2014.ISDS.Abstracts.Final.pdf


ISDS Annual Conference Proceedings 2014. This is an Open Access article distributed under the terms of the Creative Commons Attribution-
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ISDS 2014 Conference Abstracts

Using ESSENCE-FL for Situational Awareness after 
National Reports of Increased Enterovirus D68 (EV-D68) 
Infections with Severe Outcomes, September 2014
David Atrubin*

Florida Department of Health, Tampa, FL, USA

Objective
To provide situational awareness using Florida’s syndromic 

surveillance system during a 2014 outbreak of EV-D68 in other 
regions of the country

Introduction
The Electronic Surveillance System for the Early Notification of 

Community-Based Epidemics (ESSENCE-FL) receives daily (or 
bi-hourly) data from 184 emergency departments (ED) from around 
Florida. Additionally, 30 urgent care centers submit daily data to the 
system. These 214 facilities are grouped together in an acute care 
data source category. Five to six days after the start of each school 
year in Florida, ESSENCE-FL shows increased respiratory illness 
visits in the school aged population. Previous analyses of these data 
have shown that this increase is a result of increased transmission of 
the common cold among school children. In early September 2014, 
during this sustained yearly increase in respiratory visits, reports 
of more severe infection caused by Enterovirus D68 (EV-D68) in 
children in other parts of the country began circulating. Public health 
officials in Florida, as well as the media, questioned whether children 
in the state were being infected by this virus capable of causing more 
severe illness, especially among asthmatics. As is the case with many 
incipient outbreaks, syndromic surveillance played an integral role 
in early efforts to detect the presence of this illness. The task of 
providing situational awareness during this period was complicated 
by this outbreak coinciding with the start of the school year.

Methods
On September 8, 2014, ESSENCE-FL staff were made aware of 

clusters of EV-D68 occurring in Kansas City, Missouri and Chicago. 
An early release edition of the Centers for Disease Control and 
Prevention’s Morbidity and Mortality Weekly Report (September 8, 
2014) was reviewed and provided critical information about disease 
presentation and the characteristics of the population infected with 
EV-D68.1 Using the 184 hospitals only, a time series graph was created 
to look for statistical aberrations in the percentage of 0-16 year olds 
being admitted to the hospital. The discharge disposition category 
field provides an indication of the severity of the illness in the ED 
patient. ESSENCE-FL subsyndromes were analyzed to look for visits 
in excess of normal levels for the categories of DifficultyBreathing, 
Wheezing and Asthma. Specific time series graphs were created in an 
effort to detect an increase in 0-16 year old asthmatics being admitted 
to hospitals.

Results
As of September 9, 2014, no increase in admit percentage was 

observed in children 0-16 years of age. Likewise, no levels of 
Respiratory syndrome or DifficultyBreathing, Wheezing, or Asthma 
subsyndromes were seen in excess of typical levels for this time of 
year for this age group. Additionally, The Florida Department of 
Health received no reports of increased hospital admissions related 

to this seasonal increase in respiratory visits typically seen at this 
time of year.

Conclusions
No evidence of increased illness due to EV-D68 was observed in 

Florida’s syndromic surveillance ED data at the time of this writing. 
Syndromic surveillance systems often prove their worth as much by 
what is not found, rather than what is found. While these systems do 
not replace open communication with hospitals and other providers, 
there is a necessity to have near real-time surveillance when outbreaks 
are occurring - even elsewhere in the country or world. Understanding 
the periodicity in your data also facilitates the ability to provide 
accurate situational awareness. Having a specific data field (the 
discharge disposition) that allowed epidemiologists to gauge the level 
of severity of illness in an ED patient proved to be very beneficial in 
this circumstance.

Keywords
Enterovirus; Respiratory illness; school year; Emergency department 
data; admit data

Acknowledgments

Johns Hopkins University Applied Physics Laboratory

References

1. CDC. Severe Respiratory Illness Associated with Enterovirus D68 –
Missouri and Illinois, 2014. MMWR Sept 8, 2014;63:Early Release.

2. CDC Clusters of Acute Respiratory Illness Associated with Human
Enterovirus 68 —-Asia, Europe, and United States, 2008-2010. 
MMWR 2011;60:1301-4.

*David Atrubin
E-mail: david.atrubin@flhealth.gov    

Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * (1):e107, 201