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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.

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.

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.

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.

Background In 2009, a novel influenza virus (2009 pandemic influenza A (H1N1) virus (pH1N1)) caused significant disease in the United States. Most states, including Florida, experienced a large fall wave of disease from September through November, after which disease activity decreased substantially. We determined the prevalence of antibodies due to the pH1N1 virus in Florida after influenza activity had peaked and estimated the proportion of the population infected with pH1N1 virus during the pandemic. Methods During November-December 2009, we collected leftover serum from a blood bank, a pediatric children's hospital and a pediatric outpatient clinic in Tampa Bay Florida. Serum was tested for pH1N1 virus antibodies using the hemagglutination-inhibition (HI) assay. HI titers ≥40 were considered seropositive. We adjusted seroprevalence results to account for previously established HI assay specificity and sensitivity and employed a simple statistical model to estimate the proportion of seropositivity due to pH1N1 virus infection and vaccination. Results During the study time period, the overall seroprevalence in Tampa Bay, Florida was 25%, increasing to 30% after adjusting for HI assay sensitivity and specificity. We estimated that 5.9% of the population had vaccine-induced seropositivity while 25% had seropositivity secondary to pH1N1 virus infection. The highest cumulative incidence of pH1N1 virus infection was among children aged 5–17 years (53%) and young adults aged 18–24 years (47%), while adults aged ≥50 years had the lowest cumulative incidence (11–13%) of pH1N1 virus infection. Conclusions After the peak of the fall wave of the pandemic, an estimated one quarter of the Tampa Bay population had been infected with the pH1N1 virus. Consistent with epidemiologic trends observed during the pandemic, the highest burdens of disease were among school-aged children and young adults.