An outbreak of influenza that has hit the South particularly hard has now taken the lives of two children and nine adults in Alabama, according to the state department of public health.

The report from the week ending on Nov. 19 also showed that outpatient visits for flu-like symptoms have decreased since a peak in early November. Still, several other respiratory viruses continue to circulate, including COVID-19, RSV and rhinovirus, putting stress on pediatric hospitals across the region.

All districts in the state have reported flu cases in November and numbers remain much higher than last year. They still accounted for almost 7 percent of all outpatient visits during the week that ended on Nov. 19, falling from a peak of almost 12 percent three weeks ago. Last year, flu cases peaked at less than 6 percent of all visits in late December and early January.

The weekly flu report also reported 15 outbreaks of influenza the week before Thanksgiving.

Flu has spread earlier this year than expected and doctors have urged people to get vaccinated. They also recommend regular hand washing and covering coughs and sneezes. People with fever and other symptoms should stay home to prevent spreading the virus to others at school or in the workplace.

Young children have high rates of complication from the flu. Earlier this week, the Children’s Hospital Association asked President Joe Biden to declare a state of emergency to help with a surge of sick patients.

The flu activity map maintained by the U.S. Centers for Disease Control and Prevention shows flu activity at high or very high rates across the South for the week that ended on Nov. 12. Alabama is one of five states and districts in the highest flu activity category on that map.

Related: Flu in Alabama at highest level on CDC scale