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FluWatch report: April 24 to April 30, 2016 (week 17)

Overall Summary

  • In week 17, all influenza indicators declined from the previous week.
  • Elevated influenza B activity persisited in many regions across Canada: influenza B accounted for the majority of influenza detections in week 17.  Additionally, all outbreaks reported this week were due to Influenza B. This increase in influenza B is expected as influenza B often shows up later in the flu season.
  • Hospitalizations, ICU admissions and deaths among the pediatric population, while declining, continue to remain above expected levels based on the past several influenza seasons.
  • For more information on the flu, see our Flu(influenza) web page.
  • The current FluWatch report is the last weekly report for the 2015-2016 season. During the summer, monthly reports will be published starting on May 27, 2016. We will continue to monitor influenza and other respiratory infections via the RVDSS report, published every Thursday.

Are you a primary health care practitioner (General Practitioner, Nurse Practitioner or Registered Nurse) interested in becoming a FluWatch sentinel for the 2015-16 influenza season? Contact us at FluWatch@phac-aspc.gc.ca

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Organization:
Public Health Agency of Canada
Date published: 2016-05-06

Related Topics

Influenza/Influenza-like Illness Activity (geographic spread)

Influenza activity continues to be reported in the majority of regions in Canada; however, the number of regions reporting influenza activity decreased in week 17.  Localized activity was reported in a total of 12 regions across six provinces. Sporadic activity levels were reported in 28 regions across all provinces and territories. A total of 10 regions reported no influenza activity in week 17.

Figure 1. Map of overall influenza/ILI activity level by province and territory, Canada, week 17

Figure 1
Figure 1 Legend

Note: Influenza/ILI activity levels, as represented on this map, are assigned and reported by Provincial and Territorial Ministries of Health, based on laboratory confirmations, sentinel ILI rates and reported outbreaks. Please refer to detailed definitions at the end of the report. Maps from previous weeks, including any retrospective updates, are available in the mapping feature found in the Weekly Influenza Reports.

Figure 1 - Text Description

Influenza activity continues to be reported in the majority of regions in Canada; however, the number of regions reporting influenza activity decreased in week 17.  Localized activity was reported in a total of 12 regions across six provinces. Sporadic activity levels were reported in 28 regions across all provinces and territories. A total of 10 regions reported no influenza activity in week 17.

Laboratory Confirmed Influenza Detections

In week 17, the percentage of tests positive for influenza continued to decrease from the previous week [from 18% in week 16 to 17% in week 17], driven by the decline in influenza A. Compared to the previous five seasons, the percent positive (17%) reported in week 17 was above the five year average for that week and exceeded the range of expected levels (9.8%-14.0%). With the late start to the 2015-16 influenza season, these elevated levels are not unexpected.

Figure 2. Number of positive influenza tests and percentage of tests positive, by type, subtype and report week, Canada, 2015-16

Figure 2
Figure 2 - Text Description

In week 17, the percentage of tests positive for influenza continued to decrease from the previous week [from 18% in week 16 to 17% in week 17], driven by the decline in influenza A.

Nationally in week 17, there were 881 positive influenza tests reported. Influenza B continues to account for an increasing proportion of influenza detections accounting for 70% of detections in week 17. Detections remain predominantly influenza A in British Columbia and the Atlantic Region. To date, 75% of influenza detections have been influenza A and among those subtyped, the vast majority have been influenza A(H1N1) [91% (10933/11990)].

Figure 3. Cumulative numbers of positive influenza specimens by type/subtype and province, Canada, 2015-16

Figure 3

Note: Specimens from NT, YT, and NU are sent to reference laboratories in other provinces. Cumulative data includes updates to previous weeks.

Figure 3 - Text Description
Reporting
provincesTable Figure 3 - Footnote 1		 Weekly (April 24 to April 30, 2016) Cumulative (August 30, 2015 to April 30, 2016)
Influenza A B Influenza A B
A
Total		 A
(H1)pdm09		 A
(H3)		 A Table Figure 3 - Footnote UnS B
Total		 A
Total		 A
(H1)pdm09		 A
(H3)		 ATable Figure 3 - Footnote UnS B
Total
Table Figure 3 - Footnote 1

Specimens from NT, YT, and NU are sent to reference laboratories in other provinces. Cumulative data includes updates to previous weeks.

Return to Table Figure 3 - Footnote 1 referrer

Table Figure 3 - Footnote 2

Percentage of tests positive for sub-types of influenza A are a percentage of all influenza A detections.

Return to Table Figure 3 - Footnote 2 referrer

Table Figure 3 - Footnote UnS

Unsubtyped: The specimen was typed as influenza A, but no result for subtyping was available.

Return to first Table Figure 3 - Footnote UnS referrer

Table Figure 3 - Footnote x

Suppressed to prevent residual disclosure.

Return to first Table Figure 3 - Footnote x referrer
BC 26 23 <5 <5 11 2039 1016 354 669 1141
AB 14 <5 <5 6 52 3938 3625 193 120 1588
SK <5 <5 0 0 21 2328 1511 47 770 789
MB 8 <5 0 5 18 893 183 38 672 180
ON 64 23 <5 37 116 7542 3227 368 3947 2471
QC 92 6 <5 85 364 8850 1022 7 7821 2971
NB 46 8 0 38 31 1114 94 <5 Table Figure 3 - Footnote x 102
NS 6 0 0 6 0 301 0 <5 Table Figure 3 - Footnote x Table Figure 3 - Footnote x
PE 0 0 0 0 0 65 53 12 0 <5
NL <5 0 0 <5 <5 459 58 <5 Table Figure 3 - Footnote x 26
YT <5 <5 0 0 0 86 52 <5 Table Figure 3 - Footnote x 19
NT <5 0 0 <5 <5 121 90 Table Figure 3 - Footnote x <5 17
NU <5 <5 0 0 0 19 <5 0 17 14
Canada 263 72 10 181 618 27755 10933 1057 15765 9328
Percentage Table Figure 3 - Footnote 2 30% 27% 4% 69% 70% 75% 39% 4% 57% 25%

In week 17, individuals under the age of 45 accounted for 64% of influenza B detections.

To date this season, detailed information on age and type/subtype has been received for 31,858 cases. Children and teenagers (0-19) accounted for 47% of influenza B cases and approximately one third of all influenza cases. Children and teenagers (0-19), young adults (20-44) and middle-aged adults (45-64) accounted for approximately an equal proportion of influenza A(H1N1) cases (28%).

Table 1. Weekly and cumulative numbers of positive influenza specimens by type, subtype and age-group reported through case-based laboratory reporting Table 1 - Footnote 1, Canada, 2015-16
Age groups (years) Weekly (April 24 to April 30, 2016) Cumulative (August 30, 2015 to April 30, 2016)
Influenza A B Influenza A B Influenza A and B
A Total A(H1) pdm09 A(H3) A UnSTable 1 - Footnote 3 Total A Total A(H1) pdm09 A(H3) A UnSTable 1 - Footnote 3 Total # %
Table 1 - Footnote 1

Table 1 includes specimens for which demographic information was reported. These represent a subset of all positive influenza cases reported.

Return to Table 1 - Footnote 1 referrer

Table 1 - Footnote 2

Percentage of tests positive for sub-types of influenza A are a percentage of all influenza A detections.

Return to Table 1 - Footnote 2 referrer

Table 1 - Footnote 3

Unsubtyped: The specimen was typed as influenza A, but no result for subtyping was available.

Return to first Table 1 - Footnote 3 referrer

Table 1 - Footnote x

Suppressed to prevent residual disclosure.

Return to first Table 1 - Footnote x referrer
<5 23 <5 Table 1 - Footnote x 20 106 4491 1708 72 2711 1432 5925 19%
5-19 12 <5 <5 10 117 2393 1026 100 1267 2371 4766 15%
20-44 19 6 <5 12 82 5769 2750 155 2864 1986 7755 24%
45-64 39 7 <5 Table 1 - Footnote x 48 6312 2772 190 3350 970 7282 23%
65+ 51 6 <5 Table 1 - Footnote x 120 4778 1612 420 2746 1351 6130 19%
Total 144 23 6 115 473 23743 9868 937 12938 8110 31858 100%
PercentageTable 1 - Footnote 2 23% 16% 4% 80% 77% 75% 42% 4% 54% 25%    

For data on other respiratory virus detections see the Respiratory Virus Detections in Canada Report on the Public Health Agency of Canada website.

Influenza-like Illness Consultation Rate

The national ILI consultation rate decreased from the previous week from 36.1 per 1,000 patient visits in week 16, to 31.1 per 1,000 patient visits in week 17. The highest ILI consultation rate was found in the 5-19 years age group (53.8 per 1,000) and the lowest was found in the 20-64 years age group (24.4 per 1,000) (Figure 4).

Figure 4. Influenza-like-illness (ILI) consultation rates by age group and week, Canada, 2015-16

Figure 4

Delays in the reporting of data may cause data to change retrospectively. In BC, AB, and SK, data are compiled by a provincial sentinel surveillance program for reporting to FluWatch. Not all sentinel physicians report every week.

Figure 4 - Text Description

Influenza-like illness consultation rate by age-group in week 17 for the 2015-16 season:
Age 0-4: 29.1; Age 5-19: 53.8; Age 20-64: 24.4; Age 65+: 31.8

Pharmacy Surveillance

During week 17, the proportion of prescriptions for antivirals decreased from the previous week to 21.2 antiviral prescriptions per 100,000 total prescriptions, which is lower than the five year historical average for week 17. The proportion of prescriptions for antivirals remains highest among children. In week 17, the proportion reported among children was 62.5 per 100,000 total prescriptions.

Figure 5. Proportion of prescription sales for influenza antivirals by age group and week, Canada, 2015-16

Figure 5

Note: Pharmacy sales data are provided to the Public Health Agency of Canada by Rx Canada Inc. and sourced from major retail drug chains representing over 3,000 stores nationwide (excluding Nunavut) in 85% of Health Regions. Data provided include the number of new antiviral prescriptions (for Tamiflu[oseltamivir] and Relenza [zanamivir]) and the total number of new prescriptions dispensed by Province/Territory and age group.

* The average weekly proportion includes data from April 2011 to March 2015.

Figure 5 - Text Description

Proportion of antiviral prescriptions per 100,000 total prescriptions
Average National Rate (Yrs 10-11 to 14-15): 47.5.; Rate wk 17: 21.2
Proportion of antiviral prescriptions by age-group in week 17 for the 2015-16 season:
Infant: 62.5; child: 45.6; adult: 18.5; senior: 21.6

Influenza Outbreak Surveillance

In week 17, eight new laboratory confirmed influenza outbreaks were reported: seven in long-term care facilities (LTCF) and one in an institution or community setting. Of the seven outbreaks with known strains or subtypes, all were due to influenza B.

To date this season, 409 outbreaks have been reported. At week 17 in the 2014-15 season, 1,696 outbreaks were reported and in the 2013-14 season, 226 outbreaks were reported.

Figure 6. Overall number of new laboratory-confirmed influenza outbreaksFigure 5 - Footnote 1 by report week, Canada, 2015-2016

Figure 6
Figure 6 - Text Description
Report week Hospitals Long Term Care Facilities Other
35 0 0 0
36 0 0 0
37 1 1 0
38 0 0 0
39 0 2 0
40 0 2 1
41 0 0 0
42 0 0 0
43 0 1 0
44 1 3 1
45 1 1 0
46 0 0 0
47 0 0 0
48 0 1 0
49 0 1 0
50 0 2 0
51 1 1 0
52 1 0 2
1 0 2 1
2 0 2 0
3 1 4 1
4 4 6 3
5 8 6 3
6 8 10 3
7 2 17 8
8 6 27 7
9 13 24 8
10 9 23 14
11 2 21 4
12 9 15 5
13 5 12 4
14 2 14 1
15 1 11 0
16 3 9 1
17 0 7 1

Sentinel Pediatric Hospital Influenza Surveillance

Paediatric Influenza Hospitalizations and Deaths

In week 17,  the number of laboratory-confirmed influenza-associated pediatric hospitlaizations slightly decreased. A total of 34 laboratory-confirmed influenza-associated pediatric (≤16 years of age) hospitalizations were reported by the Immunization Monitoring Program Active (IMPACT) network (Figure 7). The largest proportion of hospitalizations were in children aged 2-4 years, accounting for 35% of the hospitalizations. Similar to the trend of increased laboratory detections of influenza B, 82% of pediatric hospitalizations reported in week 17 were due to influenza B.

To date this season, 1,272 hospitalizations have been reported by  the IMPACT network: 887 hospitalized cases (69%) were due to influenza A and 385 cases (31%) were due to influenza B. This season’s count of pediatric hospitalizations is nearly double that reported up to week 17 (676) in the 2014-15 season. The current year total number of cases also exceeds the total number of cases reported in the past five seasons.

A total of 195 intensive care unit (ICU) admissions have been reported. Children aged 2 to 4 and 5 to 9 years accounted for 29% and 26% respectively of ICU admissions. A total of 131 ICU cases (67%) reported at least one underlying condition or comorbidity. Eight influenza-associated deaths have been reported which is above the number of deaths reported  at this time in the last five season.

Table 2 - Cumulative numbers of peadiatric hospitalizations (≤16 years of age) with influenza reported by the IMPACT network, Canada, 2015-16
Age Groups Cumulative (30 Aug. 2015 to 30 April 2016)
Influenza A Influenza B Influenza A and B (#(%))
A Total A(H1) pdm09 A(H3) A (UnS) B Total
Table 2 - Footnote x

Suppressed to prevent residual disclosure.

Return to first Table 2 - Footnote x referrer
0-5m 120 32 5 83 33 153 (12%)
6-23m 275 75 8 192 76 351 (28%)
2-4y 254 81 <5 Table 2 - Footnote x 104 358 (28%)
5-9y 180 45 <5 Table 2 - Footnote x 124 304 (24%)
10-16y 58 18 <5 Table 2 - Footnote x 48 106 (8%)
Total 887 251 22 614 385 1272 (100%)

Figure 7. Number of cases of influenza reported by sentinel hospital networks, by week, Canada, 2015-16, paediatric and adult hospitalizations (≤16 years of age, IMPACT; ≥16 years of age, CIRN-SOS)

Figure 7

Not included in Table 2 and Figure 7 are two IMPACT cases that were due to co-infections of influenza A and B.

Figure 7 - Text Description
Report week IMPACT CIRN-SOS
35 0 0
36 0 0
37 1 0
38 2 0
39 0 0
40 0 0
41 1 0
42 0 0
43 1 0
44 0 2
45 2 0
46 1 3
47 2 1
48 2 1
49 3 7
50 3 3
51 6 7
52 13 11
1 20 20
2 14 13
3 23 26
4 38 21
5 48 45
6 77 55
7 108 93
8 148 131
9 147 117
10 146 130
11 114 120
12 90 88
13 65 90
14 58 66
15 65 41
16 40 33
17 34 12

Adult Influenza Hospitalizations and Deaths

Overall, adult hospitalizations decreased in week 17. A total of 12 laboratory-confirmed influenza-associated adult (≥16 years of age) hospitalizations were reported by the Canadian Immunization Research Network Serious Outcome Surveillance (CIRN-SOS) (Figure 7). The majority of hospitalizations were in adults ≥65 years of age (67%) and due to influenza B (70%). In recent weeks, the weekly number of hospitalizations reported by CIRN has been decreasing and an increasing proportion of hospitalizations have been due to influenza B.

To date this season, 1,131 hospitalizations have been reported by CIRN-SOS (
Table 3
).

The majority of hospitalized cases were due to influenza A (82%) and the largest reported proportion was among adults ≥65 years of age (50%). One hundred and eighty-five intensive care unit (ICU) admissions have been reported of which 130 cases reported at least one underlying condition or comorbidity. A total of 50 deaths have been reported this season with the majority of deaths reported in adults ≥65 years of age (66%).

Table 3 - Cumulative numbers of adult hospitalizations (≥16 years of age) with influenza reported by the CIRN-SOS network, Canada, 2015-16
Age groups (years) Cumulative (1 Nov. 2015 to 30 April 2016)
Influenza A B Influenza A and B
A Total A(H1) pdm09 A(H3) A(UnS) Total # (%)
Table 3 - Footnote x

Suppressed to prevent residual disclosure.

Return to first Table 3 - Footnote x referrer
16-20 Table 3 - Footnote x <5 0 <5 <5 7 (1%)
20-44 141 50 <5 Table 3 - Footnote x 41 182 (16%)
45-64 330 104 <5 Table 3 - Footnote x 43 373(33%)
65+ 445 124 24 297 120 565 (50%)
Unknown <5 0 0 <5 <5 <5 (x%)
Total 23 283 28 612 208 1131
% 82% 31% 3% 66% 18% 100%

Figure 8. Percentage of hospitalizations, ICU admissions and deaths with influenza reported by age-group (≥16 year of age), Canada 2015-16

Figure 8

Note: The number of hospitalizations reported through CIRN-SOS and IMPACT represents a subset of all influenza-associated adult and paediatric hospitalizations in Canada. Delays in the reporting of data may cause data to change retrospectively.

x - Suppressed to prevent residual disclosure.

Figure 8 - Text Description
Age-group (years) Hospitalizations (n=1127) ICU admissions (n=184) Deaths (n=50)
Table Figure 8 - Footnote x

Suppressed to prevent residual disclosure.

Return to first Table Figure 8 - Fo2tn273x referrer
16-20 0.6% Table Figure 8 - Footnote x% Table Figure 8 - Footnote x%
20-44 16.1% Table Figure 8 - Footnote x% Table Figure 8 - Footnote x%
45-64 33.1% 46.2% 30.0%
65+ 50.1% 35.3% 66.0%

Provincial/Territorial Influenza Hospitalizations and Deaths

In week 17, the number of hospitalizations reported by participating provinces and territories decreased from the previous week (from 129 in week 16 to 93 in week 17)Footnote *. Influenza B accounted for the greatest proportion of hospitalizations (63%) in week 17. The largest proportion of cases reported was in adults ≥65 years of age (43%). Among hospitalizations with influenza B, children represented 31% of cases.

Since the start of the 2015-16 season, 4,963 laboratory-confirmed influenza-associated hospitalizations have been reported. A total of 3,978 hospitalizations (80%) were due to influenza A and 985 (20%) were due to influenza B. Of the 522 ICU admissions reported, 269 (52%) were due to influenza A(H1N1). A total of 236 deaths have been reported; all but 33 were associated with influenza A (86%).

Overall this season, hospitalizations have been reported more frequently among adults ≥65 years of age. The largest proportion of ICU admissions was reported in adults 45-64 years of age and the highest proportion of fatal cases was reported in adults ≥65 years of age. Pediatric (0-19 years) and young to middle-aged adults (20-44 years) accounted for 42% of all hospitalizations and 13% of all deaths reported to date this season. Similar to findings from the IMPACT network, there have been more pediatric hospitalizations reported to date compared to the year-end totals in each of the previous
four influenza seasons
.

Figure 9. Percentage of hospitalizations, ICU admissions and deaths with influenza reported by age-group, Canada 2015-16

Figure 9
Figure 9 - Text Description
Age-group (years) Hospitalizations (n=4963) ICU admissions (n=522) Deaths (n=236)
0-4 18.9% 9.0% 2.1%
5-19 9.4% 5.9% 3.0%
20-44 13.2% 18.2% 8.1%
45-64 26.7% 44.6% 36.0%
65+ 31.8% 22.2% 50.8%

See additional data on Reported Influenza Hospitalizations and Deaths in Canada: 2011-12 to 2015-16 on the Public Health Agency of Canada website.

Influenza Strain Characterizations

During the 2015-16 influenza season, the National Microbiology Laboratory (NML) has characterized 2,233 influenza viruses [209 A(H3N2), 1,230 A(H1N1) and 794 influenza B].

Influenza A (H3N2): When tested by hemagglutination inhibition (HI) assays, 58 A(H3N2) viruses  were antigenically characterized as A/Switzerland/9715293/2013-like using antiserum raised against cell-propagated A/Switzerland/9715293/2013.  

Sequence analysis was done on 151 A(H3N2) viruses. All viruses belonged to a genetic group for which most viruses were antigenically related to A/Switzerland/9715293/2013. A/Switzerland/9715293/2013 is the A(H3N2) component of the 2015-16 Northern Hemisphere's vaccine.

Influenza A (H1N1): All of the 1,230 A(H1N1) viruses characterized were antigenically similar to A/California/7/2009, the A(H1N1) component of the 2015-16 influenza vaccine.

Influenza B:A total of 162 influenza B viruses characterized  were antigenically similar to the vaccine strain B/Phuket/3073/2013. A total of 632 influenza B viruses were characterized as B/Brisbane/60/2008-like, one of the influenza B components of the 2015-16 Northern Hemisphere quadrivalent influenza vaccine.

The recommended components for the 2015-2016 Northern Hemisphere trivalent influenza vaccine included: an A/California/7/2009(H1N1)pdm09-like virus, an A/Switzerland/9715293/2013(H3N2)-like virus, and a B/Phuket/3073/2013 -like virus (Yamagata lineage). For quadrivalent vaccines, the addition of a B/Brisbane/60/2008-like virus (Victoria lineage) is recommended.

The NML receives a proportion of the  influenza positive specimens from provincial laboratories for strain characterization and antiviral resistance testing. Characterization data reflect the results of haemagglutination inhibition testing compared to the reference influenza strains recommended by WHO.

Antiviral Resistance

During the 2015-16 season, the National Microbiology Laboratory (NML) has tested 1,390 influenza viruses for resistance to oseltamivir, 1,391 for resistance to zanamivir and 1,421 influenza viruses for resistance to amantadine. All but eight tested viruses were sensitive to oseltamivir. The eight H1N1 viruses resistant to oseltamivir had a H275Y mutation. All viruses tested for resistance were sensitive to zanamivir.  All but two influenza A viruses were resistant to amantadine (Table 4).

Table 4. Antiviral resistance by influenza virus type and subtype, Canada, 2015-16
Virus type and subtype Oseltamivir Zanamivir Amantadine
# tested # resistant (%) # tested # resistant (%) # tested # resistant (%)
Table 4 - Footnote *

NA - not applicable

Return to first Table 4 - Footnote * referrer
A (H3N2) 162 0 (0%) 162 0 (0%) 212 211 (99.5%)
A (H1N1) 833 8 (1%) 834 0 (0%) 1209 1208 (99.9%)
B 395 0 (0%) 395 0 (%) NATable 4 - Footnote * NATable 4 - Footnote *
Total 1390 8 (0.6%) 1391 0 (0%) 1421 1419 (99.9%)

International Influenza Reports

FluWatch definitions for the 2015-2016 season

Abbreviations: Newfoundland/Labrador (NL), Prince Edward Island (PE), New Brunswick (NB), Nova Scotia (NS), Quebec (QC), Ontario (ON), Manitoba (MB), Saskatchewan (SK), Alberta (AB), British Columbia (BC), Yukon (YT), Northwest Territories (NT), Nunavut (NU).

Influenza-like-illness (ILI): Acute onset of respiratory illness with fever and cough and with one or more of the following - sore throat, arthralgia, myalgia, or prostration which is likely due to influenza. In children under 5, gastrointestinal symptoms may also be present. In patients under 5 or 65 and older, fever may not be prominent.

ILI/Influenza outbreaks

Schools:
Greater than 10% absenteeism (or absenteeism that is higher (e.g. >5-10%) than expected level as determined by school or public health authority) which is likely due to ILI.
Note: it is recommended that ILI school outbreaks be laboratory confirmed at the beginning of influenza season as it may be the first indication of community transmission in an area.
Hospitals and residential institutions:
two or more cases of ILI within a seven-day period, including at least one laboratory confirmed case. Institutional outbreaks should be reported within 24 hours of identification. Residential institutions include but not limited to long-term care facilities ( LTCF) and prisons.
Workplace:
Greater than 10% absenteeism on any day which is most likely due to ILI.
Other settings:
two or more cases of ILI within a seven-day period, including at least one laboratory confirmed case; i.e. closed communities.

Note that reporting of outbreaks of influenza/ILI from different types of facilities differs between jurisdictions.

Influenza/ILI activity level

1 = No activity: no laboratory-confirmed influenza detections in the reporting week, however, sporadically occurring ILI may be reported

2 = Sporadic: sporadically occurring ILI and lab confirmed influenza detection(s) with no outbreaks detected within the influenza surveillance region Footnote †

3 = Localized:

  1. evidence of increased ILIFootnote * and
  2. lab confirmed influenza detection(s) together with
  3. outbreaks in schools, hospitals, residential institutions and/or other types of facilities occurring in less than 50% of the influenza surveillance regionFootnote †

4 = Widespread:

  1. evidence of increased ILIFootnote * and
  2. lab confirmed influenza detection(s) together with
  3. outbreaks in schools, hospitals, residential institutions and/or other types of facilities occurring in greater than or equal to 50% of the influenza surveillance regionFootnote †

Note: ILI data may be reported through sentinel physicians, emergency room visits or health line telephone calls.

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