Common winter illnesses can be tricky to tell apart

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center.

I'm your host, Amber Smith.

When someone is sick this time of year with a cough, maybe a fever, maybe body aches or congestion, it's tricky even for doctors to tell whether it's COVID or the flu or something else. Here to explain is the chief of infectious disease at Upstate, Dr. Elizabeth Asiago Reddy.

Welcome back to "The Informed Patient," Dr. Asiago Reddy.

Elizabeth Asiago Reddy, MD: Thank you, Amber. It's great to be here.

Host Amber Smith: Let's first talk in the aggregate about how each of these respiratory diseases are distinguished. Do you want to start with COVID?

Elizabeth Asiago Reddy, MD: Sure. So I think the important message here is that it's actually testing that really allows us to distinguish these viruses, one from the other. The symptoms between them are so similar that for any given patient, we really can't guarantee what they might have just based on their symptoms. So it is testing that allows us to distinguish them.

Host Amber Smith: Does it matter then if it's COVID or flu or whatever? I mean, are they all treated the same?

Elizabeth Asiago Reddy, MD: Great question. When I talk to my patients, and they call into our practice, saying, "I feel sick. I have an upper respiratory infection," I'm trying to figure out whether or not I should bring them in for testing or what kind of testing they should have. And the few things that I think are especially important are, do they have something that I could treat?

OK, so that's No. 1. And we do have some treatments for COVID and flu, so that's one thing that I might want to find out in order to determine whether or not they're a candidate for treatment. And then also, are they around people who might be at high risk if they were to have specific infection? So let's say that I know my patient is a caregiver to their elderly parent, and now they're telling me, oh, they have these respiratory symptoms. So not only am I thinking about what might be going on with them, but whether or not they might be placing their parent at risk. And specifically in that scenario, I'm thinking about COVID, which has an outsized risk for elderly patients compared to other viruses, even.

Host Amber Smith: So respiratory viruses, COVID, flu, RSV, and maybe there's others. Which one is the worst to get?

Elizabeth Asiago Reddy, MD: It really depends on what age group you're in and what underlying conditions you have. So we've been hearing a lot about COVID, flu and RSV, and generally speaking, those are the worst, and that's why we're hearing the most about them.

There's a lot of dedication towards trying to prevent them, trying to treat them, et cetera, but any of the known respiratory viruses could potentially be quite bad and specifically (for) immune-compromised individuals. But those three are generally the worst. And specifically, sometimes, as I kind of alluded to before, there are age groups that might be most especially impacted.

So for young infants, RSV is really a big danger situation. And a lot of the research and efforts that we've put into RSV vaccines or preventatives have been for that young age group. That's the individuals who are most likely to end up in the hospital, have very severe outcomes as infants, especially less than 1 year old, but including up to less than 2 years old.

And then, for COVID, it's been the opposite in elderly individuals, and it just goes up exponentially every 10-year blocks of age, so 60-year-olds, 70-year-olds, 80-year-olds, et cetera. They are at heavily increased risk of bad outcomes from COVID.

Now, that has changed a little bit with COVID as we've had increased access to vaccines and treatment. But if you look at the broad spectrum of the pandemic from the beginning, older individuals have been very severely impacted.

Host Amber Smith: Is that true with influenza as well?

Elizabeth Asiago Reddy, MD: Influenza is a little bit more of a biphasic age impacter, in that the youngest and the oldest are going to be the most severely impacted.

But people across the age spectrum can get very sick from the flu, and also similar to COVID, people with immune-compromising conditions can also get very sick with the flu.

Host Amber Smith: Can you explain what a "triple-demic" is and why infectious disease experts are concerned about it?

Elizabeth Asiago Reddy, MD: Yes. So last year was the year where we really saw all three of these pathogens take the big stage together.

Prior to that, at the beginning of COVID, of course, we implemented a lot of measures, including masking and social distancing that reduced our risk of acquiring other respiratory infections. So what we saw during the periods of time where we were implementing those preventative measures for COVID was that influenza and RSV decreased significantly.

So entering the fall of 2022, so about a year and a half ago, people were dropping those preventative measures as we found the risk of death from COVID to be dropping. We had ways to treat COVID. We had ways to prevent COVID. More people had been exposed to COVID, so it was not as dangerous as it had been, and we said, OK, it's time to open things up.

And when we did that, we found that our immune systems had not been exposed to these pathogens that we likely are exposed to on some lower level, typically, on a regular basis. And so we did end up in a situation of a triple-demic last year, and particularly our RSV, I would say was really heavily impactful last year. There was a very early peak in RSV infections in children and hospitals. Many of the pediatric hospitals were really struggling even to find beds, including in our area. We had to expand the network of hospitals that were taking children during the fall last year. And then influenza last year also experienced a very early peak.

And so by this time last year, we were almost done with our flu peak already. We had a really high peak, around November, December, that was more shifted towards the earlier fall than what we would normally see. And of course we still had a lot of people sick with COVID, so that was really the triple-demic that we experienced last year.

We are experiencing it again this year. It appears to be following a more normal pattern with respect to RSV and flu in terms of what we might have seen in years prior to COVID, but of course now we have COVID added into the mix.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Dr. Elizabeth Asiago Reddy, the chief of infectious disease at Upstate Medical University.

So I'm curious about these respiratory illnesses and whether they follow the same seasonal patterns across the world, or if they vary depending on the different cultures in the different countries. Because I've always wondered, is it the temperature or the climate that influences the spread of the disease, or is it the human behavior that may be tied to the weather that influences the spread?

Elizabeth Asiago Reddy, MD: It looks like it's both, with influenza as kind of the most classic example of this in that we see the influenza peak in the Southern Hemisphere happening during the summer of the Northern Hemisphere, and then it flip-flops during our Northern Hemisphere winter, then they're done with their flu and enjoying the nice weather in the Southern Hemisphere.

That one we can say is definitely highly weather related. It's also related to patterns of migratory birds because we see that the strains of influenza that impact humans can come from birds, and birds are following patterns of migrating from the south to the north. Again, some of this is going to be impacted by climate change in the future, but those are the typical patterns that we see.

So, I would say influenza is a very classic weather-related example, but behavior does play a role, so one of the things we saw during the most impactful times in our COVID infection period in the United States was that Southern states oftentimes experienced big spikes of COVID during the hottest months of the year because people were congregating indoors and turning on the air conditioner.

And so Florida, Texas, Arizona had major spikes during July and August that we don't typically see as frequently with other respiratory infections. And I think that was definitely behavior related in terms of congregating indoors. Of course, that is an impact of the weather, but then also was impacted by the immunological naivete (lack of exposure) of our systems at the time, that we just didn't have the background immunity to fight it off.

Host Amber Smith: It seems like most of the people who come down with symptoms of a respiratory illness are never going to know what it was, so how do they go about, at home, taking care of themselves if they've got a fever or body aches or a cough, and they know they're sick? What do you recommend? Are there any over-the-counter medicines or any practices that they should follow?

Elizabeth Asiago Reddy, MD: I know you said people are never going to know what they have. Hopefully, we can talk a little bit about COVID home testing during this conversation.

But I'll go back to the question about how to treat your symptoms. These are really like the time-tested types of interventions, such as taking acetaminophen for fevers, taking lots of fluids, especially non-sweetened beverages, water, tea, giving yourself the time to get some extra rest.

If you have a cough, dextromethorphan, which is the ingredient, and I guess the most commonly known brand name would be Robitussin (cough syrup). That definitely can be helpful for people who have bad coughs.

Pseudoephedrine can be helpful to clear out the sinuses in people who have a lot of sinus congestion, although it can raise blood pressure for people who have blood pressure issues, so there are alternative medications that you can look at when you're purchasing medications over the counter that will say, a lot of times, "suitable for people with high blood pressure."

And that's usually Mucinex. It's suitable for people with high blood pressure, though its efficacy, I would say, is a little bit more questionable. Pseudoephedrine is definitely very effective.

For anyone who uses the nasal sprays, it is important to keep in mind that nasal sprays can be highly effective. So over-the-counter nasal sprays, such as Afrin, which is a pseudoephedrine-based nasal spray, can be highly effective in reducing congestion, but it's extremely important to follow the instructions of only using them for a few days. Three days really should be the max because they can actually make your symptoms worse if you get used to them over time.

Host Amber Smith: You brought up the home testing kit for COVID. Do we still need to do that? Is that still something that needs to be on our minds?

Elizabeth Asiago Reddy, MD: Yes. I think these still do play a role, and they can be helpful. The most important thing to remember is that they are excellent at detecting a true positive, meaning that if you have symptoms that you suspect are related to COVID, and you take a COVID test, and you get those two lines, it looks positive, then in all great likelihood you have COVID. That is considered to be a dead ringer for a positive test, that we really think would be a true positive. It's very, very, very rare that you would have a false positive, almost negligibly rare.

A false negative, on the other hand, is pretty common. And this is why I feel like a lot of people get confused, so that, if I have symptoms that I'm concerned might be COVID, and I take a COVID test at home, and it's negative, there's still a 20% to 30% chance that I actually do have COVID.

So, I think people are catching up on the idea of retesting. That can help. If you test every day for three days, that can help to try and determine whether or not you truly have COVID, but it still doesn't reach the accuracy of a PCR test.

So why is this important? It's important for those people who are age 60 and up, or who have severe immune-compromising conditions who may benefit from one of the therapies for COVID, so an oral outpatient therapy, such as nirmatrelvir (with) ritonavir, which is known as Paxlovid. I think that still does play a role for certain high-risk individuals who really have a risk of progressing to severe COVID. And so those folks should try to figure out whether or not they really do have COVID because they might benefit from treatment.

And unfortunately COVID is the only test that we have regularly available for outpatient use. There have been flu tests designed and strep throat tests that have been designed, but they have not really reached heavy circulation, the way COVID tests have.

Host Amber Smith: For people who are home sick, how long should it take before they start feeling better?

And are there any red flags that would tell them they really should see their doctor?

Elizabeth Asiago Reddy, MD: Yes. Most of these illnesses, your first five days are going to be the worst. And it's still not unusual, especially for COVID and flu, for people to feel quite poorly for five days, be spending a lot of time in bed, be having fevers, but after that five-day mark, and a lot of times, even after the three-day mark, symptoms should start to improve, especially now that, like I said, we do have a little bit better background immunity to these infections.

But every person is different, so there are people, unfortunately, who are still having a couple of weeks of symptoms from either COVID or flu. Whether or not you got recent vaccinations might impact that, so certainly people who have recently been vaccinated for flu or COVID are likely to have a milder version of the illness, compared to someone who's not been recently vaccinated.

And then, other types of conditions that people might have in the background may impact the severity of their illness.

What should you be worried about?

Certainly shortness of breath is a big red flag. We worry about any of these respiratory illnesses progressing to pneumonia. So what they usually cause is sinusitis, bronchitis, laryngitis. Those are all upper-respiratory infections. They haven't gone down into your lungs. But when you start to feel short of breath, we worry that the infection has gone down into the lungs, and that is a signal of pneumonia. That's dangerous, potentially dangerous, and should be evaluated by your provider. And certainly if somebody's severely short of breath, by an emergency physician.

And then, other things, really inability to keep down anything. So sometimes, COVID or flu could be associated with gastrointestinal symptoms. If you really can't eat, you can't drink, you're becoming dehydrated, especially in the setting of fevers going on as well, then that would be another reason to seek medical attention.

Chest pain would be concerning. So, if you're feeling a lot of chest pain when you're breathing or chest pain at any time that's just not going away, that's disturbing to you, that would also be concerning.

I think those are really the major red flags that you would definitely want to give your provider a call. Or if it's very severe, go to the ED (emergency department).

Host Amber Smith: So what is done for someone who comes to the emergency department with a respiratory illness?

Maybe they do have shortness of breath or some chest pain along with it, and they've been sick for more than five days. What is done for them there? Do you test right away to see what virus it is?

Elizabeth Asiago Reddy, MD: We do the respiratory virus panel (tests) as part of routine care at Upstate. A lot of other places may not have the full panel, but they may have a rapid test for COVID, flu and RSV that will help to distinguish what's going on, at least, as we've talked about, for ones that are the most severe.

And then, you would also want to determine whether the person could possibly have a bacterial pneumonia, and that would be a constellation of signs and symptoms to include chest X-ray and reviewing what's going on with them, the severity of their illness. And if someone is considered to be at risk for having a bacterial infection, that would be something that would need to be treated with antibiotics.

Host Amber Smith: Well, let's talk about prevention. Are there vaccines available for adults and children for flu and COVID and RSV?

Elizabeth Asiago Reddy, MD: Yes, there are. So, RSV, there's a little subtlety to that answer, but I'll just go through them individually.

COVID is available for all age groups, starting at 6 months, and it has this year been formulated into a new formulation that is covering Omicron strains only. So it doesn't have any of the old strains of COVID in it, which is the first time that's been the case for the COVID vaccines. And we have the three major COVID vaccines available are Moderna, Pfizer and Novavax.

And Novavax is the only one that is a protein-based vaccine, so there's no mRNA, and that's what some people still find concerning. So those are the main COVID vaccines. And it's very simple because the vast majority of people would just need to be updated with one shot. So there's a few exceptions to that for possibly young children who have now been previously vaccinated or are (in) severe immune-compromising conditions.

And then, for influenza, the very similar situation, age 6 months and up is recommended to have an annual flu shot, and the vaccine formulation changes a little bit depending on age groups, and some younger age groups may be eligible for a nasal flu vaccine.

And then, for RSV, this is where there are some subtle differences. So for infants, there is a monoclonal antibody infusion available specifically for the youngest infants who would be experiencing an RSV season during the time they're a young infant. So the problem with that has been availability. It's highly effective, but it was impacted by lower availability than what was predicted in terms of the demand for it. So I think that one is now being reserved for infants who have immune-compromising conditions.

And then, for older adults, 60-plus, there are two new RSV vaccines. So I mentioned when I spoke about RSV that infants are at the highest risk, and that is the case, but also older individuals can experience very severe RSV infection, including RSV pneumonia. If you do end up in the hospital with RSV as an older adult, your risk of death is actually very high. So most of the people still aren't going to end up in the hospital, but if you do get to the point where RSV has driven you into the hospital, that is actually a very bad and dangerous situation.

The RSV vaccines are a single dose at this point for those individuals who are eligible, age 60 and up. And it is across the board. There's no specific conditions that you would need to have in order to be eligible. It's just based on age. And at this point, there is not a clear recommendation for any future vaccines. We need to give it some time to pan out and see. The studies have shown that at least through two years, it's offering good protection.

Host Amber Smith: Now what about pneumonia? Is there a vaccine for that?

Elizabeth Asiago Reddy, MD: A lot of people will hear their providers mention the pneumonia shot. And what the pneumonia shot actually refers to is vaccines that are used to prevent pneumococcal pneumonia.

So pneumococcal pneumonia is caused by a bacteria called Streptococcus pneumoniae. And for many, many years it was by far and away the most common cause of bacterial pneumonia. That actually changed with the advent of the vaccine. So it remains an important cause of bacterial pneumonia, and it can also cause other types of severe infections, including things like meningitis and bloodstream infections.

But the universal use of the vaccine, because it's also offered in children, the universal use of the vaccine has actually changed the landscape so that it is less common than it used to be, but it's still there as a risk, and it can make people very, very, very sick. So what has happened is that over the last several years, there have been different iterations of the pneumonia vaccine that have covered additional serotypes (strains) that are seen to be causing severe disease. So most recently, we have a vaccine that actually covers 20 different serotypes, and individuals who have immunocompromising conditions, and this is pretty broad, to include things like diabetes and heart disease, or anybody age 65 and up, should be getting a dose of that vaccine.

Host Amber Smith: In addition to vaccination, during the COVID pandemic, we heard so much about hand sanitizers and masking. Are those things that you would still recommend people do to stay healthy during the respiratory viral seasons?

Elizabeth Asiago Reddy, MD: Absolutely. Those are definitely still very important components of keeping yourself healthy, obviously. Washing your hands, across the board, even though we found that COVID doesn't tend to be transmitted through surface contact as much as some other viruses. There are plenty of viruses, including the common cold virus, rhinovirus, that is its most efficient mode of spread, is by touching things.

So, washing your hands, 100%. It'll prevent a lot of what might make you sick.

Masking, we have re-implemented masking in hospitals. Why have we done that? We really only had a very brief time where we weren't wearing masks most of the time, and they came back online. We've done that because so many of the patients who are in the hospital have severe immune compromising conditions. And obviously the conditions in the hospital are ones where people are in very close proximity to one another. So, if you're a nurse working with a patient, you have to move them in bed, you have to help clean them, you have to give them medications where you're very close by. Many of our patients are still sharing rooms in the hospital.

So, for all of those reasons, it becomes a lot more important in those environments, where we have so many high-risk people, to be extra cautious.

But definitely, for anybody who has conditions that put them at increased risk of getting sick from respiratory infections, we've been able to show that masking is effective. I definitely counter the kind of notorious, I'm going to say it's notorious now in my medical field, Cochrane study that said that masking was not effective.

It's effective. There's so much other evidence to show that masking is effective. It really is. And there's different levels to which it can be effective depending on the type of mask that you're using, but it is a very viable option to reduce the risk of catching a respiratory infection, and it's also a very viable option to reduce the risk of spreading a respiratory infection if you have one and you happen to go out somewhere.

Host Amber Smith: Well, Dr. Asiago Reddy, I appreciate you making time for this interview. Thank you.

Elizabeth Asiago Reddy, MD: Thank you. It's great to talk with you, and stay safe.

Host Amber Smith: My guest has been Dr. Elizabeth Asiago Reddy. She's the chief of infectious disease at Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

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