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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, ranked #1 by Clarivate's Journal Impact Factor. 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:

  • Influenzanet website (montage). Source: The Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Research Ethics in the European Influenzanet Consortium: Scoping Review


    Background: Influenzanet was launched in several European countries to monitor influenza-like illness during flu seasons with the help of volunteering participants and Web-based technologies. As in the case of developing fields, ethical approaches are not well developed in the collection, processing, and analysis of participants’ information. Existing controversies and varying national ethical regulations can, thus, hamper efficient cross-border research collaboration to the detriment of quality disease surveillance. Objective: This scoping review characterizes current practices on how ethical, legal, and social issues (ELSIs) pertinent to research ethics are handled by different Influenzanet country groups to analyze similarities and identify the need for further harmonization of ethical approaches. Methods: A literature search was carried out on PubMed, Web of Science, Global Digital Library on Ethics, and Bioethics Literature Database to identify ELSIs for Influenzanet country platforms. Only English-language papers were included with publication dates from 2003 to 2017. Publications were screened for the application of bioethics principles in the implementation of country platforms. Additional publications gathered from the Influenzanet Consortium website, reference screening, and conference proceeding were screened for ELSIs. Results: We gathered 96 papers from our search methodology. In total, 28 papers that mentioned ELSIs were identified and included in this study. The Research Ethics Committee (REC) approvals were sought for recruiting participants and collecting their data in 8 of 11 country platforms and informed e-consent was sought from participants in 9 of 11 country platforms. Furthermore, personal data protection was ensured throughout the Consortium using data anonymization before processing and analysis and using aggregated data. Conclusions: Epidemics forecasting activities, such as Influenzanet, are beneficial; however, its benefits could be further increased through the harmonization of data gathering and ethical requirements. This objective is achievable by the Consortium. More transparency should be promoted concerning REC-approved research for Influenzanet-like systems. The validity of informed e-consent could also be increased through the provision of a user friendly and standard information sheet across the Consortium where participants agree to its terms, conditions, and privacy policies before being able to fill in the questionnaire. This will help to build trust in the general public while preventing any decline in participation.

  • SOMAARTH Demographic, Development and Environmental Surveillance Site (montage). Source:; Copyright: The INCLEN Trust International; URL:; License: Licensed by JMIR.

    Establishing a Demographic, Development and Environmental Geospatial Surveillance Platform in India: Planning and Implementation


    Background: Inadequate administrative health data, suboptimal public health infrastructure, rapid and unplanned urbanization, environmental degradation, and poor penetration of information technology make the tracking of health and well-being of populations and their social determinants in the developing countries challenging. Technology-integrated comprehensive surveillance platforms have the potential to overcome these gaps. Objective: This paper provides methodological insights into establishing a geographic information system (GIS)-integrated, comprehensive surveillance platform in rural North India, a resource-constrained setting. Methods: The International Clinical Epidemiology Network Trust International established a comprehensive SOMAARTH Demographic, Development, and Environmental Surveillance Site (DDESS) in rural Palwal, a district in Haryana, North India. The surveillance platform evolved by adopting four major steps: (1) site preparation, (2) data construction, (3) data quality assurance, and (4) data update and maintenance system. Arc GIS 10.3 and QGIS 2.14 software were employed for geospatial data construction. Surveillance data architecture was built upon the geospatial land parcel datasets. Dedicated software (SOMAARTH-1) was developed for handling high volume of longitudinal datasets. The built infrastructure data pertaining to land use, water bodies, roads, railways, community trails, landmarks, water, sanitation and food environment, weather and air quality, and demographic characteristics were constructed in a relational manner. Results: The comprehensive surveillance platform encompassed a population of 0.2 million individuals residing in 51 villages over a land mass of 251.7 sq km having 32,662 households and 19,260 nonresidential features (cattle shed, shops, health, education, banking, religious institutions, etc). All land parcels were assigned georeferenced location identification numbers to enable space and time monitoring. Subdivision of villages into sectors helped identify socially homogenous community clusters (418/676, 61.8%, sectors). Water and hygiene parameters of the whole area were mapped on the GIS platform and quantified. Risk of physical exposure to harmful environment (poor water and sanitation indicators) was significantly associated with the caste of individual household (P=.001), and the path was mediated through the socioeconomic status and density of waste spots (liquid and solid) of the sector in which these households were located. Ground-truthing for ascertaining the land parcel level accuracies, community involvement in mapping exercise, and identification of small habitations not recorded in the administrative data were key learnings. Conclusions: The SOMAARTH DDESS experience allowed us to document and explore dynamic relationships, associations, and pathways across multiple levels of the system (ie, individual, household, neighborhood, and village) through a geospatial interface. This could be used for characterization and monitoring of a wide range of proximal and distal determinants of health.

  • Japanese businessmen wearing masks to avoid getting the flu in the city. Source: iStock by Getty Images; Copyright: franckreporter; URL:; License: Licensed by the authors.

    Twitter-Based Influenza Detection After Flu Peak via Tweets With Indirect Information: Text Mining Study


    Background: The recent rise in popularity and scale of social networking services (SNSs) has resulted in an increasing need for SNS-based information extraction systems. A popular application of SNS data is health surveillance for predicting an outbreak of epidemics by detecting diseases from text messages posted on SNS platforms. Such applications share the following logic: they incorporate SNS users as social sensors. These social sensor–based approaches also share a common problem: SNS-based surveillance are much more reliable if sufficient numbers of users are active, and small or inactive populations produce inconsistent results. Objective: This study proposes a novel approach to estimate the trend of patient numbers using indirect information covering both urban areas and rural areas within the posts. Methods: We presented a TRAP model by embedding both direct information and indirect information. A collection of tweets spanning 3 years (7 million influenza-related tweets in Japanese) was used to evaluate the model. Both direct information and indirect information that mention other places were used. As indirect information is less reliable (too noisy or too old) than direct information, the indirect information data were not used directly and were considered as inhibiting direct information. For example, when indirect information appeared often, it was considered as signifying that everyone already had a known disease, leading to a small amount of direct information. Results: The estimation performance of our approach was evaluated using the correlation coefficient between the number of influenza cases as the gold standard values and the estimated values by the proposed models. The results revealed that the baseline model (BASELINE+NLP) shows .36 and that the proposed model (TRAP+NLP) improved the accuracy (.70, +.34 points). Conclusions: The proposed approach by which the indirect information inhibits direct information exhibited improved estimation performance not only in rural cities but also in urban cities, which demonstrated the effectiveness of the proposed method consisting of a TRAP model and natural language processing (NLP) classification.

  • Facebook advertisement posted to Canadian parents’ News Feeds (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    User-Driven Comments on a Facebook Advertisement Recruiting Canadian Parents in a Study on Immunization: Content Analysis


    Background: More people are searching for immunization information online and potentially being exposed to misinformation and antivaccination sentiment in content and discussions on social media platforms. As vaccination coverage rates remain suboptimal in several developed countries, and outbreaks of vaccine-preventable diseases become more prevalent, it is important that we build on previous research by analyzing themes in online vaccination discussions, including those that individuals may see without actively searching for information on immunization. Objective: The study aimed to explore the sentiments and themes behind an unsolicited debate on immunization in order to better inform public health interventions countering antivaccination sentiment. Methods: We analyzed and quantified 117 user-driven open-ended comments on immunization posted in the Comments section of a Facebook advertisement that targeted Canadian parents for recruitment into a larger study on immunization. Then, 2 raters coded all comments using content analysis. Results: Of 117 comments, 85 were posted by unique commentators, with most being female (65/85, 77%). The largest proportion of the immunization comments were positive (51/117, 43.6%), followed by negative (41/117, 35.0%), ambiguous (20/117, 17.1%), and hesitant (5/117, 4.3%). Inaccurate knowledge (27/130, 20.8%) and misperceptions of risk (23/130, 17.7%) were most prevalent in the 130 nonpositive comments. Other claims included distrust of pharmaceutical companies or government agencies (18/130, 13.8%), distrust of the health care system or providers (15/130, 11.5%), past negative experiences with vaccination or beliefs (10/130, 7.7%), and attitudes about health and prevention (10/130, 7.7%). Almost 40% (29/74, 39%) of the positive comments communicated the risks of not vaccinating, followed by judgments on the knowledge level of nonvaccinators (13/74, 18%). A total of 10 positive comments (10/74, 14%) specifically refuted the link between autism and vaccination. Conclusions: The presence of more than 100 unsolicited user-driven comments on a platform not intended for discussion, nor providing any information on immunization, illustrates the strong sentiments associated with immunization and the arbitrariness of the online platforms used for immunization debates. Health authorities should be more proactive in finding mechanisms to refute misinformation and misperceptions that are propagating uncontested online. Online debates and communications on immunization need to be identified by continuous monitoring in order for health authorities to understand the current themes and trends, and to engage in the discussion.

  • Source: Getty Images; Copyright: stevanovicigor; URL:; License: Licensed by the authors.

    eHealth Literacy in People Living with HIV: Systematic Review


    Background: In the era of eHealth, eHealth literacy is emerging as a key concept to promote self-management of chronic conditions such as HIV. However, there is a paucity of research focused on eHealth literacy for people living with HIV (PLWH) as a means of improving their adherence to HIV care and health outcome. Objective: The objective of this study was to critically appraise the types, scope, and nature of studies addressing eHealth literacy as a study variable in PLWH. Methods: This systematic review used comprehensive database searches, such as PubMed, EMBASE, CINAHL, Web of Science, and Cochrane, to identify quantitative studies targeting PLWH published in English before May 2017 with eHealth literacy as a study variable. Results: We identified 56 unique records, and 7 papers met the eligibility criteria. The types of study designs varied (descriptive, n=3; quasi-experimental, n=3; and experimental, n=1) and often involved community-based settings (n=5), with sample sizes ranging from 18 to 895. In regards to instruments used, 3 studies measured eHealth literacy with validated instruments such as the eHealth Literacy Scale (eHEALS); 2 studies used full or short versions of Test of Functional Health Literacy in Adults, whereas the remaining 2 studies used study-developed questions. The majority of studies included in the review reported high eHealth literacy among the samples. The associations between eHealth literacy and health outcomes in PLWH were not consistent. In the areas of HIV transmission risk, retention in care, treatment adherence, and virological suppression, the role of eHealth literacy is still not fully understood. Furthermore, the implications for future research are discussed. Conclusions: Understanding the role of eHealth literacy is an essential step to encourage PLWH to be actively engaged in their health care. Avenues to pursue in the role of eHealth literacy and PLWH should consider the development and use of standardized eHealth literacy definitions and measures.

  • Source: Image created by the Authors; Copyright: Interactive Research and Development; URL:; License: Creative Commons Attribution (CC-BY).

    Using Predictive Analytics to Identify Children at High Risk of Defaulting From a Routine Immunization Program: Feasibility Study


    Background: Despite the availability of free routine immunizations in low- and middle-income countries, many children are not completely vaccinated, vaccinated late for age, or drop out from the course of the immunization schedule. Without the technology to model and visualize risk of large datasets, vaccinators and policy makers are unable to identify target groups and individuals at high risk of dropping out; thus default rates remain high, preventing universal immunization coverage. Predictive analytics algorithm leverages artificial intelligence and uses statistical modeling, machine learning, and multidimensional data mining to accurately identify children who are most likely to delay or miss their follow-up immunization visits. Objective: This study aimed to conduct feasibility testing and validation of a predictive analytics algorithm to identify the children who are likely to default on subsequent immunization visits for any vaccine included in the routine immunization schedule. Methods: The algorithm was developed using 47,554 longitudinal immunization records, which were classified into the training and validation cohorts. Four machine learning models (random forest; recursive partitioning; support vector machines, SVMs; and C-forest) were used to generate the algorithm that predicts the likelihood of each child defaulting from the follow-up immunization visit. The following variables were used in the models as predictors of defaulting: gender of the child, language spoken at the child’s house, place of residence of the child (town or city), enrollment vaccine, timeliness of vaccination, enrolling staff (vaccinator or others), date of birth (accurate or estimated), and age group of the child. The models were encapsulated in the predictive engine, which identified the most appropriate method to use in a given case. Each of the models was assessed in terms of accuracy, precision (positive predictive value), sensitivity, specificity and negative predictive value, and area under the curve (AUC). Results: Out of 11,889 cases in the validation dataset, the random forest model correctly predicted 8994 cases, yielding 94.9% sensitivity and 54.9% specificity. The C-forest model, SVMs, and recursive partitioning models improved prediction by achieving 352, 376, and 389 correctly predicted cases, respectively, above the predictions made by the random forest model. All models had a C-statistic of 0.750 or above, whereas the highest statistic (AUC 0.791, 95% CI 0.784-0.798) was observed in the recursive partitioning algorithm. Conclusions: This feasibility study demonstrates that predictive analytics can accurately identify children who are at a higher risk for defaulting on follow-up immunization visits. Correct identification of potential defaulters opens a window for evidence-based targeted interventions in resource limited settings to achieve optimal immunization coverage and timeliness.

  • Source: Wikimedia Commons; Copyright: NIAID; URL:; License: Creative Commons Attribution (CC-BY).

    Overlap of Asthma and Chronic Obstructive Pulmonary Disease in Patients in the United States: Analysis of Prevalence, Features, and Subtypes


    Background: Although asthma and chronic obstructive pulmonary disease (COPD) are clinically distinct diseases, they represent biologically diverse and overlapping clinical entities and it has been observed that they often co-occur. Some research and theorizing suggest there is a common comorbid condition termed asthma-chronic obstructive pulmonary disease overlap (ACO). However, the existence of ACO is controversial. Objective: The objective of this study is to describe patient characteristics and estimate prevalence, health care utilization, and costs of ACO using claims-based diagnoses confirmed with medical record information. Methods: Eligible patients were commercial US health plan enrollees; ≥40 years; had asthma, COPD, or ACO; ≥3 prescription fills for asthma/COPD medications; and ≥2 spirometry tests. Records for a random sample of 5000 patients with ACO were reviewed to validate claims-based diagnoses. Results: The estimated ACO prevalence was 6% (estimated 10,250/183,521) among 183,521 full study patients. In the claims-based cohorts, the comorbidity burden for ACO was greater versus asthma but similar to COPD cohorts. Medication utilization was higher in ACO versus asthma and COPD. Mean total health care costs were significantly higher for ACO versus asthma but similar to COPD. In confirmed diagnoses cohorts, mean total health care costs (medical plus pharmacy) were lower for ACO versus COPD but similar to asthma (US $20,035; P=.56). Among confirmed cases, where there was medical record evidence, smoking history was higher in ACO (300/343, 87.5%) versus asthma cohorts (100/181, 55.2%) but similar to COPD (68/84, 81%). Conclusions: ACO had more comorbidities, medication utilization, and costs than patients with asthma or COPD but differences were not seen after confirmation with medical records.

  • Assessing the impact of cross-jurisdictional data sharing on the estimation of people living with HIV in DC. Source: Image created by the authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Cross-Jurisdictional Data Exchange Impact on the Estimation of the HIV Population Living in the District of Columbia: Evaluation Study


    Background: Accurate HIV surveillance data are essential to monitor trends to help end the HIV epidemic. Owing to strict policies around data security and confidentiality, HIV surveillance data have not been routinely shared across jurisdictions except a biannual case-by-case review process to identify and remove duplicate cases (Routine Interstate Duplicate Review, RIDR). HIV surveillance estimates for the District of Columbia (DC) are complicated by migration and care seeking throughout the metropolitan area, which includes Maryland and Virginia. To address gaps in HIV surveillance data, health departments of DC, Maryland, and Virginia have established HIV surveillance data sharing agreements. Although the Black Box (a privacy data integration tool external to the health departments) facilitates the secure exchange of data between DC, Maryland, and Virginia, its previous iterations were limited by the frequency and scope of information exchanged. The health departments of DC, Maryland, and Virginia engaged in data sharing to further improve HIV surveillance estimates. Objective: This study assessed the impact of cross-jurisdictional data sharing on the estimation of people living with HIV in DC and reduction of cases in the RIDR process. Methods: Data sharing agreements established in 2014 allowed for the exchange of HIV case information (eg, current residential address) and laboratory information (eg, test types, result dates, and results) from the enhanced HIV/AIDS Reporting System (eHARS). Regular data exchanges began in 2017. The participating jurisdictions transferred data (via secure file transfer protocol) for individuals having a residential address in a partnering jurisdiction at the time of HIV diagnosis or evidence of receiving HIV-related services at a facility located in a partnering jurisdiction. The DC Department of Health compared the data received to DC eHARS and imported updated data that matched existing cases. Evaluation of changes in current residential address and HIV prevalence was conducted by comparing data before and after HIV surveillance data exchanges. Results: After the HIV surveillance data exchange, an average of 396 fewer cases were estimated to be living in DC each year from 2012 to 2016. Among cases with a residential status change, 66.4% (1316/1982) had relocated to Maryland and 19.8% (392/1982) to Virginia; majority of these had relocated to counties bordering DC. Relocation in and out of DC differed by mode of transmission, race and ethnicity, age group, and gender. After data exchange, the volume of HIV cases needing RIDR decreased by 74% for DC-Maryland and 81% for DC-Virginia. Conclusions: HIV surveillance data exchange between the public health departments of DC, Maryland, and Virginia reduced the number of cases misclassified as DC residents and reduced the number of cases needing RIDR. Continued data exchanges will enhance the ability of DC Department of Health to monitor the local HIV epidemic.

  • Source: Pexels; Copyright: mentatdgt; URL:; License: Public Domain (CC0).

    Using Geosocial Networking Apps to Understand the Spatial Distribution of Gay and Bisexual Men: Pilot Study


    Background: While services tailored for gay, bisexual, and other men who have sex with men (gbMSM) may provide support for this vulnerable population, planning access to these services can be difficult due to the unknown spatial distribution of gbMSM outside of gay-centered neighborhoods. This is particularly true since the emergence of geosocial networking apps, which have become a widely used venue for meeting sexual partners. Objective: The goal of our research was to estimate the spatial density of app users across Metro Vancouver and identify the independent and adjusted neighborhood-level factors that predict app user density. Methods: This pilot study used a popular geosocial networking app to estimate the spatial density of app users across rural and urban Metro Vancouver. Multiple Poisson regression models were then constructed to model the relationship between app user density and areal population-weighted neighbourhood-level factors from the 2016 Canadian Census and National Household Survey. Results: A total of 2021 app user profiles were counted within 1 mile of 263 sampling locations. In a multivariate model controlling for time of day, app user density was associated with several dissemination area–level characteristics, including population density (per 100; incidence rate ratio [IRR] 1.03, 95% CI 1.02-1.04), average household size (IRR 0.26, 95% CI 0.11-0.62), average age of males (IRR 0.93, 95% CI 0.88-0.98), median income of males (IRR 0.96, 95% CI 0.92-0.99), proportion of males who were not married (IRR 1.08, 95% CI 1.02-1.13), proportion of males with a postsecondary education (IRR 1.06, 95% CI 1.03-1.10), proportion of males who are immigrants (IRR 1.04, 95% CI 1.004-1.07), and proportion of males living below the low-income cutoff level (IRR 0.93, 95% CI 0.89-0.98). Conclusions: This pilot study demonstrates how the combination of geosocial networking apps and administrative datasets might help care providers, planners, and community leaders target online and offline interventions for gbMSM who use apps.

  • Source: Daily Sun; Copyright: Daily Sun; URL:; License: Fair use/fair dealings.

    Estimating the Population Size of Female Sex Workers in Three South African Cities: Results and Recommendations From the 2013-2014 South Africa Health...


    Background: Robust population size estimates of female sex workers and other key populations in South Africa face multiple methodological limitations, including inconsistencies in surveillance and programmatic indicators. This has, consequently, challenged the appropriate allocation of resources and benchmark-setting necessary to an effective HIV response. A 2013-2014 integrated biological and behavioral surveillance (IBBS) survey from South Africa showed alarmingly high HIV prevalence among female sex workers in South Africa’s three largest cities of Johannesburg (71.8%), Cape Town (39.7%), and eThekwini (53.5%). The survey also included several multiplier-based population size estimation methods. Objective: The objective of our study was to present the selected population size estimation methods used in an IBBS survey and the subsequent participatory process used to estimate the number of female sex workers in three South African cities. Methods: In 2013-2014, we used respondent-driven sampling to recruit independent samples of female sex workers for IBBS surveys in Johannesburg, Cape Town, and eThekwini. We embedded multiple multiplier-based population size estimation methods into the survey, from which investigators calculated weighted estimates and ranges of population size estimates for each city’s female sex worker population. Following data analysis, investigators consulted civil society stakeholders to present survey results and size estimates and facilitated stakeholder vetting of individual estimates to arrive at consensus point estimates with upper and lower plausibility bounds. Results: In total, 764, 650, and 766 female sex workers participated in the survey in Johannesburg, Cape Town, and eThekwini, respectively. For size estimation, investigators calculated preliminary point estimates as the median of the multiple estimation methods embedded in the IBBS survey and presented these to a civil society-convened stakeholder group. Stakeholders vetted all estimates in light of other data points, including programmatic experience, ensuring inclusion only of plausible point estimates in median calculation. After vetting, stakeholders adopted three consensus point estimates with plausible ranges: Johannesburg 7697 (5000-10,895); Cape Town 6500 (4579-9000); eThekwini 9323 (4000-10,000). Conclusions: Using several population size estimates methods embedded in an IBBS survey and a participatory stakeholder consensus process, the South Africa Health Monitoring Survey produced female sex worker size estimates representing approximately 0.48%, 0.49%, and 0.77% of the adult female population in Johannesburg, Cape Town, and eThekwini, respectively. In data-sparse environments, stakeholder engagement and consensus is critical to vetting of multiple empirically based size estimates procedures to ensure adoption and utilization of data-informed size estimates for coordinated national and subnational benchmarking. It also has the potential to increase coherence in national and key population-specific HIV responses and to decrease the likelihood of duplicative and wasteful resource allocation. We recommend building cooperative and productive academic-civil society partnerships around estimates and other strategic information dissemination and sharing to facilitate the incorporation of additional data as it becomes available, as these additional data points may minimize the impact of the known and unknown biases inherent in any single, investigator-calculated method.

  • Digitization of HIV rapid test results into a real-time map showing GPS coordinates. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Bringing Real-Time Geospatial Precision to HIV Surveillance Through Smartphones: Feasibility Study


    Background: Precise measurements of HIV incidences at community level can help mount a more effective public health response, but the most reliable methods currently require labor-intensive population surveys. Novel mobile phone technologies are being tested for adherence to medical appointments and antiretroviral therapy, but using them to track HIV test results with automatically generated geospatial coordinates has not been widely tested. Objective: We customized a portable reader for interpreting the results of HIV lateral flow tests and developed a mobile phone app to track HIV test results in urban and rural locations in Rwanda. The objective was to assess the feasibility of this technology to collect front line HIV test results in real time and with geospatial context to help measure HIV incidences and improve epidemiological surveillance. Methods: Twenty health care workers used the technology to track the test results of 2190 patients across 3 hospital sites (2 urban sites in Kigali and a rural site in the Western Province of Rwanda). Mobile phones for less than US $70 each were used. The mobile phone app to record HIV test results could take place without internet connectivity with uploading of results to the cloud taking place later with internet. Results: A total of 91.51% (2004/2190) of HIV test results could be tracked in real time on an online dashboard with geographical resolution down to street level. Out of the 20 health care workers, 14 (70%) would recommend the lateral flow reader, and 100% would recommend the mobile phone app. Conclusions: Smartphones have the potential to simplify the input of HIV test results with geospatial context and in real time to improve public health surveillance of HIV.

  • Source: The Authors/; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Facial-Aging Mobile Apps for Smoking Prevention in Secondary Schools in Brazil: Appearance-Focused Interventional Study


    Background: Most smokers start smoking during their early adolescence, often with the idea that smoking is glamorous. Interventions that harness the broad availability of mobile phones as well as adolescents' interest in their appearance may be a novel way to improve school-based prevention. A recent study conducted in Germany showed promising results. However, the transfer to other cultural contexts, effects on different genders, and implementability remains unknown. Objective: In this observational study, we aimed to test the perception and implementability of facial-aging apps to prevent smoking in secondary schools in Brazil in accordance with the theory of planned behavior and with respect to different genders. Methods: We used a free facial-aging mobile phone app (“Smokerface”) in three Brazilian secondary schools via a novel method called mirroring. The students’ altered three-dimensional selfies on mobile phones or tablets and images were “mirrored” via a projector in front of their whole grade. Using an anonymous questionnaire, we then measured on a 5-point Likert scale the perceptions of the intervention among 306 Brazilian secondary school students of both genders in the seventh grade (average age 12.97 years). A second questionnaire captured perceptions of medical students who conducted the intervention and its conduction per protocol. Results: The majority of students perceived the intervention as fun (304/306, 99.3%), claimed the intervention motivated them not to smoke (289/306, 94.4%), and stated that they learned new benefits of not smoking (300/306, 98.0%). Only a minority of students disagreed or fully disagreed that they learned new benefits of nonsmoking (4/306, 1.3%) or that they themselves were motivated not to smoke (5/306, 1.6%). All of the protocol was delivered by volunteer medical students. Conclusions: Our data indicate the potential for facial-aging interventions to reduce smoking prevalence in Brazilian secondary schools in accordance with the theory of planned behavior. Volunteer medical students enjoyed the intervention and are capable of complete implementation per protocol.

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  • Estimation of the population size of men who have sex with men in Viet Nam using the Social App Multiplier method

    Date Submitted: Oct 9, 2018

    Open Peer Review Period: Oct 13, 2018 - Oct 27, 2018

    Background: While the prevalence of HIV among men who have sex with men (MSM) in Viet Nam has been increasing in recent years, there are no estimates of the population size of MSM based on tested empi...

    Background: While the prevalence of HIV among men who have sex with men (MSM) in Viet Nam has been increasing in recent years, there are no estimates of the population size of MSM based on tested empirical methods. Objective: This study attempts to estimate the size of the MSM population in 12 provinces in Viet Nam and extrapolate from those areas to generate a national population estimate of MSM. A secondary aim of this study is to compare the feasibility of obtaining the number of users of a social app for MSM, using three different approaches. Methods: This study uses the social app multiplier method to estimate the size of MSM populations in 12 provinces, using the count of users on a social app popular with MSM in Viet Nam as the first data source, and a questionnaire propagated through the MSM community using respondent driven sampling as the second data source. A national estimation of MSM population is extrapolated from the results in the 12 provinces and the percentage of MSM reachable through online social networks is clarified. Results: The highest MSM population size among the 12 provinces is estimated in Hanoi and the lowest is estimated in Binh Dinh. On average 27.7% of MSM in provinces surveyed had used the social app Jack’D in the last 30 days, (95% CI: 17.6-37.7). Extrapolation of the results from the 12 provinces results in an estimated national population of 174,944 MSM (95% CI: 120,631–523,233) in Viet Nam. The percentage of MSM among adult males 15-49 in Viet Nam is 0.67% (95% CI: 0.46–1.99). Conclusions: This study is the first attempt to empirically estimate the population of MSM in Viet Nam, and highlights the feasibility of reaching a large proportion of MSM through a social app. The estimation reported in this study is lower than the estimated number of MSM in Viet Nam arrived at by profiling of urbanization of regions and modelling process. This study recommends that the updated estimation of the MSM population size be used to inform program planning and policy decision-making.

  • Characterizing Trends in HPV Vaccine Discourse On Reddit (2007-2015)

    Date Submitted: Oct 12, 2018

    Open Peer Review Period: Oct 12, 2018 - Oct 26, 2018

    Background: Despite the introduction of the HPV vaccination as a preventive measure in 2006, uptake rates remain suboptimal, resulting in preventable cancer mortality. Social media, widely used for...

    Background: Despite the introduction of the HPV vaccination as a preventive measure in 2006, uptake rates remain suboptimal, resulting in preventable cancer mortality. Social media, widely used for information seeking, has been shown to be influential on users’ knowledge and attitudes regarding HPV vaccination. Little is known regarding attitudes related to HPV vaccination on Reddit (a popular news aggregation site and online community), particularly related to cancer risk and sexual activity. Examining HPV vaccine related messages on Reddit may provide insights into how HPV discussions are characterized online and influence decision-making related to vaccination. Objective: We seek to observe how the HPV vaccine is characterized on Reddit over time and by user gender. Specifically, we seek to determine if: 1) Reddit messages are more related to cancer risks or sexual behavior; and 2)what other topics characterize the discussion on HPV vaccination on Reddit. Methods: We gathered all public Reddit comments from January 2007 through September 2015. We manually annotated 400 messages to generate keywords and identify themes. We then measured the similarity between each comment and lists of keywords associated with sexual behavior and cancer risk, using Latent Semantic Analysis (LSA). Next, we used Latent Dirichlet Allocation (LDA) to characterize remaining topics within the Reddit data. Results: We analyzed 22,729 messages containing the strings “hpv” or “human papillomavirus” and “vaccin”. LSA findings showed that Reddit HPV vaccine discussions are significantly more related to cancer compared to sexual behavior. Compared to women, men were similarly more likely to discuss cancer risks between 2007 (mean LSA similarity score=0.14 for men, 0.13 for women,) and 2015 (mean LSA similarity score=0.10 for men, 0.09 for women). LDA analyses demonstrated that although topics related to cancer risk (16.1%) and sexual activity (14.5%) were both widely discussed, the majority of online discussions talked about neither of these. The most frequently discussed topic was politics associated with the vaccine (17.2%). Other topics included HPV disease/immunity (13.5%), the HPV vaccine schedule (11.5%), HPV vaccine side effects (9.7%), hyperlinks to outside sources (9.1%), and the risks and benefit of HPV vaccination (8.5%). Conclusions: Reddit discourse on HPV vaccine encompasses a broad range of topics among men and women, with HPV political debates and cancer risk making up the plurality of the discussion. Our findings demonstrated that women and men were equally likely to discuss HPV, highlighting that Reddit users do not perceive HPV as a female only issue. Given the increasing use of social media as a source of health information, these results can inform the development of targeted online health communication strategies to promote HPV vaccination to young adult users of Reddit. Analyzing online discussions on Reddit can inform health communication efforts by identifying relevant, important HPV related topics among online communities.

  • Flutracking Australia Influenza-like Illness Surveillance System: Evolution of methods from 2006-2016

    Date Submitted: Sep 27, 2018

    Open Peer Review Period: Oct 4, 2018 - Oct 18, 2018

    This paper documents the evolution of Flutracking from a pilot online influenza-like illness (ILI) survey of 394 participants in a local health region to a national surveillance system with over 30,00...

    This paper documents the evolution of Flutracking from a pilot online influenza-like illness (ILI) survey of 394 participants in a local health region to a national surveillance system with over 30,000 participants in 2016. In 2018, there were over 40,000 survey responses per week in most weeks. In particular, this paper will describe how the methods have developed to meet the 1) changing aims of the system; 2) developing capabilities of the system; and 3) participant growth. The aim of this paper is to provide insights to other groups initiating participatory public health surveillance systems and to assist users of our data and reports to better understand Flutracking methods. Some of the key changes to Flutracking from 2006 to 2016 include: allowing participants to respond on behalf of other household members from 2008; adding health seeking behaviour questions in 2011; and offering an express survey and follow-up of unknown test results from 2016 onwards. The Flutracking system has demonstrated its ability to adapt to changes with minimal disruption to participants, and maintain consistency in data collection and reporting. As an example of success, Flutracking has been integrated in the Australian Government Department of Health’s regular influenza reports, and is now contributing weekly data to the transmissibility and impact measures for the Australian Government Department of Health’s application of the Pandemic Influenza Severity Assessment system. Flutracking data have consistently aligned with the timing of the peak level of influenza activity from other Australian influenza surveillance systems. Flutracking provided a unique insight into 2009 H1N1 influenza pandemic in 2009 demonstrating that the community level ILI attack rates were only slightly higher than 2008, and lower than 2007 in the community. Flutracking has demonstrated to be significantly less biased by treatment seeking behaviour and laboratory testing protocols than other surveillance systems during the 2009 influenza pandemic. In 2018, Flutracking expanded to New Zealand, with an average of over 2,800 surveys per week so far. The evolution of Flutracking’s methods has been pivotal to the success of this surveillance system.

  • Capture-recapture among men who have sex with men and among female sex workers in 11 towns in Uganda

    Date Submitted: Sep 27, 2018

    Open Peer Review Period: Oct 4, 2018 - Oct 18, 2018

    Background: Key populations at higher risk for HIV infection, including people who inject drugs (PWID), men who have sex with men (MSM), and female sex workers (FSW) are disproportionately affected by...

    Background: Key populations at higher risk for HIV infection, including people who inject drugs (PWID), men who have sex with men (MSM), and female sex workers (FSW) are disproportionately affected by the HIV/AIDS epidemic. Empirical estimates of their population sizes are necessary for HIV program planning and monitoring. Such estimates however are lacking for most of Uganda’s urban centers. Objective: To estimate the number of female sex workers (FSW) and men who have sex with men (MSM) in select locations in Uganda. Methods: We utilized conventional 2-source capture-recapture to estimate the population of FSW in Mbale, Jinja, Wakiso, Mbarara, Gulu, Kabarole, Busia, Tororo, Masaka, and Kabale and of MSM in Mbale, Jinja, Wakiso, Mbarara, Gulu, Kabarole, and Mukono from June – August 2017. Hand mirrors and key chains were distributed to FSW and MSM, respectively, by peers during capture one. A week later, different FSW and MSM distributors went to the same towns to collect data for the second capture. Population size estimates and 95% confidence intervals (CI) were calculated using the capture-recapture Simple Interactive Statistical Analysis (SISA). Prediction surface maps were created using the Kriging interpolation method for MSM and FSW densities for each town in ArcMap 10.3.1. Results: We estimated the population of FSW and MSM using two different recapture definitions: those who could present the object and those who could present the object or identify the object from a set of photos. The most credible estimates came from those who presented the objects only. The FSW population in Mbale was estimated to be 693 (95% CI: 474-912). For Jinja, Mukono, Busia, and Tororo, we estimated the number of FSW to be 802 (95% CI: 534-1069), 322 (95% CI: 300-343), 961 (95% CI: 592-1330), and 2872 (95% CI: 0-6005). For Masaka, Mbarara, Kabale, and Wakiso, we estimated the FSW population to be 512 (95% CI: 384-639), 1904 (95% CI: 1058-2749), 377 95% CI: (247-506), and 828 (95% CI: 502-1152), respectively. For Kabarole and Gulu, we estimated the FSW population to be 397(95% CI: 325-469) and 1425 (95% CI: 893-1958). MSM estimates are 381(95% CI: 299-462) for Mbale, 1100 (95% CI: 351-1849) for Jinja, 368 (95% CI: 281-455) for Wakiso, 322 (95% CI: 253-390) for Mbarara, 180 (95% CI: 170-189), for Gulu, 335 (95% CI: 258-412) for Kabarole, and 264 (95% CI: 228-301) for Mukono. Conclusions: The capture-recapture activity was one of the first done in Uganda to obtain small town-level population sizes for FSW and MSM. The prediction maps of MSM and FSW densities provide useful information for HIV program planning. We found that it is feasible to use FSW and MSM peers for this activity, but proper training and standardized data collection tools are essential to minimize bias.