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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
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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)
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What is a Mass Gathering (MG)?
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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…
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Challenges of MGs
Crowd managementStampedes, crush injuries
Security, emergency preparednessComplications of exposure
Dehydration, sunburn, heat exhaustion
Food HygieneSanitation and waste managementViolence
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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
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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…..
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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
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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
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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
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500,000 people flatten out the Golden Gate Bridge.
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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
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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
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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
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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
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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
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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
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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.
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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
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Battled many 20th century issuesSARS, H1N1, W135, regional conflicts
Knowledge relevant to PH planners globallyInternational collaborations
CDC + Saudi MoH during H1N1 2009
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http://www.hajinformation.com/index.htm
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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
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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
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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
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Respiratory Transmission
TuberculosisLonger incubation timeFew reports associated with MGsAir travel?
OthersLegionellosisMeaslesMumps
Surveillance, vaccination, respiratory hygiene
Lancet Infect Dis 2010;10:176
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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
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Lancet Infect Dis 2012;12:66-74
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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
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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
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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
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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
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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
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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)
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Non-Communicable Health Risks at MGs
Increased risk of injury associated with:
Outdoor MG in developing nationsCrowd density and moodWarm weatherExtremes of ageFemale gender
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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
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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
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Crowd Management2010 Hajj
25612 tonnes of solid waste6446 cleaning staff, 424 inspectors, 630
drivers
Central, temporary holding area
Covered transport
*~700,000 slaughtered goats
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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
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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
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http://www.cbc.ca/news/world/story/2012/04/16/boston-marathon-heat.html
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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
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TerrorismHigh density, international visibility, symbolicSparse, but extensive preparation is neededMunich Olympic Games, 1972Atlanta Olympic Games, 1996Direct effects of successful attacksPanic, rumors, hoax, bomb scares
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Infections & Sporting Events
Type of sporting event/MGInvolvement can vary
Athletes/participantsSpectatorsVolunteers/staff
Various types of ID riskRespiratoryEnteric/foodborneSTIsDiseases of close-contact (meningococcemia, MRSA)
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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
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The Big LeaguesKazakova SV et al. NEJM 2005:352;468
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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
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http://www.cchd.org/download/stats-reports/rocknroll-marathon-sapovirus-outbreak-final-report.pdf
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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….
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Health & Fitness Expo
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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
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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
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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
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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
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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)
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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
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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