Super Bowl Surveillance

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Super Bowl Surveillance
A Practical Exercise in Multi-Jurisdictional Data
Sharing
Carol Sniegoski1, MS, Wayne Loschen1, MS, Shandy
Dearth2, MPH, Joseph Gibson2, MPH, PhD, Joseph
Lombardo1, MS, Michael Wade3, MPH, MS, Matthew
Westercamp4, MS, Richard Wojcik1, MS, Guoyan
Zhang5, MD, MPH
1 The Johns Hopkins University Applied Physics
Laboratory 2 Marion County Health Department 3
Indiana State Department of Health 4 Cook County
Department of Public Health 5 Miami-Dade County
Health Department
This presentation was supported by Grant Number
P01 CD000270 from the Centers for Disease Control
and Prevention. Its contents are solely the
responsibility of the authors and do not
necessarily represent the official views of CDC.
2
Mass Gatherings
Mass gatherings

• Pre-planned
• Public

• Held for a specific limited time period
• Attended by large numbers of people (1,000
  published reports are usually 25,000)

Concentrated crowds created by temporary planned
population movements
Fourth of July Celebration
The Hajj
Super Bowl XLI
Feb 4, 2007 South Florida Pop 2,300,000
Dec 28 Jan 2, 2007 Mecca, Saudi Arabia Pop
1,500,000
Jul 4, 2007 Washington, DC Pop 580,000
112,000 visitors Average stay 4-5 days
2,500,000 pilgrims Average stay 40 days
500,000 attendees Average stay hours
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Health Implications
Milsten AM, Maguire BJ, Bissell RA, Seaman KG.
Mass-gathering medical care a review of the
literature. Prehospital Disaster Med 2002,
17151-162.
Arbon P, Bridgewater FH, Smith C. Mass gathering
medicine a predictive model for patient
presentation and transport rates. Prehospital
Disaster Med 2001, 16150-158.
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Effects on Infectious Disease
Aspects of Mass Events with Implications for
Infectious Disease Risk
Potential Effects on Infectious Disease Risk
Aspect of Mass Event

• Increase in absolute number of cases
• Increase in frequency of interpersonal contact
• Increase in proximity of interpersonal contact

Increase in population and population density
Primary Aspects
Population movement

• Locals are exposed to visitors diseases
• Visitors are exposed to local diseases
• Visitors carry disease home

New services and behaviors

• Poor hygiene in new temporary food outlets
• Increase in risky sexual behaviors

Infrastructure strain

• Breakdown in PH safeguards, e.g. food safety,
  water quality, public toilets

Secondary Aspects
Terrorism target

• Manmade pathogen release

Adapted from Schenkel K, Williams C, Eckmanns
T, Poggensee G, Benzler J, Josephsen J, et al.
Enhanced surveillance of infectious diseases
the 2006 FIFA World Cup experience, Germany.
Eurosurveill. 2006 December 200611(12)234-9.
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Population Movements and Surveillance
Visiting population brings in external disease
Surveillance for disease of local origin
Surveillance for disease brought to venue locale
Local population is exposed to external disease
Gathering Venue
External Population Sources
Visiting population is exposed to local disease
Surveillance for disease brought back from venue
locale
Surveillance for disease brought into venue locale
Visiting population takes back locally acquired
disease
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Previous Practices
Review of enhanced surveillance practices at
selected mass gatherings

• Summer Olympics
• Winter Olympics

• Super Bowl
• World Cup

• How much effort does it take?
• What surveillance data/information is shared?
• With whom?
• In what form?

As reported in literature found in PubMed,
MMWR, Eurosurveillance, or Google Scholar.
Publications were sought on the past six events
of each type Summer Olympics, Winter Olympics,
Super Bowl, and World Cup.
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How Much Effort?
Establish new notifiable disease surveillance
Establish drop-in biosurveillance system
install, train, monitor
High Setup Effort
Step up existing notifiable disease surveillance
increase conditions covered
Add new conditions to existing biosurveillance
system
Step up existing notifiable disease surveillance
shorten reporting period
Step up monitoring of existing biosurveillance
system
Low Setup Effort
Routine use of existing notifiable disease
surveillance
Routine use of existing biosurveillance system
Low Operational Effort
High Operational Effort
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What Is Shared?
Data Information
Uninterpreted facts or values independent of
assigned meaning Interpreted data that describe
the past or present
Would suggest no reaction. However, we should be
watchful of the GI syndrome among the 0-4 age
group tomorrow ...
Expert Interpretation
INFORMATION
Multivariate Analysis
Univariate Analysis
Aggregated Data
01-15-07 Fever Chest Pain 54 M 487.0
Respiratory
Cleansed Data
DATA
Raw Data
01-15-07 Fevr / CP 54 M 487.0
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Who Is It Shared With?
INTRA-JURISDICTIONAL
INTER-JURISDICTIONAL
Multiple jurisdiction venues
VENUE
e.g., World Cup
Multiple jurisdiction population sources
Single jurisdiction population sources
POPULATION SOURCES
?
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In What Form?
Free text outbreak reports
Information
Free text alert interpretations
Alert p-values and meta-information
Aggregated data counts
Raw case data
Data
Structured
Unstructured
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Previous Practices
KEY

• Enhanced Surveillance

• Enhanced Surveillance Including Syndromic

Use of Enhanced Surveillance at Selected Mass
Gatherings
Year
Event
Olympics, Summer
Olympics, Winter
Super Bowl
World Cup
1984 1986 1988 1990 1992 1994 1996 1998 2000 2001
2002 2003 2004 2005 2006 2007
LA County, CA
Mexico
Seoul, Korea
Calgary, Canada
Italy
Barcelona, Spain
Albertville, France
Lillehammer, Norway
USA
Atlanta, GA
Nagano, Japan
France
Sydney, Australia
Tampa, FL
Salt Lake City, UT
Korea Japan
New Orleans, LA
San Diego, CA
Houston, TX
Athens, Greece
Jacksonville, FL
Detroit, MI
Germany
Torino, Italy
Miami, FL
As reported in literature found in PubMed,
MMWR, Eurosurveillance, or Google Scholar.
Publications were sought on the past six events
of each type Summer Olympics, Winter Olympics,
Super Bowl, and World Cup.
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Previous Practices
Enhanced Surveillance Practices at Selected Mass
Gatherings
Venue
Surveillance


Year
Event
1984 Summer Olympics Los Angeles Augmented
n.d. reporting. Collected reportable data
syndrome counts by phone 3x/wk. 1992 Summer
Olympics Barcelona Augmented n.d. reporting by
adding diseases and increasing frequency. 1996
Summer Olympics Atlanta Augmented lab
reporting. Created surveillance for Olympic
clinics, envir. health. 1998 World Cup
France Activated n.d. reporting. Created
computer system to analyze data produce
reports. 2000 Summer Olympics
Sydney Augmented n.d. reporting. Created
surveillance for sentinel EDs, Olympic clinics,
cruise vessels, food safety, envir. health,
global epi news. 2001 Super Bowl
Tampa Created STARS. 2002 Winter Olympics
Salt Lake City Created ALERT. Installed drop-in
RODS. 2002 World Cup Korea Japan Japan
Used web-based natl Emergency Medical Info
System for new syndromic surveillance. 2004
Summer Olympics Athens Created environmental
health inspection system with daily reports. 2005
Super Bowl Jacksonville Created
BioDefend. 2006 Winter Olympics Torino Italy
Augmented n.d., lab, sentinel ILI, and toxic
exposure reporting by increasing frequency.
Created manually coded syndromic
surveillance. France Created reporting systems
for mortality, labs, limited n.d., ED. Produced
weekly summary reports. 2006 World Cup
Germany Augmented n.d. reporting in natl SurvNet
web system by increasing frequency. Required
daily summary reports from local PH.
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Level of Effort
2004 SO Athens
2005 SB Jacksonville (BioDefend)
High Setup Effort
2001 SB Tampa (STARS)
2002 WO SLC (ALERT, drop in RODS)
2000 SO Sydney (augmented created)
1996 SO Atlanta (augmented created)
1998 WC France (activated created analysis
system)
2006 WO Torino (augmented created)
2002 WC Japan Korea (created on existing IT)
1992 SO Barcelona (augmented)
2006 WC Germany (augmented on existing IT)
Low Setup Effort
1984 SO LA (augmented)
Low Operational Effort
High Operational Effort
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What Is Shared/With Whom?
1998 WC France (natl reports publicly available)
2006 WC Germany (local natl reports publicly
available)
2006 WO Torino (daily report publicly available)
Information
2002 WC Japan Korea (daily local natl stats
reports)
2004 SO Athens (env. reports sent to natl
ministry)
2005 SB Jacksonville (email alerts to PH)
2002 WO SLC (email alert notifications to PH)
2006 WC Germany (national publicly available)
2002 WC Japan Korea (national)
1998 WC France (national)
2006 WO Torino (natl regional)
2000 SO Sydney (regional)
2004 SO Athens (by county)
1996 SO Atlanta (counties)
2001 SB Tampa (in county)
Data
2005 SB Jacksonville (counties)
1992 SO Barcelona (in city)
1984 SO LA (counties)
Intra-jurisdictional
Inter-jurisdictional
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Super Bowl XLI, 2007
Chicago Bears play Indianapolis Colts in South
Florida

• All three regions routinely practice
  biosurveillance

Chicago

• Cook County Department of Public Health
• Marion County Health Department
• Indiana State Department of Health
• Miami-Dade County Health Department

S
Indianapolis
S
S

• Miami and Cook County produce routine daily
  surveillance summary reports

S
Miami
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Super Bowl Surveillance
Augmented existing biosurveillance
systems/practices for the Super Bowl period
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Super Bowl Surveillance
How much effort?
Setup effort MINIMAL

• Planning took place during joint phone calls the
  week before the event.
• PH departments were unwilling/unable to share
  data but interested in sharing information.
• JHUAPL remotely introduced new zip code groupings
  into the Miami system.
• System was operational within 24 hours.

Operational effort MINIMAL

• Miami monitored the new Chicago and Indiana zip
  code groupings.

• Miami emailed extra copies of its routine daily
  summary report.

• Chicago and Indiana received extra emails
  containing Miamis reports.

• Shared reports were readily understood due to
  participating departments using similar
  surveillance systems.

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Super Bowl Surveillance
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Significance
Ease of setup and operation

• Leveraged existing biosurveillance systems and
  practices
• No new data collection was needed
• No additional training was needed
• Departments familiarity with automated
  biosurveillance systems facilitated report sharing

Venue PH able to specifically surveil both venue
and source populations

• Key data fields and visualization tools already
  available in biosurveillance system

Venue and source PH engaged in two-way
information exchange

• Mutually comprehensible summary reports shared
  between participating locales

Approach to data and information sharing
Collect and analyze data locally, share
information inter-jurisdictionally

• Keeping data local avoids the difficulties of
  inter-jurisdictional data sharing
• Analyzing data locally captures local knowledge
• Sharing only information inter-jurisdictionally
  is efficient and captures local knowledge

Structured Information Sharing in Disease
Surveillance SystemsWayne Loschen et al.
Enhancing Event Communication in Disease
Surveillance ECC 2.0 Nathaniel Tabernero et al.
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Questions?
Wayne.Loschen_at_jhuapl.edu http//essence.jhuapl.e
du