The world’s great mass gatherings - from religious pilgrimages like the annual Haj to Saudi Arabia and India’s huge Kumbh Mela, to major sporting events like the Olympic Games and the Football World Cup - present important health challenges to organizers and participants alike.
Now, with London expecting more than five million visitors to attend Olympic events there this summer, the British medical journal, the Lancet, has published a special series of studies on mass gatherings and global health.
Every mass gathering is a medical disaster waiting to happen, each with its own particular selection of risks. The winter Olympics brings people together from all over the world, usually at the peak of the northern hemisphere’s annual flu season, and after a couple of weeks of close contact, disperses them back to their own countries.
The Haj attracts pilgrims from some of the world’s poorest countries, with poor disease surveillance and inadequate health care. In addition, many of them may be old or sick, but desperately anxious to fulfil their religious duty before the end of their lives.
In India, the Kumbh Mela has less of an international dimension but can bring together as many as 60 million people and involves mass bathing in the holy, but not necessarily very clean, River Ganges.
The biggest pop and rock music festivals bring the additional hazards of drink and drugs, and young people camping in muddy fields with more interesting things on their minds than hand washing and proper sanitation.
Sharing expertise, exploiting technology
Now a new public health specialty is developing around these major international events, allowing organizers to share their expertise, and exploit new technologies to manage risk and track disease outbreaks in real time.
A common thread in the Lancet papers is a stress on the need for international collaboration, and a move away from the old definition of mass gathering medicine as “concerned with the provision of emergency medical care at organized events with more than a thousand people in attendance”.
Organizers have to know where their participants will be coming from and how they will travel; this, combined with a knowledge of current disease outbreaks in the world, will help them plan for possible risks, and to decide whether they need to demand pre-vaccination, set up airport checks or make any special on-the-spot provision.
But currently this information is held in lots of different places - ticket sales offices, airline schedules, national health ministries, the World Health Organization. As the lead author of one of the papers, Kamran Khan of the University of Toronto, remarks: “Although the scientific and technological components and data sources needed to generate real-time intelligence that could mitigate the risks of infectious diseases during mass gatherings exist, their integration is suboptimum.”
The responsibilities of the organizers do not end when the participants leave for home. Another paper, by Ibrahim Abubakar of the UK Health Protection Agency and colleagues, cites the examples of an endurance race held in Borneo. Ten days after the event ended one of the athletes - by then in London - developed the water-borne disease leptospirosis. This was picked up by the Geosentinal health tracking system along with two similar cases the same day, one in New York, the other in Toronto. An immediate alert warned participating athletes and eventually identified 68 who had contracted the potentially serious disease.
The country with the greatest experience of holding international mass gatherings is Saudi Arabia. The authorities there take their responsibility during the Haj very seriously and a team from the Preventative Medicine Directorate in Riyadh contributed the leading paper in the series. Saudi Arabia tries to ensure that pilgrims have the necessary vaccinations before they set out - something which the Lancet suggests is in itself a useful contribution to global health. A special airport terminal has facilities for the health screening of pilgrims on arrival and departure.
Saudi Arabia has also been using new technologies to ensure the pilgrims’ health. Kamran Khan documents the Saudi response in 2009, when the annual pilgrimage coincided with the H1N1 bird flu pandemic. Realizing that traditional, paper-based reporting was going to be too slow to track an influenza outbreak, they set up a mobile phone based system, with field investigators, armed with smartphones and laptops, reporting any cases of nine infectious diseases in real time to an emergency operations centre. Among the cases they reported were two of dengue fever and 73 cases of H1N1 influenza.
Centre of expertise
Now they plan to set up a pioneering centre of expertise in the medicine of Mass Gatherings. Ziad Memish of the Preventive Medicine Directorate in the kingdom’s Ministry of Health told IRIN:
“It is hard to say for sure that this is the first, but we know from hosting the largest ever conference on mass gatherings that there was a feeling among experts from all over the world that this was needed and Saudi Arabia would be the ideal place to host it. So the Saudi Centre for Health Specialities was tasked with developing a diploma course in Mass Gathering and Disaster Medicine, which will be starting this year and will be based in Jeddah. This will create a good nucleus to establish a specialty and train people.”
The initial one-year course will have 25 students, all of them physicians or paramedics working in the main pilgrimage centres of Mecca and Medina. But Memish says the intention is to develop an international centre which will train people from all over the world.
The Lancet authors are clearly excited about the potential use of new technological tools in mass gathering medicine. One constant problem is that national governments are often reluctant to admit to outbreaks of infectious illness. The internet allows organizations like HealthMap to draw on a much wider range of informal sources, even references popping up in Twitter, to track outbreaks of human and animal disease.
Meanwhile in London, preparations are going ahead for this year’s summer Olympics, and the Saudi Arabian authorities have already been consulted by the UK Health Protection Agency. “They have been in touch about organizing some joint training activities in the run-up to the Games,” says Memish. “We have to be clear that the Olympics and the Haj are very different events, and attract very different kinds of people. But it is always good to be in touch and to share our experience together.”