The Karma system is currently undergoing maintenance (Monday, January 29, 2018).
The maintenance period has been extended to 8PM EST.

Karma Credits will not be available for redeeming during maintenance.

JMIR Public Health and Surveillance

A multidisciplinary journal that focuses on the intersection of public health and technology, public health informatics, mass media campaigns, surveillance, participatory epidemiology, and innovation in public health practice and research.


Journal Description

JMIR Public Health & Surveillance (JPHS, Editor-in-chief: Travis Sanchez, Emory University/Rollins School of Public Health) is a PubMed-indexed, peer-reviewed sister journal of the Journal of Medical Internet Research (JMIR), the top cited journal in health informatics (Impact Factor 2016: 5.175). JPH is a multidisciplinary journal with a unique focus on the intersection of innovation and technology in public health, and includes topics like health communication, public health informatics, surveillance, participatory epidemiology, infodemiology and infoveillance, digital disease detection, digital public health interventions, mass media/social media campaigns, and emerging population health analysis systems and tools. 

We publish regular articles, reviews, protocols/system descriptions and viewpoint papers on all aspects of public health, with a focus on innovation and technology in public health.

Apart from publishing traditional public health research and viewpoint papers as well as reports from traditional surveillance systems, JPH was one of the first (if not the only) peer-reviewed journal which publishes papers with surveillance or pharmacovigilance data from non-traditional, unstructured big data and text sources such as social media and the Internet (infoveillance, digital disease detection), or reports on novel participatory epidemiology projects, where observations are solicited from the public.  

Among other innovations, JPH is also dedicated to support rapid open data sharing and rapid open access to surveillance and outbreak data. As one of the novel features we plan to publish rapid or even real-time surveillance reports and open data. The methods and description of the surveillance system may be peer-reviewed and published only once in detail, in a  "baseline report" (in a JMIR Res Protoc or a JMIR Public Health & Surveill paper), and authors then have the possibility to publish data and reports in frequent intervals rapidly and with only minimal additional peer-review (we call this article type "Rapid Surveillance Reports"). JMIR Publications may even work with authors/researchers and developers of selected surveillance systems on APIs for semi-automated reports (e.g. weekly reports to be automatically published in JPHS and indexed in PubMed, based on data-feeds from surveillance systems and minmal narratives and abstracts).

Furthermore, duing epidemics and public health emergencies, submissions with critical data will be processed with expedited peer-review to enable publication within days or even in real-time.

We also publish descriptions of open data resources and open source software. Where possible, we can and want to publish or even host the actual software or dataset on the journal website.


Recent Articles:

  • Source:; Copyright: US Navy (Marie Montez); URL:; License: Public Domain (CC0).

    Opportunities for Enhanced Strategic Use of Surveys, Medical Records, and Program Data for HIV Surveillance of Key Populations: Scoping Review


    Background: Normative guidelines from the World Health Organization recommend tracking strategic information indicators among key populations. Monitoring progress in the global response to the HIV epidemic uses indicators put forward by the Joint United Nations Programme on HIV/AIDS. These include the 90-90-90 targets that require a realignment of surveillance data, routinely collected program data, and medical record data, which historically have developed separately. Objective: The aim of this study was to describe current challenges for monitoring HIV-related strategic information indicators among key populations ((men who have sex with men [MSM], people in prisons and other closed settings, people who inject drugs, sex workers, and transgender people) and identify future opportunities to enhance the use of surveillance data, programmatic data, and medical record data to describe the HIV epidemic among key populations and measure the coverage of HIV prevention, care, and treatment programs. Methods: To provide a historical perspective, we completed a scoping review of the expansion of HIV surveillance among key populations over the past three decades. To describe current efforts, we conducted a review of the literature to identify published examples of SI indicator estimates among key populations. To describe anticipated challenges and future opportunities to improve measurement of strategic information indicators, particularly from routine program and health data, we consulted participants of the Third Global HIV Surveillance Meeting in Bangkok, where the 2015 World Health Organization strategic information guidelines were launched. Results: There remains suboptimal alignment of surveillance and programmatic data, as well as routinely collected medical records to facilitate the reporting of the 90-90-90 indicators for HIV among key populations. Studies (n=3) with estimates of all three 90-90-90 indicators rely on cross-sectional survey data. Programmatic data and medical record data continue to be insufficiently robust to provide estimates of the 90-90-90 targets for key populations. Conclusions: Current reliance on more active data collection processes, including key population-specific surveys, remains warranted until the quality and validity of passively collected routine program and medical record data for key populations is optimized.

  • HIV-prevention seminar with Sub Saharan African migrants in Spain (2007). Source: Image created by the authors; Copyright: The authors; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Overcoming Barriers to HIV Prevention and Healthcare Among Sub-Saharan African Migrants in Spain


  • Source: Nellis Air Force Base (Jake Carter); Copyright: US Air Force; URL:; License: Public Domain (CC0).

    Causality Patterns for Detecting Adverse Drug Reactions From Social Media: Text Mining Approach


    Background: Detecting adverse drug reactions (ADRs) is an important task that has direct implications for the use of that drug. If we can detect previously unknown ADRs as quickly as possible, then this information can be provided to the regulators, pharmaceutical companies, and health care organizations, thereby potentially reducing drug-related morbidity and saving lives of many patients. A promising approach for detecting ADRs is to use social media platforms such as Twitter and Facebook. A high level of correlation between a drug name and an event may be an indication of a potential adverse reaction associated with that drug. Although numerous association measures have been proposed by the signal detection community for identifying ADRs, these measures are limited in that they detect correlations but often ignore causality. Objective: This study aimed to propose a causality measure that can detect an adverse reaction that is caused by a drug rather than merely being a correlated signal. Methods: To the best of our knowledge, this was the first causality-sensitive approach for detecting ADRs from social media. Specifically, the relationship between a drug and an event was represented using a set of automatically extracted lexical patterns. We then learned the weights for the extracted lexical patterns that indicate their reliability for expressing an adverse reaction of a given drug. Results: Our proposed method obtains an ADR detection accuracy of 74% on a large-scale manually annotated dataset of tweets, covering a standard set of drugs and adverse reactions. Conclusions: By using lexical patterns, we can accurately detect the causality between drugs and adverse reaction–related events.

  • Source: Freepik; Copyright: Freepik; URL:; License: Licensed by JMIR.

    The Acceptability and Feasibility of Implementing a Bio-Behavioral Enhanced Surveillance Tool for Sexually Transmitted Infections in England: Mixed-Methods...


    Background: Sexually transmitted infection (STI) surveillance is vital for tracking the scale and pattern of epidemics; however, it often lacks data on the underlying drivers of STIs. Objective: This study aimed to assess the acceptability and feasibility of implementing a bio-behavioral enhanced surveillance tool, comprising a self-administered Web-based survey among sexual health clinic attendees, as well as linking this to their electronic health records (EHR) held in England’s national STI surveillance system. Methods: Staff from 19 purposively selected sexual health clinics across England and men who have sex with men and black Caribbeans, because of high STI burden among these groups, were interviewed to assess the acceptability of the proposed bio-behavioral enhanced surveillance tool. Subsequently, sexual health clinic staff invited all attendees to complete a Web-based survey on drivers of STI risk using a study tablet or participants’ own digital device. They recorded the number of attendees invited and participants’ clinic numbers, which were used to link survey data to the EHR. Participants’ online consent was obtained, separately for survey participation and linkage. In postimplementation phase, sexual health clinic staff were reinterviewed to assess the feasibility of implementing the bio-behavioral enhanced surveillance tool. Acceptability and feasibility of implementing the bio-behavioral enhanced surveillance tool were assessed by analyzing these qualitative and quantitative data. Results: Prior to implementation of the bio-behavioral enhanced surveillance tool, sexual health clinic staff and attendees emphasized the importance of free internet/Wi-Fi access, confidentiality, and anonymity for increasing the acceptability of the bio-behavioral enhanced surveillance tool among attendees. Implementation of the bio-behavioral enhanced surveillance tool across sexual health clinics varied considerably and was influenced by sexual health clinics’ culture of prioritization of research and innovation and availability of resources for implementing the surveys. Of the 7367 attendees invited, 85.28% (6283) agreed to participate. Of these, 72.97% (4585/6283) consented to participate in the survey, and 70.62% (4437/6283) were eligible and completed it. Of these, 91.19% (4046/4437) consented to EHR linkage, which did not differ by age or gender but was higher among gay/bisexual men than heterosexual men (95.50%, 722/756 vs 88.31%, 1073/1215; P<.003) and lower among black Caribbeans than white participants (87.25%, 568/651 vs 93.89%, 2181/2323; P<.002). Linkage was achieved for 88.88% (3596/4046) of consenting participants. Conclusions: Implementing a bio-behavioral enhanced surveillance tool in sexual health clinics was feasible and acceptable to staff and groups at STI risk; however, ensuring participants’ confidentiality and anonymity and availability of resources is vital. Bio-behavioral enhanced surveillance tools could enable timely collection of detailed behavioral data for effective commissioning of sexual health services.

  • Source: Wikimedia Commons; Copyright: Holland Kati; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Trends in HIV Terminology: Text Mining and Data Visualization Assessment of International AIDS Conference Abstracts Over 25 Years


    Background: The language encompassing health conditions can also influence behaviors that affect health outcomes. Few published quantitative studies have been conducted that evaluate HIV-related terminology changes over time. To expand this research, this study included an analysis of a dataset of abstracts presented at the International AIDS Conference (IAC) from 1989 to 2014. These abstracts reflect the global response to HIV over 25 years. Two powerful methodologies were used to evaluate the dataset: text mining to convert the unstructured information into structured data for analysis and data visualization to represent the data visually to assess trends. Objective: The purpose of this project was to evaluate the evolving use of HIV-related language in abstracts presented at the IAC from 1989 to 2014. Methods: Over 80,000 abstracts were obtained from the International AIDS Society and imported into a Microsoft SQL Server database for data processing and text mining analyses. A text mining module within the KNIME Analytics Platform, an open source software, was then used to mine the partially processed data to create a terminology corpus of key HIV terms. Subject matter experts grouped the terms into categories. Tableau, a data visualization software, was used to visualize the frequency metrics associated with the terms as line graphs and word clouds. The visualized dashboards were reviewed to discern changes in terminology use across IAC years. Results: The major findings identify trends in HIV-related terminology over 25 years. The term “AIDS epidemic” was dominantly used from 1989 to 1991 and then declined in use. In contrast, use of the term “HIV epidemic” increased through 2014. Beginning in the mid-1990s, the term “treatment experienced” appeared with increasing frequency in the abstracts. Use of terms identifying individuals as “carriers or victims” of HIV rarely appeared after 2008. Use of the terms “HIV positive” and “HIV infected” peaked in the early-1990s and then declined in use. The terms “men who have sex with men” and “MSM” were rarely used until 1994; subsequently, use of these terms increased through 2014. The term “sex worker” steadily increased in frequency throughout conference years, whereas the term “prostitute” decreased over time. Conclusions: The results of this study highlight changes in HIV terminology use over 25 years, including the addition, disappearance, and changing use of terms that reflect advances in HIV research and medical practice and destigmatization of the disease. Coupled with findings from related quantitative research, HIV-related terminology recommendations based on results of this study are included. Adoption of these recommendations will further efforts to use less stigmatizing language and facilitate effective communication between health professionals and people affected by HIV.

  • Untitled. Source: Wikicommons; Copyright: Victor Grigas; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Recommendations for the Development of a Mobile HIV Prevention Intervention for Men Who Have Sex With Men and Hijras in Mumbai: Qualitative Study


    Background: As Internet and mobile phone use expands in India, there is an opportunity to develop mobile health (mHealth) interventions for marginalized populations, including men who have sex with men (MSM) and hijras (transgender women), hesitant to access traditional health care systems. Objective: The purpose of this study was to determine if an mHealth intervention was acceptable to MSM and hijras living in Mumbai, and if so, what features would be useful in targeting the prevention of HIV acquisition and to increase the quality of life among persons living with HIV/AIDS. Methods: Data from 4 focus groups with MSM and interviews with 4 hijras, 10 health service providers, and 8 mHealth developers were thematically analyzed. Results: Once the need for an mHealth intervention was confirmed, comments about features were organized into 3 themes: content, interface, and retention. Content subthemes included providing sex education for younger community members, providing information about STIs, and providing information and social support for persons living with HIV. Interface subthemes included presenting content using pictures; using videos to present stories of role models; using push notifications for testing, appointment, and medication reminders; using geolocation to link to just-in-time services; and using telemedicine to increase access to health service providers and community services. The 5 retention subthemes included keeping it fun, using gaming mechanics, developing content in regional languages, protecting confidentiality, and linking to social networking apps. Conclusions: These findings may help inform mHealth development in India.

  • The visualized female breast cancer survival proportions by senatorial district in Missouri. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Improving Visualization of Female Breast Cancer Survival Estimates: Analysis Using Interactive Mapping Reports


    Background: The Missouri Cancer Registry collects population-based cancer incidence data on Missouri residents diagnosed with reportable malignant neoplasms. The Missouri Cancer Registry wanted to produce data that would be of interest to lawmakers as well as public health officials at the legislative district level on breast cancer, the most common non-skin cancer among females. Objective: The aim was to measure and interactively visualize survival data of female breast cancer cases in the Missouri Cancer Registry. Methods: Female breast cancer data were linked to Missouri death records and the Social Security Death Index. Unlinked female breast cancer cases were crossmatched to the National Death Index. Female breast cancer cases in subcounty senate districts were geocoded using TIGER/Line shapefiles to identify their district. A database was created and analyzed in SEER*Stat. Senatorial district maps were created using US Census Bureau’s cartographic boundary files. The results were loaded with the cartographic data into InstantAtlas software to produce interactive mapping reports. Results: Female breast cancer survival profiles of 5-year cause-specific survival percentages and 95% confidence intervals, displayed in tables and interactive maps, were created for all 34 senatorial districts. The maps visualized survival data by age, race, stage, and grade at diagnosis for the period from 2004 through 2010. Conclusions: Linking cancer registry data to the National Death Index database improved accuracy of female breast cancer survival data in Missouri and this could positively impact cancer research and policy. The created survival mapping report could be very informative and usable by public health professionals, policy makers, at-risk women, and the public.

  • Source: Flickr; Copyright: National Museum of the US Navy; URL:; License: Public Domain (CC0).

    Monitoring Interest in Herpes Zoster Vaccination: Analysis of Google Search Data


    Background: A new recombinant subunit vaccine for herpes zoster (HZ or shingles) was approved by the United States Food and Drug Administration on October 20, 2017 and is expected to replace the previous live attenuated vaccine. There have been low coverage rates with the live attenuated vaccine (Zostavax), ranging from 12-32% of eligible patients receiving the HZ vaccine. Objective: This study aimed to provide insight into trends and potential reasons for interest in HZ vaccination. Methods: Internet search data were queried from the Google Health application programming interface from 2004-2017. Seasonality of normalized search volume was analyzed using wavelets and Fisher’s g test. Results: The search terms “shingles vaccine,” “zoster vaccine,” and “zostavax” all exhibited significant periodicity in the fall months (P<.001), with sharp increases after recommendations for vaccination by public health-related organizations. Although the terms “shingles blisters,” “shingles itch,” “shingles rash,” “skin rash,” and “shingles medicine” exhibited statistically significant periodicities with a seasonal peak in the summer (P<.001), the terms “shingles contagious,” “shingles pain,” “shingles treatment,” and “shingles symptoms” did not reveal an annual trend. Conclusions: There may be increased interest in HZ vaccination during the fall and after public health organization recommendations are broadcast. This finding points to the possibility that increased awareness of the vaccine through public health announcements could be evaluated as a potential intervention for increasing vaccine coverage.

  • Source: Pixabay; Copyright: 510318; URL:; License: Public Domain (CC0).

    Studying Cannabis Use Behaviors With Facebook and Web Surveys: Methods and Insights


    The rapid and wide-reaching expansion of internet access and digital technologies offers epidemiologists numerous opportunities to study health behaviors. One particularly promising new data collection strategy is the use of Facebook’s advertising platform in conjunction with Web-based surveys. Our research team at the Center for Technology and Behavioral Health has used this quick and cost-efficient method to recruit large samples and address unique scientific questions related to cannabis use. In conducting this research, we have gleaned several insights for using this sampling method effectively and have begun to document the characteristics of the resulting data. We believe this information could be useful to other researchers attempting to study cannabis use or, potentially, other health behaviors. The first aim of this paper is to describe case examples of procedures for using Facebook as a survey sampling method for studying cannabis use. We then present several distinctive features of the data produced using this method. Finally, we discuss the utility of this sampling method for addressing specific types of epidemiological research questions. Overall, we believe that sampling with Facebook advertisements and Web surveys is best conceptualized as a targeted, nonprobability-based method for oversampling cannabis users across the United States.

  • Source: Flickr; Copyright: Ryan Boren; URL:; License: Creative Commons Attribution (CC-BY).

    Incidence of Lower Respiratory Tract Infections and Atopic Conditions in Boys and Young Male Adults: Royal College of General Practitioners Research and...


    Background: The Royal College of General Practitioners Research and Surveillance Centre comprises more than 150 general practices, with a combined population of more than 1.5 million, contributing to UK and European public health surveillance and research. Objective: The aim of this paper was to report gender differences in the presentation of infectious and respiratory conditions in children and young adults. Methods: Disease incidence data were used to test the hypothesis that boys up to puberty present more with lower respiratory tract infection (LRTI) and asthma. Incidence rates were reported for infectious conditions in children and young adults by gender. We controlled for ethnicity, deprivation, and consultation rates. We report odds ratios (OR) with 95% CI, P values, and probability of presenting. Results: Boys presented more with LRTI, largely due to acute bronchitis. The OR of males consulting was greater across the youngest 3 age bands (OR 1.59, 95% CI 1.35-1.87; OR 1.13, 95% CI 1.05-1.21; OR 1.20, 95% CI 1.09-1.32). Allergic rhinitis and asthma had a higher OR of presenting in boys aged 5 to 14 years (OR 1.52, 95% CI 1.37-1.68; OR 1.31, 95% CI 1.17-1.48). Upper respiratory tract infection (URTI) and urinary tract infection (UTI) had lower odds of presenting in boys, especially those older than 15 years. The probability of presenting showed different patterns for LRTI, URTI, and atopic conditions. Conclusions: Boys younger than 15 years have greater odds of presenting with LRTI and atopic conditions, whereas girls may present more with URTI and UTI. These differences may provide insights into disease mechanisms and for health service planning.

  • Man using the AllyQuest app. Source: The Authors / Unsplash; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    A Gamified Smartphone App to Support Engagement in Care and Medication Adherence for HIV-Positive Young Men Who Have Sex With Men (AllyQuest): Development...


    Background: HIV disproportionately impacts young men who have sex with men (YMSM) who experience disparities across the HIV care continuum. Addressing antiretroviral therapy (ART) adherence among YMSM is an urgent public health priority. Technology-based interventions—particularly mobile health platforms—can provide tailored adherence interventions and allow YMSM to engage and connect with others. Objective: The objective of this study was to describe the development of AllyQuest, a novel, theoretically-based, smartphone app designed to improve engagement in care and ART adherence and social support among HIV-positive YMSM. Methods: AllyQuest was built on an established platform for patient engagement that embeds social networking and fundamental game mechanics, such as challenges, points, and rewards. A medication tracker provides reminders to promote ART adherence via personalized adherence strategies that are user and context specific; a calendar allows for reflection on adherence over time. After iterative development with input from two youth advisory boards, usability testing was conducted to assess app functionality, comprehension of the educational content, use of intervention features, and overall impressions of app relevance and appeal. A 28-day pilot trial was conducted with 20 HIV+ YMSM to evaluate intervention feasibility and acceptability. Results: Mean age of participants was 21.8 years (range 19-24), and 95% (19/20) of the participants were nonwhite. The mean time of app use was 158.4 min (SD 114.1), with a range of 13 to 441 min. There was a mean of 21.2 days of use (out of a total possible 28 days). There were 222 posts to the daily discussion social wall. Feasibility and acceptability ratings were high. Overall, participants found the app easy to use and navigate, not intrusive, and had few reported technical issues. Higher levels of app usage were positively correlated with HIV self-management outcomes, and there was a statistically significant (P<.05) positive association between the number of days logged into the app and knowledge and confidence in ability to reliably take HIV medications. Conclusions: AllyQuest represents a new, highly scalable solution that is well-suited to meet the specific prevention and care needs of HIV+ YMSM. The development of this intervention is both timely and vital, given the urgency of the ongoing HIV epidemic among YMSM.

  • Weekly relative search volume from Google Trends for the term "morcellation" (montage). Source: The Authors / / Google; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Public Awareness of Uterine Power Morcellation Through US Food and Drug Administration Communications: Analysis of Google Trends Search Term Patterns


    Background: Uterine power morcellation, where the uterus is shred into smaller pieces, is a widely used technique for removal of uterine specimens in patients undergoing minimally invasive abdominal hysterectomy or myomectomy. Complications related to power morcellation of uterine specimens led to US Food and Drug Administration (FDA) communications in 2014 ultimately recommending against the use of power morcellation for women undergoing minimally invasive hysterectomy. Subsequently, practitioners drastically decreased the use of morcellation. Objective: We aimed to determine the effect of increased patient awareness on the decrease in use of the morcellator. Google Trends is a public tool that provides data on temporal patterns of search terms, and we correlated this data with the timing of the FDA communication. Methods: Weekly relative search volume (RSV) was obtained from Google Trends using the term “morcellation.” Higher RSV corresponds to increases in weekly search volume. Search volumes were divided into 3 groups: the 2 years prior to the FDA communication, a 1-year period following, and thereafter, with the distribution of the weekly RSV over the 3 periods tested using 1-way analysis of variance. Additionally, we analyzed the total number of websites containing the term “morcellation” over this time. Results: The mean RSV prior to the FDA communication was 12.0 (SD 15.8), with the RSV being 60.3 (SD 24.7) in the 1-year after and 19.3 (SD 5.2) thereafter (P<.001). The mean number of webpages containing the term “morcellation” in 2011 was 10,800, rising to 18,800 during 2014 and 36,200 in 2017. Conclusions: Google search activity about morcellation of uterine specimens increased significantly after the FDA communications. This trend indicates an increased public awareness regarding morcellation and its complications. More extensive preoperative counseling and alteration of surgical technique and clinician practice may be necessary.

Citing this Article

Right click to copy or hit: ctrl+c (cmd+c on mac)

Latest Submissions Open for Peer-Review:

View All Open Peer Review Articles
  • Approaches to improve the surveillance, monitoring, and management of noncommunicable diseases among HIV-infected persons

    Date Submitted: May 7, 2018

    Open Peer Review Period: May 23, 2018 - Jun 6, 2018

    Low- and middle-income countries (LIMCs) are undergoing an ‘epidemiological transition’, in which the burden of non-communicable diseases (NCDs) is rising and mortality will shift from infectious...

    Low- and middle-income countries (LIMCs) are undergoing an ‘epidemiological transition’, in which the burden of non-communicable diseases (NCDs) is rising and mortality will shift from infectious diseases to NCDs. Specifically, cardiovascular disease, diabetes, renal diseases, chronic respiratory diseases, and cancer are becoming more prevalent. In some regions, particularly sub-Saharan Africa, the dual HIV and NCD epidemics will pose challenges as joint burden will have adverse effects on quality of life and will likely increase global inequities. Given the austere clinical infrastructure in many LMICs, innovative models of care delivery are needed to provide comprehensive care in resource-limited settings. Improved data collection and surveillance of NCDs among HIV-infected persons in LMICs are necessary to inform integrated NCD-HIV prevention, care, and treatment models that are effective across a range of geographic settings. These efforts will preserve the considerable investments that have been made to prevent lives lost to HIV, promote healthy aging of PLHIV, and contribute to meeting United Nations Sustainable Development Goals.

  • Piloting and Evaluation of Text-Based Illness Monitoring for Detection of Novel Influenza A Virus Infections during an Influenza A(H3N2)v Virus Outbreak in Michigan, 2016

    Date Submitted: May 11, 2018

    Open Peer Review Period: May 21, 2018 - Jun 4, 2018

    Background: Rapid reporting of human infections with novel influenza A viruses accelerates detection of viruses with pandemic potential and implementation of effective public health responses. After d...

    Background: Rapid reporting of human infections with novel influenza A viruses accelerates detection of viruses with pandemic potential and implementation of effective public health responses. After detection of human infections with influenza A(H3N2) variant viruses (“H3N2v”) associated with agricultural fairs during August of 2016, the Michigan Department of Health and Human Services worked with Centers for Disease Control and Prevention (CDC) to identify infections with variant influenza viruses using a text-based illness monitoring system. Objective: To enhance detections of influenza infections using text-based monitoring and evaluate the feasibility and acceptability of the system for use in future outbreaks of novel influenza viruses. Methods: During an outbreak of H3N2v virus infections among agricultural fair attendees, we deployed text-illness monitoring (TIM) to conduct active illness surveillance among households of youth who exhibited swine at fairs. We selected fairs with suspected H3N2v virus infections and fairs without suspect infections that met predefined criteria. Eligible respondents were identified and recruited through email outreach and/or on-site meetings at fairs. During and for 10 days after selected fairs, enrolled households received daily, automated text-messages inquiring about illness; reports of illness were investigated by local health departments. To understand the feasibility and acceptability of the system, we monitored enrollment and trends in participation and distributed a web-based survey to households of exhibitors from 5 fairs. Results: Among an estimated 500 households with a member who exhibited swine at one of 9 selected fairs, representatives of 87 (17%) households were enrolled, representing 392 household members. For fairs that were ongoing when TIM was deployed, the number of respondents peaked at 56 on the third day of the fair and then steadily declined throughout the rest of the monitoring period; 26 (30%) of 87 household representatives responded through the end of the 10-day monitoring period. We detected 2 H3N2v virus infections using TIM, which represents 17% (2/12) of all H3N2v virus infections detected during this outbreak in Michigan. Of the 70 survey respondents, 16 (23%) had participated in TIM. Of those, 73% (11/15) participated because it was recommended by fair coordinators and 80% (11/15) said they would participate again. Conclusions: Using a text-message system, we were able to monitor a large number of individuals and households for illness and detected H3N2v virus infections through active surveillance. Text-based illness monitoring systems are useful to detect novel influenza virus infections when active monitoring is deemed necessary. Participant retention and testing of persons reporting illness are critical elements for system improvement.

  • Investigating the Dynamics of Health Agency Response and Public Engagement during Public Health Emergency: A Case Study of CDC Tweeting Pattern during 2016 Zika Epidemic in the U.S.

    Date Submitted: May 10, 2018

    Open Peer Review Period: May 21, 2018 - Jun 4, 2018

    Background: Social media have been increasingly adopted by health agencies and professionals to disseminate information, interact with public, and understand public opinion. Among them, the Centers fo...

    Background: Social media have been increasingly adopted by health agencies and professionals to disseminate information, interact with public, and understand public opinion. Among them, the Centers for Disease Control and Prevention (CDC) is arguably one of the first government health agencies to adopt social media during health emergencies and crisis. It had been active on Twitter during the 2016 Zika epidemic that caused 5,168 domestic cases in the United States. Objective: This study aims to quantify the temporal variabilities in CDC’s tweeting activities over the course of Zika epidemic, public engagement in these CDC-initiated tweets (i.e., retweets and replies), and Zika case counts. It then compares the patterns of these three sets of data to identify the discrepancy and consistency among actual domestic Zika case counts, CDC response on Twitter, and public engagement in this topic. Methods: All of the CDC-initiated tweets published in 2016 with corresponding retweets and replies were collected from 67 CDC-associated Twitter accounts. Both univariate (ARIMA model) and multivariate time series analyses (CCF, mutual Shannon information entropy, ARIMAX model, Granger test) were performed in each quarter of 2016 for domestic Zika case counts, CDC tweeting activities, and public engagement in the CDC-initiated tweets. Results: CDC sent out more than 84% of its Zika tweets in the first quarter of 2016 when Zika case counts were low in the 50 U.S. states and territories. While Zika case counts increased dramatically in the second and the third quarters, CDC efforts on Twitter plunged. Time series of public engagement in the CDC-initiated tweets generally differed among quarters and from that of original CDC tweets based on ARIMA model parameters. Original CDC tweets and public engagement both had highest mutual information with Zika case counts in the 2nd quarter. Public engagement in the original CDC tweets was also substantially influenced by and preceded actual Zika epidemic. Conclusions: There were substantial discrepancies among CDC’s original tweets regarding Zika, public engagement in these tweets, and actual Zika epidemic. The patterns of these discrepancies also varied between different quarters in 2016. We discovered that although CDC was very effective in early warning of Zika in the first quarter of 2016, it failed to respond in a timely manner on Twitter during the rest of the Zika epidemic. Public engagement in CDC’s original tweets served as a more prominent predictor of actual Zika epidemic than number of CDC’s original tweets later in the year.

  • A Study to Identify Key Topics Bearing Negative Sentiment on Twitter Concerning the 2015/2016 Zika Epidemic

    Date Submitted: May 13, 2018

    Open Peer Review Period: May 21, 2018 - Jun 4, 2018

    Background: In order to understand public sentiment regarding the Zika virus, social media can be leveraged to understand how positive, negative, and neutral sentiments are expressed in society. Speci...

    Background: In order to understand public sentiment regarding the Zika virus, social media can be leveraged to understand how positive, negative, and neutral sentiments are expressed in society. Specifically, understanding the characteristics of negative sentiment could help inform federal disease control agencies’ efforts to disseminate relevant information to the public about Zika related issues. Objective: The purpose of this study was to analyze public sentiment concerning Zika using posts on Twitter and determine the qualitative characteristics of positive, negative and neutral sentiments expressed. Methods: Machine learning techniques and algorithms were used to analyze the sentiment of tweets concerning Zika. A supervised machine learning classifier was built to classify tweets into three sentiment categories: positive, neutral, and negative. Tweets in each category were then examined using a topic modeling approach in order to determine the main topics for each category, with focus on the negative category. Results: A total of 5,303 tweets were manually annotated and used to train multiple classifiers. These performed moderately well (F1 score = 0.69, 0.68) with text-based feature extraction. All 48,734 tweets were then categorized into the sentiment categories. Ten topics for each sentiment category were identified using topic modeling with a focus on the negative sentiment category. Conclusions: Our study demonstrates how sentiment expressed within discussions of epidemics on Twitter can be discovered. This allows public health officials to understand public sentiment regarding an epidemic and enables them to address specific elements of negative sentiment in real-time. Our negative sentiment classifier was able to identify tweets concerning Zika with three broad themes: neural defects, Zika abnormalities, and reports and findings. These broad themes were based on domain expertise and from topics discussed in journals such as MMWR and Vaccine. Since the majority of topics in the negative sentiment category concerned symptoms, officials should focus on spreading information about prevention and treatment research.

  • Continuous Glucose Monitoring in the Real-World: Photosurveillance of #Dexcom on Instagram

    Date Submitted: May 10, 2018

    Open Peer Review Period: May 21, 2018 - Jun 4, 2018

    Background: Individuals with diabetes are using social media as a method to share and gather information about their health via the diabetes online community. Infoveillance is one methodological appro...

    Background: Individuals with diabetes are using social media as a method to share and gather information about their health via the diabetes online community. Infoveillance is one methodological approach to examine healthcare trends. Infoveillance, however, while very effective in identifying many real-world health trends, may miss opportunities which use photographs as primary sources for data. We propose a new methodology, photosurveillance, in which photographs are analyzed to examine real-world trends. Objective: The purpose of this research is to 1) assess the use of photosurveillance as a research method to examine real-world trends in diabetes, and 2) report on real-world use of continuous glucose monitoring on Instagram. Methods: This exploratory mixed method study examined all photographs posted on Instagram identified with the hashtag, #dexcom, over a 2-month period. Photographs were coded by CGM location on the body. Original posts and corresponding comments were textually coded for length of CGM wear and CGM failure and analyzed for emerging themes. Results: 2923 photographs were manually screened, 12.1% (N=353) depicted a photograph with a CGM site location. The majority (64%, n=225) of the photographs showed a CGM site in an off-label location, while 26.2% where in an FDA approved location (abdomen), and 10.2% (n=36) were in unidentifiable locations There were no significant differences in the number of likes or comments based on FDA approval. Four themes emerged from the analysis of original posts (N-353) and corresponding comments (N=2364): 1) endorsement of CGM as providing a sense of wellbeing, 2) reciprocating encouragement and support, and 3) life hacks to optimize CGM use, and 4) sharing and learning about off-label CGM activity. Conclusions: Our results indicate that individuals successfully used CGM in off-label locations with greater frequency than the abdomen, with no indication of sensor failure, although these photographs only capture a snapshot in time. There were instances in which sensors were worn beyond the FDA-approved 7-days, however, they represented the minority in this study.

  • Implementation of digital technologies in medicine: Acceptance

    Date Submitted: May 17, 2018

    Open Peer Review Period: May 20, 2018 - May 28, 2018

    This paper discusses the acceptance of and resistance to new medical technologies in healthcare settings such as hospitals, doctors’ offices, and eHealth Centers. As users’ acceptance of new techn...

    This paper discusses the acceptance of and resistance to new medical technologies in healthcare settings such as hospitals, doctors’ offices, and eHealth Centers. As users’ acceptance of new technologies is critical for successful implementation, it is important to understand what factors influence acceptance and resistance. Therefore, a method is proposed for identifying the factors that influence the acceptance of and resistance to new technologies by both medical staff and patients. The method draws on concepts from the Technology Acceptance Model and Unified Technology Acceptance and Use of Technology model. The target groups are patients in Brandenburg and key players in the local healthcare structure, such as medical institutions and professionals. In addition, practical suggestions are given for facilitating users’ acceptance of digital solutions and innovative medical technology.