MERS PUI Surveillance and Restrospective Identification in ESSENCE-FL, 2013-2015
Authors: Munroe Julia , Straver Rachael , Rubino Heather , Pritchard Scott , Atrubin David , Hamilton Janet J. 
Published: May 2017

ObjectiveTo retrospectively identify initial emergency department (ED)and urgent care center (UCC) visits for Florida’s Middle Eastrespiratory syndrome coronavirus disease (MERS-CoV) patientsunder investigation (PUIs) in the Florida Department of Health’s(DOH) syndromic surveillance system, the Electronic SurveillanceSystem for the Early Notification of Community-based Epidemics(ESSENCE-FL), using information gathered from PUI case reportforms and corresponding medical records for the purpose ofimproving syndromic surveillance for MERS-CoV. The results ofthis study may be further utilized in an effort to evaluate the currentMERS-CoV surveillance query.IntroductionHuman MERS-CoV was first reported in September 2012. Globally,all reported cases have been linked through travel to or residence inthe Arabian Peninsula with the exception of cases associated with anoutbreak involving multiple health care facilities in the Republic ofKorea ending in July 2015. While the majority of MERS-CoV caseshave been reported in the Arabian Peninsula, several cases have beenreported outside of the region. Most cases are believed to have beenacquired in the Middle East and then exported elsewhere, with no orrare instances of secondary transmission. Two cases of MERS-CoVwere exported to the United States and identified in May 2014. Oneof these cases traveled from Saudi Arabia to Florida.DOH conducts regular surveillance for MERS-CoV through theinvestigation of persons with known risk factors. PUIs have mostoften been identified by physicians reporting directly to local healthdepartments and by DOH staff regularly querying ED and UCC chiefcomplaint data in ESSENCE-FL. ESSENCE-FL currently capturesdata from 265 EDs and UCCs statewide and has been useful inidentifying cases associated with reportable disease and emergingpathogens.MethodsFrom 2013-2015 DOH identified and investigated 62 suspectedcases 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 theidentification of MERS-CoV in May 2014 and were not included inthis analysis. DOH utilizes a MERS-CoV PUI case report form tocollect data regarding demographics, clinical presentation, and riskfactors. Retrospectively, additional documents including medicalrecords and discharge summaries were gathered and utilized toevaluate 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 andcorresponding medical records and discharge summaries. Visit detailsfor each of the identified facilities were queried in ESSENCE-FLand pulled for all visits with corresponding age at event and sex forthe patient’s visit date. Additional PUI information including chiefcomplaint, discharge diagnosis, ZIP code, race, and ethnicity weregathered for the purpose of matching corresponding ESSENCE-FLdata fields. ESSENCE-FL visit details were narrowed by ZIP code (orlack of ZIP code for residents of other countries) and match detailswere recorded and evaluated. The fields examined were not alwayscomplete in ESSENCE-FL. Visits were considered matches when allavailable data in the fields examined were consistent with informationobtained in the PUI case report form and available medical recordsand discharge summaries.ResultsOf the 52 PUIs included in this analysis, 39 sought treatmentat facilities participating in ESSENCE-FL at their time of visit.Comparing information obtained from PUI documents with dataprovided in ESSENCE-FL, 30 ED visits were successfully matchedto PUIs, including an initial ED visit for the patient with a confirmedcase of MERS-CoV.ConclusionsFollowing preliminary identification, all matches are to beconfirmed with the appropriate hospitals. Future work to examine thechief complaints associated with patients’ initial ED visits identifiedin ESSENCE-FL will serve as a way to validate and improve uponthe query currently being used as a surveillance tool for MERS-CoV.Detailing these methods also has value in the replication of thisstudy for other diseases and in the development and validation ofother disease-specific queries. Summarizing the reasons why PUIswere unable to be matched to ESSENCE-FL visits is also useful inimproving system robustness.