Quantifying Poverty as a Driver of Ebola Transmission

Background

Poverty has been implicated as a challenge in the control of the current Ebola outbreak in West Africa. Although disparities between affected countries have been appreciated, disparities within West African countries have not been investigated as drivers of Ebola transmission. To quantify the role that poverty plays in the transmission of Ebola, we analyzed heterogeneity of Ebola incidence and transmission factors among over 300 communities, categorized by socioeconomic status (SES), within Montserrado County, Liberia.

Methodology/Principal Findings

We evaluated 4,437 Ebola cases reported between February 28, 2014 and December 1, 2014 for Montserrado County to determine SES-stratified temporal trends and drivers of Ebola transmission. A dataset including dates of symptom onset, hospitalization, and death, and specified community of residence was used to stratify cases into high, middle and low SES. Additionally, information about 9,129 contacts was provided for a subset of 1,585 traced individuals. To evaluate transmission within and across socioeconomic subpopulations, as well as over the trajectory of the outbreak, we analyzed these data with a time-dependent stochastic model. Cases in the most impoverished communities reported three more contacts on average than cases in high SES communities (p<0.001). Our transmission model shows that infected individuals from middle and low SES communities were associated with 1.5 (95% CI: 1.4–1.6) and 3.5 (95% CI: 3.1–3.9) times as many secondary cases as those from high SES communities, respectively. Furthermore, most of the spread of Ebola across Montserrado County originated from areas of lower SES.

Conclusions/Significance

Individuals from areas of poverty were associated with high rates of transmission and spread of Ebola to other regions. Thus, Ebola could most effectively be prevented or contained if disease interventions were targeted to areas of extreme poverty and funding was dedicated to development projects that meet basic needs.     

The Impact of the West Africa Ebola Outbreak on Obstetric Health Care in Sierra Leone

Background

As Sierra Leone celebrates the end of the Ebola Virus Disease (EVD) outbreak, we can begin to fully grasp its impact on already weak health systems. The EVD outbreak in West Africa forced many hospitals to close down or reduce their activity, either to prevent nosocomial transmission or because of staff shortages. The aim of this study is to assess the potential impact of EVD on nationwide access to obstetric care in Sierra Leone.

Methods and Findings

Community health officers collected weekly data between January 2014—May 2015 on in-hospital deliveries and caesarean sections (C-sections) from all open facilities (public, private for-profit and private non-profit sectors) offering emergency obstetrics in Sierra Leone. This was compared to official data of EVD cases per district. Logistic and Poisson regression analyses were used to compute risk and rate estimates. Nationwide, the number of in-hospital deliveries and C-sections decreased by over 20% during the EVD outbreak. The decline occurred early on in the EVD outbreak and was mainly attributable to the closing of private not-for-profit hospitals rather than government facilities. Due to difficulties in collecting data in the midst of an epidemic, limitations of this study include some missing data points.

Conclusions

Both the number of in-hospital deliveries and C-sections substantially declined shortly after the onset of the EVD outbreak. Since access to emergency obstetric care, like C-sections, is associated with decreased maternal mortality, many women are likely to have died due to the reduced access to appropriate care during childbirth. Future research on indirect health effects of health system breakdown should ideally be nationwide and continue also into the recovery phase. It is also important to understand the mechanisms behind the deterioration so that important health services can be reestablished.     

Effectiveness of Personal Protective Equipment for Healthcare Workers Caring for Patients with Filovirus Disease: A Rapid Review

Background

A rapid review, guided by a protocol, was conducted to inform development of the World Health Organization’s guideline on personal protective equipment in the context of the ongoing (2013–present) Western African filovirus disease outbreak, with a focus on health care workers directly caring for patients with Ebola or Marburg virus diseases.

Methods

Electronic databases and grey literature sources were searched. Eligibility criteria initially included comparative studies on Ebola and Marburg virus diseases reported in English or French, but criteria were expanded to studies on other viral hemorrhagic fevers and non-comparative designs due to the paucity of studies. After title and abstract screening (two people to exclude), full-text reports of potentially relevant articles were assessed in duplicate. Fifty-seven percent of extraction information was verified. The Grading of Recommendations Assessment, Development and Evaluation framework was used to inform the quality of evidence assessments.

Results

Thirty non-comparative studies (8 related to Ebola virus disease) were located, and 27 provided data on viral transmission. Reporting of personal protective equipment components and infection prevention and control protocols was generally poor.

Conclusions

Insufficient evidence exists to draw conclusions regarding the comparative effectiveness of various types of personal protective equipment. Additional research is urgently needed to determine optimal PPE for health care workers caring for patients with filovirus.     

Information Accessibility of the Charcoal Burning Suicide Method in Mainland China

Background

There has been a marked rise in suicide by charcoal burning (CB) in some East Asian countries but little is known about its incidence in mainland China. We examined media-reported CB suicides and the availability of online information about the method in mainland China.

Methods

We extracted and analyzed data for i) the characteristics and trends of fatal and nonfatal CB suicides reported by mainland Chinese newspapers (1998–2014); ii) trends and geographic variations in online searches using keywords relating to CB suicide (2011–2014); and iii) the content of Internet search results.

Results

109 CB suicide attempts (89 fatal and 20 nonfatal) were reported by newspapers in 13 out of the 31 provinces or provincial-level-municipalities in mainland China. There were increasing trends in the incidence of reported CB suicides and in online searches using CB-related keywords. The province-level search intensities were correlated with CB suicide rates (Spearman’s correlation coefficient = 0.43 [95% confidence interval: 0.08–0.68]). Two-thirds of the web links retrieved using the search engine contained detailed information about the CB suicide method, of which 15% showed pro-suicide attitudes, and the majority (86%) did not encourage people to seek help.

Limitations

The incidence of CB suicide was based on newspaper reports and likely to be underestimated.

Conclusions

Mental health and suicide prevention professionals in mainland China should be alert to the increased use of this highly lethal suicide method. Better surveillance and intervention strategies need to be developed and implemented.     

Engagement with Health Agencies on Twitter

Objective

To investigate factors associated with engagement of U.S. Federal Health Agencies via Twitter. Our specific goals are to study factors related to a) numbers of retweets, b) time between the agency tweet and first retweet and c) time between the agency tweet and last retweet.

Methods

We collect 164,104 tweets from 25 Federal Health Agencies and their 130 accounts. We use negative binomial hurdle regression models and Cox proportional hazards models to explore the influence of 26 factors on agency engagement. Account features include network centrality, tweet count, numbers of friends, followers, and favorites. Tweet features include age, the use of hashtags, user-mentions, URLs, sentiment measured using Sentistrength, and tweet content represented by fifteen semantic groups.

Results

A third of the tweets (53,556) had zero retweets. Less than 1% (613) had more than 100 retweets (mean  = 284). The hurdle analysis shows that hashtags, URLs and user-mentions are positively associated with retweets; sentiment has no association with retweets; and tweet count has a negative association with retweets. Almost all semantic groups, except for geographic areas, occupations and organizations, are positively associated with retweeting. The survival analyses indicate that engagement is positively associated with tweet age and the follower count.

Conclusions

Some of the factors associated with higher levels of Twitter engagement cannot be changed by the agencies, but others can be modified (e.g., use of hashtags, URLs). Our findings provide the background for future controlled experiments to increase public health engagement via Twitter.     

Health Insurance Status as a Barrier to Ideal Cardiovascular Health for U.S. Adults: Data from the National Health and Nutrition Examination Survey (NHANES)

Background

Little is known about the association between cardiovascular (CV) health and health insurance status. We hypothesized that U.S. adults without health insurance coverage would have a lower likelihood of ideal cardiovascular health.

Methods and Results

Using National Health and Nutrition Examination Survey (NHANES) data from 2007–2010, we examined the relationship between health insurance status and ideal CV health in U.S. adults aged ≥19 years and <65 (N = 3304). Ideal CV health was defined by the American Heart Association (AHA) as the absence of clinically manifested CV disease and the simultaneous presence of 6–7 “ideal” CV health factors and behaviors. Logistic regression modeling was used to determine the relationship between health insurance status and the odds of ideal CV health. Of the U.S. adult population, 5.4% attained ideal CV health, and 23.5% were without health insurance coverage. Those without health insurance coverage were more likely to be young (p<0.0001), male (p<0.0001), non-white (p<0.0001), with less than a high school degree (p<0.0001), have a poverty-to-income ratio less than 1 (p<0.0001) and unemployed (p<0.0001) compared to those with coverage. Lack of health insurance coverage was associated with a lower likelihood of ideal CV health; however, this relationship was attenuated by socioeconomic status.

Conclusions

U.S. adults without health insurance coverage are less likely to have ideal CV health. Population-based strategies and interventions directed at the community-level may be one way to improve overall CV health and reach this at-risk group.     

Social Media and Internet Driven Study Recruitment: Evaluating a New Model for Promoting Collaborator Engagement and Participation

Aims

A substantial challenge facing multicentre audit and research projects is timely recruitment of collaborators and their study centres. Cost-effective strategies are required and fee-free social media has previously been identified as a potential conduit. We investigated and evaluated the effectiveness of a novel multi-format social media and Internet strategy for targeted recruitment to a national multicentre cohort study.

Methods

Interventions involved a new Twitter account, including weekly live question-and-answer sessions, a new Facebook group page, online YouTube presentations and an information page on a national association website. Link tracking analysis was undertaken using Google Analytics, which was then related to subsequent registration. Social influence was calculated using the proprietary Klout score.

Results

Internet traffic analysis identified a total of 1562 unique registration site views, of which 285 originated from social media (18.2%). Some 528 unique registrations were received, with 96 via social media platforms (18.2%). Traffic source analysis identified a separate national association webpage as resulting in the majority of registration page views (15.8%), followed by Facebook (11.9%), Twitter (4.8%) and YouTube (1.5%). A combination of publicity through Facebook, Twitter and the dedicated national association webpage contributed to the greatest rise in registration traffic and accounted for 312 (48%) of the total registrations within a 2-week period. A Twitter ‘social influence’ (Klout) score of 42/100 was obtained during this period.

Conclusions

Targeted social media substantially aided study dissemination and collaborator recruitment. It acted as an adjunct to traditional methods, accounting for 18.2% of collaborator registration in a short time period with no associated financial costs. We provide a practical model for designing future recruitment campaigns, and recommend Facebook, Twitter and targeted websites as the most effective adjuncts for maximising cost-effective study recruitment.     

Interpretation of Results of Studies Evaluating an Intervention Highlighted in Google Health News: A Cross-Sectional Study of News

Background

Mass media through the Internet is a powerful means of disseminating medical research. We aimed to determine whether and how the interpretation of research results is misrepresented by the use of “spin” in the health section of Google News. Spin was defined as specific way of reporting, from whatever motive (intentional or unintentional), to emphasize that the beneficial effect of the intervention is greater than that shown by the results.

Methods

We conducted a cross-sectional study of news highlighted in the health section of US, UK and Canada editions of Google News between July 2013 and January 2014. We searched for news items for 3 days a week (i.e., Monday, Wednesday, and Friday) during 6 months and selected a sample of 130 news items reporting a scientific article evaluating the effect of an intervention on human health.

Results

In total, 78% of the news did not provide a full reference or electronic link to the scientific article. We found at least one spin in 114 (88%) news items and 18 different types of spin in news. These spin were mainly related to misleading reporting (59%) such as not reporting adverse events that were reported in the scientific article (25%), misleading interpretation (69%) such as claiming a causal effect despite non-randomized study design (49%) and overgeneralization/misleading extrapolation (41%) of the results such as extrapolating a beneficial effect from an animal study to humans (21%). We also identified some new types of spin such as highlighting a single patient experience for the success of a new treatment instead of focusing on the group results.

Conclusions

Interpretation of research results was frequently misrepresented in the health section of Google News. However, we do not know whether these spin were from the scientific articles themselves or added in the news.     

Presence and Persistence of Ebola or Marburg Virus in Patients and Survivors: A Rapid Systematic Review

Background

The 2013–15 Ebola outbreak was unprecedented due to sustained transmission within urban environments and thousands of survivors. In 2014 the World Health Organization stated that there was insufficient evidence to give definitive guidance about which body fluids are infectious and when they pose a risk to humans. We report a rapid systematic review of published evidence on the presence of filoviruses in body fluids of infected people and survivors.

Methods

Scientific articles were screened for information about filovirus in human body fluids. The aim was to find primary data that suggested high likelihood of actively infectious filovirus in human body fluids (viral RNA). Eligible infections were from Marburg virus (MARV or RAVV) and Zaire, Sudan, Taï Forest and Bundibugyo species of Ebola. Cause of infection had to be laboratory confirmed (in practice either tissue culture or RT-PCR tests), or evidenced by compatible clinical history with subsequent positivity for filovirus antibodies or inflammatory factors. Data were extracted and summarized narratively.

Results

6831 unique articles were found, and after screening, 33 studies were eligible. For most body fluid types there were insufficient patients to draw strong conclusions, and prevalence of positivity was highly variable. Body fluids taken >16 days after onset were usually negative. In the six studies that used both assay methods RT-PCR tests for filovirus RNA gave positive results about 4 times more often than tissue culture.

Conclusions

Filovirus was reported in most types of body fluid, but not in every sample from every otherwise confirmed patient. Apart from semen, most non-blood, RT-PCR positive samples are likely to be culture negative and so possibly of low infectious risk. Nevertheless, it is not apparent how relatively infectious many body fluids are during or after illness, even when culture-positive, not least because most test results come from more severe cases. Contact with blood and blood-stained body fluids remains the major risk for disease transmission because of the known high viral loads in blood.     

A Survey of UK Healthcare Workers’ Attitudes on Volunteering to Help with the Ebola Outbreak in West Africa

Objective

To understand the barriers and enablers for UK healthcare workers who are considering going to work in the current Ebola outbreak in West Africa, but have not yet volunteered.

Design

After focus group discussions, and a pilot questionnaire, an anonymous survey was conducted using SurveyMonkey to determine whether people had considered going to West Africa, what factors might make them more or less likely to volunteer, and whether any of these were modifiable factors.

Participants

The survey was publicised among doctors, nurses, laboratory staff and allied health professionals. 3109 people answered the survey, of whom 472 (15%) were considering going to work in the epidemic but had not yet volunteered. 1791 (57.6%) had not considered going, 704 (22.6%) had considered going but decided not to, 53 (1.7%) had volunteered to go and 14 (0.45%) had already been and worked in the epidemic.

Results

For those considering going to West Africa, the most important factor preventing them from volunteering was a lack of information to help them decide; fear of getting Ebola and partners’ concerns came next. Uncertainty about their potential role, current work commitments and inability to get agreement from their employer were also important barriers, whereas clarity over training would be an important enabler. In contrast, for those who were not considering going, or who had decided against going, family considerations and partner concerns were the most important factors.

Conclusions

More UK healthcare workers would volunteer to help tackle Ebola in West Africa if there was better information available, including clarity about roles, cover arrangements, and training. This could be achieved with a well-publicised high quality portal of reliable information.     

A Multi-Site Knowledge Attitude and Practice Survey of Ebola Virus Disease in Nigeria

Background

The 2014 Ebola Virus Disease (EVD) outbreak was characterised by fear, misconceptions and irrational behaviours. We conducted a knowledge attitude and practice survey of EVD in Nigeria to inform implementation of effective control measures.

Methods

Between July 30^th and September 30^th 2014, we undertook a cross sectional study on knowledge, attitude and practice (KAP) of Ebola Virus Disease (EVD) among adults of the general population and healthcare workers (HCW) in three states of Nigeria, namely Bayelsa, Cross River and Kano states. Demographic information and data on KAP were obtained using a self-administered standardized questionnaire. The percentage KAP scores were categorised as good and poor. Independent predictors of good knowledge of EVD were ascertained using a binary logistic regression model.

Results

Out of 1035 study participants with median age of 32 years, 648 (62.6%) were males, 846 (81.7%) had tertiary education and 441 (42.6%) were HCW. There were 218, 239 and 578 respondents from Bayelsa, Cross River and Kano states respectively. The overall median percentage KAP scores and interquartile ranges (IQR) were 79.46% (15.07%), 95.0% (33.33%) and 49.95% (37.50%) respectively. Out of the 1035 respondents, 470 (45.4%), 544(52.56%) and 252 (24.35%) had good KAP of EVD defined using 80%, 90% and 70% score cut-offs respectively. Independent predictors of good knowledge of EVD were being a HCW (Odds Ratio-OR-2.89, 95% Confidence interval-CI of 1.41–5.90), reporting ‘moderate to high fear of EVD’ (OR-2.15, 95% CI-(1.47–3.13) and ‘willingness to modify habit’ (OR-1.68, 95% CI-1.23–2.30).

Conclusion

Our results reveal suboptimal EVD-related knowledge, attitude and practice among adults in Nigeria. To effectively control future outbreaks of EVD in Nigeria, there is a need to implement public sensitization programmes that improve understanding of EVD and address EVD-related myths and misconceptions, especially among the general population.     

Assessing the Impact of the National Smoking Ban in Indoor Public Places in China: Evidence from Quit Smoking Related Online Searches

Background

Despite the tremendous economic and health costs imposed on China by tobacco use, China lacks a proactive and systematic tobacco control surveillance and evaluation system, hampering research progress on tobacco-focused surveillance and evaluation studies.

Methods

This paper uses online search query analyses to investigate changes in online search behavior among Chinese Internet users in response to the adoption of the national indoor public place smoking ban. Baidu Index and Google Trends were used to examine the volume of search queries containing three key search terms “Smoking Ban(s),” “Quit Smoking,” and “Electronic Cigarette(s),” along with the news coverage on the smoking ban, for the period 2009–2011.

Findings

Our results show that the announcement and adoption of the indoor public place smoking ban in China generated significant increases in news coverage on smoking bans. There was a strong positive correlation between the media coverage of smoking bans and the volume of “Smoking Ban(s)” and “Quit Smoking” related search queries. The volume of search queries related to “Electronic Cigarette(s)” was also correlated with the smoking ban news coverage.

Interpretation

To the extent it altered smoking-related online searches, our analyses suggest that the smoking ban had a significant effect, at least in the short run, on Chinese Internet users’ smoking-related behaviors. This research introduces a novel analytic tool, which could serve as an alternative tobacco control evaluation and behavior surveillance tool in the absence of timely or comprehensive population surveillance system. This research also highlights the importance of a comprehensive approach to tobacco control in China.     

Media Coverage,Journal Press Releases and Editorials Associated with Randomized and Observational Studies in High-Impact Medical Journals: A Cohort Study

Background

Publication of clinical research findings in prominent journals influences health beliefs and medical practice, in part by engendering news coverage. Randomized controlled trials (RCTs) should be most influential in guiding clinical practice. We determined whether study design of clinical research published in high-impact journals influences media coverage.

Methods and Findings

We compared the incidence and amount of media coverage of RCTs with that of observational studies published in the top 7 medical journals between 1 January 2013 and 31 March 2013. We specifically assessed media coverage of the most rigorous RCTs, those with >1000 participants that reported ‘hard’ outcomes. There was no difference between RCTs and observational studies in coverage by major newspapers or news agencies, or in total number of news stories generated (all P>0.63). Large RCTs reporting ‘hard’ outcomes did not generate more news coverage than small RCTs that reported surrogate outcomes and observational studies (all P>0.32). RCTs were more likely than observational studies to attract a journal editorial (70% vs 46%, P = 0.003), but less likely to be the subject of a journal press release (17% vs 50%, P<0.001). Large RCTs that reported ‘hard’ outcomes did not attract an editorial more frequently than other studies (61% vs 58%, P>0.99), nor were they more likely to be the subject of a journal press release (14% vs 38%, P = 0.14).

Conclusions

The design of clinical studies whose results are published in high-impact medical journals is not associated with the likelihood or amount of ensuing news coverage.     

Does Twitter Trigger Bursts in Signature Collections?

Introduction

The quantification of social media impacts on societal and political events is a difficult undertaking. The Japanese Society of Oriental Medicine started a signature-collecting campaign to oppose a medical policy of the Government Revitalization Unit to exclude a traditional Japanese medicine, “Kampo,” from the public insurance system. The signature count showed a series of aberrant bursts from November 26 to 29, 2009. In the same interval, the number of messages on Twitter including the keywords “Signature” and “Kampo,” increased abruptly. Moreover, the number of messages on an Internet forum that discussed the policy and called for signatures showed a train of spikes.

Methods and Findings

In order to estimate the contributions of social media, we developed a statistical model with state-space modeling framework that distinguishes the contributions of multiple social media in time-series of collected public opinions. We applied the model to the time-series of signature counts of the campaign and quantified contributions of two social media, i.e., Twitter and an Internet forum, by the estimation. We found that a considerable portion (78%) of the signatures was affected from either of the social media throughout the campaign and the Twitter effect (26%) was smaller than the Forum effect (52%) in total, although Twitter probably triggered the initial two bursts of signatures. Comparisons of the estimated profiles of the both effects suggested distinctions between the social media in terms of sustainable impact of messages or tweets. Twitter shows messages on various topics on a time-line; newer messages push out older ones. Twitter may diminish the impact of messages that are tweeted intermittently.

Conclusions

The quantification of social media impacts is beneficial to better understand people’s tendency and may promote developing strategies to engage public opinions effectively. Our proposed method is a promising tool to explore information hidden in social phenomena.     

Spatiotemporal Evolution of Ebola Virus Disease at Sub-National Level during the 2014 West Africa Epidemic: Model Scrutiny and Data Meagreness

Background

The Ebola outbreak in West Africa has infected at least 27,443 individuals and killed 11,207, based on data until 24 June, 2015, released by the World Health Organization (WHO). This outbreak has been characterised by extensive geographic spread across the affected countries Guinea, Liberia and Sierra Leone, and by localized hotspots within these countries. The rapid recognition and quantitative assessment of localised areas of higher transmission can inform the optimal deployment of public health resources.

Methods

A variety of mathematical models have been used to estimate the evolution of this epidemic, and some have pointed out the importance of the spatial heterogeneity apparent from incidence maps. However, little is known about the district-level transmission. Given that many response decisions are taken at sub-national level, the current study aimed to investigate the spatial heterogeneity by using a different modelling framework, built on publicly available data at district level. Furthermore, we assessed whether this model could quantify the effect of intervention measures and provide predictions at a local level to guide public health action. We used a two-stage modelling approach: a) a flexible spatiotemporal growth model across all affected districts and b) a deterministic SEIR compartmental model per district whenever deemed appropriate.

Findings

Our estimates show substantial differences in the evolution of the outbreak in the various regions of Guinea, Liberia and Sierra Leone, illustrating the importance of monitoring the outbreak at district level. We also provide an estimate of the time-dependent district-specific effective reproduction number, as a quantitative measure to compare transmission between different districts and give input for informed decisions on control measures and resource allocation. Prediction and assessing the impact of control measures proved to be difficult without more accurate data. In conclusion, this study provides us a useful tool at district level for public health, and illustrates the importance of collecting and sharing data.     

Diffusion of Messages from an Electronic Cigarette Brand to Potential Users through Twitter

Objective

This study explores the presence and actions of an electronic cigarette (e-cigarette) brand, Blu, on Twitter to observe how marketing messages are sent and diffused through the retweet (i.e., message forwarding) functionality. Retweet networks enable messages to reach additional Twitter users beyond the sender’s local network. We follow messages from their origin through multiple retweets to identify which messages have more reach, and the different users who are exposed.

Methods

We collected three months of publicly available data from Twitter. A combination of techniques in social network analysis and content analysis were applied to determine the various networks of users who are exposed to e-cigarette messages and how the retweet network can affect which messages spread.

Results

The Blu retweet network expanded during the study period. Analysis of user profiles combined with network cluster analysis showed that messages of certain topics were only circulated within a community of e-cigarette supporters, while other topics spread further, reaching more general Twitter users who may not support or use e-cigarettes.

Conclusions

Retweet networks can serve as proxy filters for marketing messages, as Twitter users decide which messages they will continue to diffuse among their followers. As certain e-cigarette messages extend beyond their point of origin, the audience being exposed expands beyond the e-cigarette community. Potential implications for health education campaigns include utilizing Twitter and targeting important gatekeepers or hubs that would maximize message diffusion.     

Smoking or My Job? US Media Coverage of Nonsmoker-Only Hiring Policies

Objectives

Media advocacy plays a critical role in tobacco control, shaping the content of news in ways that generate public support for tobacco control. We examined US media coverage of nonsmoker-only hiring policies, which have little US public support, exploring the extent to which tobacco control advocates and experts have engaged the media on this controversial issue.

Methods

We searched online media databases (Lexis Nexis, Access World News, and Proquest) for articles published from 1995–2013, coding retrieved items through a collaborative, iterative process. We analyzed the volume, type, provenance, prominence, content and slant of coverage.

Results

We found 1,159 media items on nonsmoker-only hiring policies, most published in local newspapers in regions where such policies were enacted. The most common reason given for implementing such policies was to reduce healthcare costs. Most news items offered reasons both to support and oppose such policies; thus, the slant of the majority of news items was neutral or mixed. Tobacco control advocates or experts were infrequently cited or quoted in news items, and rarely authored opinion pieces. Those who expressed opinions were more likely to support than oppose nonsmoker-only hiring policies, for economic and health reasons. Ethical concerns about the policies were seldom raised.

Conclusions

As presented in the media, nonsmoker-only hiring policies were primarily framed in terms of business cost savings and had little connection to health initiatives. Tobacco control advocates were rarely quoted and their positions were not consistent. Given their intrusiveness and the lack of strong evidence that such business policies actually do improve worker health, tobacco control advocates may feel that the status quo is preferable to engaging on a policy that the majority of Americans dislike.     

Pandemics in the age of Twitter: content analysis of Tweets during the 2009 H1N1 outbreak

Background

Surveys are popular methods to measure public perceptions in emergencies but can be costly and time consuming. We suggest and evaluate a complementary “infoveillance” approach using Twitter during the 2009 H1N1 pandemic. Our study aimed to: 1) monitor the use of the terms “H1N1” versus “swine flu” over time; 2) conduct a content analysis of “tweets”; and 3) validate Twitter as a real-time content, sentiment, and public attention trend-tracking tool.

Methodology/Principal Findings

Between May 1 and December 31, 2009, we archived over 2 million Twitter posts containing keywords “swine flu,” “swineflu,” and/or “H1N1.” using Infovigil, an infoveillance system. Tweets using “H1N1” increased from 8.8% to 40.5% (R ² = .788; p<.001), indicating a gradual adoption of World Health Organization-recommended terminology. 5,395 tweets were randomly selected from 9 days, 4 weeks apart and coded using a tri-axial coding scheme. To track tweet content and to test the feasibility of automated coding, we created database queries for keywords and correlated these results with manual coding. Content analysis indicated resource-related posts were most commonly shared (52.6%). 4.5% of cases were identified as misinformation. News websites were the most popular sources (23.2%), while government and health agencies were linked only 1.5% of the time. 7/10 automated queries correlated with manual coding. Several Twitter activity peaks coincided with major news stories. Our results correlated well with H1N1 incidence data.

Conclusions

This study illustrates the potential of using social media to conduct “infodemiology” studies for public health. 2009 H1N1-related tweets were primarily used to disseminate information from credible sources, but were also a source of opinions and experiences. Tweets can be used for real-time content analysis and knowledge translation research, allowing health authorities to respond to public concerns.