Surveillance During Mass Gatherings

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Surveillance During Mass Gatherings

• Chryssa Gryllis MD PhD
• Dept for Surveillance and Intervention
• Hellenic Centre for Infectious Diseases Control
  (KEEL)
• EPINORTH Seminar 5-10 September 2005,
  Tallinn

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Epidemiologic Surveillance during Athens 2004
Olympic Games

• Nikoletta Mavroidi MD
• Olympic Games and Travel Medicine Office
• Hellenic Centre for Infectious Diseases Control
  (KEEL)

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13 August 2004, Opening Ceremony
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• 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

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• Olympic Cities
• Athens (all events)
• Thessaloniki
• Patras
• Volos
• Heraklion
• Ancient Olympia (shot put)

Soccer preliminaries
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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)

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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

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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

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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

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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

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KEEL Strategy

• Enhancement of the already functioning systems
  and structures

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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.)

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ENHANCEMENTS OF FUNCTIONING SYSTEMS-II

• What type of system enhancement
• Content
• Data Information flow
• Frequency of reporting
• Active Surveillance
• Coordination
• Increasing awareness
• Feedback of information!!

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ENHANCEMENTS OF FUNCTIONING SYSTEMS-III

• Content
• Disease of priority
• Modifications in the N.D.S.
• O.S.S. (Olympic Syndromic Surveillance)

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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

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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

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Sentinel Priority Syndromes

• Varicella
• Gastroenteritis
• Rubella
• Measles
• Pertussis
• Mumps
• Respiratory Infections

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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

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• 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

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• 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

Notifiable Diseases Olympic Syndromic Laboratory
Reporting
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• 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

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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

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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

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ENHANCEMENTS OF THE ALREADY FUNCTIONING SYSTEMS

• 3. Frequency of reporting
• (N.D.S. L.S.)
• Once per day, 10-11 am (1330)

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• 4. Active Surveillance
• Zero reporting
• Olympic Syndromic Surveillance (O.S.S)
• KEEL communication with certain sites (forensic
  services cruise ships)

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• 5. Coordination
• Olympic coordinators (Regional Health Systems)
• Surveillance Coordinators (Clinical Laboratory
  depts) in hospitals
• Function of the coordination team at the hospital
  level

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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)

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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 planning

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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

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• Daily Report and Data Analysis
• Analysis and report per system and/or by site at
  1500h 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 1800h

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What was considered, designed implemented
specifically for the Games- I

• 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

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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)

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Investigation Response- I

• Surveillance team (ST)
• Coordination team (CT)
• Coordination Centre (CC)
• Standard operating procedures (signal alert
  individual cases rumors CC)

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Investigation Response- II

• Increased sensitivity concerning response
• Rumors
• Single GI cases in venues
• Single 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 (gt 30 pathogens- related diseases)

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RESULTS

• Participation
• Overall morbidity
• Cases syndromes
• Outbreaks

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OG related morbidity

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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

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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 KEEL

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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

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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

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