Surveillance During Mass Gatherings Chryssa Gryllis MD PhD Dept for Surveillance and Intervention...

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)


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


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


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


KEEL Strategy

• Enhancement of the already functioning systems and structures


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.)


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!!


ENHANCEMENTS OF FUNCTIONING SYSTEMS-III

1. Content

• Disease of priority

• Modifications in the N.D.S.

• O.S.S. (Olympic Syndromic Surveillance)


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


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


Sentinel Priority Syndromes

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


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


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


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 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


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


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


ENHANCEMENTS OF THE ALREADY FUNCTIONING SYSTEMS

3. Frequency of reporting

(N.D.S. & L.S.)

• Once per day, 10-11 am (13:30)


4. Active Surveillance

• Zero reporting

• Olympic Syndromic Surveillance (O.S.S)

• KEEL communication with certain sites (forensic services – cruise ships)


5. Coordination

• Olympic coordinators (Regional Health Systems)

• Surveillance Coordinators (Clinical & Laboratory depts) in hospitals– Function of the coordination team at the

hospital level


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)



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


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


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


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


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)


Investigation & Response- I

• Surveillance team (ST)

• Coordination team (CT)

• Coordination Centre (CC)

• Standard operating procedures (signal – alert – individual cases – rumors – CC)


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)


RESULTS

• Participation

• Overall morbidity

• Cases – syndromes

• Outbreaks


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


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


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


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


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


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


Surveillance During Mass Gatherings Chryssa Gryllis MD PhD Dept for Surveillance and Intervention...

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