Mass Gatherings, Implications for Public Health and Planning

Dr Tim HealingDip.Clin.Micro, DMCC, CBIOL, FRSB, FZS

Course Director, Course in Conflict and Catastrophe Medicine

Worshipful Society of Apothecaries of LondonFaculty of Conflict and Catastrophe Medicine

What is a Mass

Gathering?

• A large number of persons (usually >1000) at a specific location for a specific purpose (usually) for a defined period of time

• An event, (organised or unplanned) is a MG if the numbers attending are sufficient to strain the planning and response resources of the community, state or nation hosting the event

Is a refugee camp effectively a Mass Gathering?

Mass gatherings are a stress test for public health. Crowds, and the infrastructures that

support them, can be an ideal setting for outbreaks of disease.

Dr Margaret Chan, Former Director-General of WHO

Types of Mass Gathering

Spontaneous (e.g. Riots)

Planned

Recurrent events

different locations

(e.g. Olympics, World Cup)

Recurrent event

same location

(e.g. Hajj, Wimbledon)

Mass Gatherings

One-off events

(e.g. Jubilee party, River pagent)

Event

Two meanings dependent on context.

1. A type of MG, such as:

– An organized occasion• social function, sports competition, political, religious or cultural gathering

– A series of individual sports competitions conducted together under one ruling body • (e.g. the Olympic Games)

– An individual sports contest• part of a larger sports occasion such as the Olympic Games.

2. A manifestation of disease or an occurrence that creates a potential for disease (International Health Regulations (IHR) 2005).

A large MGGenerally requires:

– substantial investment, capacity building, infrastructure development

– institutional adaptation

– SOPs for potential threats

– advance testing of plans, procedures, systems & personnel

– extensive training

These can be difficult to achieve in resource poor settings

– Cost of London Olympics was ca. $18 billion

– Annual govt expenditure in Sierra Leone ca. $880 million

Preparation for a Mass Gathering

Need to alter/develop public health & other sectors depends largely on:

– numbers of persons involved• attendees• participants• staff

– type of gathering• at a fixed location/spread out?• nature of gathering (affects types of attendees)

– perceived risk(s) or threat(s)

– resources available to support:• the needs of the participants• the identified health concerns

Other factors

• Pressure on infrastructure – hotels, food caterers– transport systems – accommodation– public health system

• International attention – media

• Security/terrorist threats

International norms and standards

International instruments like the IHR (2005) must be implemented in full -international health risks are real

– Key to international perception of the country's MG preparedness

– Covers issues concerning travel and health, point of entry health, notifications, vaccinations status, etc.

A safe and healthy MG requires:

Early multi-sectoral preparation involving:

• event organizers

• health emergency managers

• public health authority representatives

• local hospital emergency departments

• first-aid personnel

• other sectoral partners– police– emergency services– security services

Planning framework for a large MGShould include:• High-level committee/steering group•

• Issue-specific sub committees

• Cross-representation between:– those planning the health care response – those responsible for emergency preparedness and

disaster planning

• Clear delineation of – roles and responsibilities– command, control, coordination & communication

structures for managing the planning, operational & evaluation phases of the MG.

Health Planning

• Integral part of the overall planning process for the MG

• Plan to respond to anything that can happen at the event

AND

• Continue with all routine health protection work

Mass Gatherings – Key Planning Steps

• Risk Assessment: What might happen?

• Surveillance: How will we know when it happens?

• Response: What will we do if it happens?

Risk• Mainly a function of two variables:

– the probability of an event occurring (likelihood)– the effects of that event (impact)

• Likelihood : determined by the context of the mass gathering including:– venues– environmental risks– known disease patterns in host country, visitor’s countries– attendees’ likely immunity to infection, etc.

• Impact: base your assessment on:– the state of public health in the host country– surveillance data– experience,– literature, – expert judgment

MGs and Risk

• In a MG the risks may be amplified by factors:

– high visibility of the gathering

– occurs over a defined time & at defined locations

– wide range of visitors, participants (e.g. athletes) & VIPs

– routine surveillance systems, rescue services & clinical & public health services will be stretched

Risk assessment

Advanced risk assessment and system enhancement are critical for:

• identifying potential public health risks - natural & manmade

• preventing, minimizing & responding to public health emergencies

A risk assessment for a MG

Informs selection & implementation of risk reduction measures, response planning, & capacity development for health functions, including:

– Mass casualty management

– On-site trauma care & local hospitals

– Disease surveillance & outbreak response

– Environmental health & food safety

– Public information & health promotion

– Leadership, coordination & communication

– Emergency preparedness & response to:• natural hazards• transport crashes• structural collapse• stampedes• security incidents

The risk assessment:Identify population-related, visitor-related & environmental risk factors, including:

– Event type, duration & location

– Time, day & season of the event

– Crowd:• expected numbers• age & sex of crowd• political or religious affiliations• mood of crowd

– Availability of alcohol & drugs at the event

– Weather & local environmental hazards

– Surveillance for communicable diseases

– Availability and standards of primary , secondary and tertiary care

– Emergency services

Questions to ask - The Event

• What is the event (religious, political, sporting)?

• How will that affect the risk(s)

• When is it happening?

• Where is it happening?

Questions to ask - People

• Who is coming & where from (participants, staff, spectators)? – Nationalities

– Religious affiliations

– Languages

• How are they travelling to the country where the event is being held?

• Where will people sleep, eat etc. ?

• Where are the events?

• How are they travelling to the event itself?

Essential information!

A reasonably accurate assessment of the number of participants

The London Olympics 2012

• 10,250 Olympic athletes & 4,000 Paralympic athletes

• 20,000 press & media

• 180,000 spectators/day

• 17,000 people living in the Olympic Village

• Estimates of 4.5 million visitors to London (in fact lower)

• 26 Olympic sports in 30 venues

• 20 Paralympic sports in 21 venues

Increased Health Risks at MGs

• Disease outbreaks (numbers of people, mass catering)

• Novel diseases:

– introduced by visitors

– infection of visitors with host nation diseases

• Individuals affected by stress of the event (heart disease, stroke)

• Temperature related illness (heat, cold)

• Deliberate events

• Fast geographical spread of disease (mobile populations)

Flight itineraries were used to help predict the risk of disease outbreaks during the 2012

Olympics.

Questions to ask – Health

• Could the MG increase the likelihood of certain diseases or conditions occurring &, if so, which?

• Consequences of these for– health of participants & hosts – general community– health care provision– the MG

• Can existing control measures cope with these consequences?

• What is the level of risk for each disease/condition?

• Which diseases/conditions should be given priority for prevention, surveillance & treatment?

Assess communicable disease risks, plan for disease surveillance &

outbreak response:

• Enhancement of surveillance indicators & systems for early detection & monitoring of diseases

• Involvement of local public health agencies

• Advice on pre-event health requirements made available to attendees, e.g. vaccinations

• Disease outbreak response plans & measures

Non-communicable disease and illness at MGs• Participant factors

– Age – Pregnancy– Immunosuppression– Pre-existing conditions

• Cardiovascular disease - 43% of fatalities at the Hajj

• Environmental factors – Heat/cold, weather – Physical: containment vs. size of crowd

• Emotional / psychological factors, etc. – Type of event– Nature of participants (religious, sports fans etc.)– Crowd mood / behaviour– Drugs

Health problems at some MGs• Communicable Disease

– Measles (Paralympics, USA, 1991)– Meningococcal W135, (Hajj associated, 2000)– Botulism (Religious festival, Thailand 2006) – Influenza (World Youth Day, Sydney 2008)

• Mass injury– Ramstein Airshow, 1988 (Aircrash, 70 deaths & 346 seriously injured)– Hillsborough, 1989 (Crowd, crush, 96 deaths & 766 injured)– Hajj, 2006 (Stampede, ca. 362 deaths & 289 injured)

– MGs (1980-2007)• 215 stampedes, 7069 deaths

– Religious > political = sport = musical event

• Heat injury– Hajj , 1985 (ca. 17,700 heat illness cases)– Denver 1993 (World Youth Day, ca. 14,000 heat illness cases)

Presentations to Medical Centres in Mass

Gatherings

Common complaints Uncommon complaints

InjuriesHeat-related illnessIntoxicationGastrointestinal illness Respiratory disorders

HypothermiaHead injuryLoss of consciousnessAsthmaCardiac chest pain

Varon J, Fromm RE, Chanin K, Fillbin M, Vutpakd K. Critical Illness at mass gatherings is uncommon. J Emer Med 2003;25409–413

Public health challenges posed by MGs

• Control measures – Pathogens do not respect borders!

– Variable incubation periods – infection may not emerge until individual returns home • reaching non-resident cases • high potential for international spread• international contact tracing

• Do not discourage healthcare-seeking behavior– lack of information/no information in appropriate

languages– cost of care

• Advisory material: many languages & cultures• Still care for routine illnesses & conditions

Questions to ask - What if?

What if:

• there is a disease outbreak?

• there is a mass casualty event?

• some assumptions in the risk assessment are wrong?

• some of the assumptions were varied?

Evaluate, plan and prioritise healthcare needs for the MG including:

• Number & location of on-site first aid posts & medical facilities

• Human resource planning (e.g. ambulance paramedics, emergency physicians, nurses, first aid volunteers, safety/security officers)

• Provision of medicines, diagnostics, beds, etc.

• Education & training of healthcare personnel

• Co-ordination with local hospitals for additional medical assistance

• Implementation of Standard Operating Procedures (SOPs) defining a chain of command & communication strategy (public & media)

Food and water safety and hygiene recommendations including:

• Food hygiene standards applied by food vendors and enforced by health officers

• Safe, adequate & easily accessed supply of drinking water

• Access to adequate numbers of toilets, hand-washing facilities

Legacy planning

• Every MG is an opportunity for health legacy

• Maximisation of legacy requires early planning

• The public health component of legacy planning is vital

• Measure the impact of interventions on specific indicators before and after the MG

• Can lead to increased cooperation between components of the health sector

Surveillance and alert systems

Surveillance problems posed by large scale, extended MGs

• Increased numbers of reports– implications for staffing & data handling systems–

• May alter disease spectrum in host country, or levels of some endemic diseases

• May need – to reprioritize reporting practices to cover diseases of

particular importance

– “quick and dirty” surveillance methods

– enhanced surveillance, including new &/or different technology, methods & procedures

Surveillance Problems posed by MGs• Short time – problem for collecting information – systems sensitive

& responsive

• Large, diffuse & highly varied population

• Include diseases not normally surveyed?

• People arrive from/return to many locations

• Multiple opportunities for exposure:– air travel– food – water – physical contact

• Varying health surveillance capabilities of– host nation – originating nation(s)

• Tracking (time/location) & notification – not just in location, but after returning

Surveillance systems

• Use existing systems if possible

• Or set up suitable method (use for the MG & legacy)

But – time available?

• Syndromic surveillance– health–related data based on clinical observations – clusters of symptoms, not specific diagnoses– faster than specific surveillance

• Need to be aware of limitations:– sensitivity– specificity– positive predictive value

Preparing a Surveillance Plan

• Identify monitoring resources at all levels

• Define conditions to look for

• Establish priorities

• Set threshold / alert levels

• Identify mechanism for prompt investigation & feedback

• Link notification & response plan

Setting up a surveillance system

• Obtain data from:– Hospitals

• Emergency Departments• Lab diagnostic services

– Primary care services – Veterinary services

• Enhance– lab capacity – health protection system capacity

• Revise – staff policies – strategic emergency plans

• Test (major exercise)

Types of disease to include in enhanced surveillance

– highly infectious - outbreak potential (e.g. food-borne, meningococcal disease)

– short incubation period (likely to present during MG)

– difficult to treat or manage

– modes of transmission enhanced in a MG situation (e.g. meningitis, GI & respiratory diseases)

– may cause severe illness & need investigation &/or control measures (such as quarantine), even for a single case

– possible bioterrorism agents

Pre-MG surveillance

• Based on routine surveillance– determine baselines

– understand public health conditions in host community

• Implement new or enhanced surveillance systems well in advance in order to:

1. Determine baselines

2. Measure system effectiveness & methods employed to collect, analyse & interpret data

3. Identify all relevant stakeholders & ensure they are properly trained

Post-incident (PI) surveillance

• Expand surveillance of an incident to include incident-specific PI surveillance

• Maintain other MG surveillance activities – The occurrence of an incident does not exclude others

• Prepare systems & resources for PI surveillance during pre-MG planning to minimise disruption to on-going MG surveillance

• Appropriate command & control systems

Mass Casualty eventA Mass Gathering can easily result in a Mass Casualty event.

• an event that

– generates more patients at a time than local resources can manage

–

– requires exceptional emergency arrangements & additional or extraordinary assistance

Potential causes of mass casualties at MGs• Stampede

• Stand collapse

• Air/car crash

• Crash on transport system

• Terrorism

• Heat/cold

• Accident or incident associated with entertainment outlet

• Fire, explosion etc. at food or other outlet

• (Mass food poisoning*)

– (*Most food poisoning organisms have too long an incubation to cause problems to day

visitors)

Mass Casualties

Planning for a Mass Gathering

• Include planning for Mass Casualties

• Nature & location of these can be defined reasonably accurately

• Resources can be put on standby

• Extra resources made available

Normal health care planning

• Should also include planning for Mass Casualties

• Not possible to be so precise

• Resources are not specifically made available

Nature of event Details Outcome

Organised Mass Gathering

(e.g. Olympics, Hajj, Airshow)

Long term planningScale likely to be knownNumbers reasonably well knownLocation(s) knownMost risks determined

Systems designed and in place to deal with mass casualties

Spontaneous gathering(e.g. riots)

May be little warningLocation approximately knownNumbers unknown

Casualties must be dealt with by existing services:numbers not usually large

Unexpected event(terrorist attack,

train crash, aircrash, collapse of building)

Location unknown before eventNumbers affected uncertain

Casualties have to be dealt with by existing services which may be overwhelmed

Mass casualty events

Mass-casualty preparedness including:

• Adaptation of the standardized, tested and practiced mass casualty management system

• Capacity for rapid and timely deployment of trained personnel to areas of need

• Ongoing monitoring of weather and other hazards, and early warning systems to alert participants and organisers of dangers

• Enhanced site management, pre-hospital and hospital systems for emergency response

• Site access for emergency vehicles

• Tested communication systems and back-up.

Response

Items to include in response planning

• Nature of event

• Numbers attending

• Access– to site– to hospitals etc.

• Potential causes & most likely types of:– injury

– illness

• Weather/natural hazards

• Security

• Response capacity for these items

Establish a major incident response system

• Well rehearsed multi-agency and cross government response systems

• Effective liaison across health sector•

• Public health engagement with:

– Police & other emergency services (threat assessment, incident response)

– Central government (threat assessment, preparedness, response)

– Intelligence services (threat assessment)

Response systems

• Command & Control

• On site services– May need specialist responders (e.g. at a

motor race or an airshow)– First aiders

• Emergency Medical Services– Ambulances– A&E departments– Provision of hospital beds

• Fire Services

• Security Services

• SOPs (training)

• Communications systems (can become overloaded)

• Access & evacuation routes for emergency services & public

Communication

• Ensure that the public is kept informed

• Base reassurance on accurate information

• Do not give confusing or conflicting advice!

Terrorism

Planning, surveillance & response must take terrorism into account

Potential for mass casualties due to:• Bombings

– 1996 Atlanta Centennial Olympic Park bombing - 2 deaths, 111 injured

• Direct attack– 1972 Attack on Israeli athletes (12

dead)

– 1979: Militants occupied Grand Mosque at Mecca during Hajj (250 dead, 600 wounded)

• Deliberate release of pathogen/toxin– 1984 Rajneeshee bioterror attack

– 1995 Tokyo subway sarin attack

Identify security risks:

• Including acts of violence and terrorism. Plan for emergency response including

– Co-ordinate risk assessment, surveillance & response activities with emergency services, law enforcement, & government agencies

– Planning, training & implementation of:• venue & crowd safety measures to reduce security risks

• response to person-to-person violence, explosive devices & chemical & biological incidents

• surveillance, on-call assessment, decontamination & medical management of chemical & biological incidents.

Crowd safety at venues

• Train stewards/security in crowd control

• Clearly identified specific entrance & exit points

• Establishment of unidirectional flow of attendees

• Avoidance of overcrowding + adequate ticketing systems & public address measures

• Fire safety protocols – Emergency exits free from obstruction

– Fire & site evacuation plans

Natural hazardsAssess local risks, prepare and be able to respond to:

• Extreme weather conditions

• Other risks (e.g. Earthquake)

– Implement early warning systems

– Assessment of extreme weather vulnerability

– Adequate provision of shelter

– Develop & test evacuation plans

– Inform event attendees in a clear & concise way via flyers or local media

Prepare for & provide post-disaster mental health care including:

• Train emergency services personnel in mental health & psychosocial support

• Assess psychological & psychosocial wellbeing of the local affected population & responding emergency healthcare workers

• Facilitation of community self-help & support

London 2012

Identified Public Health risks included:

• Minor outbreaks of infectious diseases in venue(s) (e.g. Salmonella)

.

• Serious food borne/infectious illness or gastrointestinal (GI) outbreaks at event sites

• Emerging infectious/communicable disease during the event (e.g. SARS - like illness)

• Environmental risks during outdoor events (e.g. sunburn)

• Heightened security risk because of the very high public profile of the Games & the fact that London was already a terrorist target

What was done for London 2012?• Rapid lab testing

– A new GI rapid test developed for viruses, bacteria and parasites. 24 hour results (rather than several days).

• Enhanced syndromic surveillance:– Enhancement of existing systems (GP &NHS Direct) to include services

likely to be used by international visitors (emergency departments, walk-in-centres and out-of-hours GP services).• The Emergency Department Syndromic Surveillance System (EDSSS)• GP out of hours surveillance (GPOOHS)

• Undiagnosed Serious Infectious Illness (USII) surveillance: – A new system in paediatric and adult ICUs to detect potentially new and

emerging infections. – Clinicians report cases of USII directly using a customised web-based

reporting tool – For cases thought to be due to infections but where

• initial laboratory tests do not establish a diagnosis• the illness does not fit with a recognisable clinical picture• the patient is not responding to standard therapy

(This forms a large part of the legacy of the Games to the health care system in the UK)

Data & information flow systems

McCloskey B, Endericks, T. Learning from London 2012. A practical guide to public health and mass gatherings. Health Protection Agency UK, 2013.

Advice given to those attending London 2012

• Handwashing

• Avoidance of heat exhaustion– “Rehydration with water from authorised water

points or using bottled water where the cap is sealed”

• Safe sex

• Bring adequate amounts of prescription medications

• Ensure routine vaccinations are up to date • Seek medical help if unwell - from first aiders or

other medical staff at venues

• Locations and types of health facilities

• Stay in bed if ill

References• Public health for mass gatherings: key considerations, 2015

http://www.who.int/ihr/publications/WHO_HSE_GCR_2015.5/en/

• McCloskey B, Endericks, T. Learning from London 2012. A practical guide to public health and mass gatherings. Health Protection Agency UK, 2013.

• WHO/HPA Mass Gatherings toolkit (2012/3). massgatherings@phe.gov.uk

• Health Protection Agency Weekly Report. Improved public health surveillance systems to be a legacy of London Olympics. Volume 5 Number 23. 10th June 2011

• WHO. Communicable disease alert and response for mass gatherings. Technical workshop. Geneva, Switzerland, 29 –30 April 2008

• Tsouros A & Efstathiou P (ed.) Mass Gatherings and Public Health: The Experience of Athens 2004 Olympic Games. WHO/EURO, 2007

• Ahmed QA, Arabi YM, Memish ZA. Health risks at the Hajj. Lancet 2006;367:1008-15.

• Varon J, Fromm RE, Chanin K, Fillbin M, Vutpakd K. Critical Illness at mass gatherings is uncommon. J Emer Med 2003;25409–413

• Prevention and management of heat-related illness among spectators and staff during the Olympic Games – Atlanta, July 6–23, 1996. MMWR Morbidity and Mortality Weekly Report, 1996, 45:631–633.

Proper Planning & Preparation PreventsPoor Performance

Any questions?