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November 9 - November 15, 2014 (MMWR Week 46) Highlights For the 7th straight week, local flu activity is considered ‘low’. The local activity rating scale definition can be found http://www.ccbh.net/storage/flu/Cuyahoga%20County%20Flu%20Activity%20Level%20Definitions%2011.06.14.pdf Pneumonia related deaths accounted for 3.6% of all deaths. No flu related deaths so far this flu season. One confirmed case of flu associated hospitalization were reported this week. Percentage of doctor’s visits for flu like symptoms provided by athenahealth increased for 4th straight week. Number of emergency room visits due to flu like illness increased this week; 4rd straight week total was above the 5-year median. Local Flu Activity Dashboard Current Week Flu Activity X Low Mod High (All data are preliminary and may change as updated information are received.) Oct Weekly Intensity Nov Dec Jan 40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 Feb 2 3 4 5 Mar 6 7 Apr May 8 9 10 11 12 13 14 15 16 17 18 19 20 # Weeks123 2014-2015 Season Total/Trend Trending slightly above 5 year median. No flu deaths. Table 1. Cuyahoga County Influenza Data Dashboard Influenza (Flu) Indicator Percent of pneumonia deaths & number of flu related deaths - [Fig 1] Influenza like illness (ILI) doctor visits [Fig 2] Current Activity Level Pneumonia: 3.6% Flu: 0 deaths Cuyahoga: 1.71% 32.6% 26.1% (5) Athenahealth: 0.29% 1 Flu associated hospitalizations [Fig 3] School absenteeism due to ILLNESS ONLY – [Fig 4A] Cleveland: Northeast: Northwest: Southeast: Southwest: School absenteeism due to ALL CAUSES – [Fig 4B] Northeast: 2.2% Northwest: 3.9% Southeast: N/A Southwest: N/A Sentinel: 3.9% N/A 2.1% 2.7% 1.8% 2.7% N/A N/A N/A (5.3%) (14.8%) 2 N/A N/A N/A 3 1 N/A 1 N/A N/A 4 1 Emergency room visit due to ILI [Fig 5] 2.8% Sales of over-the-counter medications used to treat ILI. [Fig 6] Congestion & cough complaints [Fig 8} Vomiting & nausea complaints [Fig 9] 341 (1.7%) 1 668 633 196 (2.9%) (2.5%) 3.7% 1 1 1 Due to small percentages in figures 1-2, 4A, & 4B, caution should be used while interpreting the ‘Activity Compared to Last Week’ box. 3 1 6 2 1 1 N/A 30.0% N/A N/A 8.3% 7.7% Diarrhea complaints [Fig 10] 1 Activity Compared to Last Week 47.1% Stable For figures 1,2,4a & 4b, = (Increase > 20%), = (Decrease > -20%), = Stable (-19.9% to +19.9%) For figures 5-6 & 8-10, = (Increase > 10%), = (Decrease > -10%), = Stable (-9.9% to +9.9%) Page 1 of 8 athenahealth ILI visits slightly increasing since week 40. N=14. Close to 5 yr median. All locations trending below the 5 year median. All locations trending below 5 year median. Above 5 year median. Above 5 year median. Avg ~ 330 Near 3 yr median. Avg ~ 605 Above 3 yr median. Avg ~ 595 Above 3 yr median. Avg ~ 150 November 9 - November 15, 2014 (MMWR Week 46) Flu Summary This report is intended to provide an overview of influenza related activity occurring in Cuyahoga County while providing some information on state activity that is one week behind the current week. It will be published on a weekly basis and can be found at the following website: http://www.ccbh.net/flu-weekly-surveillance-report/ Note: Data are provisional and subject to change. Updates will be included in future reports. Pneumonia and Influenza (P&I) Mortality 3.6% of all deaths reported to the Cleveland Bureau of Vital Statistics were due to pneumonia. Adults 75 years old and older accounted for 55.6% of the pneumonia related deaths. No influenza related deaths occurred this week (Figure 1). Influenza-Like Illness (ILI) Reports One ILI sentinel provider reported no patients had ILI symptoms this week. Athenahealth reported that 0.29% of patients had flu-like symptoms this week and 0.23% for week 44 (Figure 2). ILI is defined as a fever (≥ 100◦ F), and cough and/or sore throat. School Absenteeism Participating schools in Cuyahoga County reported the percentage (median = 2.7%) of absenteeism due to any illness on Tuesday (Figure 3A). Figure 3B shows the total absenteeism due to any reason (median = 3.8%). Influenza-Associated Hospitalizations and Influenza-Associated Pediatric Mortality One confirmed case of influenza-associated hospitalization in Cuyahoga County was reported this week and 6 cases for week 45 (Figure 4). Twenty-two statewide confirmed influenza associated hospitalizations this week. No pediatric flu related deaths have occurred so far this season. Emergency Department (ED) visits and Over-the-Counter Medication Sales 2.8% of all ED visits were for fever + ILI symptoms. Approximately 55 more patients visited EDs for fever and ILI symptoms this year compared to 2013 (Figure 5). Figure 6 shows approximately 190 more OTC products per drugstore were purchased this year than in the same period in 2013. Figure 7 shows the frequency of ED visits for fever and ILI by zip code. Three other maps show, by zip code, the frequency of ED visits for three symptoms that are common during the fall and winter seasons and are of interest to the general public: congestion and cough (Figure 8), vomiting and nausea (Figure 9), and diarrhea (Figure 10). Descriptions of data sources used to complete the weekly influenza write-up can be found on the last page of this report. Additional Influenza Activity Links Weekly U.S. Influenza Surveillance Report – http://www.cdc.gov/flu/weekly Ohio Influenza Surveillance – http://www.odh.ohio.gov/features/odhfeatures/seasflu/ohfluactivity.aspx Google flu trends – http://www.google.org/flutrends Page 2 of 8 Figure 1. Percentage of Deaths Due to Pneumonia and Influenza (P&I) Cleveland Bureau of Vital Statistics 10.0% 9.0% 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 Percent Pneumonia 2 3 4 5 6 MMWR Week Percent Influenza 7 8 9 10 11 12 13 14 15 16 17 18 19 20 5 Yr Median P&I 2009/2010-2013/2014 Figure 2. Percent of Influenza-Like Illness (ILI) Visits U.S. Influenza Sentinel Provider Surveillance Network and ILI visits data via athenahealth 2.00% 1.75% ILI Visits 1.50% 1.25% 1.00% 0.75% 0.50% 0.25% 0.00% 40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 2 3 4 5 MMWR Week Cuyahoga County 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 athenahealth Hospitalizations Figure 3. Numbe r of Influenza-Associated Hospitalizations in Cuyahoga County (using ev ent date) 20 18 16 14 12 10 8 6 4 2 0 40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 MMWR Week Current Year 5 Year Median 2009-2010 - 2013-2014 Page 3 of 8 Figure 4a. School Absenteeism (Due to any Illness) in Cuyahoga County 6.0% N O Median Percent 5.0% 4.0% S C H O O L 3.0% 2.0% 1.0% 0.0% 40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 4-year Median Northwest Suburbs 2 3 4 5 6 MMWR Week Cleveland Southeast Suburbs 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Northeast Suburbs Southwest Suburbs Figure 4b. School Absenteeism (Due to any Reason ) in Cuyahoga County 8.0% 7.0% N O Median Percent 6.0% 5.0% S C H O O L 4.0% 3.0% 2.0% 1.0% 0.0% 40 41 42 43 44 45 46 47 48 49 5-year Median (Sentinel Sites) 50 51 52 53 Sentinel Sites 1 2 3 4 5 MMWR Week Northeast Suburbs Page 4 of 8 6 7 8 9 10 Northwest Suburbs 11 12 13 14 15 16 Southwest Suburbs 17 18 19 20 Figure 5. Cuyahoga County Hospital ED Visits for ILI & Fever Symptoms by Age Group 240 210 ED Visits 180 150 120 90 60 30 0 40 41 42 43 O - 4 Years Old 44 45 46 47 48 49 5 - 24 Years Old 50 51 52 53 1 25 - 49 Years Old 2 3 4 5 MMWR Week 6 50 - 64 Years Old 7 8 9 10 11 12 13 65 Years and Older 14 15 16 17 18 19 20 5 Year Median (2009/2010 - 2013/2014) Figure 6. Comparison of Average Weekly OTC Products Sold in Cuyhaoga County Drugstores 400 350 OTC Products 300 250 200 150 100 50 0 40 Antifever 41 42 43 44 45 Cold_liquid_ped 46 47 48 49 50 Cold_tablet_ped 51 52 53 1 2 3 4 5 MMWR Week Cough_syrup_ped 6 Electrolytes_ped Page 5 of 8 7 8 9 10 11 Thermometers 12 13 14 15 16 17 18 19 20 5 Year Median (2009/2010 - 2013/2014) Figure 7 Frequency of Fever and Influenza-Like Illness Complaints by Zip Code Frequency 0-2 3-8 44140 44107 44116 44145 44111 44126 44070 44138 44119 44117 44110 9 - 16 17 - 29 44108 44112 44114 44103 44106 44144 44135 44142 44017 44129 44130 44105 0-8 44140 44145 44116 44126 44070 44138 21 - 43 44107 44111 44135 44142 44017 44114 44103 44106 44144 44129 44133 44105 44125 44134 44131 44147 44128 44143 44040 44124 44022 44137 44146 44141 Ü 44121 44118 44115 44113 44104 44102 44120 44122 44127 44130 44149 44136 4412344132 4410844112 44109 44139 44141 44119 44117 44110 44 - 69 9 - 20 44022 44146 Figure 8 Frequency of Congestion and Cough Complaints by Zip Code Frequency 44124 44137 44134 44131 44147 44040 44121 44128 44125 44133 44149 44136 44143 44118 44115 44113 44104 44102 44120 44122 44127 44109 Ü 4412344132 44139 Page 6 of 8 Figure 9 Frequency of Vomiting and Nausea Complaints by Zip Code Frequency 0-8 44140 44145 44116 44126 44070 44138 4410844112 44114 44103 44106 44107 44111 44135 44142 44017 44119 44117 44110 21 - 41 42 - 65 9 - 20 44144 44129 44130 44149 44136 44105 44147 44133 44140 44145 44116 44126 44070 44138 44107 44111 44135 44142 44017 Page 7 of 8 44108 44112 4411444103 44106 44139 4412344132 Ü 44144 44129 44133 44105 44125 44134 44131 44147 44128 44040 44124 44022 44137 44146 44141 44143 44121 44118 44115 44113 44104 44102 44120 44122 44127 44130 44149 44136 44146 44119 44117 44110 44109 44022 44141 8 - 14 15 - 21 44124 44137 44134 44131 Frequency 3-7 44040 44121 44128 44125 Figure 10 Frequency of Diarrhea Complaints by Zip Code 0-2 44143 44118 44115 44113 44104 44102 44120 44122 44127 44109 Ü 4412344132 44139 Sources of Influenza Surveillance Data Six types of data sources are examined on a weekly basis to help determine the influenza activity level for Cuyahoga County: 1) Ohio Department of Health (ODH) Seasonal Influenza Activity Summary : The ODH influenza summary provides state-wide data . Data used from this report include: frequency of fever plus influenzalike illness (ILI) associated hospitalizations, number of influenza-associated pediatric mortalities, and number of lab-confirmed influenza cases. A) Influenza-associated Hospitalizations (ODRS): Influenza-associated hospitalizations are reported by the Cuyahoga County Board of Health (CCBH) and hospitals using the Ohio Disease Reporting System (ODRS). Hospitalizations can be used as an indicator of the severity of illness during a particular influenza season. This condition became reportable in January 2009. B) Influenza-associated Pediatric Mortality (ODRS): Influenza-associated pediatric mortalities are reported into ODRS by CCBH and hospital staff. Pediatric deaths can be an indicator of the severity of illness during the influenza season. This condition became reportable in 2005. C) Sentinel Providers (ILINet): Sentinel providers, through the US Influenza-like Illness Surveillance Network (ILINet), collect outpatient influenza-like illness (ILI) data. ILI is defined as a fever (> 100 F), and cough and/or sore throat without another known cause. Providers report the total number of patients seen, by age group, on a weekly basis. Sentinel providers also submit specimens for influenza testing to the ODH laboratory throughout the influenza season. There are 3 sentinel providers enrolled in Cuyahoga County for the 2014-2015 season. D) ODH Laboratory Surveillance: The Ohio Department of Health Laboratory reports the number of specimens that test positive for influenza each week. Generally, specimens are submitted by sentinel provider participants. A subset of the positive specimens is sent to CDC for further testing during the season. 2) Mortality Reporting System (Cleveland’s Vital Statistics): Cleveland Vital Statistics office reports on deaths that occur in 55 of 59 municipalities in Cuyahoga County (excludes Lakewood, Bedford, Euclid, & Parma) regarding pneumonia & influenza. 3) ILI data (athenahealth) "ILI estimates are based on insurance claims diagnoses, documented in athenahealth's database. athenahealth is a healthcare technology and services company for electronic health records, medical billing, patient engagement, and care coordination." 4) School Absenteeism data (due to illness and due to any reason): More than 50 Cuyahoga County schools provide absenteeism data for each Tuesday on the number children absent due to any illness or due to any reason as well as sentinel schools that report week absenteeism data. 5) National Retail Data Monitor (NRDM)-OTC Drug Purchases: The NRDM collects over-the-counter (OTC) drug sales information from Cuyahoga County chain drug stores and grocery stores. Pediatric cold products, antifever products, and thermometer sales are monitored on a weekly basis. 6) Emergency Department Visits (EpiCenter): EpiCenter collects emergency department chief complaint data from hospitals and urgent care facilities across Cuyahoga County and classifies them into symptom and syndrome categories. Chief complaints regarding fever + ILI symptoms are analyzed. Page 8 of 8