title: The complex relationship of realspace events and messages in cyberspace: case study of influenza and pertussis using tweets.
abstract: BACKGROUND
  Surveillance plays a vital role in disease detection, but traditional methods of collecting patient data, reporting to health officials, and compiling reports are costly and time consuming. In recent years, syndromic surveillance tools have expanded and researchers are able to exploit the vast amount of data available in real time on the Internet at minimal cost. Many data sources for infoveillance exist, but this study focuses on status updates (tweets) from the Twitter microblogging website.
  
  
  OBJECTIVE
  The aim of this study was to explore the interaction between cyberspace message activity, measured by keyword-specific tweets, and real world occurrences of influenza and pertussis. Tweets were aggregated by week and compared to weekly influenza-like illness (ILI) and weekly pertussis incidence. The potential effect of tweet type was analyzed by categorizing tweets into 4 categories: nonretweets, retweets, tweets with a URL Web address, and tweets without a URL Web address.
  
  
  METHODS
  Tweets were collected within a 17-mile radius of 11 US cities chosen on the basis of population size and the availability of disease data. Influenza analysis involved all 11 cities. Pertussis analysis was based on the 2 cities nearest to the Washington State pertussis outbreak (Seattle, WA and Portland, OR). Tweet collection resulted in 161,821 flu, 6174 influenza, 160 pertussis, and 1167 whooping cough tweets. The correlation coefficients between tweets or subgroups of tweets and disease occurrence were calculated and trends were presented graphically.
  
  
  RESULTS
  Correlations between weekly aggregated tweets and disease occurrence varied greatly, but were relatively strong in some areas. In general, correlation coefficients were stronger in the flu analysis compared to the pertussis analysis. Within each analysis, flu tweets were more strongly correlated with ILI rates than influenza tweets, and whooping cough tweets correlated more strongly with pertussis incidence than pertussis tweets. Nonretweets correlated more with disease occurrence than retweets, and tweets without a URL Web address correlated better with actual incidence than those with a URL Web address primarily for the flu tweets.
  
  
  CONCLUSIONS
  This study demonstrates that not only does keyword choice play an important role in how well tweets correlate with disease occurrence, but that the subgroup of tweets used for analysis is also important. This exploratory work shows potential in the use of tweets for infoveillance, but continued efforts are needed to further refine research methods in this field.
authors.affiliation: Graduate School of Public Health, San Diego State University, San Diego, CA, United States.
authors.forename: Anna C
authors.initials: AC
authors.lastname: Nagel
authors.forename: Ming-Hsiang
authors.initials: MH
authors.lastname: Tsou
authors.forename: Brian H
authors.initials: BH
authors.lastname: Spitzberg
authors.forename: Li
authors.initials: L
authors.lastname: An
authors.forename: J Mark
authors.initials: JM
authors.lastname: Gawron
authors.forename: Dipak K
authors.initials: DK
authors.lastname: Gupta
authors.forename: Jiue-An
authors.initials: JA
authors.lastname: Yang
authors.forename: Su
authors.initials: S
authors.lastname: Han
authors.forename: K Michael
authors.initials: KM
authors.lastname: Peddecord
authors.forename: Suzanne
authors.initials: S
authors.lastname: Lindsay
authors.forename: Mark H
authors.initials: MH
authors.lastname: Sawyer
mesh_terms: D006801:Humans; D015994:Incidence; D007251:Influenza, Human / Q000453:epidemiology*; D020407:Internet; D014917:Whooping Cough / Q000453:epidemiology*
keywords: Twitter; cyberspace; influenza; infodemiology; infoveillance; pertussis; syndromic surveillance; whooping cough