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MERS PUI Surveillance and Restrospective Identification in

ESSENCE-FL, 2013-2015


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.


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


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.


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.


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.


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.