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Olympic Games

Monitoring acute diseases during the Sydney 2000 Olympic and Paralympic Games

Sarah V Thackway, Valerie C Delpech, Louisa R Jorm, Jeremy M McAnulty and Maria Visotina

MJA 2000; 173: 318-321

Abstract - Morbidity and mass gatherings - Public health services in Sydney during the XXVII Olympiad - The NSW Health Olympic Surveillance System - The role of general practitioners during the Games - Surveillance system constraints - Public health response - Acknowledgements - References - Authors' details
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Abstract
  • The Sydney 2000 Olympic Games (the XXVII Olympiad) will be the biggest peacetime event ever held in Australia.
  • During the Games, all public health decisions will be centralised, with daily briefing sessions held to review emerging public health issues and facilitate responses.
  • Infectious diseases will be monitored and reported through the Olympic Surveillance System, with particular attention to foodborne diseases and conditions spread via the respiratory route. This system relies heavily on the cooperation of key notifiers such as emergency departments, laboratories and general practitioners.
  • The lessons learned during the Games, and the new and enhanced systems and linkages that have been developed to support it, will strengthen future disease surveillance in NSW.

The Sydney 2000 Olympic Games (the XXVII Olympiad) will be the biggest peacetime event ever held in Australia, attracting over 10 000 athletes and about 5100 officials from 200 countries, around 15 000 media people and 300 000 domestic and international visitors. The Games period will extend for 60 days; it commenced with the opening of the Olympic Athletes' Village on 2 September and ends with the closure of the Paralympic Athletes' Village on 1 November. During this period, there will be a succession of mass gatherings, including the opening and closing ceremonies and many Olympic-related activities in the city. An estimated 150 000 extra people a day will be in central Sydney between noon and 10 pm. On the night of the closing ceremony, 750 000 people will gravitate to the city centre to attend festivities, and up to 500 000 are expected on Sydney Harbour's foreshores for a fireworks spectacular.

Mass gatherings, such as sporting events and outdoor celebrations, require public health and medical services to be provided for the large numbers of people who attend.1-4 Protecting the health of the Olympic "family" (athletes and officials), visitors and residents during the Sydney Olympic Games presents unique challenges. Public health planning commenced shortly after the 1993 announcement that Sydney was to host the 2000 Games. It covers counterdisaster planning,5 environmental hazard monitoring, and food safety strategies. Here, we describe selected public health issues associated with large mass gatherings and outline enhancements made to disease surveillance in Sydney prior to the Games.


Morbidity and mass gatherings

Injuries and death
Although relatively rare, mass gatherings have been associated with significant morbidity and death. Examples include crowd crushes at Hillsborough Stadium in the United Kingdom,6 and more recently at a rock concert in Copenhagen; the collapse of a pedestrian bridge at the 1997 Maccabiah Games in Israel, which led to the deaths of four Australians and injuries to almost 60 other athletes; and terrorist activities resulted in 11 deaths at the Munich (1972) and one death at the Atlanta (1996) Olympic Games.7

Infectious agents
Infectious disease outbreaks at mass gatherings are also uncommon. Between 1966 and 1993, a review article identified 38 reports of disease outbreaks or "other instances of transmission" of disease associated with competitive sports.8 In 24 of these outbreaks the disease was transmitted by person-to-person spread associated with contact sports (such as wrestling and rugby); the most common infectious agent identified was herpes simplex virus (12 reports). Other agents implicated in person-to-person spread have included enteroviruses (cocksackieviruses and echoviruses), with many reports indicating that infection was spread through shared water sources and drinking containers.8

Infections transmitted through the air or by droplets (or both) have also been reported. This year, the largest recorded outbreak of serogroup W-935 meningococcal disease was reported to the World Health Organization.9 It involved 384 reported cases of meningococcal disease diagnosed in pilgrims from 12 countries who contracted the disease while attending the hajj in Mecca; 71 died.10 In 1991, there was an outbreak of measles in the United States at the International Special Olympic Games,10 a competition launched in 1968 to increase quality of life for people with intellectual disabilities.11 Sixteen US athletes, spectators and volunteers from seven different States were initially affected, followed by another nine (there was no follow-up among international delegations).12 The primary case was identified as a track and field athlete from Argentina, and transmission occurred during the opening ceremony (held in a domed stadium), during track and field events and at first aid stations. This outbreak is an example of the way an international sporting event can provide the means of transmission of measles even in a country where the disease is relatively uncommon.

There are a number of particular considerations for the Sydney Olympic and Paralympic Games. The first is that nine cruise ships will be berthed in Sydney Harbour, acting as floating hotels for up to 32 000 guests. Outbreaks of disease, including gastroenteritis, Legionnaires' disease, influenza, and tuberculosis are well documented aboard cruise ships,13-18 and a number of gastroenteritis and influenza outbreaks have occurred on ships visiting Sydney.19-20 The closed environment and controlled ventilation systems aboard ships create the potential for disease outbreaks to affect large numbers of individuals.

Secondly, with increased international travel, a range of communicable diseases could be imported. For example, in 1996 tourists travelling in countries where yellow fever is endemic unknowingly imported the disease into the US and Switzerland.21 The same year saw approximately 10 000 reported cases of malaria imported into the European Community.21 Measles is now rare in New South Wales, and people with recent infections have acquired the disease overseas; if measles is encountered during the Games period, it is likely to be an imported strain.

Thirdly, the Sydney Olympic and Paralympic Games will be held during spring, which, in our temperate climate, is a time generally associated with increased incidence of diseases like meningococcal infection and pertussis. Finally, an estimated 1.8 million meals will be served to athletes and officials and another one million to staff (John Shields, Food Safety Adviser, Olympic Planning Unit, personal communication), amplifying the potential for foodborne disease outbreaks.


Public health services in Sydney during the XXVII Olympiad
Public health issues associated with Olympic Games have been recognised and reported since the XIX Olympiad in Mexico City in 1968.22 Public health preparations and surveillance during the Sydney 2000 Olympic Games are based on the experience of previous Olympic Games (Box 1), particularly Atlanta.

Routine surveillance of public health conditions in NSW is conducted through 17 Public Health Units in Area Health Services and a centralised Public Health Division within the NSW Health Department (NSW Health). Under the NSW Public Health Act (1991), medical practitioners, hospital chief executives (or general managers), pathology laboratories, directors of childcare centres and school principals are required to notify certain medical conditions to the local public health unit. These data are entered into the NSW Notifiable Diseases Database (NDD) and used to track the incidence of communicable diseases across the State and monitor risks and trends to enable direct intervention to control transmission. The NDD has been effectively used to detect, confirm and monitor outbreaks in NSW. Recent examples include hepatitis A associated with the consumption of oysters,27 hepatitis A among drug users in Kings Cross28 and a cluster of cases of haemolytic-uraemic syndrome.29


The NSW Health Olympic Surveillance System
Existing NSW Health structures will be enhanced during the Games and strategic public health decisions facilitated through a centralised NSW Health Olympic Coordination Centre, which will review emerging public health issues daily. The NSW Health Olympic Surveillance System (OSS) will be used to monitor acute disease outbreaks and potentially preventable injuries.

This system integrates multiple data sources described in Box 2. It enhances existing mechanisms and includes new surveillance systems, giving particular attention to injury, food-borne diseases, conditions spread via the respiratory route and the need for rapid detection of clusters. Detecting unusual patterns of disease presents a particular challenge. At the Health Olympic Coordination Centre, a team of public health experts will examine the Emergency Department Olympic Surveillance System (EDOSS), food safety, environmental inspection and cruise ship trend data. Three-day moving averages will be used to assist in detecting unusual patterns of disease incidence.

Detection of aberrations in the NDD data will be enhanced by using a statistical method to compute a normal confidence theory interval.30 This method can detect significant differences in incidence by comparing the current situation with historical data while adjusting for reporting delays and seasonality.


The role of general practitioners during the Games
Currently, in NSW, general practitioners should routinely report clusters of disease and notify scheduled medical conditions to the local public health unit (Box 3). During the Games, this role remains vital in the early detection of unusual patterns of disease. Many conditions are notifiable on clinical suspicion rather than waiting for confirmation of the diagnosis to allow early detection of disease and timely public health intervention. GPs should be particularly aware of reporting two or more related cases of gastroenteritis or foodborne illness. Infectious diseases uncommonly encountered in Sydney (such as malaria, dengue, cholera and typhoid) should be considered among travellers with unusual presentations.


Surveillance system constraints
All surveillance systems have limitations.31 The ability of the Olympic Surveillance System to detect unusual patterns of disease depends on:

  • timely reporting of notifiable conditions by all concerned;

  • presentation of "target cases" at emergency departments; and

  • maintenance of electronic systems for data collection and transfer, and back-up options.

To ensure the valididty of newly established data collections, a range of measures were undertaken. For example, EDOSS has been trialled at mass gatherings in Sydney over the past year (eg, Olympic Test Events [September 1999], New Year's Eve 1999-2000] and the Sydney Gay and Lesbian Mardi Gras [March 2000]). In May 2000, a full trial of the system was successfully undertaken in all participating hospitals. A validation of EDOSS test data assessed how many true target cases were missed (sensitivity) and how many of those cases identified failed to fulfil the target case criteria (specificity). EDOSS performed well on both measures, with sensitivity and specificity rates around 85%. Problems with identifying target cases were addressed in subsequent training sessions.

Although the surveillance system is designed to detect disease clusters, small localised clusters of some diseases and injuries may not be identified because they are obscured by "background" levels. Measures such as enhanced reporting by laboratories and general practitioners may help overcome this. The notification of suspected clusters on clinical grounds by general practitioners is very important.


Public health response
In the event of a small disease cluster, public health units, in close collaboration with the Health Olympic Coordination Centre, will implement existing outbreak management plans.32 If unusual patterns of injury are detected, the geographical location will be provided by NSW Health to the relevant authorities, such as police or the Olympic Road and Traffic Authority.

In the event of a major public health incident, investigations will be elevated to the State level. To assist any large-scale investigations, the telephone call-room used by the NSW Health Survey Program will be on stand-by to conduct interviews or provide information to the public. Also, public health investigation teams located in public health units on the periphery of metropolitan Sydney are on stand-by, to be deployed in the event of major public health incident. In the event that an emergency is declared, the coordination and control arrangements for any investigations will come under the provisions of the NSW Healthplan,33 which provides detailed procedures to coordinate all health services and resources within the State.


Acknowledgements
We acknowledge the contribution of Ross O'Donoghue, Tim Churches, John Kaldor, Sue Campbell-Lloyd, Rob Menzies, Mark Bartlett, Kerry Chant, Michael Hills, Peter Waples, Pam Albany, Michael Flynn, Karen Banwell, the staff at public health units and the sentinel hospitals: Auburn, Blacktown, Concord, Liverpool, Nepean, Prince of Wales, Royal Prince Alfred, St Vincent's, Sydney, Royal North Shore, Ryde, Sydney Children's, St George, The New Children's, and Westmead.

References
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Authors' details
NSW Health Department, Sydney, NSW.
Sarah V Thackway, MPH, Manager, Olympic Surveillance, Olympic Planning Unit;
Valerie C Delpech, FAFPHM, Medical Epidemiologist, Communicable Disease Surveillance and Control Unit;
Louisa R Jorm, PhD, Director, Epidemiology and Surveillance Branch;
Jeremy M McAnulty, FAFPHM, Manager, Communicable Disease Surveillance and Control Unit;
Maria Visotina, MAdmin, Manager, Olympic Planning Unit.

Reprints will not be available from the authors.
Correspondence: Ms S Thackway, Olympic Planning Unit, NSW Health, Locked Mail Bag 961, North Sydney, NSW 2059.
SATHAATdoh.health.nsw.gov.au

©MJA 2000
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We appreciate your comments.

1: Lessons from previous Olympic Games

In most instances, existing surveillance systems were enhanced to monitor infectious disease outbreaks.7,23-26 During the 1992 Barcelona Games enhanced reporting for hepatitis, meningococcal disease, Legionnaires' disease and foodborne disease23 identified no increases in disease compared with the same period in previous years. However, there was an increase in reports of foodborne illness - particularly domestic foodborne illness - by emergency departments. At the 1996 Atlanta Games, enhanced surveillance of infectious diseases in eight sentinel hospitals and public health laboratories detected:

  • No increase in emergency department presentations;
  • No outbreaks of disease at Olympic venues despite increased reporting of gastrointestinal symptoms during the first week; and
  • Management of 106 people at 11 emergency departments for injuries associated with the Olympic Park bombing (including 21 admissions and one death).7
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2: The NSW Health Olympic survellance System

  • The Notifiable Diseases Database (NDD) reporting of all notifiable conditions has been enhanced in two ways. Firstly, laboratories will be contacted daily by metropolitan public health units to ensure timely reporting of notifiable diseases. Secondly, notification data from public health units will be transferred to a centralised location at NSW Health three times a day.

  • The Emergency Department Olympic Surveillance System (EDOSS) has been implemented in 15 Sydney metropolitan hospital emergency departments to monitor cases of food-related illness, Legionnaires' disease, meningococcal disease, influenza, hepatitis A, pertussis and measles. Approximately 40 hospital staff will collect specific patient data on target cases upon arrival. Data will be entered into a database locally and sent electronically to the Health Olympic Coordination Centre at 8am daily for collation and analysis, thus making EDOSS an early warning system. EDOSS will operate from three weeks before the Games until after the closure of the Olympic Village.

  • National and global epidemic surveillance: National trends in infectious diseases will be regularly reviewed through the Communicable Disease Network of Australia and New Zealand. Data from the World Health Organization and ProMed (a resource of the International Society for Infectious Diseases for Monitoring Emerging Diseases) will be reviewed to provide information on global trends.

    Olympic Surveillance System

  • The Vessel Inspection Program has been modelled on the American Vessel Sanitation Program operated by the United States Centers for Disease Control and Prevention. Cruise ship medical staff are required to report notifiable conditions and complete daily reports outlining the number of passengers on board, the number of medical consultations, hospitalisations, deaths and cases of influenza-like illness, suspected pneumonia and gastroenteritis.

  • Influenza surveillance: Trends in influenza will continue to be monitored by combining reports from major laboratories and clinical data from general practitioners in the Australian Sentinel Practice Research Network.

  • Food safety monitoring: Since early 1999, metropolitan public health units and local councils have enhanced food hygiene surveillance for food premises. This program will play an important role in minimising the occurrence of foodborne illness outside Olympic venues. In addition, NSW Health and local government officers will inspect food premises inside Olympic venues and delivery and distribution outlets to ensure compliance with food hygiene standards. Summary inspection reports will be relayed daily to NSW Health.

  • Environmental inspection program: Priority has been given to minimising risk associated with Cryptosporidium in pools and Legionnaires' disease in water cooling towers. All water-cooling systems, clinical waste management services, toilet hygiene and general public health safety matters at Olympic and Paralympic venues will be inspected before sporting events commence. Waste and toilet services will be routinely inspected and summary inspection reports relayed daily to NSW Health.
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3: Conditions notifiable by doctors under the NSW Public Health Act (1991)

Acute viral hepatitis
Adverse event following vaccination
AIDS
Foodborne illness in two or more related cases
Gastroenteritis in two or more related cases
Leprosy
Measles
Pertussis (whooping cough)
Syphilis
Tuberculosis

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