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April 10 - April 16, 2016 (MMWR Week 15) Highlights Flu activity decreased to ‘low’ this week. The flu rating scale is here: https://ccbh-new.squarespace.com/flu-weekly-reports/?rq=flu Pneumonia-related deaths accounted for 6.2% of all deaths. No flu related deaths were reported this week. 16 confirmed cases of flu associated hospitalization were reported this week and 48 cases for week 14. 2.5% of emergency room visits were due to flu like illness this week. 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 1 Feb 2 3 4 5 6 Mar 7 8 Apr May 9 10 11 12 13 14 15 16 17 18 19 20 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] Flu associated hospitalizations [Fig 3] School absenteeism due to ILLNESS ONLY – [Fig 4A] School absenteeism due to ALL CAUSES – [Fig 4B] Emergency room visit due to ILI [Fig 5] Sales of over-the-counter medications used to treat ILI. [Fig 6] Congestion & cough complaints [Fig 8} Vomiting & nausea complaints [Fig 9] Diarrhea complaints [Fig 10] Current Activity Level Pneumonia: 6.2% Flu: 0 deaths Cuyahoga: 1.32% Activity Compared to Last Week #Weeks1234 2015-2016 Season Total/Trend 1 1 1 1 2 7 1 1 1 1 1 1 1 Pneumonia (Avg.=5.0) below 5-year median. 5 flu deaths. 2.5% 11.8% Stable (2.2%) 18.1% (32) 5.3% (21.4%) (18.8%) (63.4%) (12.1%) (25.0%) (37.7%) (2.1%) 309 (5.8%) 1 Sales higher than the 5-yr median. 11.2% 9.9% 2.8% (9.7%) (5.0%) (4.9%) 5 12 7 Median = 12.0%. Normal activity. athenahealth: 0.25% 16 Northeast: Northwest: Southwest: Northeast: Northwest: Southeast: Southwest: 2.0% 2.2% 2.6% 1.5% 2.9% 5.7% 3.3% 1 athenahealth flu visits below 5-year median. N=538. On par with 5-year mdn. School absenteeism due to any illness trending above the 5-year median. School absenteeism due to any reason is trending above 5-year median. Median = 2.6%. Normal activity. Median = 10.6%. Normal activity. Median = 2.9%. Normal activity. Due to small percentages, caution should be used while interpreting the ‘Activity Compared to Last Week’ box. For figures 2, 4a-4b, = (Increase > 20%), = (Decrease > -20%), = Stable (-19.9% to +19.9%) 3 For figures 1, 5-10, = (Increase > 10%), = (Decrease > -10%), = Stable (-9.9% to +9.9%) 4 For flu related deaths (Fig 1) & Fig 3, = (Increase # of deaths/cases), = (Decrease # of deaths/cases), = Stable (Same # of deaths/cases) 2 Page 1 of 8 April 10 - April 16, 2016 (MMWR Week 15) 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-reports/?rq=flu Note: Data are provisional and subject to change. Updates will be included in future reports. Pneumonia and Influenza (P&I) Mortality 6.2% of all deaths reported to vital statistics departments in our county were due to pneumonia. Adults 65 years old and older accounted for 73.7% of all pneumonia related deaths. No influenza related deaths occurred this week; five flu deaths so far this season (Figure 1). Influenza-Like Illness (ILI) Reports Athenahealth reported that 0.25% of patients had ILI this week. One sentinel provider reported 1.32% of patients had flu like symptoms this week and 1.35% for week 14 (Figure 2). ILI is defined as a fever (≥ 100◦ F), and cough and/ or sore throat. Influenza-Associated Hospitalizations and Influenza-Associated Pediatric Mortality Sixteen confirmed cases of influenza-associated hospitalizations in Cuyahoga County were reported this week & 48 cases for week 14 (Figure 3). Three hundred fourteen statewide confirmed influenza associated hospitalizations in week 14. One statewide pediatric flu related death has occurred so far this flu season. School Absenteeism Participating schools in Cuyahoga County reported the percentage (median = 2.2%) of absenteeism due to any illness on Tuesday (Figure 4A). Figure 4B shows the total absenteeism due to any reason (median = 2.9%). Emergency Department (ED) visits and Over-the-Counter Medication Sales 2.5% of all ED visits were for fever + ILI symptoms. Approximately 55 more patients visited EDs for fever and ILI symptoms this week compared to the previous 5-year weekly median (Figure 5). Figure 6 shows approximately 145 more OTC products per drugstore were purchased this week than the previous 5-year weekly median. 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 Page 2 of 8 Figure 1. Percentage of Deaths Due to Pneumonia and Influenza (P&I) Cleveland Bureau of Vital Statistics 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 MMWR Week Percent Pneumonia Percent Influenza 5-Yr Median 2010-11 - 2014-15 Figure 2. Percent of Influenza-Like Illness (ILI) Visits U.S. Influenza Sentinel Provider Surveillance Network and ILI visits data via athenahealth 14% 13% 12% 11% 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 MMWR Week Cuyahoga County 7 8 9 10 11 12 13 14 15 16 17 18 19 20 athenahealth Figure 3. Number of Influenza-Associated Hospitalizations in Cuyahoga County (using event date) 120 110 100 90 80 70 60 50 40 30 20 10 0 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 Current Year 3 4 5 6 7 MMWR Week 8 9 10 11 12 13 14 15 16 17 18 19 20 5 Year Median 2010-2011 - 2014-2015 Page 3 of 8 Figure 4a. School Absenteeism (Due to any Illness) in Cuyahoga County 9% N O 8% 7% 6% S C H O O L 5% 4% 3% 2% 1% 0% 40 41 42 43 44 45 46 47 48 49 50 51 52 5-year Median (2010-11 - 2014-15) 1 2 Northeast Suburbs 3 4 5 6 MMWR Week 7 8 Northwest Suburbs 9 10 11 12 13 14 15 16 17 18 19 20 Southeast Suburbs Southwest Suburbs Figure 4b. School Absenteeism (Due to any Reason) in Cuyahoga County 18% 16% N O 14% 12% S C H O O L 10% 8% 6% 4% 2% 0% 40 41 42 43 44 45 46 47 48 5-year Median (2010-11 - 2014-15) 49 50 51 52 1 Northeast Suburbs 2 3 4 5 6 MMWR Week 7 Northwest Suburbs Page 4 of 8 8 9 10 11 12 13 Southeast Suburbs 14 15 16 17 18 19 Southwest Suburbs 20 Figure 5. Cuyahoga County Hospital ED Visits for ILI & Fever Symptoms by Age Group 550 500 450 400 350 300 250 200 150 100 50 0 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 MMWR Week O - 4 Years Old 5 - 24 Years Old 25 - 49 Years Old 50 - 64 Years Old 65 Years and Older 5 Year Median (2010-11 - 2014-15) Figure 6. Comparison of Average Weekly OTC Products Sold in Cuyhaoga County Drugstores 450 400 350 300 250 200 150 100 50 0 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 MMWR Week Antifever Cold_liquid_ped Cold_tablet_ped Cough_syrup_ped Page 5 of 8 Electrolytes_ped Thermometers 5 Year Median 2010-11 - 2014-15 Figure 7 Rate of Fever and Influenza-Like Illness Complaints per 100,000 by Zip Code 4412344132 44119 44117 44110 April 10th - April 16th 2016 - MMWR Week 15 Rate 0.0 - 9.2 13.5 - 23.5 23.6 - 47.7 9.3 - 13.4 44140 44145 44116 44126 44070 44138 44107 44111 44142 44017 44114 44103 44106 44129 44130 44109 68.0 - 129.4 36.3 - 67.9 4412344132 44140 44145 44116 44126 44070 44138 Page 6 of 8 4411444103 44106 44107 44111 44135 44142 44017 44119 44117 44110 4410844112 129.5 - 198.8 44144 44129 44130 44149 44136 44133 44105 44125 44134 44131 44147 44128 Ü 4 Miles 44143 44040 44124 44022 44137 44146 44141 0 1 2 44121 44118 44115 44104 44102 44113 44120 44122 44127 44109 44139 Map created and analysis performed by Epidemiology, Surveillance, and Informatics at the Cuyahoga County Board of Health. Data are preliminary. 44141 April 10th - April 16th 2016 - MMWR Week 15 0.0 - 36.2 44022 44146 Figure 8 Rate of Congestion and Cough Complaints per 100,000 by Zip Code Rate 44124 44137 44134 44131 44147 4 Miles 44040 44121 44128 44125 44133 44149 44136 44105 Ü 44143 44118 44115 44113 44104 44102 44120 44122 44127 44144 44135 4410844112 0 1 2 44139 Map created and analysis performed by Epidemiology, Surveillance, and Informatics at the Cuyahoga County Board of Health. Data are preliminary. Figure 9 Rate of Vomiting and Nausea Complaints per 100,000 by Zip Code 4412344132 44119 44117 44110 April 10th - April 16th 2016 - MMWR Week 15 Rate 62.1 - 99.1 0.0 - 48.0 99.2 - 152.8 48.1 - 62.0 44140 44145 44116 44126 44070 44138 44107 44111 44135 44142 44017 44114 44103 44106 44144 44129 44133 44105 44109 12.2 - 18.4 4412344132 44119 44117 44110 44140 44145 44116 44126 44070 44138 Page 7 of 8 18.5 - 30.9 31.0 - 48.7 44107 44111 44135 44142 44017 44114 44103 44106 44144 44129 44133 44105 44125 44134 44131 44147 44128 Ü 4 Miles 44143 44040 44124 44022 44137 44146 44141 0 1 2 44121 44118 44115 44113 44104 44102 44120 44122 44127 44130 44149 44136 4410844112 44109 44139 Map created and analysis performed by Epidemiology, Surveillance, and Informatics at the Cuyahoga County Board of Health. Data are preliminary. 44141 April 10th - April 16th 2016 - MMWR Week 15 0.0 - 12.1 44022 44146 Figure 10 Rate of Diarrhea Complaints per 100,000 by Zip Code Rate 44124 44137 44134 44131 44147 4 Miles 44040 44121 44128 44125 Ü 44143 44118 44115 44113 44104 44102 44120 44122 44127 44130 44149 44136 4410844112 0 1 2 44139 Map created and analysis performed by Epidemiology, Surveillance, and Informatics at the Cuyahoga County Board of Health. Data are preliminary. 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 2 sentinel providers enrolled in Cuyahoga County for the 2015-2016 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 (Vital Statistics): Vital Statistics offices in Cuyahoga County (Cleveland, Euclid, Lakewood, & Parma) reports the percentage of deaths that are due to pneumonia or influenza that occur within their jurisdiction. Cleveland issues death certificates for 56 of the 59 cities in the county. 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, anti-fever 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. Rates for chief complaints regarding fever + ILI and other symptoms commonly detected during the winter are analyzed. Page 8 of 8