JMIR PUBLIC HEALTH AND SURVEILLANCE Burkom et al

Original Paper

Electronic Surveillance System for the Early Notification of

Community-Based Epidemics (ESSENCE): Overview,
Components, and Public Health Applications

Howard Burkom, MSc, DPhil; Wayne Loschen, BSc, MSc; Richard Wojcik, BSc, MSc; Rekha Holtry, BSc, MSc;
Monika Punjabi, BSc, MSc; Martina Siwek, MSc, PhD; Sheri Lewis, BSc, MSc
Johns Hopkins University Applied Physics Laboratory, Laurel, MD, United States

Corresponding Author:
Howard Burkom, MSc, DPhil
Johns Hopkins University Applied Physics Laboratory
11100 Johns Hopkins Road
Laurel, MD, 20723
United States
Phone: 1 240 228 5000 ext 4361
Email: [email protected]

Abstract
Background: The Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE) is
a secure web-based tool that enables health care practitioners to monitor health indicators of public health importance for the
detection and tracking of disease outbreaks, consequences of severe weather, and other events of concern. The ESSENCE concept
began in an internally funded project at the Johns Hopkins University Applied Physics Laboratory, advanced with funding from
the State of Maryland, and broadened in 1999 as a collaboration with the Walter Reed Army Institute for Research. Versions of
the system have been further developed by Johns Hopkins University Applied Physics Laboratory in multiple military and civilian
programs for the timely detection and tracking of health threats.
Objective: This study aims to describe the components and development of a biosurveillance system increasingly coordinating
all-hazards health surveillance and infectious disease monitoring among large and small health departments, to list the key features
and lessons learned in the growth of this system, and to describe the range of initiatives and accomplishments of local
epidemiologists using it.
Methods: The features of ESSENCE include spatial and temporal statistical alerting, custom querying, user-defined alert
notifications, geographical mapping, remote data capture, and event communications. To expedite visualization, configurable
and interactive modes of data stratification and filtering, graphical and tabular customization, user preference management, and
sharing features allow users to query data and view geographic representations, time series and data details pages, and reports.
These features allow ESSENCE users to gather and organize the resulting wealth of information into a coherent view of population
health status and communicate findings among users.
Results: The resulting broad utility, applicability, and adaptability of this system led to the adoption of ESSENCE by the Centers
for Disease Control and Prevention, numerous state and local health departments, and the Department of Defense, both nationally
and globally. The open-source version of Suite for Automated Global Electronic bioSurveillance is available for global,
resource-limited settings. Resourceful users of the US National Syndromic Surveillance Program ESSENCE have applied it to
the surveillance of infectious diseases, severe weather and natural disaster events, mass gatherings, chronic diseases and mental
health, and injury and substance abuse.
Conclusions: With emerging high-consequence communicable diseases and other health conditions, the continued user
requirement–driven enhancements of ESSENCE demonstrate an adaptable disease surveillance capability focused on the everyday
needs of public health. The challenge of a live system for widely distributed users with multiple different data sources and high
throughput requirements has driven a novel, evolving architecture design.

(JMIR Public Health Surveill 2021;7(6):e26303) doi: 10.2196/26303

KEYWORDS
health surveillance; outbreak detection; population health
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awareness, such as tracking and characterization of known health

Introduction events, assessing the burden of all-hazard threats such as severe
Background weather, environmental hazards, and substance abuse, and rumor
control to enable improved public health response. In 2021,
In recent decades, public health disease surveillance relied on there are approximately 3800 ESSENCE users, including
laboratory confirmation and passive participation. Often, the approximately 3000 recent frequent users. These users are spread
lack of automated detection and reporting resulted in time delays among ESSENCE installations in 23 states and local
that impeded prompt mitigation activities. Public health jurisdictions, the DoD system, the NSSP system serving most
institutions thus began using enhanced surveillance techniques US states, and several instances in private organizations.
with the potential for timely epidemic detection and tracking.
These techniques have been incorporated in electronic and A timeline detailing the historical development of ESSENCE
increasingly internet-based health surveillance systems for is presented in Multimedia Appendix 1.
everyday use by health monitors. Intensive efforts to establish Objectives
health surveillance systems occurred at multiple institutions
and government agencies in the late 1990s. As a result, a This study aims to describe how the architecture, analytics,
substantial collection of review papers, system-specific visualizations, and user collaboration tools in ESSENCE have
evaluations, and evaluation criteria have emerged [1-4]. empowered public health at local and regional levels despite
resources that are often scarce compared with those of other
The Electronic Surveillance System for the Early Notification government institutions, with discussion of the lessons learned
of Community-Based Epidemics (ESSENCE) system originated over the past 20 years and the continuing challenges of emerging
as a collaboration between two such projects. A project of Dr population health threats. Through the main text and
Michael Lewis, then a medical resident under Dr Julie Pavlin supplementary files on the technical details, this paper will
at the Walter Reed Army Institute for Research (WRAIR), describe the various ways by which ESSENCE enables user
applied US military clinic visit data for outbreak detection in a institutions to meet the standards set for public health
project called ESSENCE [5]. Concurrently, for the same surveillance systems [11], from engaging stakeholders to
purpose, Johns Hopkins University Applied Physics Laboratory providing technical justification to sharing lessons learned. In
(JHU/APL) combined civilian data from hospital emergency the context of this paper, the Methods section refers to the data
departments (EDs), physician office visits, over-the-counter architecture, analytic methods, and visualizations provided by
(OTC) sales, and school absenteeism records, first with internal ESSENCE, and the Results section refers to the surveillance
funding, then for the State of Maryland [6]. The two groups capabilities that have thus been realized by system users.
joined forces in anticipation of possible bioterrorist activity at
the turn of the century as January 1, 2000, approached, and this Methods
collaboration, along with similar efforts at other institutions,
led to further funded development in the multicenter Bio-Event This section describes the general functionality and main
Advanced Leading Indicator Recognition Technology components of ESSENCE, including data types and
(BioALIRT) program of 2001-2003 for the Defense Advanced management, analytic methods, and visualizations. The details
Research Project Agency [7]. In leading one of four BioALIRT of these components are provided in Multimedia Appendices
research teams, the JHU/APL and WRAIR groups further 1-4.
matured the ESSENCE system concept.
System Overview
Following the terror attacks of September 11, 2001, ESSENCE ESSENCE is a health surveillance system that uses advanced
was expanded in Maryland, increasingly operationalized in state analytics and visualizations to expose anomalies in both
and local civilian health monitoring agencies and implemented traditional and nontraditional public health data, with the goal
in all global US military treatment facilities. Since then, fueled of enabling public health to find and monitor outbreaks of health
by a succession of initiatives driven by both bioterrorism and events and make decisions. ESSENCE users access a secure
natural public health concerns, versions of ESSENCE have been web-based tool to conduct disease surveillance for the purpose
implemented in the Department of Defense (DoD), the Veterans of timely detection, situational awareness, and descriptive
Administration (VA), the Centers for Disease Control and epidemiologic analysis of baseline disease patterns and
Prevention (CDC), and state and regional public health agencies outbreaks. For an effective public health response, public health
across the United States and, through collaborative DoD efforts, authorities must have the ability to identify the infected
internationally. Following the widespread use of ESSENCE population so that further spread can be contained. Leveraging
and enhancements at JHU/APL to meet users’ evolving needs, the near real-time availability of an increasing number of data
the CDC National Syndromic Surveillance Program (NSSP) sources, ESSENCE analytical and alerting capabilities provide
adopted ESSENCE in 2014 as the standard analytic surveillance an opportunity for public health users to capture the early stages
and visualization engine on the BioSense Platform for state and of an outbreak and track its progress. ESSENCE enables the
local public health monitors [8,9]. Nearly 6000 health care integration of electronic data from both clinical and nonclinical
facilities covering 49 states and the District of Columbia sources to enhance situational awareness. For most users, the
contribute ED data to the BioSense Platform daily [10]. The primary clinical data source is hospital ED chief complaint
user benefits of ESSENCE have long surpassed the Early records. In addition, based on availability, public health agencies
Notification part of its acronym to include aspects of situational incorporate other data types, such as OTC medication sales,

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poison control call center data, prescription drug data, reportable During the ingestion process, data are cleansed (eg,
disease data, vital statistics mortality data, and school absentee duplicate records removed and invalid characters removed),
data. Once raw data reach ESSENCE, the analysis, visualization, updated (eg, existing records information is updated with
and communication features of ESSENCE allow the end user new information), and categorized (eg, syndrome and
to gather and organize the resulting wealth of information into subsyndrome categories assigned to records).
a coherent view of population health status and to communicate 2. Alerting: multiple temporal and spatial alerting algorithms
findings among other users and stakeholders. are applied to each data set to develop a list of alerts or
flags for further investigation by public health officials. In
As a result of ongoing user feedback daily and event-based
addition to algorithms developed by JHU/APL and the
disease surveillance needs, ESSENCE features include spatial
WRAIR, ESSENCE can incorporate algorithms required
and temporal statistical alerting, custom querying, user-defined
by the jurisdiction where the system is deployed.
alert notifications, geographical mapping, remote data capture, 3. Analysis and visualization: ESSENCE data and alerts can
and event communications.
be analyzed and visualized in multiple ways in the system,
ESSENCE provides three main functions: both spatially and temporally.
1. Data ingestion or preprocessing: traditional and These component functions are illustrated schematically in
nontraditional data sources are electronically received by Figure 1. They are introduced in the following sections, with
ESSENCE, and many are mapped to syndrome groupings. an additional file for each to provide details.
Figure 1. Schematic overview of Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE) features
showing a sampling of users’ data types, analysis modes, and screen interfaces. ED: emergency department; GIS: geographic information system.

records, reportable disease cases, poison center call records,

Data Types and Syndrome or Feature Selection Assistant Secretary for Preparedness and Response Disaster
The types of data analyzed in ESSENCE are the prerogative Medical Assistance Teams data for disaster response [12],
and responsibility of the jurisdiction, although JHU/APL cardiovascular and other chronic diseases from inpatient
provides the capability for basic types. The ESSENCE system encounters, livestock and companion animal health encounters,
is data agnostic—the only requirement for a monitored data human vitals measurements, death records, emergency medical
type is the inclusion of a data field. The data time resolution is services and 911 calls, and climate and air quality data.
also unrestricted. Data frequencies in ESSENCE range from
seconds to years, although daily data are the most common. All Users have also incorporated or adapted data from other
but a few users monitor hospital ED data. Most ESSENCE user surveillance systems, such as the National Poison Data System
jurisdictions face the burden of acquiring their data sources, [13]. Although not all these sources have proven useful for
gaining approval for their routine intended use, and extracting routine surveillance, users have used the system to investigate
features for monitoring. The level of effort varies greatly their utility and to seek the best data usage.
depending on the data source. Various users also monitor or In separate studies or projects, individual user jurisdictions or
have monitored the records of the data sources listed below. their research partners have also used ESSENCE to analyze
Sources known to be currently or formerly tracked among users’ records of radiology impressions; genomic sequencing data;
ESSENCE systems for routine prospective monitoring include zoo animal health; environmental sensor outputs; sales of
OTC remedy sales, physician office visits, laboratory test orders specific products, such as thermometers, orange juice, and
and results, school absenteeism and health office or nurse
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tissues; social media posts and searches; and fantasy sports data. and gastrointestinal subsyndromes, such as asthma.
Multiple content formats used in ESSENCE include Health Categorization soon switched to the use of free-text chief
Level-7 (HL-7) formats for hospital data and National complaint or reason-for-visit data fields. For this categorization,
Emergency Medical Services Information System (NEMSIS) the JHU/APL ESSENCE team developed the Chief Complaint
formats for emergency medical services data. File formats Processor (CCP), a versatile, stand-alone program for weighted
include delimited or tabbed or fixed-width American Standard keyword-based classification by free-text fields. The CCP is
Code for Information Interchange (ASCII) text, XML, and highly configurable, with tables including sets of syndromes
JavaScript Object Notation (JSON). and subsyndromes with classification rules allowing complex
logic, positive and negative weighting of component terms,
Each data source has its own challenges for user jurisdictions
abbreviation and spelling rules, and a list of unmodifiable terms.
to obtain sustained electronic access from data providers and
For example, CCP puts a record with a chief complaint of
any requisite government approval. When a data stream of any
nausea or vomiting in the gastrointestinal category. The CCP
of these sources is acquired for routine monitoring, an immediate
creates a ChiefComplaintsParsed field for the use of
question is how to use the streaming data to track the health
classification rules after treatment of abbreviations, some
outcomes of interest. An often-applied procedure is to track the
misspellings, and other cleanup [14]. These classifications have
counts of subcategories of the data expected to correspond to
enabled additional natural language processing and machine
these outcomes. These subcategories are commonly called
learning initiatives by both ESSENCE developers and users,
syndromes, generalizing the medical definition of this term,
and findings from these initiatives are shared among users with
denoting disease-related collections of signs and symptoms.
each emerging health threat [15-17].
Thus, in the surveillance context, a syndrome may refer to
grouped hospital visits associated with a fixed collection of As with diagnosis code-based processing, syndrome groups are
symptoms, laboratory tests ordered for certain conditions, web tabulated, plotted, and monitored each day with statistical
searches containing sets of terms, billing records covering any alerting algorithms for early potential outbreak indications.
of a class of remedies, or other subgroups depending on the data
source. Syndrome formation is a critical step that may use only
Architecture, Security, Preprocessing, and Quality
a fraction of all streaming data and may produce few or many Management
groups to track. The number and composition of syndromes The software architecture used for ESSENCE is a 3-tier web
depend on the richness of the data, the number of outcomes of application with a presentation layer as a user front end, a
interest, and the resources of the monitoring institution for business layer for the application of algorithms, and a back end
investigation and response. for databases. All automated data transfers occur over secure
virtual private networks. Multiple, data-dependent preprocessing
Syndromes and subsyndromes used in ESSENCE vary
steps include deduplication procedures, formation of syndrome
depending on the available clinical grouping systems and the
fields, calculation of distances, and derivation of additional
needs of the user site. Early versions of ESSENCE formed
fields and flags based on jurisdictional business rules and logic.
syndrome groups using diagnosis codes, which have
The flow diagram is shown in Figure 2. Multimedia Appendix
disadvantages of late assignment and emphasis on billing
2 describes these features in detail.
practice in many medical systems. Examples include respiratory

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Figure 2. Flow diagram illustrating typical Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE)
data flow with databases and tables, generalized to account for diversity among user needs and server configurations. API: application program interface;
ED: emergency department; GIS: geographic information system.

Day-to-day users, often with only a small fraction of time

Alerting Methods Using Statistics and Artificial available for monitoring, will not wait for several minutes
Intelligence for each query. Building separate algorithms for each user
The following principles were derived from ESSENCE users data stream is impractical, especially because sufficient
to guide method selection and to clarify the interpretation of data history is unavailable for many standard time series
results. and all ad hoc series; therefore, ESSENCE methods have
been adapted from the literature and engineered for
General considerations include:
appropriate matching to the data and timely results.
• These methods are not intended to identify outbreaks • If the time series monitored by algorithms represent many
positively without supporting evidence. Their purpose is combinations of clinical groupings, age groups, and
to direct the attention of limited monitoring staff with geographic regions, excessive alerting may occur simply
increasingly complex data streams to data features that because of the number of tests applied. The summary alert
merit further investigation. They have also been useful for method was implemented to limit excessive alerting. This
corroborating clinical suspicions, rumor control, tracking method is based on the control of the false discovery rate,
of known or suspected outbreaks, monitoring of special that is, the expected ratio of false alerts to the total alert
events and health effects of severe weather, and other count, and its statistical implementation in ESSENCE is
locally important aspects of situational awareness. detailed in Multimedia Appendix 3. Aside from analytic
Successful users value these methods more for the latter methods to control alerting, default alert lists should be
purposes and do not base public health responses solely on limited to results from the time series of interest to the user,
algorithm alerts. either by system design or by the user’s active specification.
• These algorithms are one-sided tests that monitor only For example, one method of reducing the default alert list
unusually high counts, not low ones. Low counts could is to restrict algorithms to all-age time series groupings.
result from a critical outbreak situation that prevents data Depending on the scope of the user’s responsibility, the
reporting, but there are many more common reasons for alert list may also be restricted according to both
low counts (such as unscheduled closings or system epidemiological interest and the resources available for
problems), so the algorithms do not test for abnormally low investigation. For example, a monitor of a national-level
counts. system with algorithms applied to many facilities may be
• In addition to the data- and disease-specific considerations interested only in alerts with at least 5 to 10 cases. In
below, the algorithm selection was also driven by system circumstances of heightened concern, these restrictions can
considerations. Users need to monitor many types of data be relaxed, or the user can use ESSENCE advanced
rapidly. External covariates, such as climate data or clinic querying methods to apply algorithms to age groups and/or
schedules, may not be available for prompt analysis. Many subsyndromes.
methods in the literature, armed with retrospective data of
a certain type, depend on the analysis of substantial history.

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Individual alerting algorithms implemented in ESSENCE are infections, gastrointestinal infections caused by contaminated
listed and described in Multimedia Appendix 3. food or water, and rarer infections.
Visualization Surveillance systems were particularly helpful in tracking the
Both standard and user-customizable visualizations are available pandemic of the novel H1N1 influenza in 2009 [24]. The
in ESSENCE, many shaped in response to user ideas and pandemic was important as an interregional use of surveillance
requests. Highly configurable and interactive modes of data systems to track a common threat. For example, the National
stratification and filtering, graphical and tabular customization, Capital Region Disease Surveillance Network, comprising
user preference management, and sharing features allow users ESSENCE users at health departments in the District of
to query data and view geographic representations, time series Columbia and parts of the states of Maryland and Virginia,
and data details pages, and reports. Figure 2 shows examples shares population-level disease incidence information to promote
of the standard plots and maps. Multimedia Appendix 4 (Figures interjurisdictional surveillance. In 2009, this network allowed
S1-S4) summarizes key features with explanations and National Capital Region public health practitioners to track the
screenshots of novel visualizations developed for ESSENCE course of the pandemic from the spring through the fall,
to fulfill requests of the user community. comparing the overall and age-specific burden of illness to
national and neighboring state trends. A broader collaboration
Results between ESSENCE and non-ESSENCE system users adopted
a standardized definition of influenza-like illness to enable
Overview of Findings uniform local tracking of the pandemic across the United States
[25].
The results in this section represent a broad range of ESSENCE
applications, especially those not previously published in the Users have applied ESSENCE to form and share queries for
peer-reviewed literature, which demonstrate how ESSENCE indications of other infectious diseases using text from chief
monitors health threats at national, state, and local jurisdictions. complaints, discharge diagnosis, and triage notes when available.
Rather than giving the results of one analytic method applied Infectious threats tracked in published examples include general
to a particular data set, we show the results of the data waterborne diseases [26], tuberculosis [17], rabies [27], and
architecture, analytics, and visualizations described in the Middle East Respiratory Syndrome [15]. In recent years,
previous section for public health objectives achieved by users. concerns over mosquito-borne diseases have generated new
The following sections demonstrate the system simplicity, queries by multiple users and occasionally uncovered important
flexibility, and acceptability, key attributes from published cases [16].
system evaluation guidelines [18]. The examples in these
The health department of Maricopa County, Arizona, presented
sections were chosen to show the breadth and depth of the
an example of the benefits of surveillance systems in June 2018.
application to meet these criteria. For the other attributes, each
The department had added an ESSENCE query for signs of
ESSENCE user has local surveillance objectives and constraints
Rocky Mountain spotted fever, which is not endemic to that
that impose the requirements of performance metrics, such as
county, because of concerns that cases transferred from endemic
sensitivity, positive predictive value, and timeliness. Algorithms
areas might be missed. A child’s patient record was signaled
described in the analytic details supplement were developed to
by the query, and the department contacted the hospital. This
maximize the local sensitivity or positive predictive value
contact led to the reversal of a medication decision that might
tradeoff and other practical metrics.
have been fatal to the child [28].
In addition to the versions used and shared by the US
Such monitoring activities have repeatedly uncovered unreported
surveillance community, the applications below refer to the
cases of diseases for which reporting is mandatory [29]. These
open-source Suite for Automated Global Electronic
findings illustrate the importance of redundancy with systems
bioSurveillance (SAGES) toolkit that ESSENCE developers
such as ESSENCE to avoid missing important cases, even when
have provided for non-US health monitors, including
traditional reporting mandates exist.
OpenESSENCE and ESSENCE Desktop editions [19,20]. On
the basis of the features and functionality of ESSENCE, tools At the submission of this manuscript, the intense collaboration
within SAGES were developed specifically for use in low- and of ESSENCE users is focused on tracking the COVID-19
middle-income countries with limited resources but do not pandemic. General queries on COVID-like illness and specific
include some of the more recent analytics and visualization ones involving pneumonia and specific symptom sets are being
tools requested by users across the NSSP. refined and shared [30].
Infectious Disease Applications Applications for Tracking Burden of Severe Weather
Early applications of ESSENCE focused on the detection of and Natural Disaster Events
infectious disease outbreaks, with much attention paid to Health departments have used ESSENCE for preparedness,
influenza-like illness because it is a prodrome for multiple health burden assessment, and response to severe storms and
naturally occurring diseases and for many potentially other natural disasters. The state of Oregon conducted a
weaponized for bioterrorism [21,22]. Civilian [23], military successful program to mitigate the effects of wildfires [31]. This
[22], and VA [24] ESSENCE users monitored for outbreaks of program featured customized ESSENCE queries with other
seasonal and nonseasonal outbreaks of febrile respiratory coordinated efforts among state and local health departments
and preparedness teams. Among several states that use
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ESSENCE to monitor the effects of hurricanes, the Tennessee Applications for Chronic Disease and Mental Health
Health Department devised queries to determine the volume Surveillance
and clustering of patients in local hospitals because of storms
The use of ESSENCE to monitor risk factors and incidence of
in other states [32]. Effective monitoring of some events requires
chronic disease and mental health disorders has proliferated
a combination of multiple data sources. Following a prolonged
since a DoD ESSENCE study using clinic and prescription data
storm-related power outage, the health department of
to monitor behavioral health in 2004 [41]. The Boulder County,
Seattle-King County, Washington, combined data from the
Colorado Health Department recently implemented and tested
ESSENCE ED data with ambulance calls and public utility data
multiple queries to monitor mental health [42].
to monitor for cases and clusters of carbon monoxide poisoning
and food poisoning [33]. More recently, the Florida Health Addressing ESSENCE utility for chronic diseases in general,
Department monitored carbon monoxide poisoning after the Cook County Illinois health department applied machine
Hurricane Irma in 2017 [34]. Institutions using ESSENCE are learning methods to assess the utility of ESSENCE ED data for
increasingly incorporating environmental and other data sources monitoring cardiovascular disease, acute myocardial infarction,
in their systems for richer situational awareness of acute coronary syndrome, stable angina, stroke, diabetes,
disaster-related health threats [35,36]. hypertension, asthma, and chronic obstructive pulmonary
disease. From correlational validation testing based on 8 full
Applications for Mass Gathering Surveillance years of chief complaint text and electronic medical record data,
Scheduled mass gathering events such as political conventions they concluded that ESSENCE data are suitable for monitoring
and major athletic competitions concern population health all these conditions except stable angina and hypertension “at
monitors because (1) such events are bioterrorism opportunities local, state, or national levels” [43]. The Nebraska State Health
to harm many victims and gain media attention, (2) infections Department has used ESSENCE to monitor for cardiovascular
through contaminated food or water could spread rapidly disease for several years, and the Florida State Department
through the expanded population, (3) those visiting for several similarly monitors acute myocardial infarction incidence [44].
days could import infections or take them back to their own
cities, and (4) a surge of patients could overwhelm local care Applications for Injury and Substance Abuse
provider resources. Adequate preparedness and response require Surveillance
coordination across jurisdictional boundaries, but privacy laws An unexpected but arguably the most helpful benefit of
often restrict patient-level data sharing. ESSENCE syndrome ESSENCE to health department users is to facilitate
definitions and queries have been customized for many such communication and collaboration among agency divisions. An
events. In 2007, Marion County, Indiana, and Cook County, important example in the context of the ongoing opioid overdose
Illinois, were home counties for the competing teams in Super crisis has been the strengthening of connections between
Bowl XLI, and the game was hosted in Miami-Dade, Florida. syndromic surveillance specialists and groups specializing in
The health departments of these geographically distant counties injury prevention, behavioral health, and drug abuse.
were ESSENCE users, and customization of their systems for Adaptations of ESSENCE included queries for both prescription
the days surrounding the event helped coordinate surveillance and illicit drug types and overdose cluster detection to help
despite only 2 weeks’ notice after the teams were determined inform public health response tactics, such as needle exchange
[37]. and naloxone distribution.
A partnership between the Florida Department of Health and Multiple health departments have applied ESSENCE to gain
the US HHS Office of the Assistant Secretary for Preparedness awareness of the locations and subpopulations at risk of injuries
and Response to improve the response of Disaster Medical from falls [45]. The Boston Public Health Commission in
Assistance Teams produced a new ESSENCE module that was Massachusetts used it to monitor for hearing loss, acute
deployed for health monitoring of the 2012 Republican National depression, and explosion-related injuries in the aftermath of
Convention in Tampa [36]. State and county health departments the 2013 Boston Marathon bombing and subsequent manhunt.
used ESSENCE for coordinated monitoring of crowds at the The St Louis Missouri Health Department established ESSENCE
US Olympic Trials in July 2016 [38]. In January 2017, the queries for injuries indicative of bomb-making activities [46].
Washington DC Department of Health used ESSENCE queries
Monitoring for substance abuse is common among ESSENCE
along with other data sources for health surveillance at the 58th
users. The Tri-County Health Department in Colorado uses its
US presidential inauguration [39].
system to investigate the adverse effects of marijuana use [47].
For monitoring of events outside the United States, JHU/APL The Florida State Department queries for ED visits resulting
developed the SAGES system, the open-source version of from synthetic marijuana [48] and for novel street drugs, such
ESSENCE designed for global resource-limited settings, in as Flakka, as they become known public health problems [49].
2014 to monitor the 8th Micronesian Games held in Federated Recently, the opioid crisis has stimulated intense collaboration,
States of Micronesia, Pohnpei, and the 3rd International including shared syndrome definitions and analytic case-finding
Conference on Small Island Developing States in Apia, Samoa tools among geographically scattered institutions using
[40]. ESSENCE [50-52].
The ongoing adaptation of ESSENCE to meet the needs of the
understaffed public health practice community has provided a
means to share methods and information, although data are
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often not shareable. The common analytic platform has enabled practices, and epidemiological concerns. Typically, users cannot
an evolving user ecosystem of multiple working groups, and wait for several minutes for data retrieval and time-consuming
the US CDC currently hosts the NSSP Community of Practice, model runs. Alerting algorithms applied prospectively to detect
with subgroups including Syndrome Definition, Data Quality, disparate events in a wide variety of data types cannot match
and Technical Committees [53]. The Syndrome Definitions the detection performance of models developed retrospectively
committee promotes the analysis of common queries among using historical data sets labeled with target events for a
geographically scattered user sites and the US CDC [54], thus particular syndrome. The ESSENCE algorithm baselines do not
improving communication between local and national health span years, not only for storage and computational reasons but
monitors. Epidemiologists, system designers, and other also because for many users’ desired data types, stable data or
stakeholders may find and share resources on committee any data are available only within the past year. Hence,
websites and through the NSSP Knowledge Repository [30]. A ESSENCE alerting algorithms, adapted from published
primary example is the opioid overdose crisis, a noninfectious applications of models and control charts in health care settings
threat. In addition to analytics and visualizations to support the [55-57], use rolling baselines of weeks rather than years.
activities related to this crisis, developers and users have worked
together to acquire additional data sources, such as emergency
Facilitating Communication
medical incidents, poison center calls, and death records, to Multiple ESSENCE users have remarked that one of the
determine the benefit of fusing information varying in specificity system’s main benefits has been to facilitate communication
and timeliness into a common surveillance picture to better with other divisions within a health department, with external
inform awareness and interventions. local and federal agencies, and with care facilities that provide
data and can benefit from the broader geographic perspective
Regarding data standards that are essential among the many that a surveillance system enables. Hence, substantial ESSENCE
NSSP stakeholders, Multimedia Appendix 2 refers to the development has occurred in response to user requests for
reference tables and business logic to convert data field entries custom analysis comparisons, visualizations, and report formats,
into categorical values from standard sources such as the Public allowing overburdened users to concentrate on the task of
Health Information Network Vocabulary Access and routine health monitoring. In situations where data sharing is
Distribution System and from evolving standards developed by precluded by county or state regulations, ESSENCE
NSSP Data Sharing and Syndrome Definitions workgroups. communication tools have enabled information sharing. The
sharing and query-building tools in the visualization section
Discussion have been increasingly used to enhance collaboration among
NSSP subcommittees as well as individual users.
Principal Findings
In the Results section, the multiple applications of ESSENCE Multiple Analysis Modes
installations by health departments at various levels and the The applicability of individual analysis modes, such as
surveillance community initiatives enabled and expedited by univariate and multivariate time series monitoring,
the system illustrate the combined effect of the technical spatiotemporal cluster detection, and single case identification
components described in the Methods section and developed all depend on the nature and quality of available data. For
over 20 years, driven by the major influence of public health example, the spatial scan statistic implemented in ESSENCE
users. The following sections describe the lessons learned, key can avoid issues of jurisdictional boundaries, but only if data
innovations, and user-driven enhancements. location fields are present and reliably represented in the data.
In many data sources, the limitation of location fields to zip
Lessons Learned
codes or postal codes restricts the geographic precision of
Several principles have driven the success of ESSENCE since clusters of interest. Health monitors generally require multiple
its origins in the late 1990s. methods to analyze population health data. A notable example
Versatility is that ESSENCE users in multiple health departments have
discovered unreported cases of reportable disease that traditional
Users have valued the configurability and adaptability of sentinel surveillance is mandated to communicate to public
ESSENCE. Default categorization of complex data into health. The various analysis modes of ESSENCE provide
syndromic groupings has always been valuable to users who affordable and sometimes beneficial redundancy and safety net
are inexperienced or who do not have the time to formulate or functionality.
validate their own categories for monitoring. Conversely, health
departments with greater analysis capacity have long demanded The following list summarizes these lessons for developers of
surveillance systems that allow them to create their own other systems:
categories to track, and ESSENCE customization with • Accommodation for a variety of processing systems and
query-building features using both diagnosis codes and free text data types, flow, and format.
has grown along with the sophistication and broadening needs • Features facilitating shareable ad hoc queries and reports
of health department users. Precomputed, canned analysis to investigate novel concerns.
products are not found in ESSENCE. However, versatility • A suite of analytic tools allowing multiple looks at available
presents challenges to database design and to the selection and data, tools that provide prompt feedback and do not require
adaptation of statistical analysis tools. Surveillance data evolve years of data history.
with institutional information systems and formats, coding
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• Provision of default views as well as tools to modify and categories of patients who use health care systems that provide
arrange them as desired while avoiding canned or data to ESSENCE. These tools can show patient-level usage
precomputed visualizations. trends to inform the allocation of health care resources in a
• Integrated collaboration features and user events to foster community.
direct community involvement in system evolution.
Conclusions
Innovation Installations of ESSENCE have provided systems capable of
The development of ESSENCE has produced novel features in meeting public health surveillance requirements at multiple
areas of complex, disparate data management, analytical levels of purview and jurisdiction. The data architecture runs
methods, and the enhancement of user reporting and on modular configurations of a variable number of servers, with
collaboration, interrelated efforts to empower health monitors. the number contingent on the data volume, number of active
The data management advances include architecture and data users, and frequency of required analysis operations; hence, the
transfer capabilities to meet the needs of institutions with ESSENCE data architecture accommodates the acquisition and
varying resources. Analytics advances require data quality transfer processes of small and very large health departments.
examination methods and alerting algorithms appropriate for Essential to the growth of ESSENCE has been the capability
diverse data time series that meet rapid response needs and do provided to the user community to drive system development
not require more than a few months of data history. User to meet its evolving needs. Users are provided with multiple
experience enhancements include customizable visualization syndrome and subsyndrome categories but are not limited by
and reporting features that provide unique time- and them or by canned or precomputed visualizations. Tools are
resource-saving capabilities. provided to build simple or arbitrarily complex queries and
dashboards for routine monitoring. The rich set of analytic
User-Driven Enhancements methods includes alerting algorithms and other tracking tools
Recent ESSENCE projects have produced a variety of user applicable to sparse or rich data streams, with adjustment for
capability enhancements. For sharing information within and only the most common data issues. These tools require historical
across jurisdictions, web-based features allow users to share baseline data of at most a few months, both accommodating
what they are doing within ESSENCE with peers and to see limited historical data and providing fast turnaround for
what others are querying and find interesting. Text analysis and understaffed public health monitors. Although these algorithms
visualizations facilitate the creation of ad hoc local free-text cannot be tuned to particular syndromic categories or health
queries. These features provide correlation, trend, and events as in retrospective studies, they are designed for a range
association analytics to help the user determine what terms or of common data types and behaviors. Current data missingness
phrases should or should not be included in queries. and lateness indicators are also provided to help users assess
Back-end tools and checks with visualizations allow the user the reliability of the visualizations and statistics that they view.
to closely monitor the local ESSENCE system for data issues Finally, ESSENCE provides a growing suite of communications
and irregularities. These administrative capabilities help capabilities for customizable reporting, sharing, and convenient
managers and users maintain day-to-day system availability download for additional analytics. These combined features
and improve the visibility of issues that may develop over time. have streamlined onboarding, promoted methods and
information sharing among the public health community, and
Recently added visualizations and cohort clustering analytic enabled the diverse, all-hazards applications described earlier.
tools for longitudinal assessment allow users to determine

Acknowledgments
The authors would like to acknowledge the invaluable assistance provided by their colleagues and partners. The continued
ESSENCE research and development would not have been possible without the support of the CDC, DoD, VA, numerous state
and local health departments, and JHU/APL over the last 20 years. The authors especially acknowledge the numerous champions
and advisors among ESSENCE users who have dedicated time and effort to the betterment of public health surveillance.

Conflicts of Interest
None declared.

Multimedia Appendix 1
The Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE) history highlights.
[DOC File , 36 KB-Multimedia Appendix 1]

Multimedia Appendix 2
The Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE) data architecture,
security, and preprocessing.
[DOC File , 85 KB-Multimedia Appendix 2]

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Multimedia Appendix 3
Principles and details of The Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE)
alerting algorithms.
[DOC File , 257 KB-Multimedia Appendix 3]

Multimedia Appendix 4
Visualization tools in the Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE).
[DOC File , 714 KB-Multimedia Appendix 4]

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Abbreviations
CCP: Chief Complaint Processor
CDC: Centers for Disease Control and Prevention
DoD: Department of Defense
ED: emergency department
ESSENCE: Electronic Surveillance System for the Early Notification of Community-Based Epidemics
JHU/APL: Johns Hopkins University Applied Physics Laboratory
NSSP: National Syndromic Surveillance Program
OTC: over-the-counter
SAGES: Suite for Automated Global Electronic bioSurveillance
VA: Veterans Administration
WRAIR: Walter Reed Army Institute for Research

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Edited by T Sanchez; submitted 09.12.20; peer-reviewed by C Staes, B Dixon; comments to author 20.01.21; revised version received
17.03.21; accepted 12.04.21; published 21.06.21
Please cite as:
Burkom H, Loschen W, Wojcik R, Holtry R, Punjabi M, Siwek M, Lewis S
Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE): Overview, Components, and
Public Health Applications
JMIR Public Health Surveill 2021;7(6):e26303
URL: https://publichealth.jmir.org/2021/6/e26303
doi: 10.2196/26303
PMID:

©Howard Burkom, Wayne Loschen, Richard Wojcik, Rekha Holtry, Monika Punjabi, Martina Siwek, Sheri Lewis. Originally
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