Flu and RSV begin to stir
Week 5 of the disease surveillance data gap
November often marks a turning point for respiratory viruses. This is the month when RSV typically gains momentum in young children, when influenza begins circulating more widely, and when we get an early sense of what the season ahead might look like.
The federal government shutdown has now entered its fifth week, which means five weeks without the CDC’s respiratory virus surveillance dashboards. The timing is unfortunate, because we’re heading into winter without our usual national data resources, making it more difficult to understand what’s circulating. Team Force of Infection has been visiting all 50 state health department websites plus D.C. to compile the national picture. You’ll find detailed state-by-state information below.
If you’re just joining this newsletter, Force of Infection publishes a weekly report on seasonal respiratory virus activity, food recalls, and other public health updates. I share detailed data and analysis year-round, including state by state information during the winter months in regional editions.
Since the shutdown has made it harder to get high quality information, all reports will be free until the government reopens.
National Updates
Influenza activity remains low nationwide but is showing early signs of movement in several regions. Overall, influenza-like illness accounts for roughly 1-2% of outpatient and emergency department visits. However, young children are seeing early increases, which is typical at the start of the season. For instance, Indiana reports marked increases in the 0-4 age group (rising from 4.9% to 6.2% of ED visits). Michigan shows increases specifically in the under-18 population. I expect additional increases in the weeks ahead.
If you’ve been waiting until closer to flu season to get your shot, consider this your signal.
COVID-19 activity remains low across nearly all regions following the late summer wave. The virus accounts for less than 1% of emergency department visits in most states, with wastewater surveillance showing low or very low concentrations in the majority of monitoring sites. Hospitalizations have declined substantially from September peaks, and test positivity continues to trend downward. I expect activity to begin rising again as we head deeper into winter, but the good news is we are starting from a low baseline.
RSV is making the most definitive moves of the three respiratory viruses, with clear increases in children across multiple regions. Activity remains minimal in older adults and the general population, but among children under 5 there are clear increases in emergency department visits for RSV.
Stomach bugs (norovirus) is moderate nationally. Wastewater activity is moderate and rising steadily in the South. In contrast, wastewater activity remains low and quite stable in the Midwest, Northeast, and West.
Food Recalls
The following foods are being recalled because they are contaminated. Please check your cupboards and throw out any of these items:
New:
Yellow and white peaches (including those sold at Kroger) (more info)
“Dry Ghoinnya Fish” sold by New Hoque & Sons Inc. (more info)
Fresh Italian parsley (more info)
More ground cinnamon, this time sold under the Devi brand name due to potential lead contamination (more info)
Barbecue pulled pork sandwiches sold under the Deli Express label (more info)
Hormel Foods ready-to-eat frozen chicken products (more info)
In Other News
Listeria in prepared pastas sickens dozens. Over the past few weeks in the Food Recalls section, I have reported on recalls of prepared pasta meals, including those sold under the brand names of FreshRealm and Trader Joe’s. According to the CDC, at least 27 people in 18 states have been infected in a Listeria outbreak that has been linked to these recalls. 25 of these people have been hospitalized and 6 have tragically died. Given that most people sickened with Listeria do not seek medical treatment, the true number of affected individuals is likely far higher than this. The public health investigation is still ongoing, and the recalls may expand depending on its findings. This outbreak comes just months after CDC had to scale back its foodborne illness surveillance due to budget constraints.
E. coli in meat linked to urinary tract infections. Researchers looking at patients with urinary tract infections (UTIs) in Southern California found that approximately 1 in 5 UTIs may have come from meat. E. Coli isolates from over 2,000 patients were compared to over 3,000 E. Coli isolates collected from samples of chicken, turkey, beef, and pork that were bought from major grocery chains from the same region as the patients. They then used a statistical model to compare the genetic sequences between the two and were able to estimate what proportion of the human E. coli isolates originated from food-producing animals. This adds yet another reason to be follow safe food handling procedures: thoroughly cook meat until adequate internal temperatures are reached, avoid cross-contamination, and thoroughly wash hands and all surfaces that come into contact with raw meat.
State Data
Alabama:
Overall respiratory virus activity is low in Alabama.
COVID-19 activity continues to decline, with .21% of visits to the emergency department for COVID-19, down from 0.28% the week prior.
Influenza is holding steady with 0.23% of visits to the emergency department.
Only RSV activity is increasing in the state, with 0.21% of visits to the emergency department compared to 0.15% last week.
Alaska:
COVID-19 activity is low and stable in Alaska. 1.3% of visits to the emergency department were for COVID-19, down from a recent high of 2.2%. Lab-confirmed counts of COVID-19 cases are low and stable as well.
Influenza-like illness is increasing in Alaska. 1.8% of visits to the emergency department were for fever and cough or sore throat, up from 1.4% the week prior. However, current levels of activity remain below baseline.
RSV activity is minimal.
Arizona:
COVID-19 activity was low and declining in Arizona as of the recent available data, October 19th. 0.3% of visits to the ED were for COVID-19, down slightly from 0.6% in late September.
Influenza and RSV activity were both minimal in the state as of October 19th.
Arkansas:
Arkansas data is sparse.
California:
COVID-19 activity is low and stable in California, with 0.4% of visits to the emergency department. Test positivity is low and stable as well.
Influenza and RSV are minimal according to ED data. However, test positivity, while very low, is beginning to rise. Test positivity is an early indicator of activity.
Colorado:
COVID-19 activity is low in Colorado and continues to decline. 0.3% of visits to the emergency department are from COVID-19, down from a recent high of 1.1% in late August. Test positivity for SARS-CoV-2 is declining as well, and there have been no recent outbreaks of COVID-19 reported in correctional facilities or residential care facilities in the state.
Influenza-like illness activity is increasing in Colorado; 2.4% of visits to the outpatient doctor were for fever and cough or sore throat, down from a recent low of 0.7%. Visits to the emergency department are increasing as well, though they remain at low levels, lower than ED visits for COVID-19. Test positivity has increased slightly in recent weeks as well.
Activity remains minimal in the state.
Connecticut:
COVID-19 continues to decline after a peak in late September. Wastewater is very low, and reported case totals are now back down to where they were over the low points of the summer. Hospitalizations are also very low.
Influenza remains very low, with no clear signs of increasing. Influenza-related hospitalizations are in the single digits for the entire state.
RSV also remains very low, with cases low and with no hospitalizations yet reported this season.
Delaware:
Flu remains very low. Wastewater is very low and the rate of emergency department visits for ILI is minimal (0.4%) and fairly flat. There have yet to be any hospitalizations for flu reported this season.
COVID-19 appears to be quite low as well. Wastewater activity is low, and ED visits for Covid-like illness are low and flat, accounting for ~1% of all ED visits each week for the past month.
RSV looks minimal as well. Wastewater activity is very low. In addition, Delaware reports total ED visits per week for RSV and that number was just 16 last week.
Florida:
Reported cases of COVID-19 declined roughly 20% this past week and are overall fairly low right now.
RSV is increasing in Florida. RSV typically affects young children and older adults most severely. In Florida, children under 5 are showing clear signs of increased RSV activity. Overall ED visits for RSV remain low and stable, accounting for well under 1% of all emergency department visits. However, among children under 5 specifically, RSV now accounts for nearly 6% of all ED visits in that age group. Test positivity has risen to approximately 20%, and hospitalizations among children under 5 are also increasing. Florida does not disaggregate its RSV data for older adults, so it’s unclear whether this vulnerable population is experiencing similar increases.
Flu remains low but is increasing slightly. Trips to the ED and outpatient visit for ILI are increasing, as is test positivity.
Georgia:
Flu activity is minimal but increasing steadily. Outpatient visits for ILI has crept upward to 2.2% but remains below the threshold of 3.5%. Test positivity has increased as well.
RSV is picking up in Georgia. The state marks the beginning of its RSV season when test positivity exceeds specific thresholds, which differ between PCR and antigen-based tests. PCR test positivity has now crossed its threshold at 5.1%. However, antigen test positivity remains below its threshold, meaning the official start of the season has not yet been declared.
Other respiratory bugs are declining in the state. There were notable declines in test positivity for rhinoviruses/enteroviruses and for parainfluenza this past week.
I could not find data on COVID-19 activity.
Hawaii:
COVID-19 is back down to low levels after the late summer wave. Test positivity is down to 2.9%. Hospitalizations are also low.
Flu remains low with only sporadic activity. Outpatient visits for ILI are holding roughly steady at 1.7%, but test positivity is increasing a bit.
RSV remains very low, though test positivity is increasing.
Idaho:
RSV activity remains very low and sporadic in Idaho, with test positivity under 1% (the threshold for the start of RSV season in the state is 3%).
Unfortunately, I could not get the flu or COVID-19 data to load for me this week. I am not sure if the website was down or it was a problem on my end.
Illinois:
ED visits for COVID-19 are very low (0.3% of all ED visits), and hospitalizations are also very low and declining.
Flu and RSV are both stable at minimal levels, with almost no visits to the ED or hospitalizations.
However, other respiratory bugs are quite active. Rhinoviruses/enteroviruses are at 20.3% test positivity, and parainfluenza is also quite active (at 6.5% test positivity). A common bacterial cause of cold-like symptoms - Mycoplasma pneumoniae - is also quite active right now, with higher test positivity for the moment than Covid-19 (2.7% vs 2.2%).
Indiana:
COVID-19 activity is low and stable, with current levels far below what is typically seen this time of year. The most recent wastewater data is from a few weeks ago; while this is low, it does show a rather sharp increase in activity. It will be interesting to see once the data are updated if that was a transient increase or not.
Influenza-like illness in Indiana is low at 1.8% of visits to the emergency department and urgent care centers. I do note a marked increase in influenza-like illness among children ages 0 to 4, with activity rising from 4.9% to 6.2% in the last week. Children are usually the first age group to experience new seasons, so this will be something to keep an eye on in the weeks ahead, potentially signaling the onset of increased activity more generally.
Iowa:
Overall respiratory activity is below average, but is increasing. 11.4% of all ED visits were for acute respiratory syndrome during the week ending October 18 (the most recent week for which data are available).
COVID-19 is low and decreasing. Trips to the ED due to COVID-19 have decreased to 0.4%, and hospitalizations for Covid-19 are down to 0.5%.
Flu and RSV remain minimal, with no signs of an increase.
Other respiratory bugs are spreading widely: rhinoviruses/enteroviruses are at nearly 27% test positivity.
Kansas:
All-cause acute respiratory illness is stable in Kansas. COVID-19 activity continues to decline following a recent peak in summertime.
Influenza and RSV activity remain low and stable.
Kentucky:
COVID-19 is very low, accounting for <1% of all ED visits. Test positivity has also declined for the past several weeks and is quite low.
Flu remains very low. Outpatient ILI is lower than it has been at this point for the past four years, accounting for just 0.61% of all visits.
RSV is also minimal, leading to just 35 ED visits in the week ending October 25. However, there have been some slight increases in test positivity over the past few weeks.
Louisiana:
COVID-19 is low and declining; ED visits are lower now than they were over much of the summer. Test positivity is also low and declining. Hospitalizations are low.
Flu remains low, but it is increasing. ED visits have been steadily rising over the past several weeks, and flu is now causing a greater proportion of ED visits than Covid-19 (1.96% vs. 0.93%). There has been a particular increase in ED visits for flu for children aged 2 to 4 years (to 8.33%). Test positivity is also rising. Hospitalizations remain low.
RSV is picking up. ED visits remain flat for the general population, but are rising for the youngest children – those aged 0 to 1. About a month ago, trips to the ED for RSV for this age group accounted for about 1% of all ED visits; that rate has now climbed to 2.24%. Test positivity has more than doubled in the past two weeks.
Maine:
COVID-19 activity remains quiet in Maine with around 1.2% of visits to the emergency department for COVID-like illness as of the week beginning October 19th. This is a slight increase from 1.1% the week prior, but that follows over a month of declining activity.
Influenza-associated visits to the emergency department also increased slightly but remain around 1%.
Maryland:
COVID-19 activity is very low and decreasing, with low test positivity and hospitalizations.
Flu activity is low and stable. Outpatient visits for ILI are very low, at 1.3% and still well below the threshold for the start of flu season. Wastewater activity is also very low, and ED visits are at a low 1.6%.
RSV hospitalizations are low and stable. Maryland does not report other metrics for RSV that might give earlier indications of rising spread, such as wastewater activity or test positivity.
Massachusetts:
COVID-19 and flu activity are very low. Both illnesses combined accounted for just 0.5% of all ED visits this past week.
RSV activity is low but increasing. ED visits for children under the age of 5 – who tend to get hit hardest by RSV – have increased markedly over the past month, from 4.8% to 7.9%. ED visits have also increased, though to a lesser extent, for those over the age of 80, who are also relatively more affected by RSV.
Michigan:
ED visits for COVID-19, flu, and RSV are all under 1%.
COVID-19 is low and appears to be leveling out. Hospitalizations are declining.
Flu is pretty flat, except for children under the age of 18, where there have been some increases. Nevertheless, rates remain low even for those 0-1, 2-4, and 5-17.
No signs of an RSV increase yet. Things are flat, even when looking at the age cohort data for ED visits.
Minnesota:
Flu remains quiet and stable. Outpatient visits for ILI need to double from where they are now to reach the threshold for the start of flu season. Hospitalizations are very low.
COVID-19 is low and declining. ED visits for Covid-like illness are very low at 0.3% and continuing to fall. Similarly, hospitalizations are down to 0.62 per 100,000 people.
RSV hospitalizations have ticked up slightly for all ages, with a particularly notable rise among those aged 0 to 4. Hospitalizations for this age group are now at 2 per 100,000. Hospitalizations are a lagging indicator – by the time you see an increase in hospitalizations, there has already been a bit of spread, so I expect that RSV cases are rising in the state as well. (I was unable to find other RSV metrics for the state).
Mississippi:
Respiratory illnesses remain quiet. Outpatient visits for COVID-like illness and ILI are both very low and roughly equivalent in Mississippi. Wastewater activity is very low for COVID-19, flu, and RSV.
ED and urgent care visits for RSV also remain very low and flat.
Missouri:
Flu remains unseasonably quiet. ILI activity is minimal and flat, and test positivity and hospitalizations remain very low.
Unable to find data on RSV or COVID-19.
Montana:
COVID-19 cases are low and declining. Trips to the ED are declining, and weekly case totals have fallen by half since mid-September.
Flu remains very low. ED visits for ILI are at <1% of all ED visits. There have been <100 cases reported in the entire state so far this season, and just 2 hospitalizations.
RSV activity is minimal – test positivity needs to triple before it will pass the threshold for the start of the season.
Nebraska:
COVID-19 is low and roughly stable – no big swings in test positivity, ED visits or hospitalizations.
Flu remains surprisingly low. Outpatient ILI visits are actually lower now than they have been in the past month – accounting for just 0.3% of ED visits last week. Trips to the ED for ILI are also very low and well below baseline for the start of flu season.
RSV remains low and flat – with low test positivity and few trips to the ED or hospitalizations.
Nevada:
Still no updates to respiratory illness data, following the network outage this summer.
New Hampshire:
The most recent data is for the week ending October 18.
ILI activity is low, at 0.7%, though it increased slightly over the prior week. Flu wastewater activity is below detection levels across all sites in the state.
RSV activity also remains low, though the number of ED visits for RSV in children under five have increased slightly. RSV wastewater activity is below detection levels across the state.
COVID-19 wastewater is fairly low, though there are a few sites in the state with higher activity levels.
New Jersey:
COVID-19, RSV, and flu are all very quiet. Wastewater activity is very low for all three diseases. Combined, Covid-19, RSV, and flu accounted for only 0.5% of ED visits this past week in New Jersey.
COVID-19 has returned to low levels after the late summer increase - with low and declining ED visits and hospitalizations.
Flu is quiet but there are signs of increases. Outpatient visits for ILI have very slowly been creeping up and are up to 3% of all outpatient visits, though they remain below the threshold for the start of flu season.
RSV test positivity and hospitalizations are both low with no clear signs of increases.
New Mexico:
No big changes since last week. COVID-19 test positivity and hospitalizations are low and still declining following the late summer increase.
New York:
COVID-19 activity continues to decrease, ED visits for Covid are <1% of all ED visits, and case rates are down 12% in the past week. The hospitalization rate (1.5 per 100,000 people) is half of what it was in late September.
Flu reporting has now started for New York State for the season. Flu is very low. However, this past week there was a 30% increase in laboratory confirmed flu cases over the prior week.
RSV is increasing as well. The number of confirmed cases of RSV increased 24% in the last week, and hospitalizations increased as well.
For New York City,
COVID-19 continues to decline. ED visits are very low, as are hospitalizations.
Flu remains very low, but is starting to increase. ED visits are rising (though they remain at just 0.12% of all ED visits).
RSV is minimal and stable. Test positivity is around 2%, and RSV accounts for a vanishingly small 0.03% of ED visits.
Other respiratory bugs are circulating widely in the city - rhinoviruses/enteroviruses are very active, 26% test positivity; parainfluenza is also spreading.
North Carolina:
Activity for COVID-19, influenza, and RSV remain low and stable. COVID-19 symptoms constitute 1.5% of visits to the emergency department, while flu and RSV are 0.7% and 0.3%, respectively.
I do note an increase in SARS-CoV-2 concentration in wastewater, which is something to keep an eye on in future weeks.
North Dakota:
COVID-19 is low and declining. Weekly reported case totals have fallen by 54% in the past two weeks. Hospitalizations are also on the decline, with only 9 total hospitalizations for COVID-19 reported last week.
Outpatient ILI is very low (0.4%) and confirmed cases for flu and RSV remain in the single digits for the state.
Ohio:
November begins with a remarkably quiet respiratory virus situation – at least based on the hospitalization data that is available.
COVID-19 is fairly low and continuing to decline. The number of people hospitalized each week has declined from over 300 in mid-September to 130 this past week.
Flu remains very low, but is on an upward trend, with increasing hospitalizations (though the weekly totals remain <20).
RSV is very low and stable.
Oklahoma:
COVID-19 is low and still declining from the late summer wave. Wastewater is very low, and hospitalizations have dropped to 14 individuals hospitalized, down from 48 in mid-September. Test positivity is also low.
Flu activity continues to be below baseline for the start of flu season. Outpatient ILI is 1.6%, and test positivity is just 0.8%. Hospitalizations remain very low. However, wastewater activity is increasing.
RSV is very low and stable, with low wastewater activity and very low test positivity.
Oregon
COVID-19 activity is low and stable, with continued declines in test positivity and wastewater concentration.
Test positivity for influenza is very low but has increased slightly, but wastewater concentration is low and stable.
RSV activity is minimal as measured by test positivity, but I do see wastewater concentration increasing.
Emergency department data is not available.
Pennsylvania:
COVID-19, flu and RSV are all categorized as very low, with all 3 accounting for <0.5% of all ED visits.
RSV is increasing among the youngest age group (those aged 0 to 4) – reported cases have nearly doubled over the past week.
Hospitalization data rely on CDC data so have not been updated in over a month.
Rhode Island:
COVID-19 is very low and continuing to decline. Wastewater is very low. Just 0.3% of ED visits were due to Covid-19. Hospitalizations have declined from 33 in late September to 5 this past week.
Flu is minimal and stable – outpatient visits for ILI remain below baseline, and ED visits and hospitalizations are very low. However, wastewater activity has ever so slightly increased over the past week.
RSV is verrrry low, but increasing. Over the past week, trips to the ED have increased from 0.01% to 0.05%. This seems to be entirely driven by the youngest age group, those aged 0 to 4. Wastewater activity is very low.
Other respiratory bugs are spreading. Rhinoviruses/enteroviruses and parainfluenza both have notable test positivity.
South Carolina:
Respiratory illnesses are remarkably quiet as we enter November.
COVID-19 has returned to the levels it was at over the summer. Just 0.33% of ED visits were for COVID-19 this past week.
Flu is minimal and flat, with no notable increases in ED visits.
RSV remains extremely low, but there has been a slight increase in the past few weeks, particularly among those aged 0 to 4.
South Dakota:
Flu is minimal and sporadic in South Dakota. New cases and hospitalizations are in the single digits. Nevertheless, outpatient visits for ILI are slowly increasing, though they remain well below the baseline for the start of the season.
Trips to the ED for both COVID-like illness and for ILI are low and decreasing.
Trips to the ED for RSV are minimal and flat.
Tennessee:
Influenza activity remains minimal in Tennessee with just 0.2% of visits to the emergency department for influenza. This is below what is typically seen in the state this time of year. COVID-19 is similar at 0.3%, and RSV is minimal. The trajectory for all three pathogens is stable.
I do note an increase in COVID-19 activity among school-aged children 5 to 17, rising from 0.2% to 0.4% of visits to the emergency department, which is something to keep an eye on. Influenza activity has increased in school-aged children as well, but remains low nonetheless.
Texas:
COVID-19 is low and declining. ED visits are even lower now than they were during the summer lull. Hospitalizations are also low and declining.
Flu remains very low. ED visits have been slightly increasing each week for the past month, but are still quite low, at just 0.36% of ED visits.
RSV is very low but increasing. As a percent of total ED visits, RSV still accounts for a very low 0.10%. Looking at the actual numbers can give you a sense of the increases over time, however – in early September, there were about 40 ED visits per week for RSV, by late October that was near 250. Hospitalizations have also increased, particularly for those aged 0-4: the hospitalization rate is now 3.2 per 100,000 for this age group (compared to 0.3 for the overall population).
Utah:
COVID-19 is very low – nearly 90% of wastewater sites in the state are reporting low or very low activity. And only 0.27% of ED visits were due to COVID-19 over the past week.
Flu and RSV remain minimal and flat, with low test positivity, ED visits, and hospitalizations.
Vermont:
COVID-19 is low and declining, with few ED visits and low wastewater concentration in most of the state (concentrations are a bit higher in St. Albans and Ludlow).
Flu remains minimal, but is increasing. Test positivity doubled this past week to 1.9%. Approximately 1% of trips to doctors’ offices were due to ILI, and <1% of ED and urgent care visits were due to ILI this past week.
Virginia:
COVID-19, RSV, and influenza activity all remain very modest in Virginia, at 0.1 to 0.3% of visits to the emergency department. Current all-cause levels of respiratory illness are far below what is typically seen this time of year.
I do note that RSV activity is increasing in the 0 to 4 age group, now constituting 1.3% of visits to the emergency department, up from a recent low of 0.2%. An increase in RSV activity is very typical this time of year.
Around 13% of Virginians have been vaccinated against influenza, and 5% have been vaccinated against COVID-19. I’d like to see those numbers increase before the season starts in earnest.
Washington:
COVID-19 is low and declining. ED visits have fallen by more than half in the past few weeks. Hospitalizations have decreased to 0.7% of all hospitalizations in the state. Wastewater activity is low or very low in ~57% of the sites in the state; however, it is moderate or high in another 37%.
Flu is very low and stable, though in the past week ED visits have increased for those aged 0-17.
RSV is at minimal levels, with no signs of increasing.
Washington, D.C.:
COVID-19 is low, with very few new reported cases and minimal hospitalizations.
Flu is very low and roughly stable. Roughly 1% of outpatient visits for ILI were for flu this past week, well under the threshold of 2.4% for DC. Fewer than 20 laboratory-confirmed cases have been occurring each week for the past month.
West Virginia:
COVID-19 is low and declining, with just 1.31% of ED visits due to Covid-19 this past week. Severe illness is also very low – the hospitalization rate is a very low 0.39 per 100,000 people.
Flu is minimal, with very low test positivity. While ED visits remain low, they are increasing.
RSV is minimal and flat – just 0.05% of ED visits were due to RSV this past week.
Wisconsin:
There is some evidence that acute respiratory disease activity is increasing in Wisconsin. Although laboratory and hospitalization data remain stable at low levels, the percent of visits to the emergency department that are for COVID-19 are increasing specifically in the 0 to 4 age group. The 18-to-64-year-old age group is increasing as well, although I must stress that activity in both remains quite low.
Influenza and RSV activity remain minimal.
Wyoming:
COVID-19 activity continues to decline in Wyoming. However, influenza activity has begun to increase, particularly in the southeastern portion of the state. RSV activity remains minimal.
I so appreciate the work you must be putting into producing this- it must be so difficult. Thank you!
For the last several years, I have noticed that Covid wastewater numbers go up after the two week state fair period in NC, which just ended last week. It would be interesting to see if that could be confirmed scientifically.