1. 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

2. Epidemiologic Surveillance during Athens 2004 Olympic Games Nikoletta Mavroidi MD Olympic Games and Travel Medicine Office Hellenic Centre for Infectious Diseases Control (KEEL) KEEL MINISTRY OF HEALTH AND SOCIAL SOLIDARITY

3. 13 August 2004, Opening Ceremony

4. 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

5. Olympic Cities: Athens (all events) Thessaloniki Patras Volos Heraklion Ancient Olympia (shot put) KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY Soccer preliminaries

7. 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) KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

8. 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

9. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

10. Background- III Environmental 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 MINISTRY OF HEALTH & SOCIAL SOLIDARITY

12. 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 MINISTRY OF HEALTH & SOCIAL SOLIDARITY

13. KEEL Strategy Enhancement of the already functioning systems and structures KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

14. 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.) KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

15. 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!! KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

16. ENHANCEMENTS OF FUNCTIONING SYSTEMS-III 1.Content Disease of priority Modifications in the N.D.S. O.S.S. (Olympic Syndromic Surveillance) KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

17. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

18. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

19. Sentinel Priority Syndromes Varicella Gastroenteritis Rubella Measles Pertussis Mumps Respiratory Infections KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

20. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

21. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

22. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY Notifiable Diseases Olympic Syndromic Laboratory Reporting

23. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

24. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

25. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

26. ENHANCEMENTS OF THE ALREADY FUNCTIONING SYSTEMS 3. Frequency of reporting (N.D.S. & L.S.) Once per day, 10-11 am (13:30) KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

27. 4. Active Surveillance Zero reporting Olympic Syndromic Surveillance (O.S.S) KEEL communication with certain sites (forensic services – cruise ships) KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

28. 5. Coordination Olympic coordinators (Regional Health Systems) Surveillance Coordinators (Clinical & Laboratory depts) in hospitals –Function of the coordination team at the hospital level KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

29. 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) KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

30. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

31. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

32. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

33. KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

35. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

36. 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) KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

37. Investigation & Response- I Surveillance team (ST) Coordination team (CT) Coordination Centre (CC) Standard operating procedures (signal – alert – individual cases – rumors – CC) KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

38. 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 (> 30 pathogens- related diseases) KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

40. RESULTS Participation Overall morbidity Cases – syndromes Outbreaks KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

42. KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

43. OG related morbidity Total O.G. related Cases (N.D.)416, Salmonelloses: 52%, TB 17%5 (0,012%) Visits – hospitals132.1871.315 (7,5%) Syndromes OSS - hospitals 11.329 : 8,6%, GI 3,4%, RS 4,2%103 (0,08%) Visits – venues9.500N.A. Syndromes OSS – Venues 187 : 2,2%N.A. Individual GI cases – venues 24N.A. Outbreaks7 (20 – 50 cases)0 Clusters (food-borne disease) 20 (2 – 5 cases)0

44. KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

45. KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

46. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

47. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

48. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY

49. 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 KEEL MINISTRY OF HEALTH & SOCIAL SOLIDARITY