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Mass Gatherings & Travel Health AATHP Annual Travel Health Symposium June 1-2, 2012

Mass Gatherings & Travel Health AATHP Annual Travel Health Symposium June 1-2, 2012. Dr. Sergio Fanella FRCPC, FAAP, DTM&H Assistant Professor, Pediatrics & Child Health University of Manitoba. Objectives. Define mass gatherings (MG) & MG health Historical examples; experience of the Hajj

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Mass Gatherings & Travel Health AATHP Annual Travel Health Symposium June 1-2, 2012

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  1. Mass Gatherings & Travel HealthAATHP Annual Travel Health SymposiumJune 1-2, 2012 Dr. Sergio Fanella FRCPC, FAAP, DTM&H Assistant Professor, Pediatrics & Child Health University of Manitoba

  2. Objectives • Define 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)

  3. What is a Mass Gathering (MG)?

  4. What is a Mass Gathering (MG)? • Variable definitions • Minimum attendance 1,000 up to 25,000 • Large numbers attending a focused event for finite time • Planned or unplanned • Recurrent or sporadic • Spiritual, sporting, musical, etc…

  5. Challenges of MGs • Crowd management • Stampedes, crush injuries • Security, emergency preparedness • Complications of exposure • Dehydration, sunburn, heat exhaustion • Food Hygiene • Sanitation and waste management • Violence

  6. Religious MGs • Pilgrimage central to many belief systems • Historically, the journey presented the greatest risk • KumbhMela • Hindu pilgrimage along Ganges based on sun/moon • Purification rites – interrupt cycle of reincarnation • Celebrated every 3 years • Attract many non-Hindus • Largest human gathering • 2001-visible from space • 2007 – 70 million over 45 days (5 million in 1 day) • Bathing schedules for rival sects

  7. Catholic Pilgrimage to Lourdes, France • Pyrenees • 5 million Catholics annually • Shrine & spring since mid 1800s • Ensure health and cure disease • “Water Walk” • Used by > 350,000 pilgrims per year • No distinct health issues…..

  8. Life Events & Politics4 Funerals and a Wedding • Prince William & K. Middleton wedding – 1 million • Voltaire’s funeral, Paris 1796 – 1 million • Ayatollah Khomeini funeral, Tehran – 6-12 million • Pope John Paul II, Rome - 4 million over 1 week • Princess Diana’s funeral – 1 million x 6.5 km route

  9. 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, 1999 • Obama Inauguration 2009, > 1million

  10. Music, Sports, Celebrations! • Global attendance = risk of imported disease • Winter Olympics 2010 – measles outbreak • Olympics 1972, Munich – 11 deaths from terrorists • 1 death at Atlanta Olympics 1996, bombing • Violent sport fans as old as time… • South America, 1964 football match, Peru vs. Argentina • 500 injured, 318 deaths • Love Parade, Germany, 2010 • 21 deaths from a stampede in a narrow tunnel

  11. 500,000 people flatten out the Golden Gate Bridge.

  12. Perspectives from the Hajj • Rituals changed little since the time of Mohammad • Trust • Core belief • Exemplified by the risks Muslims take when travelling • Dependent on the benevolence of strangers • Brings together diverse populations, while removing national, cultural, and social boundaries

  13. Hajj - Historical • Most travellers via small boats, poor conditions • Departures – Singapore, Calcutta, Indonesia • Most disembarked in Jeddah • Frequent outbreaks of infectious diseases (cholera, typhus) • 19th/20th century, management under non-Muslim European powers

  14. Hajj – The Modern Era • Date moves forward ~10 days each year • Daytime ≥ 40oC, Night-time 10oC • May coincide with influenza season • 2009 attendance not blunted (2.5 million) • Improved access for pilgrims • 92% via air; 7% overland, 1% maritime • Jeddah still major entry point

  15. Hajj – The Modern Era • King Abdulaziz International Airport, South Terminal • Updated starting in 1980 • Dedicated to Hajj pilgrims • Final updates to be done by 2014 • Capacity is 80,000 at any one time • Customs/immigration services, health-screening • 18 hubs, each with 2 examination rooms • Large, open holding areas • Separate flow for those without visas, health records • Umrah – not compulsory, draws additional 5 million/year

  16. Hajj – The Modern Era • Intense monitoring by Saudi public health services • Stationary and mobile • Inbound and outbound populations • Set case definitions to help guide protocols • Respiratory illness, food poisoning/gastro, hemorrhagic fevers, meningococcal disease • Close relationship with WHO • Airport clinic space

  17. The Rite of Hajj • Humility, faith, unity • Synchronized acts in Mecca • Circle the Ka’aba 7 times • Stop at Mina for prayer • Journey to Mount Arafat (22 km east) • Day of Standing • Jamarat Bridge – throw stones at pillars • Animal sacrifice • Often proxy sacrifice • Final tour of Ka’aba

  18. Hajj Culture • Role of group leaders • Differences in age and gender distribution • Stampedes 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.

  19. Local Planning for the Hajj • Saudi Arabia has invested in it • 141 primary health centres, 24 hospitals (5000 beds >500 ICU beds) • 17,000 specialized staff • Coordination of all government sectors • 24 supervising committees • Strategies reviewed/revised/updated annually

  20. Battled many 20th century issues • SARS, H1N1, W135, regional conflicts • Knowledge relevant to PH planners globally • International collaborations • CDC + Saudi MoH during H1N1 2009

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

  22. Infectious Disease Challenges Associated with MGs • Nature of MGs compounds routine disease factors • Susceptibility • Effectiveness of transmission • Gastrointestinal illness • Food-borne vs. water-borne • Rapid dissemination via air travel • Type of MG influences type of infections • ex. Overcrowding = respiratory infections • Excessive ETOH/drugs - STIs

  23. Fecal-Oral Transmission • Issue with preparation or distribution of food • Usually small, occasionally large • MDR shigellosis, Nantahala National Forest, NC, USA • 50% of 12,700 attendees • Poor sanitation → high coliform loads in local streams • Secondary OBs in 3 states • Hep A OBs at youth camp in Australia • Coleslaw • Subsequent spread to 4 other states J Infec Dis 1990;162:1324 Commun Dis Intell 2004;28:521

  24. Respiratory Transmission • MGs with overcrowding • Influence of: • Incubation time • Droplets vs. airborne transmission • The infectious agent • Influenza • 2008 – World Youth Day, Sydney, Australia • 2002 – Salt Lake City Winter Olympics • Pandemic influenza A H1N1 at European music festivals Emerg Infect Dis 2006;12:144

  25. Respiratory Transmission • Tuberculosis • Longer incubation time • Few reports associated with MGs • Air travel? • Others • Legionellosis • Measles • Mumps • Surveillance, vaccination, respiratory hygiene Lancet Infect Dis 2010;10:176

  26. Vector-borne Diseases • Malaria, dengue, WNV, Yellow fever • Ex. 2007 Cricket World Cup • In 9 Caribbean nations • Some endemic for VBDs • Teams from 16 nations • 4 nations from around Indian Oceans • Chikungunya a concern • Cases ID’ed in Indian Ocean visitors to Caribbean • Has the vector Aedes • US also concerned about importation to SE USA • Averted with effective public health action

  27. Lancet Infect Dis 2012;12:66-74

  28. Zoonosis • Transmitted from animals to people • Directly or via contaminated food and water • E. coli O157 • Glastonbury Festival, UK, 1997 • Mud contaminated with cattle feces • Leptospirosis • Triatheletes, adventure racing events • Ingestion, skin and MM penetration

  29. STIs & Blood-borne • Difficult to study • Only a few options available for control of STIs • Provision of condoms • Educational programs and campaigns • 2006 World Cup • Risk of blood-borne agents limited by nature of MG • Hepatitis B and C, HIV • Long incubation period makes ID difficult

  30. Infection Risks at the Hajj • Complex, high-risk situation • Often susceptible, elderly people • Interaction with those from nations where IDs are prevalent • Moves with lunar calendar = risk changes seasonally • Classic example is NeisseriameningitidisW135 • OBs of W135 in 2000, 2001 → global spread • Prolonged NP carriage, local transmission • Gained foothold in Saudi Arabia • Controlled by immunization

  31. Other IDs at Hajj • SARS • Recognized threat early ---- Control measures • Pandemic H1N1 & Seasonal influenza • Respiratory infections most common etiology for admission to hospital • GI illness also common • Occasional cholera (1980s) • Polio

  32. Other IDs at Hajj • STIs less of a concern • Those already on HAART report poor compliance • Skin infections • Shaving of the head – Hep B?? • Pretravel immunization • Enforce existing Saudi regulations, but no current required immunization

  33. Non-Communicable Health Risks at MGs • Trauma, accidents, stampedes, terrorist attacks, heat • More deaths/injuries at MGs than IDs • Ex. Stampedes/crush injuries (MORTALITY) • 7000 deaths, 14,000 injuries over 27 years • Spectrum of severity • Severe trauma • Cuts, sprains, dizziness, abdo pain, minor trauma (MOBIDITY)

  34. Non-Communicable Health Risks at MGs • Increased risk of injury associated with: • Outdoor MG in developing nations • Crowd density and mood • Warm weather • Extremes of age • Female gender

  35. Human Stampedes • Study of 215 stampedes from 1980-2007 • Religious MGs • Sports/musical/political • Average of 33 deaths and 79 injuries per event • Little understanding of mechanisms • Smooth → stop and go flow • Crowd turbulence • 2 cofactors: • 1. Failure to address crowd size vs. infrastructure • 2. Triggering event

  36. Crowd Management • With increasing density: • Crime • Incidence of illness/injury • Severe traffic delays; pollution • Consider health of staff, participants, spectators • Water, toilets, refrigeration, suppliers, waste disposal, pest control • At some MGs, the risk is ever present • Hajj

  37. Crowd Management 2010 Hajj 25612 tonnes of solid waste 6446 cleaning staff, 424 inspectors, 630 drivers Central, temporary holding area Covered transport *~700,000 slaughtered goats

  38. Crowd ManagementModeling • Study crowd dynamics • Microscopic vs. macroscopic levels • Shown several self-organizing principals of crowds • Need good visualization & monitoring • Can result in long-term event changes • Hajj- replaced used 1-way street flow instead of multi • Crowds scheduled over time and space

  39. Weather & Environment • Heat, cold, precipitation, pollution • Heat • 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 conditions • Cooling shelters/buses, fluid intake, sun protection, exercise avoidance

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

  41. Papal visit, Denver, USA, 1992 • Sudden drop from 30C – 13C • Woodstock, NY, 1969 • Heavy rainfall led to slippery conditions • Fractures • Beijing Olympics 2008 • Cut transportation use • Lowered OPD visits for asthma

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