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Three powerful and devastating hurricanes from the 2017 Atlantic hurricane season (Harvey [August 17-September 1], Irma [August 30-September 13], and Maria [September 16-October 2]) resulted in the deaths of hundreds of persons. Disaster-related mortality surveillance is critical to an emergency response because it provides government and public health officials with information about the scope of the disaster and topics for prevention messaging. CDC's Emergency Operations Center collaborated with state health departments in Florida, Georgia, and North Carolina to collect and analyze Hurricane Irma-related mortality data to understand the main circumstances of death. The most common circumstance-of-death categories were exacerbation of existing medical conditions and power outage. Further analysis revealed two unique subcategories of heat-related and oxygen-dependent deaths in which power outage contributed to exacerbation of an existing medical condition. Understanding the need for subcategorization of disaster-related circumstances of death and the possibility of overlapping categories can help public health practitioners derive more effective public health interventions to prevent deaths in future disasters.

The emergence of Zika virus in the Americas in 2015 and its association with birth defects and other adverse health outcomes triggered an unprecedented public health response and a demand for testing. In 2016, when Florida exceeded state public health laboratory capacity for diagnostic testing, the state formed partnerships with federal and commercial laboratories. Eighty-two percent of the testing (n = 33 802 of 41 008 specimens) by the laboratory partners, including Florida’s Bureau of Public Health Laboratories (BPHL; n = 13 074), a commercial laboratory (n = 19 214), and the Centers for Disease Control and Prevention (CDC; n = 1514), occurred from July through November 2016, encompassing the peak period of local transmission. These partnerships allowed BPHL to maintain acceptable test turnaround times of 1 to 4 days for nucleic acid testing and 3 to 7 days for serologic testing. Lessons learned from this response to inform future outbreaks included the need for early planning to establish outside partnerships, adding specimen triage strategies to surge plans, and integrating state and CDC information systems.

ObjectiveUsing Florida’s syndromic surveillance data, to describe the increase in seizure activity in the days after Hurricane Irma made landfall in 2017IntroductionOn September 10, 2017, Irma made landfall in the Florida Keys as a Category 4 hurricane and subsequently tracked up the west side of the state. Due to the size of the storm, it impacted nearly all of Florida. The Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE-FL), the state’s syndromic surveillance system, captures 98% of the emergency department (ED) visits statewide and has historically served a vital function in providing near real-time ED data that are used to track post-disaster morbidity and mortality. After previous hurricanes and tropical storms, increases in carbon monoxide poisonings, animal bites, and injuries have been documented. During post-Irma surveillance, an additional increase in seizure-related ED visits was observed.MethodsTwice-daily Hurricane Irma surveillance reports were produced from Sept 10-22, 2017. In addition to specialized queries specific to storm surveillance, analysis was conducted using ESSENCE-FL’s syndrome and subsyndrome categories. The subsyndrome category of Seizure captures ED visits which list the words seizure or convulsion in the patient chief complaint. Daily number of seizure visits were compared against a 28-day baseline using an exponentially weighted moving average algorithm. Additionally, daily seizure visits as a percentage of total ED visits were calculated and plotted.ResultsOn September 11, 12, and 13, ED visits for seizures were increased above the expected levels. On these dates respectively, 336 visits (270 expected, p < 0.01), 349 visits (278 expected, p < 0.01), and 306 visits (267 expected, p < 0.01) seizure visits occurred statewide. September 10 showed the largest increase in seizure visits as a percent of all visits.ConclusionsRoutine post-storm surveillance was able to identify an increase in seizure visits at EDs in Florida. This hurricane-related increase, while not detected using our syndromic surveillance system during previous storms, supports findings of increased emergency medical service calls for convulsions and seizures after Hurricanes Katrina and Rita (both in 2005) found by other researchers (Davis et al., 2013). Due to the size, strength, and projected path of Hurricane Irma, stress (a known seizure trigger) is a possible biological explanation for the increase that was observed. A greater understanding of storm-related public health threats allows the Florida Department of Health to better plan for these events and communicate this information to the public and our partners. Post-storm analysis was complicated by large changes in overall ED volumes during and immediately following the hurricane, and further exploration of the association found in this study is encouraged.ReferencesDavis JS, Allan BJ, Pearlman AM, Carvajal DP, Schulman CI., Optimal emergency personnel allocation after a natural disaster, Am J Disaster Med. 2012 Winter;7(1):31-6.

Objective This roundtable will provide a forum for national, state, and local managers of syndromic surveillance systems to discuss how they identify, monitor, and respond to changes in the nature of their data. Additionally, this session will focus on the strengths and weakness of the syndromic surveillance systems for supporting program evaluation and trend analysis. This session will also provide a forum where subject matter experts can discuss the ways in which this deep understanding of their data can be leveraged to forge and improve partnerships with academic partners. Introduction As syndromic surveillance systems continue to grow, new opportunities have arisen to utilize the data in new or alternative ways for which the system was not initially designed. For example, in many jurisdictions syndromic surveillance has recently become population-based, with 100% coverage of targeted emergency department encounters. This makes the data more valuable for real- time evaluation of public health and prevention programs. There has also been increasing pressure to make more data publicly available – to the media, academic partners, and the general public.

Objective This study assesses the utilization of triage notes from emergency departments (EDs) and urgent care centers (UCCs) for active case finding in ESSENCE-FL during the Zika response. Introduction The Florida Department of Health (DOH) utilizes the Electronic Surveillance System for the Early Notification of Community Based Epidemics (ESSENCE-FL) as its statewide syndromic surveillance system. ESSENCE-FL comprises of chief complaint data from 231 of 240 EDs, representing 96 percent of the total number of EDs in Florida. Historically, syndromic surveillance has categorized patient chief complaint data into syndromes for the purpose of disease surveillance or outbreak detection. Triage notes are much longer free- text, pre-diagnostic data that capture the presenting symptoms and complaints of a patient. Methods Triage notes are being collected from 24 EDs, representing ten percent of total reporting EDs, and seven UCCs, representing 17% of total reporting UCCs. Triage notes were made a searchable field in ESSENCE-FL during Zika enhanced surveillance efforts, which facilitated additional case finding of Zika. During the period of February 3, 2016 – July 25, 2016, a free-text query was created to run against the concatenated chief complaint- discharge diagnosis (CCDD) and triage note fields: ^zika^,or,^ziki^,or,^zica^,or,^zeeka^,or,^zeeca^,or,^microcep^, or,^zyka^ Additional queries were created to detect foreign travel visits of interest within the CCDD and triage note fields. Results of these queries were analyzed and communicated to county and regional epidemiologists daily for investigation. Results The triage note specific queries identified 18 Zika triage note and 11 foreign travel triage note visits of interest. All of these visits were reviewed and investigated by county epidemiologists. These triage note queries identified one case of Zika that had not been previously reported to public health. Of note, seven additional cases of Zika infection were identified using the CCDD field in ESSENCE-FL (five of the seven flagged in both the CCDD and triage note field). Conclusions Results from this analysis provide evidence that triage notes within syndromic surveillance systems play a role in active case finding when emerging diseases arise. However, only 31 out of 272 total reporting facilities are submitting triage note to ESSENCE-FL, representing only 11% of reporting facilities. Relying on chief complaint and discharge diagnosis data only would have resulted in an undetected case of Zika that would have not been captured by our free-text Zika query. The increased detection of Zika cases allows for public health intervention, including mosquito control response, which in turn reduces the chance of Zika spreading locally in Florida. Triage notes often provide pertinent information for determining when a flagged CCDD needs to be investigated further. Making triage notes a required data element for Meaningful Use compliance would benefit case finding conducted through syndromic surveillance.

Objective To retrospectively identify initial emergency department (ED) and urgent care center (UCC) visits for Florida’s Middle East respiratory syndrome coronavirus disease (MERS-CoV) patients under investigation (PUIs) in the Florida Department of Health’s (DOH) syndromic surveillance system, the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE-FL), using information gathered from PUI case report forms and corresponding medical records for the purpose of improving syndromic surveillance for MERS-CoV. The results of this study may be further utilized in an effort to evaluate the current MERS-CoV surveillance query. Introduction Human MERS-CoV was first reported in September 2012. Globally, all reported cases have been linked through travel to or residence in the Arabian Peninsula with the exception of cases associated with an outbreak involving multiple health care facilities in the Republic of Korea ending in July 2015. While the majority of MERS-CoV cases have been reported in the Arabian Peninsula, several cases have been reported outside of the region. Most cases are believed to have been acquired in the Middle East and then exported elsewhere, with no or rare instances of secondary transmission. Two cases of MERS-CoV were exported to the United States and identified in May 2014. One of these cases traveled from Saudi Arabia to Florida. DOH conducts regular surveillance for MERS-CoV through the investigation of persons with known risk factors. PUIs have most often been identified by physicians reporting directly to local health departments and by DOH staff regularly querying ED and UCC chief complaint data in ESSENCE-FL. ESSENCE-FL currently captures data from 265 EDs and UCCs statewide and has been useful in identifying cases associated with reportable disease and emerging pathogens. Methods From 2013-2015 DOH identified and investigated 62 suspected cases of MERS-CoV, including one confirmed case in May 2014. Specimens were collected from all 62 patients under investigation (PUIs) and 61 were ruled out. Of the 61 PUIs who were ruled out, ten were part of the contact investigation initiated following the identification of MERS-CoV in May 2014 and were not included in this analysis. DOH utilizes a MERS-CoV PUI case report form to collect data regarding demographics, clinical presentation, and risk factors. Retrospectively, additional documents including medical records and discharge summaries were gathered and utilized to evaluate PUIs identified in ESSENCE-FL. Name of the facility where PUIs presented, date and time of visit, age at event, and sex were identified using PUI case report forms and corresponding medical records and discharge summaries. Visit details for each of the identified facilities were queried in ESSENCE-FL and pulled for all visits with corresponding age at event and sex for the patient’s visit date. Additional PUI information including chief complaint, discharge diagnosis, ZIP code, race, and ethnicity were gathered for the purpose of matching corresponding ESSENCE-FL data fields. ESSENCE-FL visit details were narrowed by ZIP code (or lack of ZIP code for residents of other countries) and match details were recorded and evaluated. The fields examined were not always complete in ESSENCE-FL. Visits were considered matches when all available data in the fields examined were consistent with information obtained in the PUI case report form and available medical records and discharge summaries. Results Of the 52 PUIs included in this analysis, 39 sought treatment at facilities participating in ESSENCE-FL at their time of visit. Comparing information obtained from PUI documents with data provided in ESSENCE-FL, 30 ED visits were successfully matched to PUIs, including an initial ED visit for the patient with a confirmed case of MERS-CoV. Conclusions Following preliminary identification, all matches are to be confirmed with the appropriate hospitals. Future work to examine the chief complaints associated with patients’ initial ED visits identified in ESSENCE-FL will serve as a way to validate and improve upon the query currently being used as a surveillance tool for MERS-CoV. Detailing these methods also has value in the replication of this study for other diseases and in the development and validation of other disease-specific queries. Summarizing the reasons why PUIs were unable to be matched to ESSENCE-FL visits is also useful in improving system robustness.

Flakka is a synthetic drug (class: cathinones) that been responsible for numerous emergency department visits and over 30 deaths in Florida over the last year. In August 2015, Florida Department of Health (FDOH) partner agencies requested flakka-related health data in an effort to better understand the epidemiology and context of this problem. ESSENCE-FL emergency department data and poison control calls were analyzed to describe the epidemiology of this emergent drug. Having near real-time surveillance systems capable of providing timely, relevant data is critical in quickly characterizing emerging public health issues and helping to prioritize available resources.

This study investigates a potential day of the week effect for myocardial infarction related chief complaints in the age group of 18 - 64 years by analyzing emergency department data in ESSENCE-FL.

During the spring of 2009, pandemic influenza A (H1N1) virus (pH1N1) was recognized and rapidly spread worldwide. To describe the geographic distribution and patient characteristics of pH1N1-associated deaths in the United States, the Centers for Disease Control and Prevention requested information from health departments on all laboratory-confirmed pH1N1 deaths reported from 17 April through 23 July 2009. Data were collected using medical charts, medical examiner reports, and death certificates. A total of 377 pH1N1-associated deaths were identified, for a mortality rate of .12 deaths per 100,000 population. Activity was geographically localized, with the highest mortality rates in Hawaii, New York, and Utah. Seventy-six percent of deaths occurred in persons aged 18-65 years, and 9% occurred in persons aged ≥ 65 years. Underlying medical conditions were reported for 78% of deaths: chronic lung disease among adults (39%) and neurologic disease among children (54%). Overall mortality associated with pH1N1 was low; however, the majority of deaths occurred in persons aged

During the 2009 influenza pandemic, due to the 2009 pandemic influenza A (pH1N1) virus, there were an estimated 44 infections for every excess emergency department visit for influenza-like illness in Florida.

Background Reports of acute hepatitis C in young persons in the United States have increased. We examined data from national surveillance and supplemental case follow-up at selected jurisdictions to describe the US epidemiology of hepatitis C virus (HCV) infection among young persons (aged ≤30 years). Methods We examined trends in incidence of acute hepatitis C among young persons reported to the Centers for Disease Control and Prevention (CDC) during 2006-2012 by state, county, and urbanicity. Sociodemographic and behavioral characteristics of HCV-infected young persons newly reported from 2011 to 2012 were analyzed from case interviews and provider follow-up at 6 jurisdictions. Results From 2006 to 2012, reported incidence of acute hepatitis C increased significantly in young persons-13% annually in nonurban counties (P = .003) vs 5% annually in urban counties (P = .028). Thirty (88%) of 34 reporting states observed higher incidence in 2012 than 2006, most noticeably in nonurban counties east of the Mississippi River. Of 1202 newly reported HCV-infected young persons, 52% were female and 85% were white. In 635 interviews, 75% of respondents reported injection drug use. Of respondents reporting drug use, 75% had abused prescription opioids, with first use on average 2.0 years before heroin. Conclusions These data indicate an emerging US epidemic of HCV infection among young nonurban persons of predominantly white race. Reported incidence was higher in 2012 than 2006 in at least 30 states, with largest increases in nonurban counties east of the Mississippi River. Prescription opioid abuse at an early age was commonly reported and should be a focus for medical and public health intervention.

The Florida Department of Health (FDOH) electronically receives both urgent care center (UCC) data and hospital emergency department (ED) data from health care facilities in 43 of its 67 counties through its Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE-FL). This project will investigate and describe the differences between the data received from these two sources and provide best practices for grouping and analyzing these data sources.

The sensitivity and predictive value of a surveillance system (ESSENCE-FL) originally designed for syndromic data to identify possible outbreak activity using data from a reportable disease system was examined. ESSENCE-FL-generated alerts were compared with confirmed outbreak activity for different infectious diseases over a 52-week period. Results showed that although overall sensitivity of the system to detect outbreak activity was fairly low, the positive predictive value was relatively high. This evaluation concludes that the application of reportable disease data within the ESSENCE-FL syndromic surveillance system is useful for prompting users of possible outbreak activity that warrants further inquiry.

Objective In light of recent outbreaks of pertussis, the ability of Florida Department of Health’s (FDOH) Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE-FL) to detect emergent disease outbreaks was examined. Through a partnership with the Johns Hopkins University Applied Physics Laboratory (JHU/APL), FDOH developed a syndromic surveillance system, ESSENCE-FL, with the capacity to monitor reportable disease case data from Merlin, the FDOH Bureau of Epidemiology’s secure webbased reporting and epidemiologic analysis system for reportable diseases. The purpose of this evaluation is to determine the utility and application of ESSENCE-FL system generated disease warnings and alerts originally designed for use with emergency department chief complaint data to reportable disease data to assist in timely detection of outbreaks in promotion of appropriate response and control measures. Introduction Reportable disease case data are entered into Merlin by all 67 county health departments in Florida and assigned confirmed, probable, or suspect case status. De-identified reportable disease data from Merlin are sent to ESSENCE-FL once an hour for further analysis and visualization using tools in the surveillance system. These data are available for ad hoc queries, allowing users to monitor disease trends, observe unusual changes in disease activity, and to provide timely situational awareness of emerging events. Based on system algorithms, reportable disease case weekly tallies are assigned an awareness status of increasing intensity from normal to an alert category. These statuses are constantly scrutinized by county and state level epidemiologists to guide disease control efforts in a timely manner, but may not signify definitive actionable information. Methods Within the ESSENCE-FL query portal, the Merlin Reportable Diseases Data Source was selected with a weekly time resolution by event date. Case Classification included all confirmed, probable and suspect cases, reported and not yet reported, during the time period of week 35, 2011, to week 35, 2012. The ESSENCE Weighted Moving Average (EWMA 1.2) detector was used to classify weekly counts as either of normal, warning or alert status based on previous weeks’ counts, indicating the possibility of an emerging outbreak. These weekly statuses were then compared with outbreaks reported in Merlin’s fully integrated outbreak reporting system and with outbreak reports submitted to EpiCom, Florida’s EpiX or health alert network. An ESSENCE-FL generated warning or alert was considered valid if a corresponding outbreak of 2 or more epi-linked pertussis cases were reported in either Merlin’s outbreak module or in EpiCom. For the sake of brevity in this abstract, the analysis of pertussis is presented, while other reportable disease conditions of immediate interest will be presented at the conference. Results Examination of 494 pertussis cases reported from September 2011 to September 2012 showed that of 53 weeks, 38 weeks contained normal case counts, 11 weeks generated warnings, and 4 weeks produced alerts. The number of warnings that corresponded to actual outbreaks was 6 of 11, whereas 2 of the 4 alerts matched reported outbreaks. Of the remaining 38 weeks, 12 had outbreaks reported with no warning or alert generated by ESSENCE-FL. When comparing confirmed outbreak status with ESSENCE-FL weekly data count status, warning/alert versus normal, it was found that the sensitivity of ESSENCE-FL to detect a true outbreak was 40.0% while the specificity was 78.8%. This comparison generated a positive-predictive value of 53.3% and a negative predictive value of 68.4%. Conclusions The ability of ESSENCE-FL to act as a first alert system for emerging disease events using Merlin reportable disease data should be considered with constraint. While warnings or alerts about potential pertussis outbreaks were generated correctly about half the time, the nearly one-third of reported outbreaks with no warning or alert makes the utility of the alerts questionable as far as initiating immediate action without prior verification of the alert. Florida does not currently have a requirement for centrally documenting all outbreaks, so it is likely that outbreaks occurred but were not recorded, precluding verification of all outbreaks.

Objective U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Preparedness and Response (ASPR) partnered with the Florida Department of Health (FDOH), Bureau of Epidemiology, to implement a new process for the unidirectional exchange of electronic medical record (EMR) data when ASPR clinical assets are operational in the state following a disaster or other response event. The purpose of the current work was to automate the exchange of data from the ASPR electronic medical record system EMR-S into the FDOH Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE-FL) system during the 2012 Republican National Convention (RNC). Introduction ASPR deploys clinical assets, including an EMR system, to the ground per state requests during planned and no-notice events. The analysis of patient data collected by deployed federal personnel is an integral part of ASPR and FDOH’s surveillance efforts. However, this surveillance can be hampered by the logistical issues of field work in a post-disaster environment leading to delayed analysis and interpretation of these data to inform decision makers at the federal, state, and local levels. FDOH operates ESSENCE-FL, a multi-tiered, automated, and secure web-based application for analysis and visualization of clinical data. The system is accessible statewide by FDOH staff as well as by hospitals that participate in the system. To improve surveillance ASPR and FDOH engaged in a pilot project whereby EMR data from ASPR would be sent to FDOH in near real-time during the 2012 hurricane season and the 2012 RNC. This project is in direct support of Healthcare Preparedness Capability 6, Information Sharing, and Public Health Preparedness Capability 13, Public Health Surveillance and Epidemiological Investigation. Methods In 2011, FDOH approached ASPR about securely transmitting raw EMR data that could be ingested by ESSENCE-FL during ASPR deployments in the state. Upon conclusion of an agreement for a date exchange pilot, data elements of interest from the ASPR EMR were identified. Due to the modular design ESSENCE-FL Microsoft SQL databases were easily adapted by the Johns Hopkins University Applied Physics Laboratory (JHU/APL) to add a new module to handle receipt of ASPR EMR data including code to process the files, remove duplicates and create associations with existing reference information, such as system-defined geographic regions and age groups. Scripts were developed to run on the ASPR server to create and send updated files via secure file transfer protocol (SFTP) every 15 minutes to ESSENCE-FL. Prior ASPR event deployment data was scrubbed and sent to ESSENCE-FL as a test dataset to ensure appropriate receipt and ingestion of the new data source. Results EMR data was transmitted through a central server at ASPR to ESSENCE-FL every 15 minutes during each day of the 2012 RNC (August 26–31). In ESSENCE-FL, configuration allowed the data to be queried, analyzed, and visualized similar to existing ESSENCE-FL data sources. In all, data from 11 patient encounters were successfully exchanged between the partners. The data were used by ASPR and FDOH to simultaneously monitor in near real-time onsite medical response activities during the convention. Conclusions Timely access to patient data can enhance situational awareness and disease surveillance efforts and provide decision makers with key information in an expedient manner during disaster response and mass gatherings such as the RNC. However, data are siloed within organizations. The collaboration between FDOH, ASPR and JHU/APL made EMR data sharing and analysis more expeditious and efficient and increased timely access to these data by local, state, and federal epidemiologists. The integration of these data into the ESSENCE-FL system created one location where users could go to access data and create epidemiologic reports for a given region in Florida, including the RNC. To achieve these successes with partners in the future, it will be necessary to develop partnerships well in advance of intended data exchange. Future recommendations include robust pre-event testing of the data exchange process and planning for a greater amount of lead-time between enacting the official agreement and beginning data exchange.

Objective. Florida, the fourth most populous state in the nation, has had historically low incidence rates of pertussis, the only vaccine-preventable disease with increasing numbers of reported cases. We compared the epidemiology and incidence rates of pertussis in Florida with other states and the United States. Methods. We used Florida and federal surveillance data from 2000 through 2006. Results. Reported incidence of pertussis in Florida, numbers of cases, and proportions of adolescents and adults all increased during the seven-year study period. Florida incidence rates increased from 0.44 to 1.28, but the state's incidence was always ranked 45th or lower among the states. Reported pertussis cases and those among adolescents and adults in Florida increased during the study period. Ten counties, containing 60% of Florida's population, reported two-thirds of the state's cases. Conclusions. Pertussis reported from Florida mirrored national trends with increasing incidence, numbers of cases, and proportions of adolescent and adult cases. Despite the increases, Florida maintained its historic pattern of pertussis incidence rates that are consistently lower than national figu es. Limited laboratory diagnostics and a focus on the pediatric population likely contributed to the lower rates of pertussis in Florida. More emphasis on surveillance of adolescent and adult cases is needed.

Introduction Pregnant women have been identified as a high risk group for severe illness with 2009 pandemic influenza A(H1N1) virus infection (pH1N1). Obesity has also been identified as a risk factor for severe illness, though this has not been thoroughly assessed among pregnant women. The objectives of this study were to provide risk estimates for adverse maternal and neonatal outcomes associated with pH1N1 illness during pregnancy and to assess the role of obesity in these outcomes. Methods We established a retrospective population-based cohort of all live births occurring in Florida during the first 15 months of the pandemic. Illness with pH1N1 during pregnancy was ascertained through record linkage with the Florida state notifiable disease surveillance database. Data from the birth record, including pre-pregnancy body mass index, were analyzed to assess risk of adverse outcomes associated with pH1N1 illness. Results A total of 194 women were identified through surveillance with pH1N1 illness during pregnancy. Children born to women with pH1N1 illness during pregnancy were at increased risk for low birth weight [OR (95%CI): 1.78 (1.11-2.860)], premature birth [2.21 (1.47-3.330)], and infant death [4.46 (1.80-11.00)], after adjusting for other factors. Women with pH1N1 illness during pregnancy were at increased risk for severe outcomes including admission to an intensive care unit. Obesity was an observed risk factor, both for the more severe pH1N1 illness detected through surveillance, and for severe maternal outcomes. Conclusions Case-patients in this analysis likely represent the most severely ill subset of all women infected with pH1N1 during pregnancy, limiting the generalizability of these findings to more severely ill patients rather than influenza infection in general. Nevertheless, these results suggest that more severe pH1N1 illness during pregnancy is associated with adverse neonatal outcomes and that pregnant women should continue to be targeted for appropriate prophylaxis and early treatment.