mass gatherings and public health risks: local and ......identification and risk assessment (hira)...

SESSION 50

Mass gatherings and public health risks: Local and provincial perspectives on hazard identification risk assessment (HIRA) approaches in Ontario

Panel presentation

March 28, 2019

The Ontario Public Health Convention

Emergency Preparedness, Response and Recovery pathway

3:00 p.m. to 4:30 p.m.

PublicHealthOntario.ca

Disclosure of commercial support

2

• None of the presenters at this session have received financial support or in-kind support from a commercial sponsor.

• None of the presenters have potential conflicts of interest to declare.


Learning objectives

3

At the end of this session, participants will be able to:

1. Describe evidence-informed practices for hazard identification and risk assessment (HIRA) relevant to public health activities in mass gatherings.

2. Compare and contrast examples of HIRA approaches for mass gatherings, based on panelists’ presentations.

3. Reflect on strategies and challenges in applying HIRA approaches in public health practice.


Panelists

4

• Dr. Yasmin Khan (Public Health Ontario)

• Clint Shingler (Ministry of Health and Long-Term Care)

• Ellen Chan (Public Health Ontario)

• Kelly Magnusson (Simcoe Muskoka Dist. Health Unit)

• Effie Gournis (Toronto Public Health)


Session agenda

5

Topic Speaker Time

Welcome, introductions and opening activity Yasmin Khan & Ellen Chan

20 min

HIRA context Clint Shingler 8 min

Developing a HIRA framework for infectious diseases

Yasmin Khan & Ellen Chan

10 min

Presentation Q&As All 5 min

Role of HIRA in planning for mass gathering events Kelly Magnusson 10 min

Linking HIRA to surveillance tools in Toronto Effie Gournis 10 min

Presentation Q&As All 5 min

Small-group discussions All 7 min

Closing remarks and questions Panel 10 min

Wrap-up and evaluation Yasmin Khan 5 min

PublicHealthOntario.ca 6

Yasmin Khan

Mass gatherings and public health


What is a mass gathering (MG)?

7

A planned or spontaneous event where the number of people attending could strain the planning and response resources of the community or country hosting the event.

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



Types of MG events

8




Public health planning for mass gatherings

9

• Largely driven by context and risk

• An assessment process is crucial to understanding risks

• Enables analysis of MG characteristics which introduce or enhance threats to public health




Three steps for reducing public health risks at MGs

10

1. Risk assessment: What might happen, and how likely is it to happen?

2. Surveillance: How will we know when it happens?

3. Response: What will we do when it happens?




Questions to consider during presentations

11

1. Which tools/templates could be useful in planning for a mass gathering in your jurisdiction? Which types of the presented tools could be useful to your context?

2. Are there specific considerations for your jurisdiction?

3. What other resources would be helpful for your local work?

HIRA Context

Clint Shingler

Health System Emergency Management Branch

Ministry of Health and Long-Term Care

March 28, 2019

Outline

1. Expectations

2. Current State

3. HIRA at HSEMB

4. From HIRA to Awareness

A Ready & Resilient Health System

13

Expectations

• World Health Organization

– 2005 International Health Regulations (IHR)

– 2018 Self-Assessment Reporting Tool (SPAR)

– 2018 Joint External Evaluation (JEE) of Canada

• Office of the Fire Marshall and Emergency Management

– 2009 Emergency Management and Civil Protection Act (EMCPA)

• Requirement for all municipalities, provincial ministries and designated ABCs

to conduct HIRA

– 2018 Provincial HIRA currently in approvals

• Ministry of Health and Long-Term Care

– 2018 Ontario Public Health Standards (OPHS)

14

IHR, SPAR and JEE Highlights

• IHR 2005 – Formal expectations for surveillance and notification

• “Each State Party shall develop, strengthen and maintain…the capacity to detect, assess, notify and report events…”

• SPAR 2018 – Indicators regarding risk assessment, 5-level scale

• “Qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or the absence of beneficial influences.”(adapted from Last JM, Spasoff RA, Harris SS, ed. A dictionary of epidemiology. Fourth edition. New York: Oxford University Press;2001)

• JEE of Canada 2018 – Indicators regarding surveillance, reporting and

preparedness

15


16

SPAR

Example

indicators

and levels


17

D2 REAL TIME SURVEILLANCE D2.1 Indicator and event based surveillance systems D2.2 Interoperable, interconnected, electronic real-time reporting system D2.3 Analysis of surveillance data D2.4 Syndromic surveillance systems D3 REPORTING D3.1 System for efficient reporting to WHO, FAO and OIE D3.2 Reporting network and protocols in country R1 PREPAREDNESS R1.1 Multi-hazard national public health emergency preparedness and response plan is developed and implemented R1.2 Priority public health risks and resources are mapped and utilized

JEE

Example

indicators

EMCPA

18

Hazard and risk assessment and infrastructure

identification

5.1 (2) In developing an emergency management program,

every minister of the Crown and every designated agency,

board, commission and other branch of government shall

identify and assess the various hazards and risks to public

safety that could give rise to emergencies and identify the

facilities and other elements of the infrastructure for which

the minister or agency, board, commission or branch is

responsible that are at risk of being affected by

emergencies. 2002, c. 14, s. 7.

OPHS 2008 1) Identify and assess the relevant hazards and risks to

public health

a) The board of health shall identify and assess relevant

hazards and risks to public health by:

i) Identifying the hazards relevant to public health within the

health unit that may give rise to a public health emergency

and/or emergency with public health impacts.

ii) Assessing the risk of the identified hazards using qualitative

and/or quantitative measures of probability and consequence

which, at a minimum, capture information through a risk-

assessment methodology.

iii) Ranking and recording the assessed risks to public health

based on qualitative and/or quantitative measures of probability

and consequence. Risks shall be prioritized from high to low

based on the ranking of probability and consequence.

iv) Including hazard-identification and risk-assessment materials

in a confidential appendix to the board of health emergency

response plan.* At a minimum the following shall be included:

• Process for hazard identification;

• Methodology for risk assessment; and

• Results of hazard identification and risk assessment.

b) The board of health shall include as a high priority risk

any hazard of provincial significance that is identified by the

Chief Medical Officer of Health.

2018

5) The board of health shall conduct processes that maintain awareness of:

a) Public health hazards and risks that may give rise to an emergency or disruption;

b) Incidents that may disrupt public health service delivery;

c) Continuity of operations vulnerabilities to disruption; and

d) Priority populations in the community and the potential for them to experience disproportionate health impacts from emergencies or disruptions.

19

HIRA at Different Levels

20

HIRA at Different Levels

• But for a mass gathering?

21

HIRA at HSEMB (The Past)

• Annual HIRA

• Lessons from mass gatherings:

– A good HIRA important to scale and focus health planning

– The development of tools and capacity will help streamline

process and build local resilience

– How far to take low-likelihood, high impact hazards?

– Link with non-health partners critical, i.e. security

22

HIRA at HSEMB (The Present)

• “Daily HIRA” …not a HIRA

– Ongoing, active gathering and sensemaking

– All staff participate

– Intelligent social media flagging

– Mass gathering decision flow

• Mass Gathering HIRA Tool

– For hazards outside of public health

– Comprehensive

23

HIRA at HSEMB (The Present)

Mass gathering decision flow

• Assess influencing factors

• Local check-in

• Determine posture

24

Passive Monitoring Info Sharing, Tracking &

Engagement

Dedicated Project Team, MEOC

Response


Yasmin Khan, Consultant Physician Ellen Chan, Senior Program Specialist

Developing an internal framework for infectious disease mass gathering HIRAs


• To develop an evidence-informed HIRA framework that supports preparedness and planning for the provincial public health system of infectious disease impacts on population health during mass gatherings.

Project objective


Project activities

27

Scoping review Review recent

PHO HIRAs Initial stakeholder

consultation

Iterative development:

HIRA framework


How are risk assessments for mass gatherings conducted by other public health organizations?

A scoping review on MGs and risk assessment

Arksey, H. and O’Malley, L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 8:1 19-32


Scoping review: Year of publication

29

0

2

4

6

2004 2006 2008 2009 2010 2012 2013 2014 2015 2016 2017

Nu

mb

er

of

Incl

ud

ed

Art

icle

s

Year


Scoping review: Mass gathering type

30

4

8

5 2

1

8

Planned

Unspecified

Both

Sporting events

Political

n= 20

Music festival


WHO Collaborating Centres for MGs

31


WHO process

32

Dapeng J, Ljungqvist A, Troedsson H, editors. The health legacy of the 2008 Beijing Olympic Games: successes and recommendations. Geneva (CH): World Health Organization; 2010.


Highlighted areas from the scoping review

33

1. Process: Many public health agencies have adapted WHO’s flowchart and process for conducting HIRAs

2. Event context: Factors such as event/participant characteristics, environmental factors provide staff with background information to guide assessments

3. Risk assessment: Probability and impact scales are commonly provided, with their combinations assigned a level of risk


Stakeholder consultations

34

• Three groups of stakeholders consulted through facilitated in-person meetings

MOHLTC

• Request, use, disseminate HIRAs for health system planning

PHO managers & leaders

• Review, consult on, develop HIRAs

PHO staff

• Develop and/or consult on HIRAs

Scoping review Review recent

PHO HIRAs Initial stakeholder

consultation

Iterative development:

HIRA framework


Needs identified from consultations

35

• Importance of initial scoping

• To understand context + intended use in planning/response

• Ongoing collaboration and leadership involvement throughout

• Support, structure and guidance for PHO staff to prepare HIRAs in a collaborative, consistent manner

• The “so what”: Preliminary recommendations for planning priorities based on HIRA results

• Simple and understandable results in a timely manner

• Build in evaluation after HIRA and event completion


Development process

Scoping forms

Reference materials

Staff worksheet

HIRA template

Debrief questions

36

The HIRA framework


Steps for developing a provincial HIRA

37

7) Complete evaluation activities and update framework

6) PHO submits final HIRA deliverable to MOHLTC

5) Review/ revise/approvals (PHO)

4) Analyze/ assess and prioritize risks (PHO)

3) Identify issues and risks (PHO)

2) Scoping, set context, define approach (MOHLTC + PHO)

1) MOHLTC requests HIRA from PHO


Selected framework components

38


Future sharing and discussion opportunities

39

• Knowledge sharing

• Looking for input from the group


Acknowledgements

40

• PHO project advisory committee and project team

• Consulted stakeholders at MOHLTC and PHO

ROLE OF HIRA IN PLANNING FOR MASS

GATHERING EVENTS

KELLY MAGNUSSON

MANAGER, EMERGENCY MANAGEMENT PROGRAM

SIMCOE MUSKOKA DISTRICT HEALTH UNIT

SIMCOE MUSKOKA:

HOME TO MASS GATHERING EVENTS

42

MASS GATHERINGS

Mass Gathering versus Special Occasion

Events

SMDHU Definition

• Provincial/Municipal Planning Priority

• Coordinated Health System

• Multi-jurisdictional

• High Profile/Politically Sensitive

• Temporary Infrastructure

• Volume of People/Duration

43

SMDHU HIRA

Identify Hazards Risks

• Literature Reviews

• Community/Provincial Based HIRA

• Event Specific Hazards

• Previous Events

Determine Risk:

Probability/Consequences

Vulnerabilities

• Vulnerable Populations

• Limitations (Capacity/Capability)

• Health System Readiness and

Resiliency

Identify Planning Priorities

• Mitigations/Contingency and IAP’s

HAZARD IDENTIFICATION RISK

ASSESSMENT

EXAMPLE OF SMDHU HIRA OUTCOME

ROLE HIRA PLAYS IN MASS GATHERING

PLANNING

• On-going hazard assessments

throughout event

• Determines potential public

health issues/hazards

• Establishes public health

planning priorities

• Identify public health roles &

accountabilities

• Informs planning and

development of IAP’s, Mitigation

and Contingency Plans

• Helps to assess health system

implications, gaps or needs

• Informs communication

planning & messaging

Planning Priorities

Operational Areas Related Activities

Environmental Health Investigations and Enforcement

Food Related Hazards

Water Related Hazards

Tobacco Enforcement

Health Hazard Investigations and Weather Related Assessments

Health Hazard Identification and Assessment

Hazardous Materials

Solid Waste Management

CBRNE

Indoor Air Quality

Flooding

Extreme Weather

Infection Control, Disease Investigation and Surveillance

Outbreak and Infection Control

Surveillance

Weather Related/Environmental Surveillance

Communicable and Non-Communicable Diseases – Acute Care Enhanced Surveillance (ACES)

SMDHU Public Inquiry Information Lines (Health Connection)

Mass Opioid Overdoses - ACES and through Community Partners

Safety, Health Promotion and Communication

Alcohol and Substance Misuse, Injury Related Events and Harm Reduction Strategies

Sexual Health

Drug and Alcohol Related Harms

Tobacco Education

Infection Control and Illness Prevention

Food and Water Safety

Extreme Temperature

Road and Pedestrian Safety

Incident Management Systems & Infrastructure

Modified IMS/EOC Activations (Command and Control Centers)

On-Site Unified Command (Headquarters Operations)

Communication Systems & Planning Cycles

Logistics Technological/Critical Infrastructure Failures

Health and Safety

PARTNERSHIPS & COLLABORATION

LOGISTICS

• Informs response and continuity

planning

• Determines capacity and

resourcing needs

• Assists with scheduling

• Identifies Health & Safety

considerations

• Impacts and needs (Costs:

Financial, Human Resource and

Physical Resourcing Needs)

HEALTH SYSTEM COLLABORATION

REPORTING & SURVEILLANCE

Linking HIRA to surveillance

tools in Toronto

Effie Gournis – Associate Director - CDC

Anne Arthur – Manager – CD Surveillance

TOPHC – March 28, 2019

Overview

o Mass gatherings and Toronto context

o When is Toronto HIRA needed?

o What does Toronto HIRA look like?

o Planning and tools developed

Toronto and mass events

• Canada’s largest city

• International hub

• Infrastructure and venues for large

events

• History of large scale events

• Actively wants to host events

https://www.toronto.ca/legdocs/mmis/2016/ex/bgrd/backgro

undfile-90908.pdf

Why Toronto?

Source: Tourism Toronto promotional material

Routine large events – part of annual plan

Mass gatherings – routinely happen

Large event vs mass gatherings –

when does it matter?

TPH considered mass gatherings as a function of

capacity of hosting community (as per WHO) rather than

number of participants.

o Informs planning and preparedness decisions

o Decision to enhance surveillance activities

Planning when Provincial/Federal HIRA exists

Questions:

o Does it apply to Toronto context?

o Is it current or too much time lapsed?

o Are there hazards that may present differential or

specific risk to Toronto’s population?

o Has anything changed in the larger disease

landscape?

Toronto HIRA process

Adapted from the Simcoe-Muskoka District Health Unit's Mass Gathering Plan and the Ontario Ministry of

Community Safety and Correctional Services' HIRA Workbook

o Review threats already identified by other HIRAs

o Review literature, media reports and health reports

for additional hazards

o Draft version of likelihood matrix (Table 5)

o Review with internal leads – mix of roles across

organization

Common threats and risk levels - example

Health Threat Risk Level

(Likelihood/Impact) Rationale

Food and waterborne illness Medium

(Frequent/Moderate) These tend to be among the most common infectious health events

experienced at MGs.28 The risk could be worsened by the time of year, as several of these illnesses increase during the summer in Toronto.

Select respiratory diseases

(MERS-CoV, Legionnaire's

disease, other novel respiratory agent)

Medium

(Unlikely/Significant) Diseases in this category do not frequently occur at MGs that are similar to

those likely to be held in Toronto. Although MERS-CoV is a concern at the

Hajj,61 that MG is very different from the average Toronto MG. However, this

health threat would have a high impact and attract a lot of media attention if it did occur.

Other Communicable

Diseases (Measles, Mumps, Ebola)

Medium

(Probable/Moderate) While not every disease is likely to emerge at a MG in Toronto (e.g., Ebola,

Zika), outbreaks/cases of measles and mumps have been reported at MGs in the past.54,60

Bioterror Agents (e.g., Anthrax)

Medium (Rare/Major) Concern about these attacks has been heightened since the 2001 anthrax

attacks, but bioterror attacks are rare.56 It would attract an extreme level of

attention and cause a great deal of fear should it occur. It would most likely be reported to first responders than discovered through surveillance.

Injuries (related to

toxicity/substance use/abuse)

Low (Frequent/Minor) Injuries related to substance use have been observed at other MGs, including sporting events62 and music festivals.5

Injuries (physical harm, not

related to substance use/abuse)

Low (Frequent/Minor) Frequently observed at other MGs,5,63 these injuries can place a strain on the health care system.

Sexually transmitted infections

Low (Unlikely/Minor)

The impact will be seen after the event has passed.

Tool - Surveillance plan for large events

Developed a plan with following objectives:

o Decision-making process for identifying which events

require enhanced surveillance activities

o Tools to collect needed information

o Inventory of surveillance strategies and potential

enhancements

o List of scalable processes, communications pathways,

and a report template

Reasons for potential enhancements

o Event-specific surveillance requirements

o Provincial surveillance requirements

o TPH planning/response process initiated, with CD

surveillance considerations

o TPH is implementing and validating a new

data/info source

Assessment worksheet

Objective:

o Collect information about the event as it becomes available

o Assist surveillance team and other stakeholders in identifying event characteristics that would suggest enhanced surveillance

o Help efficiently develop initial surveillance recommendations

o Document identified risks and surveillance recommendations

Event characteristics collected and

assessed

oEvent Size (# of participants and attendees)

oDuration

oCurrent health risks (local, national, and international) in Toronto

oProfile of international visitors and their health risks (e.g. vaccination status)

oLocation (including whether there are multiple sites and/or jurisdictions)

oMedia profile

oSecurity concerns (including the presence of political and religious

dignitaries)

oTime of year (seasonality for weather-related issues)

oPresence of temporary food premise locations

oParticipant demographics

oOther information on specific health status (if known) concerns of the

attendees

Process flow chart

• Uses information collected on

worksheet to make decisions

• Consistent application of

decision points

• Applied to all new or updated

large events in Toronto

Hazard Identification and Risk Assessment •Review provincial HIRA (if applicable) •Assess need for TPH-specific HIRA

Check event against list of routine events types,

assess if any characteristics have changed Continue with routine surveillance

Consider sending information package

CDSU and IIS AD review, consultation, and

determination of whether enhanced

surveillance is indicated

Determine if a Hazard Identification and

Risk Assessment is needed

Event type is on list and characteristics are

unchanged

Event type is not on list or characteristics have

changed

Yes

No

Document recommended CD surveillance approach •Surveillance objectives by event phase

•Operational plan (e.g., system enhancements, scheduling, communication)

Review/discuss surveillance recommendations with stakeholders

Implement event-specific communicable disease surveillance

strategy

CDSU Assessment •Review surveillance requirements •Event •Province

•TPH

Evaluate/Assess (as needed)

Disseminate Findings

Indicated

Do any of the following considerations apply? •Event-specific surveillance requirements •Provincial surveillance requirements

•TPH planning/response process initiated, with CD surveillance considerations

•TPH is implementing and validating a new data/info source

Request/inquiry related to surveillance for a large

event received

Not indicated

Initiate MG Worksheet

Determine Recommended Surveillance Approach Conduct gap analysis with existing systems. Develop a tracking system for event escalation and investigation. Consider enhancements to: •Data access, collection, and management •Data analysis and interpretation •Reporting and dissemination

Not needed

Needed

No

Routine large events

• Toronto’s large recurring

events were assessed

and documented

• Assessments of events

updated if event

characteristics change

(e.g. World Pride,

change in time of year

for event)

Type Specific Events

Regularly Scheduled Sporting Events Maple Leafs games Honda Indy Raptors games Blue Jays games Argonauts games, etc.

Toronto Pride Month Pride Parade Dyke March Trans March, etc.

Community Fairs and Festivals Toronto Caribbean Carnival Taste of Little Italy Taste of the Danforth Canada Day fireworks, etc.

Canadian National Exhibition

Music, Film, and Art Festivals Toronto International Film Festival Canadian Music Week Field Trip NXNE Just for Laughs Word on the Street, etc.

Political Protests G20 protests Demonstrations at Queen's Park 2017 Women's March Toronto, etc.

Other Routine Events Conferences Marathons, etc.

Type Specific Events

Regularly Scheduled Sporting Events

Maple Leafs games Honda Indy Raptors games Blue Jays games Argonauts games, etc.

Toronto Pride Month Pride Parade Dyke March Trans March, etc.

Community Fairs and Festivals Toronto Caribbean Carnival Taste of Little Italy Taste of the Danforth Canada Day fireworks, etc. Canadian National Exhibition

Music, Film, and Art Festivals Toronto International Film Festival Canadian Music Week Field Trip NXNE Just for Laughs Word on the Street, etc.

Political Protests G20 protests Demonstrations at Queen's Park 2017 Women's March Toronto, etc.

Other Routine Events Conferences Marathons, etc.

• Assessing internal and external signals

• Daily aberration detection • Any regular seasonal monitoring • Changing frequency of analysis • Analyzing specifically for MG-related

exposures • Analyze local media for CD info • Add MG venues as GIS layer

• Routine reporting • Regular suite of reports,

including: • Monthly surveillance report • Weekly ARI report • VPD annual report

• Ad hoc media availability • Frequent MG-specific reporting • Syndromic surveillance reporting • Frequent conference calls

• Routine data sources, including: • iPHIS • ACES • Refer to matrix for more

• Use EMCT for situational awareness • Use FirstWatch • Use iPHIS for syndromic surveillance • Receive PHOL data

• Outbreak response support • Emerging disease support • Develop and iteratively review an

enhanced surveillance plan • Develop a structured communications

plan • Find new data/info sources • Enhanced surveillance evaluation and

assessment

Action

Data Access, Collection & Management

Data Analysis & Interpretation

Report & Dissemination

Changes to the Surveillance Cycle

Summary

o Planning is essential and tools help

o PH preparedness gaps identified through HIRA

o Assessments for routine large events can be done in

advance

o Assessments for common PH threats in mass events

can be available in advance

o Coordination and collaboration among federal,

provincial, and other municipal partners is key

Acknowledgements

o Martha Hunter

o Leslie Shulman

o CD Surveillance Team

Questions [email protected]


Small-group table discussions


Questions to consider during presentations

71

1. Which tools/templates could be useful in planning for a mass gathering in your jurisdiction? Which types of the presented tools could be useful to your context?

2. Are there specific considerations for your jurisdiction?

3. What other resources would be helpful for your local work?


Risk assessment, collaboration & resilience

Closing remarks and questions

From HIRA to Awareness: A Ready and Resilient Health System

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mass gatherings and public health risks: local and ......identification and risk assessment (hira)...

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