Infections at Music Festivals and Other « Young » People Mass Gatherings

Infections at music festivals and other « young » people mass gatherings

-- Dr. Philippe Gautret, Dr. Elisabeth Botelho-Nevers

Institute for Infectious Diseases and Tropical Medicine, Marseille URMITE CNRS-IRD UMR6236 EuroTravNet Marseille, ©France by author

ESCMID London 3 April 2012 ASSISTANCEESCMID PUBLIQUE Online Lecture Library HOPITAUX DE MARSEILLE EUROTRAVNET Mass gatherings

• WHO : events attended by a sufficient number of people to strain the planning and response ressource of a community, state or nation. • Concentration of people temporally and spacially • The public health response to MGs is analogous to that for public health emergency or disasters in which© bythe author existing infrastructure is inadequate for the surge in demand. ESCMID Online Lecture Library Oxegen, Punchestone Racecourse, Ireland, 2004 • Oxegen 2004: the impact of a major music festival on the workload of a local hospital. Nix CM et al., Ir Med J 99: 167-9. • Music Festival 80,000 attendees – 3 days • Nass General Hospital 45% increase in the emergency dpt 51% inpatients Trauma+++ (few ©infections) by author 47% consumed alcool and/or illicitESCMID substances Online Lecture Library

Top 6 Music festivals in Europe 2011 • Rock Werchter, Belgium (110,000 – 3 days) • Roskilde European Music Festival, Denmark (110,000 – 4 days) • Exit Festival, Novi Sad, Serbia (150,000 – 4 days) • Glastonbury festival, Pilton, Somerset, England (150,000, 3 days) • Paléo Festival, Nyon,© byFrance author (225,000 – 6 days) • Szigest Festival, Budapest,ESCMID Hungary Online (390,000 Lecture –4 days Library)

Main characteristics

• Out-door

• Young population

Other « young » people mass gatherings

• Cultural events – University festivals, dance festivals…

• Religious events

• Political meetings,© largeby author weddings …

ESCMID Online Lecture Library Infections at music festivals: an artistical concern "Yeah, I'm happy to be here," shrugs Paul Simon "I've got a throat infection so if I'm not at the top of my game, that's the reason."

GlastonburyESCMID Online 2011 Lecture Library Infections at music festivals: a public health concern

Outbreaks and music festivals -- A mini-review of the litterature © by author

ESCMID Online Lecture Library Faecal-oral transmission and gastro-intestinal diseases at music festivals and other mass gatherings

ESCMID Online Lecture Library Rainbow family meeting, US, 1987 • A large outbreak of antibiotic-resistant shigellosis at a mass gathering. Wharton M et al., J Infect Dis 1990; 162: 1324-8.

• 1987, annual meeting of the Rainbow Family, Nantahala National Forest, USA • > 50% of the 12,700 attendees infected • Shigella sonnei • Inadequate sanitation resulted in high coliform loads in a stream used as a source of drinking water

ESCMID Online Lecture Library Gastro-intestinal diseases Michigan Womyn's Music Festival, US, 1988

ESCMID Online Lecture Library Michigan Womyn's Music Festival, US, 1988

• An outbreak of shigellosis at an outdoor music festival. Lee LA, et al. Am J Epidemiol 1991; 133: 608-15.

• August 1988, 5-day outdoor music festival in Michigan, USA (females only) • 3,175 women with gastroenteritis over 6403 attendees • Incubation 2 days • Uncooked tofu salad in cause (prepared by attendees) • Shigella sonnei outbreak started among staff and continued in attendees • Limited access to soap and running water for hand washing was present © by author

ESCMID Online Lecture Library Gastro-intestinal diseases Glastonbury music festival, England, 1992

ESCMID Online Lecture Library Glastonbury,1992

• An outbreak of Campylobacter infection associated with the consumption of unpasteurised milk at a large festival in England. Morgan D. et al., Eur J Epidemiol 1994; 10: 581-5.

• June 1992, Glastonbury Music festival, South West England, open-air • ≈70,000 people • 72 cases laboratory confirmed Campylobacter infection • Age 20-30 years

• Significant association with unpasteurized milk consumption sold at the festival © by author

ESCMID Online Lecture Library Gastro-intestinal diseases San Juan festival, Catalonia, Spain, 2002

ESCMID Online Lecture Library San Juan festival, Spain, 2002

A foodborne outbreak of Salmonella infection due to overproduction of egg- containing foods for a festival. Camps N, et al. Epidemiol Infect. 2005 133:817-22

• 23 June 2002, Catalonia, Spain, Festival of St John • Alert with 30 cases of diarrhea • 1435 cases,117 cases hospitalized, 47 foreign tourists (UK, France, Italy, Germany, the Netherlands, Ireland, Belgium, Denmark, Switzerland). • Incubation periods = 15 hours (10 to 23h) • Consumption of ‘coca de crema’ cakes with vanilla cream : 100% of cases enrolled in case-control study consumed ‘coca’ vs 20% in controls • Salmonella enterica serotype Enteritidis (154 stools from patients, food handlers, products) © by author

• The number of ‘cocas’ manufactured was above the capacity of the bakery

ESCMID Online Lecture Library

Gastro-intestinal diseases Youth camp, Australia, 2003

• A multi-jurisdictional outbreak of hepatitis A related to a youth camp-- implications for catering operations and mass gatherings. Munnoch et al., Commun Dis Intell 2004; 28(4): 521-7

• 24-28 April 2003 youth camp in Central Australia (350 people) • June 2003, notification of an outbreak of 21 cases of acute hepatitis A • Coleslaw in cause

ESCMID Online Lecture Library Gastro-intestinal diseases Nagoya university festival, Japan, 2008

ESCMID Online Lecture Library Nagoya university festival, Japan, 2008

Food poisonning by Staphylococcus aureus at a university festival. Kitamoto et al., Jpn J Infect Dis 2009; 62: 242-3

• June 2008, Nagoya University Festival, Japan – 50,000 attendees • Alert with 10 visitors with nausea, vomiting and stomachache following crepe ingestion • 75 cases: incubation period = 4.2 hours (1 to 9.5 hours) • Symptoms: 90% vomiting, 89% nausea, 73% diarrhea, 69% abdominal pain, 24% fever • Staphylococcus aureus with coagulase III and enterotoxins A et C (stools, fingers from patients and students that had eaten crepes) • Crepes were prepared by students prior the festival and kept at room temperature © by author

ESCMID Online Lecture Library Gastro-intestinal diseases

Drinking water, un-pasteurized milk, excessive production of foods ©and by meals author prepared by large numbers of non-professional food handlers may be sources of infection during festivals. Need to implement food safety programs and education during massESCMID gatherings. Online Lecture Library Gastro-intestinal diseases

Importance of adequate sanitation at mass gatherings ESCMIDwith large Onlineaccess to Lecture soap and Librarywater

Gastro-intestinal diseases Glastonbury music festival, England, 1997

ESCMID Online Lecture Library Glastonbury, 1997

• Outbreak of Escherichia coli O157 Infection Associated with a Music festival. M. Crampin, G Willshaw, R Hancock, T Djuretic, C Elstob, A Rouse, T. Cheasty, J. Stuart. Eur J Clin Infect Dis 1999, 18: 286-288

• June 1997, Glastonbury Music festival, South West England, open-air • ≈ 80,000 attendees • Cows grazed on the site 2 days before festival with heavy rain turned the site into a quagmire • 7 cases of diarrhea, 1 case of haemolytic uraemic syndrome (18 months old) • Symptoms: diarrhoae (1), haemorraghic colitis (6) • Mean age 21 years • Escherichia coli O157 Vero cytotoxine© by 2,author phage type 2 (patient stools and 1 bovine isolate) • No food or water source found but high level of mud contamination on hands and face.

ESCMID Online Lecture Library Gastro-intestinal diseases

© by author Mud in music festivals may serve as vehicule of infection… ESCMID Online Lecture Library Gastro-intestinal diseases Ukrainian dance festival, Dauphin, Canada, 2001 • Outbreak of diarrheal illness in attendees at a Ukrainian dance festival, Dauphin, Manitoba-May 2001. Macey J, Lior L, Johnston A, Eliott L, Krahn D, Nowicki D, Wylie J. Can Commun Dis Rep. 2002 Sep 1;28(17):141-5 • 4-5 May 2001, Ukrainian dance festival (430 dancers and > 450 spectators) • From 6 to 18 May, 59 cases with acute watery diarrhea, 2 were hospitalized • Cryptosporidium parvum (2 stools) • Mean age = 15.4 years, 53% were female • Mean incubation time = 7 days • Contact with an hotel swimming pool in 83% of cases © by author

ESCMID Online Lecture Library Gastro-intestinal diseases

Recreative water may be a source of infection during festivalsESCMID Online Lecture Library Gastro-intestinal diseases Respiratory transmitted diseases at music festivals and other mass gatherings

ESCMID Online Lecture Library World Youth Day, Sidney, Australia, 2008

ESCMID Online Lecture Library World Youth Day,Sidney, Australia, 2008

Influenza outbreaks during World Youth Day 2008 Mass Gathering. Blyth CC et al., Emerging Infectious Diseases. 2010; 16: 809-15.

• 15 to 20 July 2008, World Youth Day, Sydney, Australia • 223,000 young pilgrims from 170 countries, 400,000 attendees • 227 attendees visited clinics for influenza illness and were tested • 100 confirmed influenza cases (44.1%) • True extent of infection unknown • Median age 21 years, 62.8% female • Numerous strains were identified: oseltamivir-sensitive and oseltamivir- resistant Influenza A (H1N1), influenza A (H3N2) virus and 2 strains of influenza B virus. © by author • Novel viruses were introduced in Australia during this mass gathering by pilgrims from Europe and US.

ESCMID Online Lecture Library Respiratory transmitted diseases Rock Werchter, Belgium, 2009

ESCMID Online Lecture Library Rock Werchter, Belgium, 2009

Community transmission of Influenza A (H1N1)v virus at a rock festival in Belgium, 2-5 July 2009. Gutierrez I. et al., Eurosurveillance 2009; 14

• 2-5 July 2009, Rock Werchter festival, Belgium, >113,000 attendees, international • Supposed index case from Israel • 14 confirmed-cases of pandemic Influenza A (H1N1)v (30 ILI cases) • Cases in Belgium (12), Luxembourg (1) and The Netherlands (1) • First outbreak of pandemic 2009© influenza by author associated with mass gathering

ESCMID Online Lecture Library Respiratory transmitted diseases Sziget festival, Hungary, 2009

ESCMID Online Lecture Library Sziget festival, Hungary, 2009

Travel-related Influenza A (H1N1) infections at a rock festival in Hungary. A virus may hide another one. Botelho. et al., J Travel Med. 2009; 17:197-8.

• 11-18 August 2009, Sziget festival, Budapest, Hungary, 390,000 attendees, international (25% French attendees) • ILI rate : 3.6 per 100,000 individuals • Eight confirmed-cases of pandemic Influenza A (H1N1)v (rtPCR) 57.1% of ILI cases. • 15.3% positive H1N1 among ILI patients in Europe at the same time © by author • 2 cases in French attendees

ESCMID Online Lecture Library Respiratory transmitted diseases Exit festival, Novi Sad, Serbia, 2009

ESCMID Online Lecture Library Exit festival, Serbia, 2009

Importation of pandemic influenza virus A (H1N1) in autonomus province of Vojvodina in preepidemic period.. Ristic M et al., Med Pregl. 2010; LXIII:502-5.

• 14-16 July2009, Exit festival, Novi Sad, Serbia, 150,000 attendees, international (20,000 non-Serbian) • 49 confirmed-cases of pandemic Influenza A (H1N1)v (rtPCR) • Young adults 20-29 years, 64.2% males) • 40% H1N1 cases in Serbia were linked to Exit festival © by author

ESCMID Online Lecture Library Respiratory transmitted diseases Taizé, France, 2010

Spotlight on measles 2010: Measles outbreak among travellers returning from a mass gathering, Germany, September to October 2010. Plaff G. et al., Euro Surveill. 2010; 15:pii=19750

• Participants in religious Taizé meetings in France (3500 attendees – 4 days) • 13 primary cases of measles in German people, median age 16.5 years, ten females, 3 cases hospitalized in Germany, none were vaccinated • 17 secondary and 7 tertiary cases in Germany (non-immune people) • Virus D4-Manchester

ESCMID Online Lecture Library Respiratory transmitted diseases Granada wedding, Spain, 2010

Spotlight on measles 2010: An ongoing outbreak of measles in an unvaccinated population in Granada, Spain, October to November 2010. Lopez Hernandez B. et al., Euro Surveill. 2010; 15:pii=19746

• Participants to a wedding, Andalucia, Spain • 25 cases of measles, living in the same neighborhood, age from 7 months to 38 years • Secondary cases in schools, hospital: total 59 cases • Belong to a subpopulation with low vaccination coverage (ideological vaccine objections)

ESCMID Online Lecture Library Respiratory transmitted diseases Navarra village festival, spain, 2006

Mumps outbreak in young adults following a village festival in the Navarra region, Spain, August 2006. Gerstel L. et al., Euro Surveill. 2006; 11:pii=3078

• Annual Festival of a village of Navarra, Spain from 21-25 July 2006 (4500 inhabitants + visitors from neighboring villages) • 19 cases of mumps identified, 53% were males, aged from 18 to 37 years • 94% of cases attended at the festival • Most of cases have been vaccinated twice, however with Rubini strain for the second dose in 6 cases • 58 other cases were reported after in Navarra.

ESCMID Online Lecture Library Respiratory transmitted diseases Easter Youth Festival, Austria, 2006

Mumps outbreak in young adults following a festival in Austria, 2006. Schmid D. et al., Euro Surveill. 2008; 13:pii=8042

• Easter youth Festival, Austria, 16 April 2006 • 16 first cases of mumps reported in early may 2006 • A total of 214 cases were finally found • Age median 24 years • 50% of cases occurred in non-vaccinated people • 40% of cases received only one dose of vaccine • 36% of cases presented complications and 22.4% were hospitalized © by author

• Vaccination campaign was conducted leading to end of outbreak ESCMID Online Lecture Library Respiratory transmitted diseases

Young people mass gatherings can concentrate respiratoryESCMID transmitted Online diseases Lecture and amplify Library their transmission with further international spread

© by author VPD may spread during mass gathering in unvaccinated people or in people vaccinated with unadapted viral strains. ESCMID Online Lecture Library Big Day Out Music Festival, Australia, 2007 and 2009 Sexual-risk behaviour, self-perceived risk and knowledge of sexually transmissible infections among young Australians attending a music festival. Lim MS et al., Sex. Health 2007; 4: 51-6 Home-based chlamydia testing of young people attending a music festival- who will pee and post? Sacks-Davis R et al., BMC Public Health 2010; 10: 376

• Big Day Out, Melbourne, Australia, 40-50,000 attendees •Questionnaires, median age 20 years •38-39% did not use condom all or most of the time •47% had multiple partners •43% of sexually experienced had © by author not used a condom because of alcohol use •36% reported hazardous drinking and 33% used illicit drugs in the past month

ESCMID Online Lecture Library

© by author Young people attending music festivals are sexually active people with limited knowledge about STI, and behaviourESCMID that Online put them Lecture at risk of Library infections Top 6 Music festivals in Europe

• Rock Werchter, Belgium (100,000 – 3 days) H1N1 outbreak 2009 • Roskilde European Music Festival, Denmark (110,000 – 4 days) • Exit Festival, Novi Sad, Serbia (150,000 – 4 days) H1N1 outbreak 2009 • Glastonbury festival, Pilton, Somerset, England (150,000, 3 days) Campylobacter outbreak 1992 – E. coli outbreak© by 1997author • Paléo Festival, Nyon, France (225,000 – 6 days) • Szigest Festival, Budapest Hungary (390,000 –4 days)ESCMID H1N1 outbreak Online 2009 Lecture Library

Conclusions (surveillance)

• Infections related to music festivals and others young people mass gatherings are probably underestimated.

• Relation with festival may be difficult to establish, notably for long-incubation diseases and international events. © by author • Importance of syndromic surveillance.

• ImportanceESCMID of adequateOnline Lecture laboratory Library facilities.

Conclusions (prevention)

• Correct immunization of young people likely to participate to MG (MMR, Influenza, Hepatitis B/A?, Meningitis?)

• On-site advice about food-hygiene, hand- hygiene, cough etiquette and use of condoms.

• Adequate sanitation. ESCMID Online Lecture Library

Thank you for your attention

SpecialESCMID thanks Online to Dr Lecture Botelho-Nevers Library