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Mass gatherings: Why they matter. When local becomes global
The Quarterly 2011

 


This article was written by Dr Susan Keam, derived from material presented by Dr Michael Hills on 6 September 2010 at RACMA/HKCCM 2010.


We live in a very mobile world and, as a consequence, what happens today in one place can spread across the world very quickly. We should not forget the issues with the SARS outbreak from China and Hong Kong in 2003, and how rapidly the virus spread (figure 1). We are worried about this sort of thing recurring and we will continue to encounter new viruses throughout the 21st Century.


However, these issues are not limited to infectious diseases. If we look at another recurring event, the Hajj, we can that see that over the years hundreds of people have been killed in mass casualty events such as fires, crushing, trampling in stampedes, or demonstrations. Nevertheless, at each point they have been remediated, mitigated and services expanded. Over 2 million people from all over the world go to the Hajj each year, and infectious communicable diseases such as meningitis are also a problem with such a large gathering. To minimise this risk, the Saudi authorities have had to put in place many control measures to protect pilgrims (e.g. mandatory vaccination).

The big global sporting events, such as the World Cup and the Olympic Games also attract large international audiences that are mobile. Interestingly, an outbreak of Legionnaire’s Disease at the time of the 1998 FIFA World Cup was not identified at the time, but subsequently, it was recognised that there were 20 cases of Legionnaire's Disease in people who had visited Paris in June 1998: 11 were French residents and 9 were European tourists; of these, four died (20%). Even though this was a small outbreak, it has to be managed in the context of the event and mobility of the attendees.

In another example, a child from Japan with measles travelled by air to the US to participate in the Little League World Series, transiting through several airports enroute. During the journey, transmission within airports and to adjacent passengers in-flight led to two generations of measles (figure 2). Why is this important? International teams representing 74 countries/territories participated, with 265,000 young children. If around 30% of these children aren’t immunised against measles (reflecting current immunisation patterns), there is potential for an epidemic and this needs to be controlled using epidemiological investigation and contact tracing.


This example highlights need to maintain the highest possible vaccination coverage along with strong disease surveillance and outbreak alert and response capabilities.

Opportunities to build capacity

In the setting of mass gatherings there are a number of threats and opportunities that we can use to build knowledge and experience in both the immediate situation and longer term. Threats are multifaceted, but are usually amenable to a structured approach to assessment and management. Opportunities include capacity building for immediate and longer term synergies with other roles (which require multi-agency coordination such as emergency management) and knowledge transfer to new team members. What do we know is that what goes wrong in such events and emergencies is communication.

We can ask the question, "What are we trying to 'manage'?" The answer is "all of those things that can go wrong". We are trying to deal with the effects of uncertainty on our objectives as a health service (i.e. maintain our normal service delivery while providing additional care services during the event for visitors and, in the context of international events, the possibility of international disease spread, as well as managing the interests of new stakeholders who are involved in running the events) in the context of a mass gathering (defined as an event attended by a sufficient number of people for a defined period of time to strain the planning and response resources of a community, state or nation).

Some mass gatherings are easy to plan for (e.g. recurrent annual events at the same venue) however spontaneous events can be more difficult. By working with the more controlled events, plans and processes can be but in place to enable a rapid response to the challenges of spontaneous events. Nevertheless, mass gatherings are associated with some unique challenges:

  • Health systems are stretched to surge capacity
  • Business-as-usual behavioural health measures are difficult/impossible to implement
  • Require holistic approaches to risk mitigation across disciplines/ministries
  • Introduction and dissemination of new diseases
  • Communication of risk made difficult by international dimension (languages, cultures, etc) and media pressures
  • The need to respond to Mass Gatherings is often triggered by political interest, public scrutiny and national pride and therefore needs to be managed carefully
  • Breaking down silos of vertical work ("cylinders of excellence")
  • The need to pool and distil expertise of the last few years
  • To include the communicable disease issues into the wider context
  • To establish "Situational Awareness"
  • To manage media interest
  • Pressure on the infrastructure & existing public health system
  • Fluctuating populations
  • Need for real-time decision-making
  • Challenges for control measures
    • High potential for international spread & introduction of diseases
    • International contact tracing

The public health implications of mass gatherings include a potential increased risk for disease transmission because of the variability and mobility of those attending the event, increased media attention, and the potential for the mass gathering as a target for actions of a bioterrorist nature. However, chemical, food safety and radionuclear events should also be considered, therefore an "All Hazard" approach is recommended. This means that a single framework to deal with an emergency of whatever cause should be used, and tactics adjusted to suit the specific cause. Key stakeholders in planning and implementation include fire, ambulance, police, business, airport, government, army, hospitals, security, transport, food services, media, customs, event organisers and volunteers.

Coordination with others is essential (figure 3), and health-related planning needs to


Integrated with the overall planning structures. There is a need to:

  • Establish a high-level planning committee or steering group
  • Develop issue-specific planning committees that report to the high-level committee.
    • Communicable disease prevention and control
    • Medical Services
    • Environmental Health etc.
  • Ensure cross-representation between the groups
  • Ensure clear delineation of roles and responsibilities
  • Establish clear delineation of the command, control, coordination and communication structures


Structured Approach

A structured approach to risk management (e.g. the International Standard ISO 31000: 2009) is recommended, because it enhances existing programs and arrangements, establishes interaction with stakeholders, provides thorough documentation, ensures that risks are clearly identified and analysed and provides results based on logical analysis, as well as a methodical approach to planning. ISO31000 defines risk as the "effect of uncertainty on objectives", and moves from being just a process to establishing a set of general principles and a framework. This is often expressed in terms of consequences and likelihood.

The general principles of ISO 31000 are that the approach

  • Creates value
  • Is an integral part of organizational processes (not an add-on)
  • is part of decision making
  • Explicitly addresses uncertainty
  • Is systematic, structured and timely
  • Is based on the best available information
  • Is tailored
  • Takes human and cultural factors into account
  • Is transparent and inclusive
  • Is dynamic, iterative and responsive to change
  • Facilitates continual improvement and enhancement of the Organization

However, the framework (figure 4) is key, and the most important component of the framework is the mandate and commitment from senior management.


Figure 4



The 2009 University Games and EXIT Music Festival in Serbia and the UK Glastonbury Music Festival are good examples of how preparedness for mass gatherings can be successfully modified when faced with a sudden change in the environment. These were events planned for June and July 2009. They required modification in the context of the Influenza A H1N1 pandemic of mid 2009. The Pandemic was declared in April 2009 (Phase 5 declared on April 29 and phase 6 declared on June 11). Existing plans for these three mass gatherings required ongoing changes, which would depend on the spread and severity of the disease, and changes of strategies e.g. testing and antiviral use to minimise the impact of the pandemic.

Serbian Response

The 25th University Games was held on 1-12 July at 53 sites, with 600 athletes from 143 countries, 10,000 volunteers, 5,000 staff and an estimated 500,000 Spectators attending. The 10th EXIT music festival was held on 9-13 July at Petrovaradin fortress, Novi Sad, with an estimated 190,000 visitors (including 20,000 from abroad) and a campsite for 6,000 persons.

A special working group from the Serbian Ministry of Health was convened for implementation of the Preparedness Plan. Preparation for these mass gatherings in context of pandemic influenza included implementing the following key objectives:

  • Detect first cases
  • Reduce spread of disease
  • Monitor the epidemiological situation
  • Mitigate morbidity and mortality through timely diagnosis and treatment of cases according to national guidelines

The working group communicated rapidly with the delegations coming to the events, particularly the university games (Information Bulletin to delegations on 8 June 2009), established criteria for cancelling the event (a death or >1% of the attendees having evidence of the disease), worked out how to isolate and manage suspected and confirmed cases, implemented infection control procedures (masks used by healthcare workers and provided to suspected or confirmed cases to minimise spread and enhanced disease surveillance processes.

The Serbia Influenza A (H1N1) 2009 early outbreak pattern was



And this is how it related to these two events:



The few cases seen at the university games don’t appear to have amplified the outbreak. In contrast, a number of local people acquired H1N1 from the visitors at the EXIT festival amplified the outbreak; however, this was predominantly less severe.

Conclusions from Serbia

  • Both mass gatherings went ahead as planned.
  • Transmission of influenza A (H1N1) at both events was inevitable due to the nature of the infection
  • Preparations were put in place to mitigate the situation through detection, isolation options and treatment of cases in Serbia.
  • It is uncertain if cancellation of either event would have impacted on the public health situation for Serbia, as cases were already identified in both locations ahead of the events
  • The EXIT festival most likely amplified transmission locally in Novi Sad.


Glastonbury Festival United Kingdom

This music festival was held between 24th and 28th June 2009, with 135,000 ticketed individuals attending and 35,000 artists, organising, security, medical and other staff In May 2009 there was discussion about whether the festival should be cancelled because of the H1N1 pandemic; based on the best available information, a decision was made to go ahead.

The Risk Mitigation strategy was aimed at minimising disease spread without disrupting the event. This included:

  • Specific protocols for dealing with suspected cases of H1N1
  • Access to and training in use of PPE
  • Immediate access to antiviral stocks
  • Sample testing arrangements
  • Holding facilities (Isolation units)
  • Recovery teams
  • Transportation arrangements

The strategy was implemented with:

  • a single medical team coordinating provision of healthcare across site
  • Health Protection Agency leading on response to cases of H1N1
  • Full support of festival organisers
  • Regular risk review through three-times-daily Silver command meetings.

The impact of the Influenza A (H1N1) pandemic on the media and public anxiety was a huge issue that was successfully managed through having

  • a good communications manager (discouraging unwell people from attending and allaying public fears)
  • well trained, ‘up to speed’ spokespeople
  • regular updates to media, with people available to give interviews at short notice.

The health risk management team embedded themselves within the command structure at the tactical level (fire, police, ambulance, organisers, security etc.) making sure that everyone had the best picture available.

Post-Festival Analysis

  • 6 cases of H1N1 were identified clinically, and all were confirmed in laboratory
  • the Holding units worked well
  • there was no evidence supporting festival as a major foci of spread


How do we link from the local site to the global and vice versa?

The most important factor is good two-way communication. There is a need for good communication up through the chain of command and then back down to grass roots level. The International Health Regulations (IHR) (2005) is key to achieving this. The IHR (2005) is one of two legally binding global agreements about procedures to protect public health and has been adopted at the World Health Assembly (2005) and is binding on all WHO Member States and the Holy See (2007). The IHR mission statement is “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade”, and in practice the IHR moves away from a process-driven approach to infectious diseases at borders to a risk management basis that has the capacity to identify, manage and communicate communicable disease risks. The IHR describes the required core capacities at each local, intermediate, national and regional and international level (figure 5).


Figure 5


IHR Outbreak Management guidance includes:

  • Developing/establishing policies, priorities structures, tools and procedures to manage events that threaten public health
  • Identifying and clarifying roles and responsibilities, and providing guidance for alert and response activities
  • Facilitating standardised data management, risk assessment and response
  • Gaining approval from the agencies (government and others) involved
  • Anticipating/predicting what will happen following implementation of the system

Note: the system should be evaluated and tested to ensure its function BEFORE the mass gathering.

So to minimize international disease spread, the risk management plan needs to have strategies in place to manage continuous risks using routine measures ("sanitary" points of entry and conveyances for travellers, goods, etc.), specific measures for certain known risks (vector control, vaccination and standing recommendations) and also the need for sudden heightening of risks if necessary, including detection (information & verification, notification, risk assessment) and response (support to investigation and control, information and recommendations).

The IHR seeks to strengthen national capacity through:

  • National disease surveillance, prevention, control and response systems
  • Epidemiology
  • Laboratories
  • Case management
  • Infection control
  • Social mobilisation
  • Communications
  • Public health security in travel and transport
  • Ports
  • Airports
  • Ground crossings

In recent years, there has been effective collaboration between the WHO and event organisers. WHO involvement in recent and upcoming mass gatherings includes:
Sporting events: such as the 2008 Beijing Olympics and the upcoming London Olympics 2012; religious events namely the July 2008 World Youth Day in Sydney. Other events: such as the CHOGM Commonwealth Summit, Trinidad & Tobago in November 2009. Other Collaborations include observers from future Games, such as the 2014 Brazil FIFA World Cup. And as organisers is worth mentioning that the IOC / FIFA now include public health management in their bids and the importance of early involvement, including at the bid stage (e.g. London Olympics).

Currently the WHO support to event organisers is based on:

  • Requests by event organisers, local, regional and national health authorities and organising and other sporting committees
  • Risk assessment conducted by organisers and national health authorities
  • In 2009 and 2010 elements of prevention, alert & response to communicable disease risks focussed on Pandemic Influenza A (H1N1) risks
  • Assistance with risk assessment (RA) process and planning health measures based on the RA
  • Review of existing health planning arrangements
  • Establishing or improving data sharing and reporting mechanisms.
    • This includes the design of SITREPS and establishing WHO input process for feeding into international surveillance systems (IHR) (figure 6)
  • As a platform for discussion between international sporting/religious organisations and national event organising authorities at MoH or other ministries
  • Providing Event-specific MG health planning tools (e.g. WADEM (Research); Northwest Center for Public Health [http://www.nwcphp.org/training/courses/mass-gatherings]) and access to Informal Virtual Interdisciplinary Advisory Group on mass gatherings (iVIAG; http://www.who.int/csr/mass_gatherings/en/)

q 2011 680-10 Figure 6



However there are other risks that require cross-disciplinary coordination and for which public health involvement is necessary (e.g. police, military etc).

So, if you have the opportunity as a Medical Director to be a part of the planning for a future Mass gathering event, get involved - it will allow you to advance your planning and coordination in your local area in conjunction with others, so that the potential for something to go wrong is minimized.


Dr Michael Hills
FRACMA

Acknowledgements: thanks to the WHO and all the contributing members of the Informal Virtual Interdisciplinary Advisory Group on Mass Gatherings

Disclaimer: Views expressed are those of the author, who is not an official of the WHO. The content is in part based on a Slide Set supporting the content of WHO Publication "Communicable Disease Alert and Response for Mass Gatherings (MG) June 2008". Prepared by the author and members of the Informal Virtual Interdisciplinary Advisory Group (iVIAG) for the WHO Global Alert and Response, Health and Security Interface. The author is a member of the Advisory Group




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