Outbreak Outlook: Week 4 of DIY Surveillance

Unusually quiet autumn for respiratory infections

Week 4. Still no CDC data. Still checking all 50 states plus D.C. ourselves. I’m starting to wonder what will come first: flu season or the end of the shutdown.

I would like to extend a big thank you to my research assistant Anna, who’s been in the trenches with me, first working on Crisis Averted, now on Force. None of this would be possible without her.

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. However, the federal shutdown means the data provided by the CDC on respiratory infections and norovirus are not being updated. To fill the gap, Force of Infection has been visiting each state website plus Washington, D.C. to get the latest on what’s going around.

Since the shutdown has made it harder to get high quality information, all reports will be free until the government reopens.

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National Updates

Mother Nature is cutting us a break. This is one of the quietest periods for respiratory virus activity that I’ve seen in a long time. Here’s hoping it stays that way for the duration of the shutdown (and beyond!).

COVID-19 activity continues to decline around the country, now at low or very low levels in most states. There is very little in the way of influenza activity yet, so there is still time to get your flu shot if you have not already. RSV stirred in a few states, particularly in young kids, but remains at very low levels overall.

One exception: norovirus is trending upward nationally. In the South, activity is moderate but has actually decreased a bit over the past week. Norovirus has passed from low to moderate activity and is rising in the Northeast, and while it remains low in the Midwest, it is trending upward there as well. Activity remains low and stable in the West.

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Food Recalls

The following foods are being recalled because they are contaminated. Please check your cupboards and throw out any of these items:

New:

• Haetae (HT) Ground Cinnamon Powder due to potential lead contamination (more info)

• Kenz Henz “Grade AA Large Pasture Raised eggs” sold in Houston, Texas (more info)

• Yet more shrimp due to possible cesium-137 contamination: shrimp sold under a variety of brand names, including Best Yet, Waterfront Bistro, AquaStar, and Publix (more info)

• Ready-to-eat breakfast burrito and wrap products containing eggs, including some sold in bulk for institutional use, under a variety of brand names, including: El Mas Fino, Los Cabos, and Midamar (more info)

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In Other News

• Mpox spreading in California. Public health officials in California have identified three recent, unrelated cases of mpox, all with no history of international travel: two in Los Angeles and one in Long Beach. This suggests that community transmission is occurring. Notably, these cases are clade 1, which is different from the clade IIb strain that caused the 2022 epidemic. Historically, clade 1 mpox causes more severe illness; all three individuals had to be hospitalized. Mpox can spread through physical and sexual contact and tends to transmit in close social networks.

• Common cause of cold-like symptoms is spreading. Parainfluenza is increasing nationally, per BIOFIRE Syndromic Trends. Parainfluenza can cause of a range of cold-like symptoms, including fever, cough, runny nose, and sore throat. In children, infection can also lead to more severe infection of the upper and lower respiratory tract, including croup, bronchitis and pneumonia, causing symptoms like a barking cough and wheezing.

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State Data

Alabama:

• COVID-19 continues to decline to low levels in Alabama; 0.28% of visits to the emergency department were for COVID-19, down from 0.31% the week prior.

• Influenza activity increased slightly but remains low. RSV activity remained very low and stable.

Alaska:

• COVID-19 activity continues to decline in Alaska with 1.1% of visits to the emergency department for COVID-like illness, down from 1.6% the week prior.

• Influenza and RSV activity remains at very low and stable levels as well.

• Current activity for all three viruses remains well below what is typically seen in Alaska this time of year.

Arizona:

• COVID-19, influenza, and RSV activity are all low in Arizona as measured by emergency department visits and hospitalizations. Wastewater concentration is also low and stable.

Arkansas:

• Arkansas data is sparse.

California:

• COVID-19 activity is low and declining in California. 1.6% of visits, 0.4% of visits to the emergency department were for COVID-19, down from a recent high of 2.6% in late August. Current COVID activity is low compared to this point in previous seasons. Hospital admissions are low as well, as is test positivity.

• Influenza and RSV activity are both very low and stable in California.

Colorado:

• COVID-19 activity continues to decline in Colorado, with 0.3% of the visits to the emergency department for COVID-19, down from a recent high of 1.1%.

• Influenza and RSV activity remain minimal, according to both emergency department visits and wastewater concentration. Inpatient hospitalizations for all three viruses are minimal.

Connecticut:

• COVID-19 is low and activity continues to decline from the early fall wave. Wastewater concentration is low and declining, and reported cases have fallen by more than two-thirds since mid-September. Hospitalizations have also declined by three-quarters since the end of September.

• Flu remains minimal, with very low reported cases and hospitalizations.

• RSV remains very low, though activity has slowly picked up since September, with cases moving from the single digits per week into the 10-20 cases per week range.

Delaware:

• COVID-19 is low, with declining hospitalizations and reported cases.

• Flu is not particularly active yet: total reported flu cases since the end of September are still <50. Delaware’s tracker also follows flu vaccinations. In the past few weeks, about 12% of Delaware residents have been vaccinated. I hope to see that number climb quite a bit in the next several weeks.

• RSV also remains minimal, with the number of ED visits so low that it is hidden on the state’s dashboard to protect patient privacy.

• Wastewater activity tells a similar story: activity is very low for COVID-19, flu, and RSV in Delaware.

Florida:

• COVID-19 reported cases have fallen dramatically in the past two months, from a peak of over 14,000 in late August to roughly 1,500 this past week. (Of course, reported case are far lower than actual cases, since most people are not testing or reporting the outcomes of their tests so these should not be taken as exact numbers, but rather given a sense of magnitude of change).

• RSV remains low but is picking up. ED visits generally held steady—but those for the youngest children, who tend to be among the most severely affected by RSV— had an increase. Test positivity and hospitalizations have also increased over the past few weeks.

• Flu data had not updated for the past week as of time of writing.

Georgia:

• “Due to the lapse in federal appropriations and associated federal government shutdown, some data required for the Georgia Influenza Report are not available. As a result, the weekly report will be paused until federal operations and data sharing resume.”

Hawaii:

• COVID-19 activity has been declining in Hawaii for around two months now, but in the most recent week there was a slight increase in activity. Test positivity rose from 2.9 to 3.3%, and the percent of hospital admissions that are for COVID-19 increased from 0.8% to 1.1%. However, emergency department visits continued to decline. Overall COVID activity in Hawaii is still low.

• Influenza activity in Hawaii has increased in recent weeks but remains at low levels. Emergency department visits for influenza have risen to 0.9% from a recent low of 0.3%. Test positivity has been rising as well. It’s a good time to get your flu shot if you haven’t already.

• RSV activity in Hawaii is moderate, according to the Department of Health’s assessment.

Idaho:

• Test positivity and visits to healthcare providers for COVID-19 are both low and stable.

• Influenza activity is minimal with 1.4% of visits to the doctor for fever and cough or sore throat and 1.3% of visits to the emergency department for influenza-like illness.

• RSV activity is minimal.

Illinois:

• Activity for all three major pathogens is minimal in Illinois. Visits to the emergency department range from 0% to 0.2% depending on the pathogen. Overall, 8.6% of visits to the emergency department were for any kind of acute respiratory illness.

• There has been a recent increase in all-cause emergency department visits in the 0 to 4 age group and a more modest increase in the 5 to 17 age group, but levels remain low nonetheless.

Indiana:

• COVID-19 activity is quite low in Indiana. Emergency department visits for COVID-like illness are well below what is typically seen this time of year, and there are very few hospitalizations. There has been a dramatic increase in wastewater concentration, but given that other indicators are so low and no other states are showing similar movements, I’m inclined to think it’s a data blip. I will keep an eye on it.

• Influenza activity is minimal in Indiana. 1.3% of visits to the emergency department or urgent care centers were for influenza-like illness (ILI), which is defined as fever and cough or sore throat. A similar percentage of visits to outpatient doctors was for influenza-like illness. Current ILI activity is below what is typically seen this time of year in the state.

Iowa:

• Data has not been updated since October 11 as far as I can tell.

Kansas:

• All-cause respiratory illness is stable in Kansas, constituting around 10% of visits to the emergency department.

• COVID-19 activity has declined to 0.2% of visits to the emergency department, down from a recent high of 1% of visits.

• RSV activity is minimal. Influenza activity is minimal as well.

Kentucky:

• The Kentucky data is confusing to me as I’m still not seeing the 2025-2026 season, but the dashboard says it was updated on October 22nd. If what I’m seeing is accurate, then COVID-19, influenza, and RSV activity are all low or minimal and stable.

Louisiana:

• COVID-19 activity is low and declining in Louisiana with 1.1% of visits to the emergency department, down from a recent high of 3.9% in late August.

• Influenza-related emergency department visits have been drifting up, now at 1.9%. The 2- to 4-year-old age group is most affected, followed by the 5- to 11-year-old age group.

• RSV activity is minimal overall, but there have been noticeable increases in the 0 to 1 age group and the 2 to 4 age group. RSV activity peaks in the state during the November to January time frame, so I expect continued increases.

Maine:

• As of October 12th, both COVID-19 and influenza-related visits to the emergency department were low at around 1%. Wastewater data is not currently available for the state.

Maryland:

• COVID-19 cases and hospitalizations continue to fall, and are back down to fairly low levels.

• Flu remains minimal, with very low wastewater activity, and ILI outpatient visits still well below baseline. Maryland seems to be doing pretty well with their flu vaccinations so far this year. As I prepared the newsletter this week, I noticed that many of the states that reported vaccination data had reached about 12% of the population so far (I expect this to increase substantially in the coming weeks). But in Maryland, that number is already 16%. My family got ours so we’re doing our part!

• RSV hospitalizations remain low and stable (and in the single digits for the state).

Massachusetts:

• Using estimates to account for reporting delays, Massachusetts Department of Public Health calculates that all-cause acute respiratory disease is very low, accounting for 8.1% of ED visits between October 12-18.

• COVID-19 is estimated to be very low, with declines in reported cases and ED visits over the past few weeks.

• Influenza-like illness (ILI) is minimal and stable in Massachusetts, and remains below baseline for the start of flu season.

• RSV remains minimal as well.

Michigan:

• COVID-19, RSV, and flu are all causing minimal trips to the ED and hospitalizations in Michigan.

Minnesota:

• COVID-19 is back down to low levels following the small late summer/early fall wave. Wastewater activity has decreased dramatically, and the proportion of trips to the ED and hospitalizations due to COVID was a very low 0.3% last week.

• ILI activity remains minimal and stable, with no clear signs of an increase yet.

• RSV test positivity remains very low, but it has been gradually increasing over the past couple weeks. However, hospitalizations remain minimal.

• Rhinoviruses (a common cause of colds) are spreading widely in Minnesota right now, with higher case rates than the state has reported in over a year.

Mississippi:

• COVID-19 activity is low and declining. Trips to the ED for COVID-like illness are very low, as is wastewater concentration.

• ILI activity increased slightly this past week, though it remains lower than average for this time of year.

• RSV is quiet. Wastewater activity is very low, as are trips to the ED and urgent care due to RSV (though they have increased slightly over the past few weeks). I was not able to find other RSV indicators.

Missouri:

• Influenza-like illness remains minimal and flat. Just 0.8% of ED visits were due to ILI last week.

• I was not able to find data on COVID-19 or RSV.

Montana:

• COVID-19 cases are lower than their peak at the end of September, but they did increase slightly this past week.

• Flu and RSV remain minimal and flat.

Nebraska:

• COVID-19 is low and decreasing. COVID-like ED visits are currently at a low 1.1%; test positivity and hospitalizations are also low and trending down.

• Flu remains very low, though there were slight increases in test positivity and ED visits. ‘

• RSV remains minimal and stable. No signs of an increase in ED visits and only a slight uptick in test positivity.

Nevada:

• Several public health dashboards are back online in Nevada after the network outage this summer; unfortunately, the ones for COVID-19 and respiratory surveillance still have not been updated since August.

New Hampshire:

• Not all data was updated yet for this week at time of writing.

• Acute respiratory illness remains very low or low in all New Hampshire counties.

• RSV and flu are at non-detectable levels in the wastewater at all wastewater sites in the state. COVID-19 wastewater concentration ranges from low to moderate across the various wastewater sites in the state.

New Jersey:

• COVID-19 is low – wastewater activity is very low, ED visits are low and continuing to fall, accounting for just 0.3% of all ED visits this past week. Hospitalizations are also low and declining.

• Flu remains very low. Wastewater activity is very low and ED visits for influenza are minimal and stable, accounting for 0.2% of all ED visits. Outpatient visits for ILI remain well below the regional baseline for the start of flu season, however, they have been slowly—and jaggedly—increasing over the past few weeks and are up to 3%. Case rates are also showing small, but persistent increases.

• RSV is minimal and stable across all indicators.

New Mexico:

• Acute respiratory infection is minimal, and below normal for this time of year. COVID-19, flu, and RSV are all minimal in New Mexico: just 0.62% of all diagnoses at discharge from the ED were for one of these diseases this past week.

• COVID-19 cases and hospitalizations are quite low and continue to decline after the small wave that peaked last month.

• Both flu and RSV are close to zero.

New York:

• COVID-19 continues to decline after the peak in mid-September. Trips to the ED for COVID-19 accounted for 1% of all ED visits this past week. While this is a bit higher than the lows that were reached over the summer, rates continue to steadily decline. Hospitalizations are similarly on the decline. Case rates are also falling for the New York population as a whole; however, for the oldest age groups, cases have actually increased a bit over the past few weeks.

• Flu data reporting has not yet started for the state for this season.

• In NYC, respiratory illness is on the rise. Last week, respiratory illness accounted for nearly 8% of all ED visits.

  • Flu remains very low, but it did increase substantially this past week – doubling from 0.05% of ED visits to 0.1%.

  • RSV similarly remains at minimal levels, but is increasing.

  • COVID-19 is very low and continues to decline, with very few trips to the ED or hospitalizations.

North Carolina:

• COVID-19 is declining in North Carolina. 1.5% of visits to the emergency department were for COVID-19, down from a recent high of 4% in early September. Inpatient hospitalizations and wastewater concentration are low as well. The concentration is also low.

• Influenza-like illness and RSV activity are minimal according to all metrics, including wastewater concentration.

North Dakota:

• RSV and COVID-19 activity all remain low in North Dakota. In fact, influenza-like illness is minimal, with just 0.5% of visits to the doctor for fever and cough or sore throat.

Ohio:

• COVID-19 hospitalizations continue to decrease following the state’s peak in mid-September. Flu and RSV activity remain minimal according to inpatient hospitalization data.

• In Montgomery County, which publishes more information than the state, emergency department visits for influenza-like illness have increased slightly to 1.9%, though this is still below the activity seen at this time last year.

Oklahoma:

• COVID-19 activity is low and falling. Wastewater activity has declined, test positivity is low, and hospitalizations have decreased by two-thirds since mid-September.

• Flu activity remains minimal and stable. ILI accounted for 1.4% of outpatient visits to sentinel providers, which remains below baseline for the start of flu season. Flu test positivity is also very low, at 0.9%.

• RSV activity remains low and stable across much of Oklahoma. RSV test positivity is far below baseline for the start of the season at a statewide level. However, activity has spiked and is above baseline activity levels in the northeast of the state.

Oregon:

• COVID-19 activity has declined back to low levels in Oregon. Wastewater activity is showing stable activity in about half of all sites in the state, and a sustained decrease in another third, with no sites showing sustained increases. Test positivity has decreased from about 21% in mid-September, down to about 6%

• Flu is low. Wastewater activity remains very low with only sporadic detections. Test positivity remains very low and flat.

• RSV remains minimal. Just as for flu, wastewater activity is very low with 91% of sites reporting non-detectable levels. Test positivity remains very low, but has increased slightly in the past week.

• Oregon relies on federal government reporting for emergency department visits and hospitalizations for COVID-19, flu, and RSV, so no updates are available for these metrics.

Pennsylvania:

• Respiratory illnesses are pretty low right now, accounting for about 10% of all trips to the ED in the past week. The big three (COVID-19, flu, and RSV) are all very low in Pennsylvania right now, each accounting for <0.05% of all ED visits.

• COVID-19 wastewater activity has fallen quite a bit over the past month, from high to very low levels. Wastewater activity for flu remains minimal and stable.

• Pennsylvania relies on CDC data for hospitalizations, and so no updated data on hospitalizations for COVID-19, flu, or RSV are available.

Rhode Island:

• COVID-19 activity is on the decline in Rhode Island. Wastewater activity has declined to very low levels. The proportion of ED visits due to COVID-19 has been cut in half over the past month, and is down to 0.4% of all ED visits. Hospitalizations have also been decreasing.

• Flu season has still not started, with the rate of outpatient provider visits due to ILI still under the regional baseline for the start of the season. Wastewater activity is also minimal.

• RSV remains minimal and stable, accounting for just 0.01% of all ED visits and with very low wastewater activity. Nevertheless, wastewater activity has been steadily increasing over the past several weeks.

South Carolina:

• This is a quiet end of October.

• The small late summer/early fall COVID-19 wave has fully receded, with ED visits for COVID-19 back down to ~0.5% of all ED visits.

• Flu remains very low, but activity may be increasing a bit. Test positivity is rising, but visits to the ED for flu are low and stable, and outpatient visits for ILI are at 1.4%, which remains below the baseline for the start of flu season in South Carolina.

• RSV is very low, but trips to the ED have increased slightly over the past few weeks.

South Dakota:

• Flu remains minimal in South Dakota, with only sporadic cases. Outpatient visits for ILI remain very low, at 0.58% of visits. Only 21 trips to the ED last week were due to ILI.

• ED visits due to COVID-like illness are low and decreasing (26 total last week).

• RSV is minimal and stable; zero visits to the ED last week were due to RSV.

Tennessee:

• COVID-19, flu, and RSV all appear to be very low right now.

• Of all trips to the ED in Tennessee, just 0.3% were due to COVID-19, 0.2% were due to flu, and 0.0% were due to RSV this past week in the state.

• Hospitalizations for COVID-19 are still a bit elevated following the small wave last month, but they are on the decline.

• Flu is minimal and stable, with ILI accounting for 1.3% of outpatient visits. Rates are slightly higher in the Northeast region of the state, but are still very low.

Texas:

• COVID-19 activity continues to fall, as flu activity picks up. For the first time since early summer, there were more trips to the ED last week for flu (797) than for COVID-19 (563). However, hospitalizations due to flu remain low.

• COVID-19 hospitalizations have also decreased notably in the past several weeks, from 3.8 per 100,000 individuals at the end of August down to 0.7. The differential impact of severe COVID-19 on those 65 and older bears repeating: during that same time period, the hospitalization rate went from 15.5 down to 3.7 (that is, the ‘low’ they are now at is the same as the high for the entire population back during the peak of the wave).

• RSV activity remains very low, but is also slowly increasing week-over-week, having risen to 250 ED visits this week, from 195 the week before. This increase is occurring, as expected, almost entirely among the youngest children – most sharply among those under 1 year of age, closely followed by those from 2-4 years of age. RSV hospitalizations for those 0-4 years more than doubled this past week, to 3.3 per 100,000.

Utah:

• Things are really quiet in Utah. COVID-19 has dropped back down to very low levels, with very few ED visits or hospitalizations.

• Emergency room trips for COVID-19, flu, and RSV combined is just 0.4% of all ED visits.

• There are no clear increases in ED visits or hospitalizations for flu or RSV.

Vermont:

• Flu remains minimal in Vermont, with <1% of trips to the ED and urgent care for ILI or for diagnosed influenza. There are no reported ILI outbreaks in places where you tend to see spread early, such as long-term care facilities, schools, and childcare centers.

• COVID-19 is low and declining. Wastewater activity is low, and ED visits continue to decline from their mid-September peak.

Virginia:

• COVID-19, flu, and RSV are all at minimal levels, and combined account for 0.5% of all ED visits in Virginia. The youngest children, those aged 0-4, account for the highest proportion of ED visits for all three diseases.

• Emergency department and urgent care visits have declined notably for COVID-19 over the past month, are holding steady for flu, and are slowly but steadily increasing for RSV.

Washington:

• COVID-19 continues to decline. Trips to the ED have fallen by half in the past few weeks, and hospitalizations have declined from 1.5% at the beginning of October to 0.6%.

• Emergency department visits and hospitalizations for both flu and RSV remain minimal and flat.

• Just under 14% of Washingtonians have already received their flu shot this season – anytime over the next couple weeks is just about the ideal time to go and get yours if you haven’t already.

Washington, D.C.:

• COVID-19 is low and declining. The weekly case rate has declined substantially over the past few weeks and is back down to low levels.

• Outpatient ILI is very low, at 1% it is still well below the regional baseline of 2.4% for the start of flu season.

West Virginia:

• Influenza activity is minimal in West Virginia, though there has been a small increase in emergency department visits for influenza symptoms; 1.7% of visits to the emergency department are for influenza-like illness, an increase from 1.7% the week prior.

• COVID-19 activity remains low and continues to fall. 1.3% of visits to the emergency department are for COVID-like illness. RSV activity remains minimal.

Wisconsin:

• Since data dashboards are not loading properly, but the state has offered the following assessment:

• Statewide respiratory illness levels are low.

• COVID-19 activity is decreasing in emergency department data, laboratory testing and wastewater data.

• Influenza and RSV activity levels are minimal based on emergency department, laboratory testing, and wastewater data.

• Rhinovirus/enterovirus activity levels are elevated; parainfluenza virus activity is increasing.

Wyoming:

• COVID-19 has declined notably over the past month, and is now close to the lows it reached over the summer, as measured by reported cases.

• Flu remains minimal, with few reported cases, and outpatient visits for ILI at 1.6%, well below the baseline for Wyoming of 5.36%.

• RSV remains minimal, based on reported cases.