Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered Podcast. I'm Dr Neha Pathak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine. 

In today's episode, we're gearing up for cold and flu season, which tends to ramp up in October and November and can last all the way through February. As we move into fall, it's more important than ever to stay informed about the vaccinations that help keep us healthy and protected during the colder months. 

In this episode, we're diving into some of the most essential fall vaccinations, including updates on the flu shot, the latest COVID-19 boosters, and the growing role of the RSV vaccine. We'll also touch on what to expect if you're planning to get multiple vaccinations and tips for making the vaccination process as smooth as possible.

Let me introduce my guest, Dr Vin Gupta. Dr Gupta is a practicing pulmonologist who currently serves as an NBC and MSNBC medical correspondent. He's also chief medical officer at Amazon. Welcome to the WebMD health discovered podcast, Dr Gupta.

Vin Gupta, MD, MPA: Thanks so much for having me. 

Pathak: I am really excited to dig into our conversation today because I have been trying to make various vaccine appointments for three kids of various ages and an 88-year-old father, and it's been just bananas. Before we jump into all of the questions that we have around our fall vaccines, I'd love to talk about your own personal health discovery, particularly around communication. I know that that's something that you're really passionate about. What was that aha moment for you around how to communicate the importance of these different vaccines?

Gupta: I do think about this a lot because I didn't expect to be playing this role, just like you, communicating to the public or to some segment of the public why it's important to get vaccinated or any number of public health issues that I think we're spending far more time talking about. Because the public is interested in talking about things that can help them live longer, focusing on health span, not just lifespan. It does feel like there's been this inflection point over the last few years, post the worst of the pandemic, where there's much more interest in talking about health issues at the national level on news shows where I contribute a lot.

Because there's an appetite for it and to learn. I do think that one of the silver linings of the COVID pandemic is that the public is much more attuned, and their ear is far more to the ground on these issues. My journey here was completely unexpected, which I think is something I talk a lot about to trainees that are interested in health communication. I didn't strategize or expect any of this. It just happened really organically. 

I'm a pulmonologist, but I spent a lot of time in the 2010s getting exposure to communications, either through my role in the US Air Force reserves, where they subsidize medical training. In turn, I got a lot of curriculum in leadership, especially from a military perspective. A lot of that focus was clear communication from a command and control standpoint.

I studied a lot in the way of public policy. And so I was, and remain a clinically active pulmonologist, but with a deep, deep interest in effective communication and leadership skills. It dovetails over the last, I'd say, seven years where a lot more of the issues we're talking about, whether it's vaccines, whether it's climate and health, whether it's vaping, lung health now is very much public health.

It's been something that I take very seriously, as I know you do. It's a way that I, as an ICU doctor, believe can have an impact well beyond the bedside and hopefully keep people healthy and at home. I do think now, more than ever, accurate health information delivered accessibly and clearly from trusted messengers, you could argue, is more important now than ever before. 

Pathak: Let's dig into the prevention piece of it. Since fall is getting into full swing, people are wondering about the optimal timing for vaccines. So, how do you think about counseling patients around the optimal timing for things like the flu vaccine and COVID vaccines? 

Before we get to that, what do we even mean by when we say optimal? People are always saying, what does that mean when you say what's the optimal timing?

Gupta: I just saw an op-ed in the New York Times that actually flashed on my phone about 30 minutes ago. It talked about this exact issue. Unfortunately, I think because we have access to multivariate sources of information, there's a lot out there, and more information doesn't necessarily mean better or clearer guidance for patients.

I think it's. It's causing a lot of confusion. To be very clear, when should you get the vaccine for a respiratory virus like COVID or flu to provide you the strongest amount of protection against severe illness as the weather gets colder? We know that there is a period of vulnerability where we're all vulnerable, but especially if you're medically higher risk because of age or a preexisting condition, between the months of, say, November and the end of February, that four-month window is when we want to maximize your protection.

What's the optimal window to get vaccinated with these annual boosters so that between November and the end of February, just to try to guardrail it, you are durably protected with maximum protection? That goes back to what we now know about these vaccines: yes, annual boosts make sense, but it turns out that annual boosts don't necessarily give you the same level of protection for a 12-month period. You have strong protection about two weeks after you get one of these booster shots for flu or COVID. That peak protection last for after that two-week acclimatization phase, where your body is responding, and your immune system is responding to the vaccine. You have that peak protection that really starts to attenuate about four months after. And so you have that four, maybe up to six-month window of strong to very strong protection from the vaccine against severe illness. That's when you start to see a tail effect really go underway.

So, for the individual who gets vaccinated, I always recommend the end of September to the middle of October for your COVID-19 and your flu shots. You can get them at the same time. I actually got them in the same arm about five days ago and had some soreness in that arm. I was a little tired the next day. By the middle of the next day, I was back to myself. And I did it, and that sort of end-of-September to mid-October window because I really want to enter the month of November with optimal or the strongest protection possible and have that protection last about four to six months.

So, to get me through the end of February into the early spring, March or April, you're still good because we know flu season, especially, can lag and seems to be longer and longer every single year. But that's what I think about when I think about optimal protection for my patients.

That might be anybody; it doesn't necessarily have to be with somebody with underlying lung disease, but anybody. I really think about the end of September to the middle of October window to get your COVID and flu shots. That's the window that's ideal.

I think what's happened and what we've seen, Dr Pathak, is because we have multivariate sources of information, there are some people that I know who got COVID vaccinated in August or in September with a prior version of the booster, and that's okay, but that's not optimal.

Pathak: And you're talking about the COVID vaccine that they got boosted in August.

Gupta: That's right. So when we talk about optimal, we're really talking about how do we maximize protection with the most updated shots for that November to end of February, early March period. And that's where I would say, make sure you wait. As now we have available to us the updated versions of the code and the flu booster shots for this respiratory viral season, and to target the end of September to mid-October.

Pathak: Okay, that's really helpful because I definitely had a lot of patients asking me about the COVID booster during the summer wave. And now they're sort of following up and saying, well, okay, now I had it in August. So, do I wait four months, or what do I need to do at this point? Or I think I might have had COVID. So, clarity around that would be really helpful, too.

Gupta: We don't have definitive data on, well, if you had COVID in June, here's when you should definitely get the booster shot. However, based on the best available data, the recommendation is to wait between 90 and 120 days. So, three to four months after you've recovered from your bout of COVID to then get that season's booster shot. And so if you're somebody that's listening and you had a bout of COVID in June, and if you're mapping out about three months from that, I'd say between three and four months in that window, now's a good time to go ahead and get your booster shot. And what's the reason? The idea is to give your immune system about a 90-day break at least so that it can properly respond to the vaccine itself.

You know, it's come down from its high of battling the infection again. And now it's had a chance to recover and respond to the booster shot. And so that 90-day guidance is at least recommended. It's what I counsel my patients to do. It's what I counsel the public to do on my platforms. And I think it makes sense.

Something similar: should you have had flu? For example, I think there's less flu going around in summer than COVID, but if that happened randomly to you, wait for that three-month period as well. If you're somebody who got the old booster shot, So the 2023 version, but say in August, because you saw a lot of people around you having COVID, I would have a conversation with your medical provider, frankly, to make sure that we understand, especially if you're medically higher risk, maybe you have an immunocompromising condition or take powerful medications that suppress your immune system, perhaps you're an individual that should actually get a second vaccine this season, the updated version, a few months later. I suspect that's going to apply to a small subsegment of viewers today. And so I would caution anybody if they've already gotten a booster shot and was the old shot in August to hold off on yet another shot. Have a conversation with their medical provider.

If you're in that exception group that is on a powerful immunosuppressive medication, if you have a serious underlying condition requiring dialysis, maybe you do actually need that updated shot right about now into the end of the year but have a conversation with your medical provider.

Pathak: That's great advice. And I kind of want to get into a little bit around messaging for the public when we're talking about what these vaccines can and can't do. 

Can you talk a little bit about what we're talking about when we say the effectiveness of these vaccines and what we're hoping that these vaccines do not that you won't have a case at all, or you won't be infected at all? 

Gupta: This is so critical, Dr Pathak, for lay understanding, to reset expectations, and, in some cases, to rebuild trust. I think what we missed, and I noticed this firsthand as a pulmonologist in the pandemic, was that we were overstating or oversetting expectations from the public on what these vaccines could and cannot do, based on our prior knowledge on, say the flu vaccine. In every single case, from now on, and I suspect well into the future, we should make sure we're clear with the public on what to expect from these vaccines.

Because now there are forces out there that are looking to discredit vaccines at every turn. So we have to be very clear on what success looks like and what success has long looked like with these vaccines for respiratory viruses; again, using flu as a predicate is the vaccines are designed to keep you out of an intensive care unit with severe pneumonia, full stop.

They are not meant to prevent infection. If we had visuals and a chalkboard, maybe we could map this out. But really, what ends up happening is that the vaccines mobilize an army of immune cells in your body that are sort of backward and deployed in your body. They're deployed in areas throughout your lungs to fight off severe pneumonia, but they're not as forward deployed in your throat and your nostrils.

And so it is very much the case that you could get the COVID shot or this season's annual flu shot. Be protected because you have all these reinforcements of T cells and antibodies in your lungs; they're backward deployed, but you have less of those as we go up the respiratory tract into our oropharynx, into our nostrils, you have less of them.

It's almost your front line where you breathe in some of these viruses. So it's very common. It should not be unexpected that you could be fully protected with all your booster shots and still come down with a runny nose from COVID-19 or flu with a sore throat and upper respiratory symptoms because that's not where our immune cells really double down.

It's really to protect against pneumonia. And that's what these vaccines do really well. They prevent severe illness, and that's what they've always done really well. In the future, when we talk about the RSV vaccine, which, by the way, if you're 60 years of age and older, the one-shot vaccine, a one-time vaccine, something that you should be thinking about, I would stagger it by two weeks. You can get COVID-19 and flu at the same time. Then, two weeks later, get the RSV vaccine. But by the way, the RSV vaccine is not going to protect you from infection and a positive test and maybe sniffles from RSV. But it will protect you from severe pneumonia, and that needs to be how we talk about it.

I think we should even go so far as to actually explain in simpler terms, the immune system response. To me, it makes a lot of sense. And then it can help make the skeptical individual be like, well, how is it possible? I still have a positive test and sniffles, but you're saying the vaccine works.

I think now we've gotten to the point, Dr Pathak, where we actually have to explain some of this to rebuild trust.

Pathak: Dr Gupta, I have to say I love the imagery, and I wish that we had visuals of what you just described. As a VA primary care doctor, I really thoroughly enjoyed the military analogies, but I think that it's so helpful as well. You know, in some of my counseling, when I talk about the flu shot, it's not necessarily even just about the flu symptoms. So, as you described the upper respiratory symptoms, et cetera. If you have heart disease, if you have diabetes, because you do, you're so well protected from the intense inflammatory response of fighting off pneumonia or potentially having pneumonia that can also impact you because you have heart disease or diabetes. You're protecting yourself from those conditions as well. 

Gupta: Oh, absolutely. I think that's what people don't realize is that there's a cascading effect where if you're fighting off one severe illness, and to your point, maybe you're battling severe flu and you didn't get vaccinated. Not only are you putting at risk or potentially disturbing the equilibrium with your other chronic diseases if you're battling other chronic diseases, but you're also, and I think this is something we, we don't talk about it a lot, but you're opening yourself up and making yourself susceptible to secondary infection.

There are many people that I sadly have cared for with COVID-19 that landed them in an ICU, who ended up having a secondary bacterial pneumonia because the immune system is so busy fighting off one thing that it doesn't have enough reinforcements to fight off the next thing. And then, often, that's a mortal event.

We really need to help people understand how the vaccine works because, again, there are a lot of malevolent forces out there, mischaracterizing what the vaccine does and doesn't do and is using a misunderstanding of effectiveness to then question purpose. And that's what us as highly credentialed providers, need to push back in an accessible but scientific way, and I think we do it in this way. It's actually going to disarm those that are looking to misinform.

Pathak: And then I'd love to also honor folks that do have some side effects from the vaccination.

What are some of those side effects that you can expect? We should, as health professionals, honor those symptoms and acknowledge that, yes, these types of things can happen. 

Gupta: Absolutely. Anticipatory guidance is critical. I'll give you my example. I got COVID and flu in my right deltoid at night after coming off an ICU shift, and I knew I was off the next day. I had child care, so I had all the chess pieces in place so I could just relax. I'm glad I did that because it hit me at 9 am, about 14 hours later. I was super tired, pretty sore, feeling a little chilly, and ended up needing to just be in bed.

I took some over-the-counter ibuprofen, hydrated, and by the middle of the day, I was feeling totally fine. Still, I think people should expect fatigue, maybe even feeling flu-like symptoms like chilliness and soreness. Those are overwhelmingly what you're going to experience, if anything. It's okay. And it's going to resolve. It might take somebody maybe a little longer, maybe a full day, maybe it might take 48 hours. 

And I recognize that that's hard on a lot of people who have jobs, who may not have childcare, who might have to go to work the next morning. And so there are a lot of barriers here that I love that you framed it as honoring because we do need to honor that, and anticipatory guidance is important. I'd rather people figure out to the best of their ability and situations how they can time a 24-hour period of rest and recovery to the maximum extent possible to ultimately do something that's going to save them a lot of time down the road, which is averting sickness in the 1st place is going to cost way more in terms of time than dealing with the side effects that I think are quite manageable. And the overwhelming number of cases that are going to require far less time. So I think we frame it that way, anticipatory guidance, but what you're also averting potentially could be far more costly time-wise. It's helpful.

Pathak: We often hear patients say, well, you know, I've got a little bit of a cold, or my child has a slight fever. You know, their symptoms are very typical for a cold. What are some of the situations in which you would say, let's go ahead with the vaccine? You've taken the time. You've set up all your chess pieces versus no, we really should hold off and plan for another time at this moment.

Gupta: My wife is a pediatrician. We talked about this. I would recommend that short of febrile illness, your child or you as an adult are actively fevering with a temperature of 101.3 degrees or higher, or maybe there's something truly going on here that we want to make space for from a recovery standpoint.

If you're having upper respiratory symptoms, don't have a fever. Then it's okay, and you should still push ahead if you're planning on getting the vaccine. But with febrile illness or real fever. That's where I would say, pause, let your body recover, whatever your immune system is fighting off, let that process happen, and let's see if we can reassess in 48 to 72 hours.

It's hard to get black-and-white guidance when it comes to battling a sickness and should you get the vaccine? I usually gate it to febrile illness or not.

Pathak: I'm so thankful for your time. I'd like to yield the final two minutes to you if you have final thoughts and bite-sized action items for our audience listening today to protect themselves as we head into the fall and winter.

Gupta: You know, what I'd say more than anything else, especially for those with an underlying chronic disease who might be sick or 60 years of age and older, make sure you have a care plan in place with your medical provider. We've talked a lot now about vaccines in proactive ways you can stay healthy.

Another thing that you can do is make sure that if you unfortunately do test positive for COVID-19, or flu, or RSV, that you have a plan in place with your provider to get ready access to treatment. And so, what does that mean? That means going to COVID tests.gov to get your free allocation of COVID tests. You can go there right now, and you'll get some tests shipped directly to your doorstep.

Because if you test positive for COVID, there's treatment that's available, but it's most beneficial if taken rapidly. Similar to flu. If you have flu-like symptoms, maybe it's COVID, maybe it's flu, or maybe it's none of the above. Getting access to your medical provider to get a test, especially because you're probably going to have to go into a clinic to get a flu test, that's important. Because with treatment for flu, time also matters. So make sure, especially if you're medically higher risk because of your underlying condition or because of being sixty years of age and older, that you have a care plan in place as we enter the colder months. 

Pathak: Thank you so much for being with us today, Dr Gupta. We've talked with Dr Vin Gupta about all things: fall vaccination from flu and COVID and even touching on the RSV vaccine. Dr Gupta really helped us manage our expectations about what it means to be fully protected when we get one of these vaccinations, and he also helped us understand that being vaccinated and protected doesn't necessarily mean we might not test positive and have symptoms.

It's all about turning these infections from wild and potentially life-threatening to mild and controllable. To find out more information about Dr Vin Gupta, visit vinguptamd.com, and we'll have the link in our show notes. Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform.

If you'd like to send me an email about topics you're interested in or questions for future guests, please do. Please send me a note at WebMDpodcast at WebMD.net. This is Dr Neha Pathak for the WebMD Health Discovered podcast.