Outbreak Outlook: Week 6 of DIY disease surveillance

Flu, COVID-19 and RSV activity remain low but are building momentum

We’re now six weeks into the federal government shutdown, which means six weeks without the CDC’s respiratory virus surveillance dashboards. In their absence, Team Force of Infection has been visiting all 50 state health department websites plus D.C. to piece together the national picture of what’s circulating.

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.

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National Updates

The overall story is fairly consistent across the country: COVID-19 remains low nearly everywhere, influenza activity is low but rising, and RSV is arriving, particularly in young children. But there are notable regional differences in timing and intensity.

COVID-19 remains low nearly everywhere, but I do believe we’ve hit (or will soon hit) an inflection point, where activity begins to rise. For now, most states report ED visits under 0.5%, with wastewater activity minimal.

Influenza remains minimal or low nationally but is beginning to wake up, with the clearest activity in the South and some early stirring elsewhere. Hawaii has entered flu season with moderate activity (ED visits at 2.1%, test positivity at 13%), and Arizona has surpassed its seasonal baseline. In the Northeast, New York saw lab-confirmed cases jump 49% in the past week. Most states, however, remain well below their seasonal baselines, but with ongoing increases.

RSV is showing the most regional variation. The South is leading, with Florida reporting about 7% of pediatric ED visits for RSV and test positivity exceeding 20% in children under 5. Other areas in the South, including Virginia, Georgia, Tennessee, and Texas are also seeing notable increases in young children. The Northeast and West show only early signs of activity. The Midwest remains quietest, with minimal activity and limited signs of increase.

Nationally, norovirus wastewater activity is moderate and increasing. This is being driven by the South — where norovirus has been moderate for a few weeks and continues to rise — and the Northeast, where activity has shot up over the past week to moderate levels. Wastewater activity remains low in the Midwest, with notable decreases in the past week, and it remains low and fairly 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:

• ByHeart Infant Formula due to potential botulism contamination. Botulism is extremely dangerous to infants (more info)

• Peach salsa sold under the Snowfruit label (more info)

• First and Last tomato sauces, distributed in Connecticut and Massachusetts (more info)

• Oven Dried Fish distributed to customers of African Food on Wheels in the Bronx, NY only (more info)

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In Other News

• Botulism outbreak in infants linked to infant formula. 13 infants have been hospitalized since August with botulism after consuming ByHeart infant formula (see recall notice above). Botulism is caused by a toxin produced by the bacteria Clostridium botulinum. Symptoms can include: poor feeding, drooping eyelid, a weak or altered cry, and poor feeding. Treatment is available for infant botulism, and medical care should be sought immediately.

• Bird flu is spreading on US poultry farms. More than 3.5 million chickens, turkeys, and ducks on poultry farms have been culled in the past month due to spreading H5N1. Due to reductions in recent months of the federal workforce and changes in transparency and reporting, there is not good visibility on the spread among poultry. Given the risk of spillover into humans, this is concerning.

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State Data

Alabama:

• Overall, the big three respiratory viruses (COVID-19, RSV, and flu) are low, but RSV and flu are increasing, accounting for 0.3% and 0.4% of ED visits, respectively.

• Covid-19 activity is minimal and continuing to decline. Just 0.2% of trips to the ED this past week were for Covid-19.

Alaska:

• COVID-19 is low. After a few months of decreases, there was a slight increase this past week in lab-confirmed cases this past week. Too soon to tell if it is a blip or part of a sustained increase.

• Flu remains quite low, with no big shifts in the past week in reported cases.

• RSV has more than doubled in the past week, from 7 lab-confirmed cases last week to 19 this week. To put this in context, during last winter’s RSV peak in Alaska, there were 320 weekly confirmed cases.

Arizona:

• COVID-19 activity is minimal, but reported cases increased slightly this past week.

• Flu season is here: Outpatient visits for ILI were at 1.8% this past week, which surpasses the baseline for the state. There was also a nearly 30% increase in reported cases over the previous week.

• RSV remains minimal and fairly stable (over the past five weeks, there have been 10-20 reported cases each week, with no clear pattern of increases or decreases).

Arkansas:

• It is a bit tricky to get a feel for what is going on with respiratory illnesses in Arkansas based on limited data (solely flu hospitalizations and deaths). Flu hospitalizations are low, with only 20 hospitalizations reported so far this season. However, there can be substantial community spread before there is a clear rise in severe outcomes like hospitalization.

California:

• COVID-19 activity is low and stable in California, with just 0.3% of visits to the emergency department for COVID-like symptoms. Hospital admissions are low and stable as well, as is test positivity. Hospital admissions are low and stable as well, as is test positivity.

• Influenza activity and RSV activity are both very low, but rising slowly. Children are experiencing higher levels of activity than adults, but current activity for both viruses remains below what is typically seen this time of year.

Colorado:

• COVID-19 is low and continuing to decline, with less than a quarter of a percent of all ED visits due to COVID-19 last week. Positivity rates at sentinel sites are also declining.

• Flu remains minimal but is steadily increasing. Flu accounted for just 0.2% of all ED visits this past week, but ED visits for flu have increased every week for the past month, as have hospitalizations. In addition, test positivity nearly tripled in the past week.

• RSV remains minimal with no signs of increasing activity yet: ED visits, hospitalizations and test positivity are all flat.

• So far, approximately 20% of Colorado residents have received a flu shot this season, and only 9% have received an updated Covid-19 vaccine. I’d like to see these numbers increase in the next few weeks before flu season kicks in, and before the next Covid wave.

Connecticut:

• COVID-19 indicators are a bit mixed. ED visits are a bit elevated, accounting for 1.4% of trips to the ED every week for the past few weeks (lows over the summer were more around 0.4%). This level has been stable for several weeks. However, wastewater concentration, hospitalizations and reported cases have both declined since late September and are fairly low.

• Flu and RSV remain very quiet.

Delaware:

• COVID-19 is low. Wastewater activity is very low and declining,

• Data for flu and RSV is delayed this week, so no updates.

Florida:

• COVID-19 reported cases have now been declining for 10 straight weeks, and are 1/12 (i.e., 8%) of what they were in August.

• RSV is on the rise, with increasing ED visits, positivity rates, and hospitalizations. About 7% of ED visits were for RSV for children under the age of 5 last week, and for the southeast region of the state, that number climbs to 9%. Test positivity for this age group now exceeds 20%.

• Influenza data was not updated this week (most recent data available is from Week 43).

Georgia:

• Flu remains minimal, but it is waking up. Outpatient visits for ILI continue to increase (up to 2.3%), though they remain well below the threshold for the start of the season, unusually low for this time of year. However, test positivity more than doubled in the past week, up from 1% to 2.3%.

• RSV is rising. In Georgia, the start of RSV season is marked by two consecutive weeks in which PCR test positivity exceeds 3% and antigen test positivity exceeds 10%. Currently, the PCR threshold has passed that threshold (it is at 6.3% test positivity), but antigen testing remains well below the threshold at just 1.4%.

• Several other causes of cold and flu are circulating widely in the state right. Rhinoviruses/enteroviruses rebound last week, and are now up to a quite high 36.4% test positivity. Parainfluenza and adenovirus are also quite active.

Hawaii:

• Flu season is upon us in Hawaii. Activity is moderate, all indicators are moving upward, and the speed at which they are doing so is increasing. ED visits for flu increased to 2.1% of all ED visits last week, and have doubled in the past two weeks. Test positivity is up to 13%. Hospital admissions remain very low, at 0.7% of all hospitalizations; but this is also nearly a doubling from the week before.

• COVID-19 is minimal and continues to decline.

• RSV remains minimal, with no signs of increasing yet.

Idaho:

• COVID-19 is low. ED and urgent care visits have been holding fairly steady over the past month, around 1.6%. Test positivity is declining, and was at 8.2% last week.

• Flu is minimal; just 1.5% of trips to urgent care or the emergency department were due to flu last week. However, there have been slight increases over the past month.

• RSV remains minimal, with no signs of increase.

• Hospitalization data have not been updated in a few weeks.

Illinois:

• COVID-19 is very low, accounting for just 0.3% of ED visits this past week. Hospitalizations are also very low.

• Flu is minimal, but there are early signs of increasing. Test positivity has increased from 0.5% to 0.9% in the past week. However, ED visits remain flat at 0.1%.

• RSV is low and increasing.

• Enteroviruses/rhinoviruses (a common cause of colds) are quite elevated, but on the decline.

Indiana:

• COVID-19 data is a little out of date. Last updated October 21st. At that time, COVID activity was very low and stable.

• Influenza activity in Indiana remains minimal with just 1.3% of visits to the emergency department and urgent care centers for fever and cough or sore throat. Current activity is a little below what is typically seen this time of year. Surprisingly, even the oft-beleaguered 0-4 age group saw a decline in ILI activity during the week ending Oct 25.

Iowa:

• Iowa’s data is a little out of date with the last report covering October 19th to October 25th. At that time, COVID-19 activity was quite low and stable, as was influenza and RSV activity.

• There are some early signs of increase for RSV, with emergency department visits and inpatient hospitalizations both rising, but levels remained low compared to previous seasons.

Kansas:

• COVID-19 activity is low and stable in Kansas with 0.2% of visits to the emergency department for COVID-like illness.

• Influenza and RSV activity is minimal in the state.

Kentucky:

• COVID-19 activity is very low and stable in Kentucky with close to 0% of visits to the emergency department for COVID-19. Activity is far below what is typically seen this time of year.

• Influenza and RSV activity are minimal and stable. RSV stands out as slightly higher in the 0 to 4 age group, constituting around 1% of visits to the emergency department, but trends are stable.

Louisiana:

• COVID-19 is low and stable in Louisiana with around 1% of visits to the emergency department for COVID-like illness. There have been increases in activity amongst children, which could indicate that activity is picking up again. Children are often the first to experience new trends in respiratory illness.

• Influenza activity is minimal but rising in Louisiana. Around 2.3% of visits to the emergency department are for influenza-like illness. Activity is increasing most prominently in children, which is typical. Activity has increased for three weeks in a row now but remains below the threshold that marks the start of flu season (as measured by activity; we are already into flu season by the calendar). Test positivity is increasing as well.

• Similarly, RSV activity remains below what is typically seen this time of year in the state but has risen for several consecutive weeks. Parainfluenza and adenovirus activity, which cause cold and flu-like symptoms, are also increasing.

Maine:

• COVID-19 activity is rising in Maine after more than a month of declines. The percent of visits to the emergency department that are for COVID-19-like symptoms has climbed for two weeks in a row now to 1.3%. Emergency department visits for influenza-like illness have also been rising, now at 1%, though remain at low levels

Maryland:

• COVID-19 activity is low and declining in Maryland, with very few people hospitalized for COVID-19. Deaths from COVID-19 in Maryland have ranged from 0 to 5 per day in recent months.

• Influenza activity is minimal with 1.6% of visits to the doctor for fever and cough or sore throat. This is below the state baseline of 2.7% that marks the onset of flu season. 1.8% of visits to the emergency department are for influenza-like illness. Wastewater concentration for influenza is very low. Current activity is below what is typically seen this time of year. Around a fifth of Maryland residents have received their influenza vaccine so far.

• RSV activity is minimal as measured by inpatient hospitalizations.

Massachusetts:

• COVID-19 activity is very low and stable in Massachusetts, with 0.4% of visits to the emergency department for Covid-like symptoms. Current activity is far below what is typically seen this time of year.

• Influenza activity is also low, but there have been notable increases in the most vulnerable groups: children under the age of five and adults over the age of 80 have both seen a recent jump in ED visits for influenza.

• RSV activity is low but increasing. Children under the age of five have seen sustained and meaningful increases in visits to the emergency department for RSV. Young children and older adults are at highest risk for severe RSV infection.

Michigan:

• The Michigan data I found is a little out of date, covering up to the week ending October 25th. At that time, COVID-19 activity was low and stable, with around 0.3% of visits to the emergency department for COVID-like illness.

• Influenza and RSV activity were minimal and stable as well, just 1.1% of visits to the outpatient doctor were for fever and cough or sore throat.

Minnesota:

• COVID-19 is low and stable in Minnesota, with around 0.3% of visits to the emergency department for COVID-like symptoms. Hospitalizations for COVID-19 are low and stable as well.

• Influenza-like illness is very low but increasing. Test positivity for RSV is increasing as well.

Mississippi:

• Mississippi does not share very much data, but from what I can tell both COVID-like illness and influenza-like illness are low and stable.

Missouri:

• Influenza activity is minimal in Missouri. One percent of visits to the emergency department are for influenza-like illness. Test positivity is also low. Current activity is well below what is typically seen this time of year in the state.

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

Montana:

• COVID-19 activity has been declining steadily since the recent September peak.

• Influenza activity is minimal in Montana. Test positivity is very low, and there are very few influenza hospitalizations. Less than 1% of visits to the emergency department are for influenza-like illness. Current activity is well below what is typically seen this time of year in the state.

• RSV activity is minimal.

Nebraska:

• COVID-19 activity is low. Test positivity held roughly steady, as did trips to the ED for Covid-like illness (at 1%). Hospitalizations continued to decline.

• Flu is minimal and pretty stable, with no major changes in test positivity, ED visits, outpatient sentinel visits, or hospitalizations. Outpatient ILI visits last week were at just 0.5%, substantially below the 3% threshold for the start of flu season.

• RSV remains very low. Test positivity continues to inch upward, but ED visits remain near-zero as do hospitalizations.

Nevada:

• COVID-19 and respiratory virus dashboards still have not been updated since the network outage in August.

New Hampshire:

• Influenza activity is very low and sporadic in the state. Outpatient visits for ILI are at 0.6% and stable. Hospitalizations remain very low, but have increased a bit. Wastewater activity remains non-detectable at most sites in the state.

• COVID-19 wastewater is low to moderate across all sites in the state. Hospitalizations continue to decline.

• RSV activity remains minimal, with no clear signs of increased activity. Wastewater activity remains non-detectable in most sites in the state.

New Jersey:

• COVID-19, flu, and RSV are all at very low levels of activity right now. ED visits for all 3 illnesses combined amount to 0.5% of all ED visits.

• Outpatient visits for ILI are at 3%, still below the 4.5% regional baseline for the start of flu season. Both test positivity and hospitalizations for flu remain very low.

New Mexico:

• COVID-19 is very low. After a few months of declines, ED visits increased slightly this past week, to 0.5% of all ED visits, but it remains to be seen if this will form a trend. Wastewater activity and hospitalization are both very low.

• Flu remains very low. Wastewater activity is minimal. Trips to the ED are also minimal, but have been very slowly increasing for the past several weeks.

• RSV remains minimal, with no clear signs of increasing.

New York:

• COVID-19 ED visits are very low and continuing to fall, as is test positivity and the hospitalization rate.

• Flu remains low, but is increasing. The number of lab-confirmed cases increased by 49% last week, and hospitalizations increased by 71%. Emergency department visits for flu (excluding NYC) increased the past week, to nearly 5% of all visits.

• RSV remains very low, but is on the rise as well. Confirmed cases increased 19% in the past week.

• For NYC:

  • Overall, visits to the ED for respiratory illnesses are rising.

  • COVID-19 is stable and low, accounting for just .18% of all ED visits this past week. Hospitalizations continue to be on an overall downward trend.

  • Flu is increasing. This past week, trips to the ED for flu doubled (though they remain very low overall, at just 0.22% of all ED visits). Hospitalizations also increased slightly.

  • RSV remains minimal, but both ED visits and hospitalizations have increased slightly.

  • Rhinoviruses/enteroviruses – a common cause of colds – continue to dominate respiratory panel results, with 26% test positivity.

North Carolina:

• COVID-19, RSV influenza are both low and stable in North Carolina. Emergency department visits are <1% for each. Wastewater concentration of SARS-CoV-2 is low and declining as well

North Dakota:

• COVID-19 remains low, but reported cases increased slightly this past week. Hospitalizations are low and stable.

• Flu is also very low. Outpatient visits for ILI have held roughly steady for the past month at about 0.5%. Test positivity has steadily risen over the past month, but also remains very low.

• RSV remains minimal.

Ohio:

• Hospitalizations for COVID-19 remain low and held roughly stable this past week, with 127 people hospitalized.

• Both flu and RSV, hospitalizations remain very low (<20 each per week), but both increased slightly this past week.

• Ohio only provides data on hospitalizations for Covid, flu and RSV – while hospitalization data is useful to understand severity and healthcare system capacity, because hospitalizations are a lagging indicator, they are relatively less useful for understanding the current scale of community spread compared to other metrics, such as wastewater activity or outpatient visits. As such, while hospitalizations are low, it is not possible to say based on hospitalization data whether broader community activity is also low.

Oklahoma:

• COVID-19 is low and stable. Test positivity has been gradually declining since early September, and is now at a low 2.8%. Wastewater activity is low. Hospitalizations are also low and stable.

• Flu is minimal. Wastewater activity is rising – however, that increased activity is not yet showing up in other indicators. Test positivity is low and stable, ILI activity is at just 1.5%, and hospitalizations remain very low.

• RSV is minimal and stable.

Oregon:

• COVID-19 test positivity is down. Wastewater activity is stable or decreasing across all sites in the state.

• Flu is very low. Test positivity is minimal, but is on an increasing trend. Wastewater activity is minimal, with only sporadic detections. Hospitalizations are minimal.

• RSV is minimal and stable, well before the threshold for the start of the season. Wastewater activity, just like for flu, is minimal with only sporadic detections. Test positivity remains very low, with no signs of increases, and there was only 1 hospitalization reported for the state.

Pennsylvania:

• Emergency department visits for all three major pathogens remain minimal and stable. However, there has been some increase in the percent of ED visits for respiratory symptoms (any respiratory illness cause) among the 0 to 4 age group. Wastewater concentration of SARS-CoV-2 and influenza A are both minimal as well. Current activity remains well below what is typically seen this time of year.

Rhode Island:

• Flu is low but rising. ED visits more than tripled in the past week, from 0.07% to 0.23%. Outpatient visits for ILI increased slightly this past week to 1.36%. However, wastewater activity remains very low and flat. In addition, hospitalizations are extremely low – just one person was admitted last week due to flu.

• COVID-19 is low and continuing to fall. Wastewater activity is very low. ED visits last week were down to 0.23% of all ED visits. Hospitalizations are very low (<10 for the entire state).

• RSV remains minimal. Reported cases of RSV are rising, but ED visits remain stable. Wastewater activity remains very low but has been steadily increasing the past few weeks.

• There are several other respiratory bugs circulating in Rhode Island right now. Enteroviruses/rhinoviruses continue to spread widely, as does parainfluenza.

South Carolina:

• Really quiet early November. After decreasing substantially over the past two months, COVID-19 has stabilized at very low levels.

• Flu is minimal and stable, with no signs of increasing yet.

• RSV remains very low and it also held steady this past week, at just 0.11% of ED visits.

South Dakota:

• Influenza activity is minimal and sporadic in the state. Outpatient visits for ILI remain very low, at just 0.61% of outpatient visits, far below the baseline for the start of flu season.

• The number of ED visits for Covid-like illness and ILI were identical this week – 34 visits each.

• RSV remains minimal, with no reported visits to the ED due to RSV this past week.

Tennessee:

• COVID-19 and flu are causing similar levels of more severe illness right now – Covid accounted for 0.4% of ED visits this past week and flu accounted for 0.3%. Overall, both appear to be gradually rising.

• RSV is picking up but remains low overall. For children under 5, ED visits have doubled in the past week, from 0.5% to 1%.

Texas:

• Respiratory illness is pretty low right now, though flu has overtaken Covid in Texas for the moment in terms of trips to the ED.

• Flu remains low, but is rising, with 0.48% of ED visits due to flu this past week. No notable increase in hospitalizations yet, however.

• COVID-19 is very low. ED visits due to COVID-19 are lower now than at any point in the past year, accounting for just 0.2% of all ED visits. Hospitalization rates are also very low and decreasing.

• RSV remains minimal, but increasing steadily. For children under 5 years of age, ED visits are over 1%, and the hospitalization rate is 3.6 per 100,000.

Utah:

• COVID-19, flu, and RSV are all at really low levels in Utah, together accounting for less 0.5% of all ED visits.

• Covid-19 wastewater activity is low or very low in 94% of sites in the state. Covid-19 vaccinations for this year are very low, even compared to where other states are right now – just 1.5% of Utahns have received a dose this season.

• Flu remains unusually low as well. Just 0.45% of all outpatient visits were for ILI this past week. Hospitalizations are minimal.

• RSV is minimal and flat – no signs of an uptick even among more vulnerable populations.

Vermont:

• COVID-19 ED visits and wastewater activity both tell the same story: activity is low and declining. Vaccinations for this season are still pretty low – only 10% of Vermonters have been vaccinated so far.

• Flu remains minimal, but activity is slowly increasing. Last week, 1.29% of outpatient visits were due to ILI compared to 0.9% the previous week. Test positivity is also increasing. Seasonal flu vaccination rates are a bit higher than for Covid – at 19% – but I am still hoping to see that rise a bit before flu season really kicks off.

• I couldn’t find any RSV data.

Virginia:

• Acute respiratory illness has been rising in Virginia for four consecutive weeks. However, current activity remains well below what is typically seen this time of year.

• RSV activity is increasing very sharply in children ages 0 to 4, now totaling 2.3% of visits to the emergency department. I also note small increases in influenza and COVID-19 activity in children, but RSV leads.

• Around 13% of Virginians have been vaccinated against influenza and around 5% for COVID-19. 32% of Virginians 75 and older have received the RSV vaccine.

Washington:

• COVID-19 continues to fall. Wastewater activity is very low or low in nearly 90% of wastewater sites in the state. ED visits for Covid-19 are down to just 0.4% of all visits. Hospitalizations are also on the decline, and are lower right now than at this point the past couple years.

• Flu is minimal and stable. No signs of an uptick yet.

• RSV is minimal. There is no sign of an uptick for the general population yet, but trips to the ED are rising for little kids – for those 1-2 years of age, ED visits have risen to 0.6% (versus 0.0% for the total population).

Washington, D.C.:

• COVID-19 is low and decreasing. After a peak reported case rate of 23 per 100,000 people in mid-September, the case rate has fallen to 1.8. Hospitalizations have also declined and are very low.

• Flu remains low. Outpatient visits for ILI increased a bit this past week, to 1%, but remains well below the threshold for the start of the flu season for DC (2.4%). Test positivity is also increasing.

West Virginia:

• COVID-19 activity is low but increasing in West Virginia. Around 1.4% of visits to the emergency room were for COVID symptoms during the week ending November 1st. Current activity is stable.

• Influenza activity is minimal but increasing in West Virginia. 2.3% of visits to the emergency department were for influenza symptoms, up from a recent low of 1.8%. However, test positivity remains very low at around 2%.

Wisconsin:

• COVID-19 activity is low and stable in Wisconsin. Just 0.3% of visits to the emergency department were for COVID-like symptoms, a level of activity that has remained stable for a few weeks now. There has been an increase in COVID activity in children ages 0 to 4, rising to 0.5% from a recent low of 0.1%.

• Influenza activity is minimal in all age groups, as is RSV activity.

Wyoming:

• COVID-19 continues to decline, with just 24 newly reported cases this past week versus 99 in late September. (Keep in mind that actual case totals are far higher than these reported totals; this is just the cases that were lab confirmed and reported to the public health department).

• Flu remains low, but is increasing. Outpatient visits for ILI increased to 2.5% last week (the baseline for the start of the season is 5.4%).

• RSV remains minimal.