surveillance during mass gatherings chryssa gryllis md phd dept for surveillance and intervention...
TRANSCRIPT
Surveillance During Mass Gatherings
Chryssa Gryllis MD PhDDept for Surveillance and Intervention
Hellenic Centre for Infectious Diseases Control (KEEL)
EPINORTH Seminar 5-10 September 2005, Tallinn
Epidemiologic Surveillance during
Athens 2004 Olympic Games
Nikoletta Mavroidi MDOlympic Games and Travel Medicine Office
Hellenic Centre for Infectious Diseases Control (KEEL)
KEELMINISTRY OF HEALTH AND SOCIAL SOLIDARITY
13 August 2004, Opening Ceremony
Why specific public health planning for the OG?• Mass gathering athletic event (visitors,
spectators, journalists, Olympic Family)• Considerable pressure on the country΄s
infrastructure • Conditions potentially favoring disease
occurrence and transmission• Framework for potential deliberate release • High political – economic profile• Increased publicity and high media interest
KEEL
MINISTRY OF HEALTH & SOCIAL SOLIDARITY
Olympic Cities:• Athens (all events)• Thessaloniki • Patras • Volos • Heraklion • Ancient Olympia (shot put)
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
Soccer preliminaries
Background- I
• 200 countries – 28 athletic disciplines • 18.000 athletes and technical staff
(~70% Europe and N. America, Australia) • 1- 3.000.000 visitors (~80% air travel) (
1.000.000)• 20.000 journalist – media personnel • 30 - 150.000 volunteers (OG &
Paralympics)
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
Definitions
• “Inside the fence”: – Anything or anyplace directly related to the
Olympic Games or the Olympic Family• Venues • Ol. Family Hotels• Cruise ships• Broadcasting centres • Olympic Village
• “Outside the fence”: everything else in the Olympic cities/areas
• Olympic Period: 19/7 – 5/10/2004
Background- II
• Country population: 10.000.000• Athens region population: 3.600.000• PH Services:
– MoH (regulation, legislation – operational aspects)– KEEL– PH Depts in districts & regions
• Total of 52 Districts and 10 regions• 11 districts of Olympic interest
– National School for Public Health – Central Public Health Laboratory– Central Food Authority
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
Background- IIIEnvironmental controls
“Inside the fence”: • Environmental control by Districts• All level food inspection by National Food Agency“Outside the fence”: • Environmental control by Districts• Food Inspection (retail food consumption sites) by
Districts• Food inspection (all the production/processing level
to the catering level) by the N.F.A.• Animal – agricultural products: by the services of Mo
Agriculture
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
KEEL OBJECTIVES
• Outbreak detection – investigation – management
• Detection – management of deliberate release related disease
• Action – intervention after isolated cases of notifiable diseases
• Evaluation of prevention/ intervention measures
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
KEEL Strategy
• Enhancement of the already functioning systems and structures
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
ENHANCEMENTS OF FUNCTIONING SYSTEMS-I
• Mandatory Notification System (46 diseases)
• Laboratory Surveillance (10 enteric pathogens +12 immunology tests)
• Sentinel Net (Primary Health Care Physicians)
• Olympic Syndromic Surveillance (O.S.S.)
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
ENHANCEMENTS OF FUNCTIONING SYSTEMS-II
What type of system enhancement:1. Content
2. Data & Information flow
3. Frequency of reporting
4. Active Surveillance
5. Coordination
6. Increasing awareness
7. Feedback of information!!
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
ENHANCEMENTS OF FUNCTIONING SYSTEMS-III
1. Content
• Disease of priority
• Modifications in the N.D.S.
• O.S.S. (Olympic Syndromic Surveillance)
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
NDS Priority Diseases-1
• According to:– Frequency / probability– Potential to cause outbreak– Incubation period – mode of transmission– Severity of disease– Necessity to apply PH control measures
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
NDS Priority Diseases-2
WHICH ONES: • Immediate notification diseases [12] (very
high threat BT & diphtheria, rabies, SARS)• Meningitis/ meningococcal disease• Legionellosis - influenza• Measles – Pertussis• Zoonoses (brucellosis)• Food borne & water borne diseases
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
Sentinel Priority Syndromes
• Varicella• Gastroenteritis• Rubella • Measles • Pertussis • Mumps • Respiratory Infections
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
Olympic Surveillance Syndromes
• Respiratory infection with fever• Bloody diarrhea• Gastroenteritis (diarrhea, vomiting), without blood• Febrile illness with rash• Meningitis, encephalitis, or unexplained acute
encephalopathy/delirium• Suspected viral hepatitis (acute)• Botulism-like syndrome• Lymphadenitis with fever• Sepsis or unexplained shock• Unexplained death with history of fever• Other syndrome of possible interest to PH
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
2. Data and Info flow (A)
Inside the fence
• Polyclinic of the Olympic Village
• Athletic venues (220 dispensaries)
• 10 cruise ships
• 4 hotels in Athens + 4 in the other cities
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
2. Data and Info flow (B)
Outside the fence (6 cities)• 25 Olympic Hospitals (21 General Hospitals –
4 specialized hospitals) – 17/25 in Athens• 29 Hospitals (21 G.H. – 8 Sp.H.) 17/29 in Athens
+• 15 Hospitals in the private sector• 50 primary health care physicians sentinel net
• Forensic pathology Services ad hoc network
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
Notifiable Diseases Olympic SyndromicLaboratory Reporting
2. Data – Information flow HOW?To K.E.E.L.• By fax – telephone – email
From K.E.E.L. • By fax – telephone • To District Public Health Depts, if action to be taken
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
Epidemiological Surveillance of Communicable Diseases in Olympic Venues
Information type and form INSIDE THE FENCE:• 11 Syndromes surveyed were included in
the ATHOC2004 Medical Record Form filled for each patient presenting to any venue clinic
• Priority notifiable diseases forms provided• Forms of both types sent to the
ATHOC2004 Coordination Centre• KEEL staff (1 person/round) in the
ATHOC2004 coordinating centre & at the Polyclinic
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
Venues
What is different?• Physicians in venues (volunteers)
asked/expected to notify both (syndromes & mandatory notification diseases)
• Venue physicians select syndromes – not familiar with PH surveillance and usefulness– poor training
• KEEL staff enhancing sensitivity of surveillance
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
ENHANCEMENTS OF THE ALREADY FUNCTIONING SYSTEMS
3. Frequency of reporting
(N.D.S. & L.S.)
• Once per day, 10-11 am (13:30)
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
4. Active Surveillance
• Zero reporting
• Olympic Syndromic Surveillance (O.S.S)
• KEEL communication with certain sites (forensic services – cruise ships)
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
5. Coordination
• Olympic coordinators (Regional Health Systems)
• Surveillance Coordinators (Clinical & Laboratory depts) in hospitals– Function of the coordination team at the
hospital level
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
INTENSIFICATION OF THE ALREADY FUNCTIONING SYSTEMS
6. Increasing Awareness• Training
– KEEL staff (EPIET seminars, attended other conferences and seminars abroad)
– Healthcare personnel (28, 7 only for RBC threats)
– Collaborating agency personnel (Fire Brigade, Police, EMS
– ATHOC2004 volunteers (2000 medical and nursing staff, private and military)
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
INTENSIFICATION OF THE ALREADY FUNCTIONING SYSTEMS
6. Increasing Awareness• Training seminars• Condensed – easy to grasp - action oriented
information– Training material
• 3 training opportunities (1h) for the ATHOC2004 volunteers – 3 different groups – many volunteers not trained – needed more time– PH perspective should be present from the
beginning via the IOC planningKEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
INTENSIFICATION OF THE ALREADY FUNCTIONING SYSTEMS
7. Feedback of Information• Daily report to Health Sector Coordinating
Centre at MoH (SOTY)• Daily report to the representative of MoH at
the Press Centre • Unable to make this report public in our
website• Cumulative results were sent to the hospitals
in Sep- Oct 2004
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
Daily Report and Data Analysis• Analysis and report per system and/or by site at
15:00h by the KEEL Surveillance Team – Dept of Epi and Intervention– Olympic Syndromic Surveillance team– Cruise ship team– RBC team– Foreign experts
• Denominators • Integrated approach – Automated analysis
– EpiData 3.02 – SAS 8.2 – R 1.9.1 (Poisson – Binomial) • Discussion by the KEEL Coordination Team• Global daily report by 18:00h
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
What was considered, designed & implemented specifically for the Games- I
1. Privately practicing physicians in six Olympic cities
– contact through medical associations– focus to specific conditions (GI clusters,
legionella, suspicion of rare/severe disease)
2. 10 forensic pathology services (pathology findings of diseases for immediate report)
3. Enhanced collaboration with Districts – School of Public Health – National Food Agency
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
What was considered, designed & implemented specifically for the Games- II
4. Mapping of the laboratory investigation capacity
5. Enhancement of the laboratory capacity (funding – reference centers – training – guidelines / protocols- lab network for BT response)
6. Meeting with PH experts from previous mass gathering events (May 2004)
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
Investigation & Response- I
• Surveillance team (ST)
• Coordination team (CT)
• Coordination Centre (CC)
• Standard operating procedures (signal – alert – individual cases – rumors – CC)
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
Investigation & Response- II
• Increased sensitivity concerning response RumorsSingle GI cases in venuesSingle cases of syndromes other than GI - RS
• Four outbreak investigation teams – rotating schedule
• Fact sheets for general public & media• Protocols/guidelines for single case and
outbreak management (> 30 pathogens- related diseases)
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
RESULTS
• Participation
• Overall morbidity
• Cases – syndromes
• Outbreaks
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
Daily % participation of the O.D.Hospitals in the M.N.S.-Athens 2004 O.G.
0,00%
10,00%
20,00%
30,00%
40,00%
50,00%
60,00%
70,00%
80,00%
90,00%
100,00%
Dates
% p
arti
cip
atio
n o
f th
e h
osp
ital
s
Number of visits /per day in the venues, Athens 2004 O.G. 30/7-28/8/04
0
100
200
300
400
500
600
700
Dates
N. o
f vis
its
REST POLYCLINIC
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
OG related morbidity
Total O.G. related
Cases (N.D.) 416, Salmonelloses: 52%, TB 17% 5 (0,012%)
Visits – hospitals 132.187 1.315 (7,5%)
Syndromes OSS - hospitals
11.329 : 8,6%, GI 3,4%, RS 4,2% 103 (0,08%)
Visits – venues 9.500 N.A.
Syndromes OSS – Venues
187 : 2,2% N.A.
Individual GI cases – venues
24 N.A.
Outbreaks 7 (20 – 50 cases) 0
Clusters (food-borne disease)
20 (2 – 5 cases) 0
Συνδρομική Επιτήρηση Τμήμα Επειγόντων Περιστατικών (Αττική: Ενήλικες)
Αναπνευστική λοίμωξη με πυρετό
Αριθμός Περιστατικών
Μετακινούμενος Μέσο ς όρος 2003Μετανικούνος μέσος όρος 2004
Αριθμός
20
30
40
50
60
70
80
Ημέρες
01/08/04 06/08/04 11/08/04 16/08/04 21/08/04 26/08/04 31/08/04
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
Συνδρομική Επιτήρηση Τμήμα Επειγόντων Περιστατικών (Αττική: Ενήλικες)
Γαστρεντερίτιδα (διάρροια, εμετός) χωρίς αιμορραγία
Αριθμός περιστατικώνΜετακινούμενος Μέσος Ορος 2003
Μετακινούμενος Μέσος .Όρος 2004
Αριθμός
30
40
50
60
70
80
90
Ημέρες
01/08/04 06/08/04 11/08/04 16/08/04 21/08/04 26/08/04 31/08/04
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
Overall points
• Awareness/clinical suspicion• Laboratory confirmation• Reporting by physicians• Preparedness plans • Management of incidents (personal protection
included)• Response – coordination – collaboration with other
agencies/ ministries etc • Training events (July 2003 – June 2004 : 28 training
events, average 1,5d/event, ~ 2.000 healthcare workers
• Importance of SARS experience
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
What have we learned- I
• Increased sensitivity – participation
• Increased capacity for response
• Separation of surveillance-response
• Lack of sufficient time – 2 yrs absolutely necessary – PH infrastructure critical
• Administrative and logistical support
• Contingency planning for KEELKEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
What have we learned- II
• PH perspective important “inside the fence”
• Should be integrated in the initial and global planning - need to influence IOC plans
• Benefit from PH experts with previous similar experience
• International advisors
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY
What have we learned- III
• Clear definition of objectives in the framework of increased sensitivity
• Cost effectiveness
• Enhancement /long-term benefit
• Challenge of the post-Games era!– Not enough pre-OG planning for the post-OG
assimilation of activities/plans
KEELMINISTRY OF HEALTH & SOCIAL SOLIDARITY