direct contact with other people touching the same surfaces and just contact with the same boogers, if you will, or saliva. And so, those are the major differences between them. But again, it's mostly the fact that COVID and flu affect other organs such as the heart, the brain, digestive system that we don't see in RSV.

Host: Yeah. I see what you mean. Now, I know there's vaccine for RSV. Who can and should be vaccinated against RSV?

Dr. Jaime Gonzalez: Right now, as it stands, there's two groups that are eligible for the vaccine. One group is individuals older than 60 years of age, obviously for the prevention of respiratory disease or any severe disease. In older individuals, the early results are that it shows about a 67% to 82% effectiveness. And then, the second group is pregnant women between 32 to 36 weeks of pregnancy. And it has shown some protection primarily to the infant up to about 6 months after birth.

Host: Yeah. And you mentioned that especially the newborns up to six months are especially high risk, so that makes sense. And this would be a nightmare scenario, doctor, but can people get COVID, flu and RSV at the same time? Is that a thing? Is that possible?

Dr. Jaime Gonzalez: While not common, it is certainly possible. I've seen it maybe twice in the hospital, but they affect the body in different ways and attack different parts of the body. So, certainly, you know, having a similar route of transmission through the nose, through the breathing, can cause someone, you know, technically, to have all three viruses. And especially if somebody has those three, can then transmit it to other people.

Host: Yeah. That's just as we were saying, this sort of viral trifecta. I mean, no thank you, and I'm sure we all feel the same way. So, glad to hear that the incidence of that are, you know, are relatively low. Just wondering, if a person goes to urgent care or the ED with symptoms, do you just automatically test for all three? Has that become a thing where you just sort of, you know, like I know when I've taken my kids for strep throat test, they test for everything, flu, strep, COVID, anything they can possibly test for with that swab. In other words, you know, then if you are testing for all of them, how do you determine which one it is?

Dr. Jaime Gonzalez: Yeah. I think one of the things that came out of COVID is that, believe it or not, it has been a little bit easier to test for things. We have a low trigger to test for different viruses. The testing method is similar. You know, we use the swabs, nasal swabs. We use similar, they call it PCR techniques to test for the virus. But, you know, it depends, and I always do this with any type of illnesses and when I see patients, is it going to change the management or the treatment plan? So, you know, in the hospital, someone's showing symptoms of a respiratory virus. We can either test for COVID because it's faster and it's quicker. And then if it tests negative and we still think that there's some type of viral illness going on, we would do a respiratory panel to test for all kinds of viruses like rhinovirus, RSV, all of that, but in the sense that if we think it's going to change anything, right? With there being so few limited treatment options for all three viruses, and especially with varying degrees of effectiveness, if a patient's going to do well and they're low risk and, you know, we send them home, usually the treatment is just supportive care, which, you know, rest, hydration, for all three viruses. And individuals, you know, with higher risk of severe disease, vulnerable groups, if we think that they're going to be admitted to the hospital, or if they're going to have a severe disease, we test for all three or different types of viruses. So for example, someone is at risk for severe COVID, we test them. And it turns out they do have COVID, then we can start Paxlovid on the outpatient side or, you know, remdesivir on the inpatient side. But then, that makes a difference, right? Because if somebody has the flu, we have Tamiflu. And unfortunately, we don't have an effective treatment for RSV yet. That's sort of how it would change the management.

Host: Yeah. As you say, like the best defense against RSV is the vaccine. And with the others with COVID and flu, you have some options. And I know we've had the COVID vaccine since like, what, late 2020. And I know there's a new vaccine or new booster. So, how does it differ? And we think about the new strains, is it focusing on something different and do they think it's going to be as effective as previous boosters or vaccines? It's so many things swirling around in my head. But basically, what do you think about the new booster and really, who should be receiving this vaccine?

Dr. Jaime Gonzalez: Yeah, I mean, the new booster was re-modified to target the mutations of the newer variants. Right now, the current one is targeting the Omicron variant. And it also includes all the previous strains that we've had.

Host: So, sort of backwards compatible if you will.

Dr. Jaime Gonzalez: Yeah.

Host: Okay.

Dr. Jaime Gonzalez: Yeah, in the IT world.

Host: That's what I was thinking. I was thinking about well if you buy a Blu Ray player it still plays DVDs. So if you get the latest, greatest COVID booster, then it covers what's current, and then the previous ones, hopefully.

Dr. Jaime Gonzalez: Yeah. They just introduce a new spike protein that is what the virus attaches to. So, you know, it's recommended for everyone right now six months and older, again, especially the ones who are at higher risk of severe disease, 65 and older, immunocompromised, chronic medical conditions.

Host: I want to find out how things are going in the area there at Salinas and Monterey, are cases going up? How are the hospitalizations? Are folks being affected? You know, the long haulers, long COVID, are you still seeing cases of that as well?

Dr. Jaime Gonzalez: Yeah. I mean, we're getting a sense that the COVID cases are going up just from-- I know for the past two or three months, we were getting an increase in hospitalizations and people with COVID as well as presenting to our ED. It's sort of calmed down a little bit from that, from what we saw about two months ago. But, you know, we don't have an exact number nowadays because people are self-testing at home and those don't get reported. We are seeing some people with prolonged disabilities, some with chronic breathing issues. We get patients who had some mild dementia, and then COVID just kind of tipped them over the edge and now it's like full-blown dementia. Those are the type of cases I'm seeing in terms of long COVID in the hospital. But, you know, I work on the inpatient side, I don't interact much with the outpatient side. But from the inpatient side, from what we've seen, yeah, the people are weaker, you know, people that have had COVID are a little bit just fragile.

Host: Yeah. It feels like we've been living with this and dealing with this for so long. But in terms of viruses, and infectious diseases, it really is nothing in terms of the duration of this. But we've never defeated influenza. We've never defeated the flu long term, and I wanted to circle back to that because I know that influenza can kill, right? So, I'm wondering who should be vaccinated for the flu virus? Is it six months and older, pregnant women, all the above? Who should get that vaccination?

Dr. Jaime Gonzalez: Yeah, pretty much all of the above.

Host: All the above? Yeah.

Dr. Jaime Gonzalez: Anyone over six months old, we think you know everyone older than that should get it to just help reduce the symptoms, reduce the severity of it, especially, you know, with the possibility of the other viruses lurking around and wreaking havoc while your body's trying to defend itself against the flu. Anything you can do to prevent severe disease will help, as we have seen with other viruses. And this is especially true in the same groups, you know, that are higher risk.

Host: Yeah, I wanted to ask you, as we get close to wrapping up here, I think I've heard this, I don't think I'm imagining this, that you can get the COVID and flu vaccines at the same time, though not recommended for the same arm necessarily. But I wanted to speak to an expert about that when we think about folks who want to get all three, one-stop shopping, how, when, which arms, all that good stuff.

Dr. Jaime Gonzalez: Right now the Advisory Committee and Immunization Practices, the ACIP, they're recommending to get as many vaccines as possible at once if you can. It's not so much because it's more effective or less effective one way or another, but primarily to just make it easier for everyone to get the vaccine in one sitting instead of having to schedule these out at separate times. And then, some people don't like feeling sore from the vaccine or how it makes them feel, so if you can kind of just do it all at once for the convenience sake. For some people, spacing them out makes more sense and so whatever it takes and whatever makes it more likely for you to get vaccinated. Everyone is different and has different ways of convincing themselves to do something. So if one way works better for you, then do it that way. As long as you get the vaccines is what we're recommending.

Host: Yeah. I had one expert on who said that there's some recommendation that if you normally have been getting your COVID shots in your right arm, maybe switch to your left arm for this latest booster. But she admitted that there's no real science behind that. It's just something people are saying. So as you're saying, you know, whatever works for you, if, people like to spread out the pain, if you will, fine. If they want them one-stop shop, that works too, right?

Dr. Jaime Gonzalez: Yeah. For me, it's like, I know the COVID shot is a little bit more painful for me than the flu, and so I put that one on the arm that I use less.

Host: I just want to give you a chance as we wrap. Just final thoughts, takeaways, the viral trifecta and what we can do to try to protect folks.

Dr. Jaime Gonzalez: Yeah. I mean, I said this during COVID, and I'll say it again with these respiratory viruses, let's remember to be mindful of our loved ones or friends, neighbors, fellow human beings that, you know, we don't know how someone else will react to an illness. And so if you're sick or if you tested positive for any of these viruses, please avoid close contact with others to prevent that other person from getting sick. That to me is kindness and I know that there was some maybe families restrained because of it. But, you know, as a practicing physician in this community and having master's in public health, I'm a big fan of spreading kindness, but not diseases, so if we can just be mindful of others.

Host: I love that. That should be on a t-shirt. All props to you, but spread kindness, not diseases. That is just so perfect. Great way to end this today. Thank you so much. You stay well.

Dr. Jaime Gonzalez: Thank you for having me.

Host: And if you found this podcast to be helpful, please be sure to tell a friend, neighbor or family member and subscribe, rate and review this podcast and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well and we'll talk again next time.