Mass Gatherings & Travel Health

AATHP Annual Travel Health SymposiumJune 1-2, 2012

Dr. Sergio Fanella FRCPC, FAAP, DTM&HAssistant Professor, Pediatrics & Child

HealthUniversity of Manitoba

ObjectivesDefine mass gatherings (MG) & MG health

Historical examples; experience of the Hajj

Discuss infectious diseases (ID) issues related to MG

Review non-ID risks during MG; crowd behavior

Discuss risks associated with sporting-related MG (some examples)

What is a Mass Gathering (MG)?

What is a Mass Gathering (MG)?

Variable definitionsMinimum attendance 1,000 up to 25,000

Large numbers attending a focused event for finite timePlanned or unplannedRecurrent or sporadicSpiritual, sporting, musical, etc…

Challenges of MGs

Crowd managementStampedes, crush injuries

Security, emergency preparednessComplications of exposure

Dehydration, sunburn, heat exhaustion

Food HygieneSanitation and waste managementViolence

Religious MGsPilgrimage central to many belief systemsHistorically, the journey presented the greatest riskKumbh Mela

Hindu pilgrimage along Ganges based on sun/moonPurification rites – interrupt cycle of reincarnationCelebrated every 3 yearsAttract many non-HindusLargest human gathering

2001-visible from space2007 – 70 million over 45 days (5 million in 1 day)

Bathing schedules for rival sects

Catholic Pilgrimage to Lourdes, FrancePyrenees5 million Catholics annuallyShrine & spring since mid 1800sEnsure health and cure disease“Water Walk”Used by > 350,000 pilgrims per yearNo distinct health issues…..

Life Events & Politics4 Funerals and a Wedding

Prince William & K. Middleton wedding – 1 millionVoltaire’s funeral, Paris 1796 – 1 millionAyatollah Khomeini funeral, Tehran – 6-12 millionPope John Paul II, Rome - 4 million over 1 weekPrincess Diana’s funeral – 1 million x 6.5 km route

Politics and MGs>5 million for H. Mubarek’s departure February 2011>3 million for anti-Iraq war in Rome, 2003“Battle in Seattle”, WTO Meeting, 1999Obama Inauguration 2009, > 1million

Music, Sports, Celebrations!

Global attendance = risk of imported diseaseWinter Olympics 2010 – measles outbreakOlympics 1972, Munich – 11 deaths from terrorists1 death at Atlanta Olympics 1996, bombingViolent sport fans as old as time…

South America, 1964 football match, Peru vs. Argentina500 injured, 318 deaths

Love Parade, Germany, 201021 deaths from a stampede in a narrow tunnel

500,000 people flatten out the Golden Gate Bridge.

Perspectives from the Hajj

Rituals changed little since the time of Mohammad

TrustCore beliefExemplified by the risks Muslims take when travellingDependent on the benevolence of strangers

Brings together diverse populations, while removing national, cultural, and social boundaries

Hajj - HistoricalMost travellers via small boats, poor conditionsDepartures – Singapore, Calcutta, IndonesiaMost disembarked in JeddahFrequent outbreaks of infectious diseases (cholera, typhus)19th/20th century, management under non-Muslim European powers

Hajj – The Modern EraDate moves forward ~10 days each yearDaytime ≥ 40oC, Night-time 10oCMay coincide with influenza season

2009 attendance not blunted (2.5 million)

Improved access for pilgrims92% via air; 7% overland, 1% maritimeJeddah still major entry point

Hajj – The Modern EraKing Abdulaziz International Airport, South Terminal

Updated starting in 1980Dedicated to Hajj pilgrimsFinal updates to be done by 2014Capacity is 80,000 at any one time

Customs/immigration services, health-screening 18 hubs, each with 2 examination roomsLarge, open holding areasSeparate flow for those without visas, health recordsUmrah – not compulsory, draws additional 5 million/year

Hajj – The Modern EraIntense monitoring by Saudi public health services

Stationary and mobileInbound and outbound populations

Set case definitions to help guide protocolsRespiratory illness, food poisoning/gastro, hemorrhagic fevers, meningococcal diseaseClose relationship with WHOAirport clinic space

The Rite of HajjHumility, faith, unitySynchronized acts in Mecca

Circle the Ka’aba 7 timesStop at Mina for prayerJourney to Mount Arafat (22 km east)Day of Standing

Jamarat Bridge – throw stones at pillarsAnimal sacrifice

Often proxy sacrificeFinal tour of Ka’aba

Hajj CultureRole of group leadersDifferences in age and gender distributionStampedes still a concern (esp. Jamarat site)Only when adequately healthy

Special wheelchair lanes Palliative pilgrims discouraged; non-Muslims

Weapon/drug/alcohol/tobacco-free, sexual relations not allowed.

Local Planning for the Hajj

Saudi Arabia has invested in it141 primary health centres, 24 hospitals (5000 beds >500 ICU beds)17,000 specialized staffCoordination of all government sectors

24 supervising committees

Strategies reviewed/revised/updated annually

Battled many 20th century issuesSARS, H1N1, W135, regional conflicts

Knowledge relevant to PH planners globallyInternational collaborations

CDC + Saudi MoH during H1N1 2009

http://www.hajinformation.com/index.htm

Infectious Disease Challenges Associated with MGs

Nature of MGs compounds routine disease factors

SusceptibilityEffectiveness of transmission

Gastrointestinal illnessFood-borne vs. water-borne

Rapid dissemination via air travelType of MG influences type of infections

ex. Overcrowding = respiratory infectionsExcessive ETOH/drugs - STIs

Fecal-Oral Transmission

Issue with preparation or distribution of foodUsually small, occasionally large

MDR shigellosis, Nantahala National Forest, NC, USA50% of 12,700 attendees Poor sanitation → high coliform loads in local streamsSecondary OBs in 3 states

Hep A OBs at youth camp in AustraliaColeslawSubsequent spread to 4 other states

J Infec Dis 1990;162:1324Commun Dis Intell 2004;28:521

Respiratory Transmission

MGs with overcrowdingInfluence of:

Incubation timeDroplets vs. airborne transmissionThe infectious agent

Influenza2008 – World Youth Day, Sydney, Australia2002 – Salt Lake City Winter OlympicsPandemic influenza A H1N1 at European music festivals

Emerg Infect Dis 2006;12:144

Respiratory Transmission

TuberculosisLonger incubation timeFew reports associated with MGsAir travel?

OthersLegionellosisMeaslesMumps

Surveillance, vaccination, respiratory hygiene

Lancet Infect Dis 2010;10:176

Vector-borne DiseasesMalaria, dengue, WNV, Yellow feverEx. 2007 Cricket World Cup

In 9 Caribbean nationsSome endemic for VBDsTeams from 16 nations4 nations from around Indian Oceans

Chikungunya a concernCases ID’ed in Indian Ocean visitors to CaribbeanHas the vector AedesUS also concerned about importation to SE USAAverted with effective public health action

Lancet Infect Dis 2012;12:66-74

ZoonosisTransmitted from animals to peopleDirectly or via contaminated food and waterE. coli O157

Glastonbury Festival, UK, 1997Mud contaminated with cattle feces

LeptospirosisTriatheletes, adventure racing eventsIngestion, skin and MM penetration

STIs & Blood-borneDifficult to study

Only a few options available for control of STIs

Provision of condomsEducational programs and campaigns2006 World Cup

Risk of blood-borne agents limited by nature of MG

Hepatitis B and C, HIVLong incubation period makes ID difficult

Infection Risks at the Hajj

Complex, high-risk situationOften susceptible, elderly peopleInteraction with those from nations where IDs are prevalent

Moves with lunar calendar = risk changes seasonallyClassic example is Neisseria meningitidis W135

OBs of W135 in 2000, 2001 → global spreadProlonged NP carriage, local transmissionGained foothold in Saudi ArabiaControlled by immunization

Other IDs at HajjSARS

Recognized threat early ---- Control measures

Pandemic H1N1 & Seasonal influenzaRespiratory infections most common etiology for admission to hospitalGI illness also common

Occasional cholera (1980s)Polio

Other IDs at HajjSTIs less of a concern

Those already on HAART report poor compliance

Skin infectionsShaving of the head – Hep B??

Pretravel immunizationEnforce existing Saudi regulations, but no current required immunization

Non-Communicable Health Risks at MGs

Trauma, accidents, stampedes, terrorist attacks, heat

More deaths/injuries at MGs than IDsEx. Stampedes/crush injuries (MORTALITY)7000 deaths, 14,000 injuries over 27 years

Spectrum of severitySevere traumaCuts, sprains, dizziness, abdo pain, minor trauma (MOBIDITY)

Non-Communicable Health Risks at MGs

Increased risk of injury associated with:

Outdoor MG in developing nationsCrowd density and moodWarm weatherExtremes of ageFemale gender

Human StampedesStudy of 215 stampedes from 1980-2007

Religious MGsSports/musical/politicalAverage of 33 deaths and 79 injuries per event

Little understanding of mechanisms Smooth → stop and go flowCrowd turbulence

2 cofactors:1. Failure to address crowd size vs. infrastructure2. Triggering event

Crowd ManagementWith increasing density:

CrimeIncidence of illness/injurySevere traffic delays; pollution

Consider health of staff, participants, spectators Water, toilets, refrigeration, suppliers, waste disposal, pest controlAt some MGs, the risk is ever present

Hajj

Crowd Management2010 Hajj

25612 tonnes of solid waste6446 cleaning staff, 424 inspectors, 630

drivers

Central, temporary holding area

Covered transport

*~700,000 slaughtered goats

Crowd ManagementModeling

Study crowd dynamicsMicroscopic vs. macroscopic levels

Shown several self-organizing principals of crowdsNeed good visualization & monitoringCan result in long-term event changes

Hajj- replaced used 1-way street flow instead of multiCrowds scheduled over time and space

Weather & EnvironmentHeat, cold, precipitation, pollutionHeat

1985 Hajj – 1000 deaths, 18,000 ER visits for heatstroke

Heat index useful predictor of demand for medical care (air temp + humidity)Increased risk with age extremes, medical conditionsCooling shelters/buses, fluid intake, sun protection, exercise avoidance

http://www.cbc.ca/news/world/story/2012/04/16/boston-marathon-heat.html

Papal visit, Denver, USA, 1992Sudden drop from 30C – 13C

Woodstock, NY, 1969Heavy rainfall led to slippery conditionsFractures

Beijing Olympics 2008Cut transportation use Lowered OPD visits for asthma

TerrorismHigh density, international visibility, symbolicSparse, but extensive preparation is neededMunich Olympic Games, 1972Atlanta Olympic Games, 1996Direct effects of successful attacksPanic, rumors, hoax, bomb scares

Infections & Sporting Events

Type of sporting event/MGInvolvement can vary

Athletes/participantsSpectatorsVolunteers/staff

Various types of ID riskRespiratoryEnteric/foodborneSTIsDiseases of close-contact (meningococcemia, MRSA)

Infections & Sporting EventsAthletes & Close Contact - MRSA

Athletes, mostly in contact sports.Risk factors for infection:

Physical contactSkin damageSharing of equipment/clothing

HS/College Football playersPenn College – 7/10 hospitalizedTurf burns, shaving, sharing unwashed towels, balms

Wrestlers

Fencers???

MMWR 2003 Vol 52 (33):793

The Big LeaguesKazakova SV et al. NEJM 2005:352;468

Infections & Sporting EventsAthletes & Close Contact - Enteric

Las Vegas Marathon December 4th, 2011Dec 6th – SNHD received complaints of diarrheal illness in runners

SNHD sent out online surveys1146 respondents

528 met case definition85% diarrhea56% emesis, 31% fever

Most (81%) reported illness btn 18:00-00:00 on Dec 4th

http://www.cchd.org/download/stats-reports/rocknroll-marathon-sapovirus-outbreak-final-report.pdf

Univariate analysis = only drinking water from a water station during the race (RR 1.75)9 ill local runners provided stool samples

2 RT-PCR + for sapovirus2/7 negative tests also had viral particles on EM2/2 + for sapovirus from ill kids of ill runners

Exposure likely BEFORE the raceCommon exposure the AM before race dayDec 3rd morning….

Health & Fitness Expo

Transmission of Norovirus Among Professional Athletes and Staff,

2010Began with media reports Nov/Dec 2010Team MDs interviewed players/staff on GE symptoms

Activities while illOther household ill contactsAsked to provide samples

27/30 teams responded; 400 players, 378 staff assessed

21 players (5.3%), and 3 staff (<1%) on 13 teams4/5 stool samples + for norovirus genogroup II4 teams with >1 case

Infections Within the Local Population

Imported Measles, Youth Sporting Event USA, 2007PIDJ 2010;29:794-800

Large event, cumulative attendance >265,000 x 10 daysIndex case – 12 yo boy from Japan

Several flights/busesStayed in dorm with other athletesFever & rash ~60 hours from start of travelIUTD ???

Contact tracing of all 471 event staff/athletes41% no documentation of prior measles immunity

Additional tracing of 1250 people in 8 statesConfirmed 7 additional measles cases

Genotype D5 (from Japan)US customs officerAdult passengerCorp representative2 college students

*only 22% of international attendees provided formal documentation

Measles and Medals and 2010 Winter Olympics

http://www.cbc.ca/news/canada/british-columbia/story/2010/03/30/bc-measles-outbreak.html

http://www.promedmail.org/direct.php?id=20100406.1102

Advice for Athletes Attending Sporting Events

Risk AssessmentGeography, climate, seasonInfrastructure (housing, food, other attendees)

Communicable diseaseVaccine-preventable (well ahead of time)Others (MRSA)

Vancouver OlympicsTdap, MMR, VZV, Hepb, Meng C conjugateInfluenza*

Clin J Sport Med 2011;21:67–70)

Advice for Athletes Attending Sporting Events

Food Safety & Enteric DiseasesWash hands (soap/water) always before eatingOwn supply of ETOH hand sanitizerIf possible eat meals at event-sanctioned sitesReport SSx ASAP

Prevention of STIsNon-communicable risk

MVAs, trauma, IVDU, ETOH use

Mass GatheringsSports, religion, music, political events

Not all are created equal

Bringing not just people togetherMG medicine a relatively new field

Needs more research

Infectious and non-infectious risks