JMIR Publications

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  Theme Issue 2020: Novel Coronavirus...

  Dec 3, 2020

  Evaluating the Need for Routine COVID-19 Testing of Emergency Department Staff: Quantitative Analysis

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  Authors List:

  • Yuemei Zhang  
  • Sheng-Ru Cheng  

  Abstract:

  Background: As the number of COVID-19 cases in the US continues to increase and hospitals experience shortage of personal protective equipment (PPE), health care workers have been disproportionately affected. However, since COVID-19 testing is now easily available, there is a need to evaluate whether routine testing should be performed for asymptomatic health care workers. Objective: This study aimed to provide a quantitative analysis of the predicted impact that regular testing of health care workers for COVID-19 may have on the prevention of the disease among emergency department patients and staff. Methods: Using publicly available data on COVID-19 cases and emergency department visits, as well as internal hospital staffing information, we developed a mathematical model to predict the impact of periodic COVID-19 testing of asymptomatic staff members of the emergency department in COVID-19–affected regions. We calculated various transmission constants based on the Diamond Princess cruise ship data, used a logistic model to calculate new infections, and developed a Markov model based on the average incubation period for COVID-19. Results: Our model predicts that after 180 days, with a transmission constant of 1.219e-4 new infections/person², weekly COVID-19 testing of health care workers would reduce new health care worker and patient infections by approximately 3%-5.9%, and biweekly testing would reduce infections in both by 1%-2.1%. At a transmission constant of 3.660e-4 new infections/person², weekly testing would reduce infections by 11%-23% and biweekly testing would reduce infections by 5.5%-13%. At a lower transmission constant of 4.067e-5 new infections/person², weekly and biweekly COVID-19 testing for health care workers would result in an approximately 1% and 0.5%-0.8% reduction in infections, respectively. Conclusions: Periodic COVID-19 testing for emergency department staff in regions that are heavily affected by COVID-19 or are facing resource constraints may significantly reduce COVID-19 transmission among health care workers and previously uninfected patients.

  • JMIR Public Health Surveill 2020;6(4):e20260

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  Editorial

  Dec 3, 2020

  Population Size Estimation Methods: Searching for the Holy Grail

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  Authors List:

  • Joyce J Neal  
  • Dimitri Prybylski  
  • Travis Sanchez  
  • Wolfgang Hladik  

  Abstract:

  Accurate size estimates of key populations (eg, sex workers, people who inject drugs, transgender people, and men who have sex with men) can help to ensure adequate availability of services to prevent or treat HIV infection; inform HIV response planning, target setting, and resource allocation; and provide data for monitoring and evaluating program outcomes and impact. A gold standard method for population size estimation does not exist, but quality of estimates could be improved by using empirical methods, multiple data sources, and sound statistical concepts. To highlight such methods, a special collection of papers in JMIR Public Health and Surveillance has been released under the title “Key Population Size Estimations.” We provide a summary of these papers to highlight advances in the use of empirical methods and call attention to persistent gaps in information.

  • JMIR Public Health Surveill 2020;6(4):e25076

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  Infoveillance, Infodemiology, Digital...

  Dec 2, 2020

  How Internet Contracts Impact Research: Content Analysis of Terms of Service on Consumer Product Websites

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  Authors List:

  • Caitlin Weiger  
  • Katherine C Smith  
  • Joanna E Cohen  
  • Mark Dredze  
  • Meghan Bridgid Moran  

  Abstract:

  Background: Companies use brand websites as a promotional tool to engage consumers on the web, which can increase product use. Given that some products are harmful to the health of consumers, it is important for marketing associated with these products to be subject to public health surveillance. However, terms of service (TOS) governing the use of brand website content may impede such important research. Objective: The aim of this study is to explore the TOS for brand websites with public health significance to assess possible legal and ethical challenges for conducting research on consumer product websites. Methods: Using Statista, we purposefully constructed a sample of 15 leading American tobacco, alcohol, psychiatric pharmaceutical, fast-food, and gun brands that have associated websites. We developed and implemented a structured coding system for the TOS on these websites and coded for the presence versus absence of different types of restriction that might impact the ability to conduct research. Results: All TOS stated that by accessing the website, users agreed to abide by the TOS (15/15, 100%). A total of 11 out of 15 (73%) websites had age restrictions in their TOS. All alcohol brand websites (5/15, 33%) required users to enter their age or date of birth before viewing website content. Both websites for tobacco brands (2/15, 13%) further required that users register and verify their age and identity to access any website content and agree that they use tobacco products. Only one website (1/15, 7%) allowed users to display, download, copy, distribute, and translate the website content as long as it was for personal and not commercial use. A total of 33% (5/15) of TOS unconditionally prohibited or put substantial restrictions on all of these activities and/or failed to specify if they were allowed or prohibited. Moreover, 87% (13/15) of TOS indicated that website access could be restricted at any time. A total of 73% (11/15) of websites specified that violating TOS could result in deleting user content from the website, revoking access by having the user’s Internet Protocol address blocked, terminating log-in credentials, or enforcing legal action resulting in civil or criminal penalties. Conclusions: TOS create complications for public health surveillance related to e-marketing on brand websites. Recent court opinions have reduced the risk of federal criminal charges for violating TOS on public websites, but this risk remains unclear for private websites. The public health community needs to establish standards to guide and protect researchers from the possibility of legal repercussions related to such efforts.

  • JMIR Public Health Surveill 2020;6(4):e23579

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  Innovative Methods in Public Health...

  Dec 2, 2020

  Outcomes of the Deployment of the Auto-Visual Acute Flaccid Paralysis Detection and Reporting (AVADAR) System for Strengthening Polio Surveillance in Africa...

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  Authors List:

  • Johnson Muluh Ticha  
  • Godwin Ubong Akpan  
  • Lara MF Paige  
  • Kamel Senouci  
  • Andrew Stein  
  • Patrick Briand  
  • Jude Tuma  
  • Daniel Rasheed Oyaole  
  • Reuben Ngofa  
  • Sylvester Maleghemi  
  • Kebba Touray  
  • Abdullahi Ahmed Salihu  
  • Mamadou Diallo  
  • Sisay Gashu Tegegne  
  • Isah Mohammed Bello  
  • Umar Kabo Idris  
  • Omosivie Maduka  
  • Casimir Manengu  
  • Faisal Shuaib  
  • Michael Galway  
  • Pascal Mkanda  

  Abstract:

  Background: As we move toward a polio-free world, the challenge for the polio program is to create an unrelenting focus on smaller areas where the virus is still present, where children are being repeatedly missed, where immunity levels are low, and where surveillance is weak. Objective: This article aimed to describe a possible solution to address weak surveillance systems and document the outcomes of the deployment of the Auto-Visual Acute Flaccid Paralysis Detection and Reporting (AVADAR) project. Methods: This intervention was implemented in 99 targeted high-risk districts with concerns for silent polio circulation from eight countries in Africa between August 1, 2017, and July 31, 2018. A total of 6954 persons (5390 community informants and 1564 health workers) were trained and equipped with a smartphone on which the AVADAR app was configured to allow community informants to send alerts on suspected acute flaccid paralysis (AFP) and allow health worker to use electronic checklists for investigation of such alerts. The AVADAR and Open Data Kit ONA servers were at the center of the entire process. A dashboard system and coordination teams for monitoring and supervision were put in place at all levels. Results: Overall, 96.44% (24,142/25,032) of potential AFP case alerts were investigated by surveillance personnel, yielding 1414 true AFP cases. This number (n=1414) reported through AVADAR was higher than the 238 AFP cases expected during the study period in the AVADAR districts and the 491 true AFP cases reported by the traditional surveillance system. A total of 203 out of the 1414 true AFP cases reported were from special population settings, such as refugee camps and insecure areas. There was an improvement in reporting in silent health areas in all the countries using the AVADAR system. Finally, there were 23,473 reports for other diseases, such as measles, diarrhea, and cerebrospinal meningitis, using the AVADAR platform. Conclusions: This article demonstrates the added value of AVADAR to rapidly improve surveillance sensitivity. AVADAR is capable of supporting countries to improve surveillance sensitivity within a short interval before and beyond polio-free certification.

  • JMIR Public Health Surveill 2020;6(4):e18950

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  Infoveillance, Infodemiology, Digital...

  Nov 30, 2020

  Social Media as a Research Tool (SMaaRT) for Risky Behavior Analytics: Methodological Review

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  Authors List:

  • Tavleen Singh  
  • Kirk Roberts  
  • Trevor Cohen  
  • Nathan Cobb  
  • Jing Wang  
  • Kayo Fujimoto  
  • Sahiti Myneni  

  Abstract:

  Background: Modifiable risky health behaviors, such as tobacco use, excessive alcohol use, being overweight, lack of physical activity, and unhealthy eating habits, are some of the major factors for developing chronic health conditions. Social media platforms have become indispensable means of communication in the digital era. They provide an opportunity for individuals to express themselves, as well as share their health-related concerns with peers and health care providers, with respect to risky behaviors. Such peer interactions can be utilized as valuable data sources to better understand inter-and intrapersonal psychosocial mediators and the mechanisms of social influence that drive behavior change. Objective: The objective of this review is to summarize computational and quantitative techniques facilitating the analysis of data generated through peer interactions pertaining to risky health behaviors on social media platforms. Methods: We performed a systematic review of the literature in September 2020 by searching three databases—PubMed, Web of Science, and Scopus—using relevant keywords, such as “social media,” “online health communities,” “machine learning,” “data mining,” etc. The reporting of the studies was directed by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Two reviewers independently assessed the eligibility of studies based on the inclusion and exclusion criteria. We extracted the required information from the selected studies. Results: The initial search returned a total of 1554 studies, and after careful analysis of titles, abstracts, and full texts, a total of 64 studies were included in this review. We extracted the following key characteristics from all of the studies: social media platform used for conducting the study, risky health behavior studied, the number of posts analyzed, study focus, key methodological functions and tools used for data analysis, evaluation metrics used, and summary of the key findings. The most commonly used social media platform was Twitter, followed by Facebook, QuitNet, and Reddit. The most commonly studied risky health behavior was nicotine use, followed by drug or substance abuse and alcohol use. Various supervised and unsupervised machine learning approaches were used for analyzing textual data generated from online peer interactions. Few studies utilized deep learning methods for analyzing textual data as well as image or video data. Social network analysis was also performed, as reported in some studies. Conclusions: Our review consolidates the methodological underpinnings for analyzing risky health behaviors and has enhanced our understanding of how social media can be leveraged for nuanced behavioral modeling and representation. The knowledge gained from our review can serve as a foundational component for the development of persuasive health communication and effective behavior modification technologies aimed at the individual and population levels.

  • JMIR Public Health Surveill 2020;6(4):e21660

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  Theme Issue 2020: Novel Coronavirus...

  Nov 27, 2020

  The Relationship Between Demographic, Socioeconomic, and Health-Related Parameters and the Impact of COVID-19 on 24 Regions in India: Exploratory...

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  • Ravi Philip Rajkumar  

  Abstract:

  Background: The impact of the COVID-19 pandemic has varied widely across nations and even in different regions of the same nation. Some of this variability may be due to the interplay of pre-existing demographic, socioeconomic, and health-related factors in a given population. Objective: The aim of this study was to examine the statistical associations between the statewise prevalence, mortality rate, and case fatality rate of COVID-19 in 24 regions in India (23 states and Delhi), as well as key demographic, socioeconomic, and health-related indices. Methods: Data on disease prevalence, crude mortality, and case fatality were obtained from statistics provided by the Government of India for 24 regions, as of June 30, 2020. The relationship between these parameters and the demographic, socioeconomic, and health-related indices of the regions under study was examined using both bivariate and multivariate analyses. Results: COVID-19 prevalence was negatively associated with male-to-female sex ratio (defined as the number of females per 1000 male population) and positively associated with the presence of an international airport in a particular state. The crude mortality rate for COVID-19 was negatively associated with sex ratio and the statewise burden of diarrheal disease, and positively associated with the statewise burden of ischemic heart disease. Multivariate analyses demonstrated that the COVID-19 crude mortality rate was significantly and negatively associated with sex ratio. Conclusions: These results suggest that the transmission and impact of COVID-19 in a given population may be influenced by a number of variables, with demographic factors showing the most consistent association.

  • JMIR Public Health Surveill 2020;6(4):e23083

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  Theme Issue 2020: Novel Coronavirus...

  Nov 23, 2020

  Leveraging a Cloud-Based Critical Care Registry for COVID-19 Pandemic Surveillance and Research in Low- and Middle-Income Countries

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  Authors List:

  • CRIT Care Asia
  • Madiha Hashmi  
  • Abi Beane  
  • Srinivas Murthy  
  • Arjen M Dondorp  
  • Rashan Haniffa  

  Abstract:

  The COVID-19 pandemic has revealed limitations in real-time surveillance needed for responsive health care action in low- and middle-income countries (LMICs). The Pakistan Registry for Intensive CarE (PRICE) was adapted to enable International Severe Acute Respiratory and emerging Infections Consortium (ISARIC)–compliant real-time reporting of severe acute respiratory infection (SARI). The cloud-based common data model and standardized nomenclature of the registry platform ensure interoperability of data and reporting between regional and global stakeholders. Inbuilt analytics enable stakeholders to visualize individual and aggregate epidemiological, clinical, and operational data in real time. The PRICE system operates in 5 of 7 administrative regions of Pakistan. The same platform supports acute and critical care registries in eleven countries in South Asia and sub-Saharan Africa. ISARIC-compliant SARI reporting was successfully implemented by leveraging the existing PRICE infrastructure in all 49 member intensive care units (ICUs), enabling clinicians, operational leads, and established stakeholders with responsibilities for coordinating the pandemic response to access real-time information on suspected and confirmed COVID-19 cases (N=592 as of May 2020) via secure registry portals. ICU occupancy rates, use of ICU resources, mechanical ventilation, renal replacement therapy, and ICU outcomes were reported through registry dashboards. This information has facilitated coordination of critical care resources, health care worker training, and discussions on treatment strategies. The PRICE network is now being recruited to international multicenter clinical trials regarding COVID-19 management, leveraging the registry platform. Systematic and standardized reporting of SARI is feasible in LMICs. Existing registry platforms can be adapted for pandemic research, surveillance, and resource planning.

  • JMIR Public Health Surveill 2020;6(4):e21939

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  Theme Issue 2020: Novel Coronavirus...

  Nov 17, 2020

  COVID-19 Surveillance in a Primary Care Sentinel Network: In-Pandemic Development of an Application Ontology

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  Authors List:

  • Simon de Lusignan  
  • Harshana Liyanage  
  • Dylan McGagh  
  • Bhautesh Dinesh Jani  
  • Jorgen Bauwens  
  • Rachel Byford  
  • Dai Evans  
  • Tom Fahey  
  • Trisha Greenhalgh  
  • Nicholas Jones  
  • Frances S Mair  
  • Cecilia Okusi  
  • Vaishnavi Parimalanathan  
  • Jill P Pell  
  • Julian Sherlock  
  • Oscar Tamburis  
  • Manasa Tripathy  
  • Filipa Ferreira  
  • John Williams  
  • F D Richard Hobbs  

  Abstract:

  Background: Creating an ontology for COVID-19 surveillance should help ensure transparency and consistency. Ontologies formalize conceptualizations at either the domain or application level. Application ontologies cross domains and are specified through testable use cases. Our use case was an extension of the role of the Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) to monitor the current pandemic and become an in-pandemic research platform. Objective: This study aimed to develop an application ontology for COVID-19 that can be deployed across the various use-case domains of the RCGP RSC research and surveillance activities. Methods: We described our domain-specific use case. The actor was the RCGP RSC sentinel network, the system was the course of the COVID-19 pandemic, and the outcomes were the spread and effect of mitigation measures. We used our established 3-step method to develop the ontology, separating ontological concept development from code mapping and data extract validation. We developed a coding system–independent COVID-19 case identification algorithm. As there were no gold-standard pandemic surveillance ontologies, we conducted a rapid Delphi consensus exercise through the International Medical Informatics Association Primary Health Care Informatics working group and extended networks. Results: Our use-case domains included primary care, public health, virology, clinical research, and clinical informatics. Our ontology supported (1) case identification, microbiological sampling, and health outcomes at an individual practice and at the national level; (2) feedback through a dashboard; (3) a national observatory; (4) regular updates for Public Health England; and (5) transformation of a sentinel network into a trial platform. We have identified a total of 19,115 people with a definite COVID-19 status, 5226 probable cases, and 74,293 people with possible COVID-19, within the RCGP RSC network (N=5,370,225). Conclusions: The underpinning structure of our ontological approach has coped with multiple clinical coding challenges. At a time when there is uncertainty about international comparisons, clarity about the basis on which case definitions and outcomes are made from routine data is essential.

  • JMIR Public Health Surveill 2020;6(4):e21434

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  Surveillance Systems

  Nov 17, 2020

  Availability and Quality of Surveillance and Survey Data on HIV Prevalence Among Sex Workers, Men Who Have Sex With Men, People Who Inject Drugs, and...

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  Authors List:

  • Sonia Arias Garcia  
  • Jia Chen  
  • Jesus Garcia Calleja  
  • Keith Sabin  
  • Chinelo Ogbuanu  
  • David Lowrance  
  • Jinkou Zhao  

  Abstract:

  Background: In 2019, 62% of new HIV infections occurred among key populations (KPs) and their sexual partners. The World Health Organization (WHO) recommends implementation of bio-behavioral surveys every 2-3 years to obtain HIV prevalence data for all KPs. However, the collection of these data is often less frequent and geographically limited. Objective: This study intended to assess the availability and quality of HIV prevalence data among sex workers (SWs), men who have sex with men (MSM), people who inject drugs, and transgender women (transwomen) in low- and middle-income countries. Methods: Data were obtained from survey reports, national reports, journal articles, and other grey literature available to the Global Fund, Joint United Nations Programme on HIV/AIDS, and WHO or from other open sources. Elements reviewed included names of subnational units, HIV prevalence, sampling method, and size. Based on geographical coverage, availability of trends over time, and recency of estimates, data were categorized by country and grouped as follows: nationally adequate, locally adequate but nationally inadequate, no recent data, no trends available, and no data. Results: Among the 123 countries assessed, 91.9% (113/123) presented at least 1 HIV prevalence data point for any KP; 78.0% (96/123) presented data for at least 2 groups; and 51.2% (63/123), for at least 3 groups. Data on all 4 groups were available for only 14.6% (18/123) of the countries. HIV prevalence data for SWs, MSM, people who inject drugs, and transwomen were available in 86.2% (106/123), 80.5% (99/123), 45.5% (56/123), and 23.6% (29/123) of the countries, respectively. Only 10.6% (13/123) of the countries presented nationally adequate data for any KP between 2001 and 2017; 6 for SWs; 2 for MSM; and 5 for people who inject drugs. Moreover, 26.8% (33/123) of the countries were categorized as locally adequate but nationally inadequate, mostly for SWs and MSM. No trend data on SWs and MSM were available for 38.2% (47/123) and 43.9% (54/123) of the countries, respectively, while no data on people who inject drugs and transwomen were available for 76.4% (94/123) and 54.5% (67/123) of the countries, respectively. An increase in the number of data points was observed for MSM and transwomen. Overall increases were noted in the number and proportions of data points, especially for MSM, people who inject drugs, and transwomen, with sample sizes exceeding 100. Conclusions: Despite general improvements in health data availability and quality, the availability of HIV prevalence data among the most vulnerable populations in low- and middle-income countries remains insufficient. Data collection should be expanded to include behavioral, clinical, and epidemiologic data through context-specific differentiated survey approaches while emphasizing data use for program improvements. Ending the HIV epidemic by 2030 is possible only if the epidemic is controlled among KPs.

  • JMIR Public Health Surveill 2020;6(4):e21688

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  Theme Issue 2020: Novel Coronavirus...

  Nov 16, 2020

  Reinfection with SARS-CoV-2: Discrete SIR (Susceptible, Infected, Recovered) Modeling Using Empirical Infection Data

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  Authors List:

  • Andrew McMahon  
  • Nicole C Robb  

  Abstract:

  Background: The novel coronavirus SARS-CoV-2, which causes the COVID-19 disease, has resulted in a global pandemic. Since its emergence in December 2019, the virus has infected millions of people, caused the deaths of hundreds of thousands, and resulted in incalculable social and economic damage. Understanding the infectivity and transmission dynamics of the virus is essential to determine how best to reduce mortality while ensuring minimal social restrictions on the lives of the general population. Anecdotal evidence is available, but detailed studies have not yet revealed whether infection with the virus results in immunity. Objective: The objective of this study was to use mathematical modeling to investigate the reinfection frequency of COVID-19. Methods: We have used the SIR (Susceptible, Infected, Recovered) framework and random processing based on empirical SARS-CoV-2 infection and fatality data from different regions to calculate the number of reinfections that would be expected to occur if no immunity to the disease occurred. Results: Our model predicts that cases of reinfection should have been observed by now if primary SARS-CoV-2 infection did not protect individuals from subsequent exposure in the short term; however, no such cases have been documented. Conclusions: This work concludes that infection with SARS-CoV-2 provides short-term immunity to reinfection and therefore offers useful insight for serological testing strategies, lockdown easing, and vaccine development.

  • JMIR Public Health Surveill 2020;6(4):e21168

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  Theme Issue 2020: Novel Coronavirus...

  Nov 13, 2020

  Analysis of the COVID-19 Epidemic Transmission Network in Mainland China: K-Core Decomposition Study

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  Authors List:

  • Lei Qin  
  • Yidan Wang  
  • Qiang Sun  
  • Xiaomei Zhang  
  • Ben-Chang Shia  
  • Chengcheng Liu  

  Abstract:

  Background: Since the outbreak of COVID-19 in December 2019 in Wuhan, Hubei Province, China, frequent interregional contacts and the high rate of infection spread have catalyzed the formation of an epidemic network. Objective: The aim of this study was to identify influential nodes and highlight the hidden structural properties of the COVID-19 epidemic network, which we believe is central to prevention and control of the epidemic. Methods: We first constructed a network of the COVID-19 epidemic among 31 provinces in mainland China; after some basic characteristics were revealed by the degree distribution, the k-core decomposition method was employed to provide static and dynamic evidence to determine the influential nodes and hierarchical structure. We then exhibited the influence power of the above nodes and the evolution of this power. Results: Only a small fraction of the provinces studied showed relatively strong outward or inward epidemic transmission effects. The three provinces of Hubei, Beijing, and Guangzhou showed the highest out-degrees, and the three highest in-degrees were observed for the provinces of Beijing, Henan, and Liaoning. In terms of the hierarchical structure of the COVID-19 epidemic network over the whole period, more than half of the 31 provinces were located in the innermost core. Considering the correlation of the characteristics and coreness of each province, we identified some significant negative and positive factors. Specific to the dynamic transmission process of the COVID-19 epidemic, three provinces of Anhui, Beijing, and Guangdong always showed the highest coreness from the third to the sixth week; meanwhile, Hubei Province maintained the highest coreness until the fifth week and then suddenly dropped to the lowest in the sixth week. We also found that the out-strengths of the innermost nodes were greater than their in-strengths before January 27, 2020, at which point a reversal occurred. Conclusions: Increasing our understanding of how epidemic networks form and function may help reduce the damaging effects of COVID-19 in China as well as in other countries and territories worldwide.

  • JMIR Public Health Surveill 2020;6(4):e24291

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  Letter to the Editor

  Nov 11, 2020

  Authors' Reply to: Errors in Tracing Coronavirus SARS-CoV-2 Transmission Using a Maximum Likelihood Tree. Comment on “A Snapshot of SARS-CoV-2 Genome...

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  Authors List:

  • Carla Mavian  
  • Simone Marini  
  • Mattia Prosperi  
  • Marco Salemi  

  Abstract:

  • JMIR Public Health Surveill 2020;6(4):e24661

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