Prep for the Holidays
Tis the season of turkey stuffing and stuffed-up noses — not to mention stocking stuffers and stuffed-down emotions. Lots of stuff. (You get it.)
So let’s segue from my series on weight loss to talk about the weightiness of the holiday season. Over the coming weeks, I’ll be discussing how to protect our bodies, minds, and spirits throughout the holidays — essentially a “Yuletide guide to staying safe and sane.” I know I could use all the help I can get!
Today, I’m starting with FOUR TIPS to help protect yourself from the cornucopia of viruses out there. (Next week, we’ll start our dive into the other stuff.)
Let’s begin with what I’m seeing most in my office right now:
Flu, RSV, rhinovirus, adenovirus, a very little bit of COVID, and myriad other viral infections.
Underlying health conditions exacerbated by haphazard routines and/or the lack of adequate time to meet basic health needs.
The normal and expected physical and behavioral manifestations of anxiety, depression, and chronic stress.
But viruses are the most immediate complaint. How can you try to avoid “going viral” and what can you do if it happens to you?
Be Glad You Got Vaccinated Against COVID – and if you haven’t been, now is the time.
The primary series (plus the original booster for older and higher-risk people) continues to hold up well against death and severe disease, even with the new variants.
What about the buzz about “waning immunity” from the primary vaccine series? Vaccine-acquired protection against infection (that is, getting COVID at all) does gradually wane as antibody levels fall — as expected — after a vaccine dose. The same is true after an infection. This is NOT synonymous with “we are no longer protected from COVID three months after the last shot or infection.” Why? Because our immune systems have sophisticated memories. Upon (re)exposure to coronavirus, your immune system makes fresh batches of antibodies to fight the virus, and your T cells get activated to fight severe disease.
Ok, but what about waning immunity against severe COVID outcomes? Aren’t some experts saying that everyone over 18 MUST get the new bivalent booster shot because the protection against serious disease wanes, even after three shots? Yes, but here’s the story: some weak data suggest that our protection against serious outcomes may decline after two or three shots, but these data sets themselves have some underlying issues. Depending on the comparison group, the data can look like protection against serious disease is "waning," when what’s probably occurring is that immune protection in the comparison group is actually growing as a result of more people getting infected.
In addition, in the studies above, a COVID case was considered “severe disease” in a young person simply if they visited an ER or urgent care which — given the number of uninsured people and the shortage of primary care doctors in this country — is hardly a good proxy for disease severity. In other words, where else would a sick, feverish 25-year-old without a personal physician go when they need to decide if they have COVID versus the flu?
So, should you get a COVID booster if you’ve already had the primary series and maybe even a bout of COVID itself? You can read my latest column on the COVID booster here — my advice hasn’t changed since then.
The gist on the boosters: It’s true that the new bivalent Pfizer and Moderna shots have been shown to increase antibody levels in human subjects. That’s nice, and it makes intuitive sense that a round of fresh antibodies might mean a transiently reduced risk for infection. But my patients who got COVID only a few weeks after the new booster (like Rochelle Walensky did), some of whom were laid up for a week, have wondered what that extra shot really did for them above and beyond what the other 3 or 4 shots provided. We just don’t know. The data for these latest boosters simply don’t exist. My 5-time vaccinated patients who got COVID are proof NOT that the vaccines aren’t amazing — they are! — but that we need to use data instead of assumptions or anxiety to guide medical decision-making.
To me, the more pressing question about the new bivalent boosters is: do people who’ve had the bivalent shot (following the original vaccine series) have a reduced risk of serious COVID outcomes? The answer: Right now we simply do not know. We might ask this question next: as a proxy for severe disease, has the new bivalent booster at least been shown to improve T cell immunity, the arm of our immune system that is responsible for protecting against severe disease? The answer is no; it hasn’t.
Of course no one wants to get COVID. But it’s important to know that immunity against COVID (and other viruses) is essentially cumulative. Like doing reps at the gym, the more “encounters” with the virus and with the vaccine (caveat about the vaccine below), the more protection we gain against serious COVID outcomes the next time we cross paths with this bug. It’s a myth that each successive infection is inevitably worse. In general the very opposite is true!
The upshots:
As of today, I am not convinced that protection against severe disease wanes after the primary COVID vaccine series (= three shots for adults under age 50; or four shots for those over age 50 or with compromised immune systems and/or underlying health issues), but this could change.
The COVID vaccines are a miracle of modern science. They are life-saving particularly for high risk and older people. But boosters are not necessary for every single person, regardless of age, underlying health, or number of prior vaccine doses or COVID infections.
There is no one-size-fits-all solution for anything in medicine.
The physical risks of getting more COVID shots than you actually need are probably low unless you’re a healthy teenage or young adult male whose risk for vaccine-induced myocarditis is tiny but probably higher than it is for serious COVID outcomes.
In my opinion, the main downsides of telling patients that “more is better” when it comes to COVID vaccine doses is that we risk 1) mismanaging people’s expectations about the vaccine and 2) inadvertently eroding trust in medical messengers and in the vaccine itself. The vaccine is incredibly effective at doing what it’s supposed to do — but it’s not everything to everyone!
As always, understanding data and accepting the limitations of any medical intervention opens up space to manage the other threats to our health — importantly, over which we do have some control. For example…
Get your flu shot.
Similar to COVID shots, the flu vaccine cannot and does not block infection (i.e. you can still get the flu), but the flu shot turns the influenza virus into a more manageable illness. And good news! This year, the flu shot looks to be a good match against the circulating strains of flu, so go out and get your flu shot! Here is my longer column about the flu for more info.
Try not to freak out every time you have a sniffle, cough or cold.
I realize this is easier said than done on the heels of a global pandemic! What are people the sickest from these days? Based on what I’m seeing in DC, it’s the flu. I’ve seen COVID only a few times in November — a lot less than earlier this fall — as a result of vaccine-induced and infection-acquired immunity. As above, the COVID and flu shots do the heavy lifting against serious outcomes. The antiviral for flu called Tamiflu can help mitigate symptoms if it is initiated within 24-48 hours of symptoms. Like everything, though, it’s not a panacea.
Right now, respiratory viruses are having a heyday. While these viruses can look alike, causing cough, sore throat, aches, and congestion, most patients I’m seeing have the common cold due to adenovirus or rhinovirus, for example. How do I know this? My office offers a “Biofire” nasal swab — a PCR test that detects the genetic material for common respiratory viruses in order to help direct treatment. It’s mostly helpful to reassure patients that a) they don’t need antibiotics (viruses don’t respond to antibiotics like a Z-pack, b) they don’t have RSV when they have an infant or toddler at home, and c) they have a virus that has a name and that is known to dissipate on its own and/or with hydration, rest, and over-the-counter medications like Acetaminophen or Ibuprofen for aches and Fluticasone nasal spray for sinus congestion.
Side note: Yesterday the Wall Street Journal had a nice article on RSV for those of you with little ones at home. I feel your pain!
How long are we contagious with these viruses?
With COVID, we can try to know when we’re contagious or not by using the rapid antigen tests (which I call “contagiousness tests”) — i.e. a positive home COVID test means you have contagious levels of virus in your nose. Conversely, a negative home COVID antigen test means you do not have contagious levels of virus in your nose. Note that a negative home COVID test does not necessarily mean you don’t have COVID — hence the utility of the PCR test if needed for diagnostic purposes.
For other viruses, the honest answer is: we don’t know how long people are contagious for. It depends on variables like the patient’s symptom severity; immunity, including vaccine status; the amount of virus they’re carrying (aka “viral load”); and of course the conditions around them (outdoors versus indoors). We can make an educated guess that we’re no longer contagious from RSV or flu, for example, when symptoms are clearly improving and we’ve been fever-free for at least 24 hours without fever-reducing medications.
How much you want to risk getting your elderly relatives sick with your head cold is up to you, to them, and your shared tolerance for risk. As always, you should talk to your doctor for specific recommendations on testing, isolation, and treatment.
Boost your immune system.
There’s no compelling evidence that things like zinc, quercetin, and vitamin C do much of anything, though they also can’t do much harm. My best advice is to:
Catch up on sleep!
Don’t skip meals and hydrate well!
Get outside in nature, soak in some sunshine, and get your body moving!
Wear a mask if desired, with managed expectations that in order for masks to work they must be high-grade, well-fitted, and used consistently. (P.S. There's no need to grumble at people who aren't masked because a) the real-world effectiveness of masking to reduce virus transmission is minimal based on the best studies to date (though this is incessantly and HOTLY debated), b) the downsides of masking are not zero depending on the person and — most importantly of all — because c) one-way masking can work well to protect the wearer!) So I say go for it if you want the potential for added personal protection.
Download that meditation app — and use it this time!!
Make sure you’ve filled all your prescriptions before you head out of town!
Catch up with any vaccines you missed during the pandemic. (Just because COVID took center stage doesn’t mean that shingles, measles, and hepatitis went away!)
You can watch my Instagram series with current answers to FAQ about vaccines, boosters, and managing the season of viruses here.)
Next week I’ll talk more about underlying health conditions, then I’ll segue to emotional and behavioral health ideas for holiday harmony (to the extent that’s a thing).
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Speaking of emotional disharmony, check out this week's pod!
On this episode of Beyond the Prescription, author Mike Bassett and I discuss his 2021 book, The Man in the Ditch, about his massive life mistake and his path toward redemption and self-compassion. Mike offers hope to anyone down in the ditch — whether they landed there after a traumatic event or they dug the ditch themselves.
Mike is living proof that good people sometimes do bad things, and I was thrilled to talk with him. I learned a lot!
As always, my newsletter subscribers get early access to the pod every Monday night before the official Tuesday launch. Give it a listen now on Apple, Spotify, or wherever you find podcasts. And I’d be thrilled if you could rate and review the show. It helps me a ton!
I will see you next week. Until then, be well.