Emergencias 2017;29:257-265

REVIEW Formación acreditada Mass gatherings: a systematic review of the literature on large events

Pedro Llorente Nieto 1,2 , Gregorio González-Alcaide 3, José M. Ramos 1,2

We reviewed the literature on mass gatherings published worldwide to determine event types and topics or epidemio - Authors affiliation: 1 logic aspects covered. Articles using the term mass gatherings indexed in the Scopus database between 2000 and Departamento de Medicina Clínica, Universidad Miguel 2015 were reviewed. Of the 518 returned, we selected 96 with relevant information. The main event types studied Hernández de Elche, Alicante, were related to sports (46%), music (25%) or religious/social content (23%), and the most commonly studied loca - Spain. 2Servicio de Medicina Interna, tions were the United States (n=21), the Kingdom of (n=17), Australia (n=11), and the United Kingdom Hospital General Universitario de (n=10). The four most often studied events were the Hajj (n=17), the Olympic games (n=13), World Youth Day (n=8), Alicante, Spain. and the FIFA World Cup (n=6). The main topics studied were models of (n=55), health care evaluation by 3Departamento de Historia de la Ciencia y Documentación, means of rates of patients presenting for care or transferred to hospitals (n=21), respiratory pathogens (n=18), syn - Universitat de València, Valencia, dromic surveillance (n=10), and the global spread of diseases (n=10). Mass gatherings are an emerging area of study Spain. addressed by various medical specialties that have focused on studying the health care models used at such events. Contribution of authors: Emergency is particularly involved with this research topic. All authors have confirmed their authorship in the author's Keywords: Mass gatherings. Emergency health services. Epidemiologic monitoring. World health. . Disas - responsibilities documents ters. Large events: victims, incidents. publication agreement and assignment of rights to EMERGENCIAS.

Corresponding author: Mass gatherings: a systematic review of the literature on large events Pedro Llorente Nieto Departamento de Medicina Clínica, Universidad Miguel We reviewed the literature on mass gatherings published worldwide to determine event types and topics or epidemio - Hernández de Elche logic aspects covered. Articles using the term mass gatherings indexed in the Scopus database between 2000 and Avenida de la Universidad, s/n 2015 were reviewed. Of the 518 returned, we selected 96 with relevant information. The main event types studied 03202 Elche, Spain were related to sports (46%), music (25%) or religious/social content (23%), and the most commonly studied loca - E-mail: tions were the United States (n=21), the Kingdom of Saudi Arabia (n=17), Australia (n=11), and the United Kingdom [email protected]

(n=10). The four most often studied events were the Hajj (n=17), the Olympic games (n=13), World Youth Day (n=8), Article information: and the FIFA World Cup (n=6). The main topics studied were models of health care (n=55), health care evaluation by Received: 4-4-2016 means of rates of patients presenting for care or transferred to hospitals (n=21), respiratory pathogens (n=18), syn - Accepted: 11-8-2016 Online: 23-6-2017 dromic surveillance (n=10), and the global spread of diseases (n=10). Mass gatherings are an emerging area of study addressed by various medical specialties that have focused on studying the health care models used at such events. Editor in charge: is particularly involved with this research topic. Guillermo Burillo Putze, MD, PhD. Keywords: Mass gatherings. Emergency health services. Epidemiologic monitoring. World health. Public health. Disas - ters. Large events: victims, incidents.

Introduction pic Games, World Sports Championships, etc.), playful, religious nature acts (pilgrimages to Mecca- Hajj and The concept of mass gatherings (MGs), should be Umra) or Social acts; as well as those concentrations of an indispensable part of any assessment and manage - people that can occur in massive migratory move - ment of health risks at major events. There are several ments, located within a refugee camp or in other less definitions for MGs. In general, it is understood for con - specific areas 1. On the other hand, if we use the termi - centrations of more than 1,000 people, in a specific lo - nology of the International Health Regulations (IHR), we cation and for a specific purpose, although it should be will refer as an event to that manifestation of disease or noted that most of the literature refers to multitudinous event that may be a potential trigger for the disease, as acts that exceed 25,000 people. For its part, the World defined in the IHR of 2005 2. Health Organization (WHO) defines it as "an event at - The IHR, which entered into force on June 15, tended by a sufficient number of people that requires a 2007, is an international legal instrument binding on all specific preparation, planning and response resources of WHO member states, whose purpose is to assist the in - a community, state or nation". In relation to this defini - ternational community in preventing and addressing tion, it is necessary to qualify the concept of "event". In public health risks, which may cross borders and threa - risk management, an event is a type of MG that organi - ten populations around the world. It also obliges coun - ses events, whether that is sports competitions (Olym - tries to strengthen their surveillance and health respon -

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se means in order to detect, report and control public of the two words together, singular or plural, in addi - health events. The fact that any public health event is tion to the derived form indicated: "mass gathering" or notified in a timely and open manner is an essential as - "mass gatherings” or “massive gathering” or “massive pect of ensuring global security. It has long been gatherings". No restrictions of any kind were initially es - known that MGs provide the ideal conditions for the tablished: any search field, all areas and that had been transmission of various diseases. Therefore, specific mo - published between January 1, 2000 and September 30, nitoring measures are essential in order to facilitate a 2015 (date of completion of the search). The search beneficial development of these activities and for the yielded 518 documents, of which letters to the editor, health of the community involved in MGs and those re - editorials, reviews or book chapters were excluded. The gions that host them 3. remaining 260 papers were eligible. The titles and abs - This work aims, on the one hand, to give a current tracts of the papers were read by two authors (PL and overview of the management of MGs at the global level JMR) and 164 documents were excluded for the follo - because, although some are carried out thousands of wing reasons: language other than English, French or kilometres from our usual scope of action, they are of Spanish (n = 14); works with duplicate data (n = 4); great global importance and can be very valuable to were not available in digital format (n = 7); and not di - study the spread of communicable diseases and impro - rectly analysed the management of an event (n = 139). ve the health systems of both the countries that are After these processes, 96 studies were included in the welcoming the MGs and those that export visitors to review (Figure 1). them. And, on the other hand, the production in Spa - Of the 96 articles selected, the following informa - nish on the subject is practically non-existent, so a re - tion was collected and analysed: title of the published view of the literature in our language can facilitate the document, year of publication, journal, country and promotion of initiatives that lead to a Spanish model of specialty or area of knowledge of the researchers, year management in the MGs, being able to adapt models of the event, days of duration, event name, type and preset 4,5 in other countries, following the recommenda - country where it is celebrated, whether it is a retrospec - tions of the European Union. For all this, the main ob - tive or prospective study, type of study, number of peo - jective of this review is to better understand the events ple studied, number of people attending the event, no - studied in recent years, which may also favour a path sological entities, measurement, category and of research in this field of medicine in Spanish-speaking conclusions. It is important to emphasize that there are countries. As secondary objectives, we consider the sub - 6 papers that include several MGs in their analysis, so jects investigated and the journals and countries res - that in total 164 events were reviewed. ponsible for the publications on the MGs. Results and Discussion Method Countries of the authors signing the work We searched through the documents included in the Scopus database containing the concept consisting The 96 documents included in the review are sig -

518 ublications Identification in Scopus Letters to the editor, editorials, revisions, erratum, and chapters of books or articles of press are excluded

Screening 260 publications

Eligibility 260 publications We excluded 164 due to this reasons: – Language other than English, French or Spanish (n=14) – Duplicate jobs (n=4) – Are not available in digital format (n=7) – Do not directly analyze the management of an event.(n=139) Included 96 publications

Figure 1. Flow chart for job selection.

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Table 1. Countries of the 122 institutions that signed the 96 Table 2. Publication magazines of the documents included in documents included in the review of the literature on mass the review of the literature on mass gatherings of people gatherings) Journal N (%) Country N (%) Prehospital and 23 (24) United States of America 25 (26) Eurosurveillance 5 (5.2) Australia 17 (17.7) Prehospital Emergency Care 5 (5.2) United Kingdom 14 (14.6) Journal of Emergency Medicine 4 (4.2) Canada 8 (8.3) Eastern Mediterranean Health Journal 4 (4.2) Kingdom of Saudi Arabia 8 (8.3) American Journal of Emergency Medicine 2 (2.1) Sweden 6 (6.3) BMC Public Health 2 (2.1) Germany 5 (5.2) British Journal of 2 (2.1) France 4 (4.2) Emergency Medicine Journal 2 (2.1) Japan 3 (3.1) Epidemiology and 2 (2.1) Iran 3 (3.1) Iranian Red Crescent Medical Journal 2 (2.1) Italy 3 (3.1) Journal of 2 (2.1) Singapore 2 (2.1) Wilderness and Environmental Medicine 2 (2.1) South Africa 2 (2.1) Australasian Journal of Paramedicine 1 (1) Greece 2 (2.1) Australian Journal of Emergency Management 1 (1) Afghanistan 1 (1) Chinese Medical Journal 1 (1) Denmark 1 (1) Chronic Diseases in Canada 1 (1) Egypt 1 (1) Clinical Infectious Diseases 1 (1) Slovenia 1 (1) Clinical Microbiology and Infection 1 (1) Findland 1 (1) Communicable diseases intelligence 1 (1) Hungary 1 (1) Disaster Medicine and public health preparedness 1 (1) India 1 (1) Disaster Prevention and Management 1 (1) Indonesia 1 (1) EMA - Emergency Medicine Australasia 1 (1) Ireland 1 (1) Emerging Infectious Diseases 1 (1) Fiji Islands 1 (1) European Journal of Emergency Medicine 1 (1) Israel 1 (1) Gaceta Médica de México 1 (1) Jordan 1 (1) Infectious Disorders - Drug Targets 1 (1) Kiribati 1 (1) Influenza and other Respiratory Viruses 1 (1) Mexico 1 (1) International Journal of STD and AIDS 1 (1) Nigeria 1 (1) Journal of Clinical Virology 1 (1) Poland 1 (1) Journal of Emergency 1 (1) Qatar 1 (1) Journal of Emergency Primary Health Care 1 (1) Switzerland 1 (1) Journal of epidemiology and global health 1 (1) Taiwan 1 (1) Journal of Health Care for the Poor and Underserved 1 (1) Trinidad and Tobago 1 (1) Journal of Infectious Diseases 1 (1) Journal of Medical Internet Research 1 (1) Journal of 1 (1) ned by authors from 122 different institutions. Most of Journal of 1 (1) these publications were signed by US authors (n = 25, Journal of Telemedicine and Telecare 1 (1) 26%), followed by Australia (n = 17, 16.7%), United Medecine et Chirurgie du Pied 1 (1) Kingdom (n = 14, 14.6%), Canada = 8, 8.3%) and Medical Journal Armed Forces India 1 (1) Kingdom of Saudi Arabia (KSA) (n = 8, 8.3%). The Afri - Medical Journal of Australia 1 (1) PLoS ONE 1 (1) can representation would be on the part of Morocco, Proceedings of the National Academy of Sciences Nigeria and South Africa, with 1 article each. On the of the United States of America 1 (1) Asian side stand out, apart from KSA, Iran and Japan, Public Health 1 (1) with 3 works each, respectively (Table 1). Revue d'Epidemiologie et de Sante Publique 1 (1) 1 (1) Travel Medicine and Infectious Disease 1 (1) Magazines and specialties of research Vaccine 1 (1) Virologica Sinica 1 (1) The documents have been published in 52 different West Indian Medical Journal 1 (1) scientific journals, including Prehospital and Disaster Western Pacific surveillance and response journal 1 (1) Medicine (n = 23), Prehospital Emergency Care (n = 5), Eurosurveillance (n = 5), Eastern Mediterranean Health Event types Journal (n = 4) and Journal of Emergency Medicine (n = 4). It should be noted that 8 journals (15.4%) have pu - The main events studied were sports (n = 75, blished two documents and 75% of journals (n = 39) 46%), musical (n = 41, 25.1%), and religious/social had only one document (Table 2). events (n = 37, 22.7%). In one study, it is important Although MGs have different specialties of medicine to highlight the coordination and implementation of involved, publications dealing with emergency medici - a medical emergency service with a nursing and me - ne, intensive care or catastrophes represent the most dical team, which provides information on 26 Ameri - commonly treated perspective (n = 51, 53.1%) follo - can football league matches held over four years in wed by epidemiology and public health (n = 17; the same stadium 6. In a more specific way, the most 17.7%) and infectious diseases and vaccination (n = 14, studied event was the "Hajj" (religious) (n = 17). The 14.6%) (Table 3). next most-discussed event was the "Olympic Games"

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Table 3. Disciplines of the documents included in the review taken into account when assessing the risks in a MGs. of the literature on mass gatherings of people These and other biotoxins are contemplated in docu - Discipline N (%) ments or technical reviews such as that of Orlando 11 Emergency Medicine, Intensive care and disasters 51 (53.1) Cenciarelli et al. . Epidemiology and public health 17 (17.7) Except for very special cases, such as the one des - Infectious diseases and vaccination 14 (14.6) cribing the Kumbh Mela event of India 2013 12 in General Practice 6 (6.2) which 70% of patients attended were due to upper Sports Medicine 3 (3.1) respiratory tract , the majority of medical ca - Communication and new technologies 2 (2.1) Science 1 (1) re provided in the coming MGs (n = 58; 60.4%), in Travel Medicine 1 (1) non-severe cases, with a prevalence of headache, in - Paediatrics 1 (1) volvement of the musculoskeletal system or other enti - ties related to temperature, such as dehydration or he - at stroke. (sports) (n = 13), the "World Youth Day" (n = 8) and the "Football World Cup"). In this section, we would Topics covered like to point out that although the most studied event was the pilgrimage to Mecca in the KSA (Hajj), The topics covered in the works have been grouped there are only three publications led by this country into the approaches described below. as the first signatory and that, considering all the signatures of the authors, the presence of Saudis in Different health care models proposed in MGs eight papers with various collaborations with Europe - In our review there are 55 articles that in one way an countries, Australia and the United States, which or another describe the composition of the medical can be explained by the international character of equipment prepared to meet the MGs. Some defend the event and the research interest aroused by the the benefit of lowering patient transfer ratios to the event in countries with greater scientific develop - hospital if there is a present within the te - ment. Something similar happens with Sweden, am 13 and others demonstrate that non-medical staff which appears initially with a single publication led (paramedics and nurses) working on a previously esta - by this country, but taking into account collabora - blished protocol also lower those ratios 14,15 . tions with authors from other countries, it rises to six. This could be related to the location in Stoc - Evaluation of assistance with the use of patient kholm of the European Centre for Disease Prevention presentation ratios and transfer ratios and Control project as a monitoring and response The second most recurrent topic is the measure - support unit in the MGs. ment of medical usage rates (MUR) or medical service use rates (n = 29), mainly the patient attendance rate Nosological entities (PAR) in the event per 1,000 attendees (patient pre - sentation rates), and the transfer rate to the hospital In relation to the nosological entities, it is possible (TRH) without defining mode of transport (ambulan - to divide them into two distinct blocks: those that are ce, police car, private, etc.) per 1,000 or 10,000 at - of transmissible or infectious origin and non-commu - tendees (transport-to-hospital rate). Some studies nicable diseases. Regarding the first group, we have point it out as ambulance transfers (AT). This rate is several that deal with the transmission of respiratory more likely to indicate the most serious cases or that microorganisms, mentioning the work that deals with require human or material means not available at the the circulation of these in the pilgrims of Hajj 2012 7, event. These data are fundamental in estimating or as - which suggests the rapid acquisition of respiratory vi - sessing the human and material resources needs of a ruses, especially rhinovirus, during the stay of the pil - MG 16 . grims in the KSA in the celebration of the Hajj and the Table 5 shows the number of attendees, patients potential that they have to extend it in their countries attended, PAR, TRH and type of event problems with of origin. An outbreak of influenza has also been des - available information. Thus, in sports events, the me - cribed among pilgrims attending World Youth Day in dians of PAR and TRH were 1.7 and 0.07, ranging Australia 8 which reflects the rate of attacks based on from 159 to 2.57 in a popular cycling race 17 and where the pilgrims were accommodated. Among the 0.048 and 0.009 in those attending the World Cup 18 . communicable diseases are also rotavirus and the des - At musical events, the median PAR and TRH was 2.51 cription of an outbreak of gastroenteritis during the and 0.21, ranging from 23.9 to 1.7 of the Burning celebration of Independence Day in Kiritabi 9 in which Man of the year 2011 19 , and 0.004 and 0.005 of the for 15 days 1,118 cases were reported, 103 of them Toronto Rocks 20 , respectively. In the two religious hospitalized. Although not commonplace, malicious events collected 21,22 , the PAR was 0.27 and 0.13, res - dispersal of toxic or biological elements, such as the pectively and the TRH of 0.039 and 0.35, respectively. Osho attack 10 in which a sect contaminated food with In the rest of events not included in the 3 major enteric salmonella in order to win local elections that groups, it was 1.65 and 0.48, and 0.077 and 0.002, affected 751 people in the United States, have to be respectively 23-26 .

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Table 4. Events and countries of celebration included in the review of the literature on mass gatherings Event Studied Country where Type Number (Original name of the event) the event is held of event of times studied 9 Concerts a United Kingdom Music 9 Chicago Large Indoor Arena United States Various 29 4 years of Mass gatherings in the University of Virginia Stadium United States Various 26 Hajj Kingdom of Saudi Arabia Religion 17 Olympics Games b Australia, United States, Greece, United Kingdom, Italy Sports 13 World Youth Day Australia Religion 8 FIFA Soccer World Cup Germany, France, Japan, South Korea, South Africa Sports 6 Royal Adelaida Show Australia Exposition 2 Toronto Rocks Canada Musical 2 The New York Great State Fair United States Exposition 2 Formula 1 United States, Singapur Sports 2 Cricket World Cup Antigua, Barbados, Granada, Guyana, Jamaica, St Lucia, St Kitts and Nevis, Trinidad and Tobago and St Vincent and the Grenadines Sports 1 Children’s fun fair Germany Television show 1 The Oakbank Easter Racing Carnival Australia Music 1 Melbourne Commonwealth Games Australia Sports 1 APEC / WORLD RUGBY CUP Australia Various 1 Tamworth Country Music Festival Australia Musical 1 BC Ride to conquer cancer Canada Sports 1 Canada Day Canada Politics 1 2 night EDME Canada Music 1 World Police and Fire Games Canada Sports 1 New Hampshire funding race Canada Sports 1 Summer Rock Taipei Festival China-Taipei Music 1 Yellowstone National Park United States Natural park 1 Burning man 2011 United States Music 1 Boston Sports Venue United States Sports 1 California Speedway United States Sports 1 Republican National Convetion United States Politics 1 Convenciones mundiales Sky acrobatico United States Sports 1 The Tough Guy experience United States Sports 1 The California 500 United States Sports 1 Kansas speedway United States Sports 1 Baltimore Marathon United States Sports 1 The Mosh Pit experience United States Music 1 Dayton Airshow United States Sports 1 National Collegiate Athletic Association Final Four victories of the University of North Carolina men's basketball team United States Sports 1 Rainbow Family of Living Night United States Environmentalism 1 Taize (France) peregrination France, Germany Religion 1 Sziget Island Rock Festival Hungary Music 1 Kumbh Mela India Religion 1 Ashura at Karbala Irak Religion 1 Holy Shroud Exhibition Italy Religion 1 The Catholic Jubilee Italy Religion 1 16th Italia Super Cup Italy Music 1 First East Asian Football Championship and European vs South American Cup Japan Sports 1 The Suwa Onbashira Festival Japan Religion 1 Eid Al Adha holiday Jordan Religion 1 South Tarawa independence celebrations Kiribati Politics 1 Moulay Abdellah Amghar moussem Morocco Religion 1 Guadalajara International Book Fair (FIL) Mexico Comercial 1 19th Nigerian Universitary Games Nigeria Sports 1 Urs of Baba Farid Pakistan Religion 1 Euro Football Cup Poland and Ukraine Sports 1 Leicester Tigers Rugby Footbal Club and the Leicester Racecourse United Kingdom Sports 1 Cornwall solar eclipse United Kingdom Astronomical Event 1 Leeds Outdoor Music Festival United Kingdom Music 1 Suffolk Show 2011 United Kingdom Music 1 Asian Youth Games Singapore Sports 1 EU Summit Sweden Politics 1 aWakestock, Download, Rockness, Wireless, Tinthepark, V Festival, Bestival, Creamfields, Isleofwightfest; bOlympic, Paralympic, winter and summer.

Airborne microorganisms asles, etc., as discussed above, have been treated on MERS CoV coronavirus, H1N1 influenza virus, me - several occasions (18 articles).

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Table 5. Patients included by each centre participating in the study Event Type Number of Number of RPA RHT Type of Assistance (Original name of the event) of event attendees people served BC Ride to conquer cancer Sports 8,142 5,182 159.95 2.57 Green (85.6%) Yellow (4.6%), red (0.33%), rest not determined. Winter Olympics Sports 2,607 330 126.6 1.13 Mainly musculoskeletal problems. World Police and Fire Games Sports 10,599 1,462 109.4 2.32 Musculoskeletal problems (58%). California 500 NASCAR Sports 234,000 923 4.3 0.046 Soft tissue wounds (32%) and headaches (30%). California Speedway Sports 152,000 485 3.19 0.085 Soft tissue wounds (29%) and headaches (27%). Winter Olympics Sports 410,160 1,003 2.69 0.0012 Trauma (n=211), respiratory (n=88), miscellaneous medical problems(n=69), and digestive (n=52). Formula 1 EEUU Sports 265,500 588 2.21 1.2 Headaches, blisters and sprains. Formula 1 Singapur Sports 327,698 711 2.17 0.03 Musculoskeletal problems (59%) and heat related problems (19%). 19th Nigerian University Games Sports 80,000 494 2.1 Minor (57%), intermedium (47%), major (3%). Kansas speedway Sports 1,003,846 1,305 1.3 0.02 Headaches, (24.1%), lacerations (9.3%), other (7.8%). FIFA World Soccer Cup Sports 2,705,197 1,661 1.21 0.05 Blisters, lacerations (19%), headache (11.5%), abdominal pain (6.9%). Commonwealth Games Sports 4,098,390 3,514 1.16 0.073 Headache, soft tissue wounds, blisters and other (64.1%). Fire jumpers Sports 52,000 58 1.12 0.32 Burns (28%), lacerations (27%), musculoskeletal (18%), intoxications and alcohol (14%) . American Football matches Sports 1,544,244 1,681 1.09 0.07 Minor problems (87.6%). The Leicester Racehorse Sports 33,962 16 0.47 Minor assistance. Only 1 hospital transfer. EA y Toyota CUP Sports 211,581 51 0.25 0.05 Trauma. Abdominal pain and colds (58.8%). Leicester Tigers Rugby Football Sports 252,421 47 0.19 Minor assistance, only 2 hospital transfers. FIFA World Soccer Cup Sports 455,000 22 0.048 0.0009 Musculoskeletal and inflammatory processes. Burning Man 2011 Music 53,735 2,307 23.29 1.628 Soft tissue wounds, dehydrations, eye problems and urine infections. EDME Canada Events Music 20,301 70 4.09 1.98 Altered level of consciousness, intoxications and airway compromises. Mosh Pit experience Music 240,000 1,542 2.51 0.21 Lacerations and abrasions (17%), musculoskeletal apparatus (20%). Taipei Summer Rock Music 50,000 28 0.56 0.02 Syncope (46%). Toronto Rocks Music 450,000 1,870 0.0042 0.0005 35.2% requested water, sun cream and band aids. Holy Shroud Exhibition Religious 2,113,128 583 0.27 0.039 Cardiac problems (30.2%), trauma (19.7%). The Suwa Onbashira festival Religious 850,000 237 0.132 0.035 Trauma (57%). The rest include problems related with temperature. Royal Adelaida Show Commercial 622,234 1,028 1.652 0.077 Minor wounds and lacerations (35%). New York State Fair Commercial 950,973 2,075 0.48 0.0027 Related with dehydration (11.4%), lacerations (10.6%), and falls (10.2%). Children s fun fair Children 100,000 192 1.92 0.14 Minor trauma (53.6%), headaches and mild (10.9%), insect bites (10.4%). European Union Summit Politics 50,000 143 2.7 0.17 Wounds and other assistance related with political protests. RPA: Rate of patients attended; RHT: Rate of Hospital Transfers.

Syndromic Surveillance agents. This model was introduced by the Centres for A few years ago, Fernando Simón, the current direc - Disease Control (CDC) in the 1990s as an alternative tor of the Centre for the Coordination of Alerts and He - way to locate outbreaks and emerging diseases. alth Emergencies (CCAES), together with other collea - In our list, it is essential to cite the description of gues, referred to syndromic surveillance as a new the system established in London during the Olympic challenge in public health 27 . In MGs, it is essential to and Paralympic Games of 2012 28 . This work has registe - base epidemiological attention on surveillance of red some 339,000 assists, and provides data of the syndromes. We need to use previously established he - syndromic indicators developed in this specific system. alth data in the protocols that provide clues as to what This shows the potential of these systems in identifying may be happening after clinical observations at the pla - unusual or serious outbreaks of infectious diseases or ce of care, rather than awaiting the confirmation of the other incidents of public health impact. diagnoses by the laboratory. All this in order to alert early, in the event that an event or outbreak needs a Globalization of diseases specific public health response. Globalization is a fact that does not escape diseases. The European Union has developed alert systems, Attendees at a MG in Italy contracted measles, which a and in 1996 it adopted a program of Community ac - few days later was in Slovenia or Germany where a mu - tion dedicated to the prevention of AIDS and other sic concert contributed to its propagation 29 . Another communicable diseases. This systems have been called example that we can cite in this area are the implica - syndromic surveillance systems, and have increased sin - tions of a pandemic declaration on global health, which ce the terrorist attacks of 2001 in the United States to can logically coincide with the holding of global events. act quickly on the deliberate release of biological From this case, there are a number of lessons learned

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by the team that covered the Asian Youth Games in they were completed, they rose by 33%, and 16% of 2009 during the H1N1 pandemic 30 and which ran the sex workers acknowledge having started their activity risk of being cancelled with the different consequences during the celebration of the games, and 7% who that can result, both economic and social, in addition moved to London for the Olympic Games. It is im - to the sanitary ones. portant to consider these experiences when planning other events, because they warn us of changes in be - Psychological problems haviour or types of care that can be treated, for In the field of mental health, we have the expe - example, from a preventive point of view prior to the rience of an Australian team during the World Youth celebration of MGs. Where there is a large concentra - Day in Sydney in 2008, which cites the Madrid edi - tion of people, for a certain time, one must also take tion in 2011. It reflects the lack of specific informa - into account the health complications that may appe - tion on this subject and has as objectives to detail the ar through what the attendees eat or drink 9. We have plan established in Sydney for this MG and the mana - other examples, such as the one studied in a caravan gement of data and lived situations 31 . of Iranian pilgrims who we headed to Hajj 41 , with an Social psychology is necessary to identify risk be - attack rate of 21%. Outbreaks of Salmonella , giardia - haviours in MGs, but it is very important to evaluate sis or rotavirus have also been reported during the the information of their studies in an integrative way World Cup in Germany in 2006 42 , where cases of to the other risks present. In 2014 a member of the other pathogens such as Campylobacter , norovirus or School of Psychology of the University of Sussex and measles were also observed. a representative of the Department of Urbanism of Mecca concluded in their study 32 that there is a cer - Prevention of infections and antibiotic treatment tain perception of security in individuals who are part and in particular the use of vaccines in of a crowd, a false sense of security. It is enough to a preventive way is represented in this review with two remember that, in 2015, a human avalanche in the studies 43,44 , which assign some protective factor of in - Hajj killed about 2,000 pilgrims 33 . fluenza vaccine, although such studies have limitations and some conflicts of interest are present in receiving in Weather a direct or indirect way funds from the laboratories ma - The effect of climate affects people directly. Therefo - nufacturers of such vaccines. Antimicrobial and re, it is logical that this analysis becomes part of the its inadequate use are addressed in a study of Australian preventive and care aspects in the MGs. In our review, pilgrims attending the KSA for Hajj 45 . Apart from the we found several papers dealing with the topic from knowledge of the pilgrims about the correct use of anti - one perspective or another. During the Kansas Speed - biotics, we observed that 26.3% get antibiotics in the way, an automobile race, the increase in temperature is KSA without prescription and 47.5% come with the an - associated with an increase in patient presentation rates tibiotics bought in Australia . and, conversely, rainfall decreases these rates 34 . In the analysis of another MG, in this case an aerial show, the Publications in Spanish conclusions are similar, adding the enhancer factor that The only work in the Spanish language of this re - also has the humidity in the increase of the patients’ at - view 46 describes and analyses the health effects during tended 35 . the international book fair in Guadalajara, Mexico. In a preventive way, we must try to raise the aware - This event attracts more than 750,000 attendees, at - ness of the participants in the use of protective measu - tending health services to 0.1% of them (n = 794). res against the harmful effects of the sun, a subject of - Headache, pharyngitis and non-serious accidents were ten not taken into account sufficiently, considering the the most frequent occurrences during the event in fact that many of these events are held in daytime and most age groups, and in this event no infectious pro - in open spaces 36 . cesses derived from vector transmission, food or speci - fic infections such as influenza were detected. It is ne - Organization of MGs cessary to take into account that this type of events Another organizational aspect, which, due to our have a low profile because they are of cultural type, it own experience as well as the bibliography we have is not habitual the consumption of alcohol and the in this regard 37-39 , is not valued enough is the provi - population is very dispersed within the different age sion of paediatric doctors or nurses in the health co - groups. However, prevention and planning is deemed verage of these events and not only those aimed at necessary because of the risk of climate-related effects, children, those in which the families have an outstan - earthquakes or terrorist attacks. ding presence. Sometimes we are not aware of the number of actors and medical events related to MGs. New technologies in MGs During the London Olympics in 2012, different sour - The use of new technologies and social networks ces of information were observed 40 , such as the follo - such as Twitter or Facebook is part of the future of re - wing: 1.8% of sexual assaults were related to the search in MGs 47 . As an example, during the Eurocup Olympic Games; calls received on a telephone coun - 2012 celebration in Poland and Ukraine, a survey 48 was selling line fell by 16% during the games, but once published in UEFA's official Facebook profile to assess

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the impact of public health messages, specifically those References related to the importance of vaccination for measles in those attending this event. The answer suggests that 1 Moreno Millán E, Raposo Triano MF, Álvarez Leiva C. Atención sani - taria en acontecimientos colectivos de larga duración: ¿sirve el mo - these messages were not followed by 77% of the fans. delo de la Exposición de Sevilla’ 92 para la de Zaragoza’ 08? Emer - It is for this reason that we need to strengthen and in - gencias. 2008;20:125-30. vestigate ways of using these tools more effectively wi - 2 Reglamento Sanitario Internacional. Ginebra, Suiza: Organización Mundial de la Salud; 2005. (Consultado 21 Marzo 2016). Disponible thin the public health messages associated with MGs, en: http://www.who.int/ihr/es/ especially because of their low cost and the rapid ac - 3 Al-Tawfiq JA, Memish ZA. Mass gathering medicine: 2014 Hajj and cess to the population they enable. Umra preparation as a leading example. Int J Infect Dis. 2014;27:26- 31. 4 Communicable disease alert and response for mass gatherings: Key considerations. Geneva, Switzerland: World Health Organization; 2008. (Consultado 21 Marzo 2016). Disponible en: http://www.who.int/csr/ Conclusions and final reflections Mass_gatherings2.pdf 5 Zielinski A, Pawlak BJ, React project. Toolbox for implementation of The conclusions of the review can be summarized as surveillance at mass gatherings. WP 4: Surveillance during mass ga - therings. Warsaw, Poland: National Institute of Public Health - Natio - follows: nal Institute of Hygiene; 2011. (Consultado 21 Marzo 2016). Dispo - - The main events studied were related to the Hajj and nible en: http://www.rki.de/EN/Content/Prevention/React/Work/ wp4/WP_4_ToolBox.pdf?__blob=publicationFile sporting events, with the KSA and the United States 6 Martin-Gill C, Brady WJ, Barlotta K, Yoder A, Williamson A, Sojka B, being the main countries in which the research has et al. Hospital-based healthcare provider (nurse and physician) inte - been focused. The main topic discussed was the he - gration into an emergency medical services-managed mass-gathe - ring event. Am J Emerg Med. 2007;25:15-22. alth care model in relation to these events. 7 Benkouiten S, Charrel R, Belhouchat K, Drali T, Salez N, Nougairede - MGs constitute a new area of incipient medical kno - A, et al. Circulation of respiratory viruses among pilgrims during the wledge or discipline, which relates to different medi - 2012 Hajj Pilgrimage. Clin Infect Dis. 2013; 57:992-1000. 8 Staff M, Torres MI. An influenza outbreak among pilgrims sleeping cal and surgical specialties, particularly emergency, in - at a school without purpose built overnight accommodation facili - tensive and disaster medicine. ties. Commun Dis Intell Q Rep. 2011;35:10-5. 9 Tabunga T, Utiera M, Tekoaua R, Tibwe T, Tira T, Toatu T, et al. Res - - This field of medicine would require specific training ponse to a large rotavirus outbreak on South Tarawa, Kiribati, 2013. of medical and care personnel to attend these events Western Pac Surveill Response J. 2014;5:9-14. that is related to the guidelines emanating from rese - 10 Török TJ, Tauxe RV, Wise RP, Livengood JR, Sokolow R, Mauvais S, et 47,49 al. A large community outbreak of salmonellosis caused by intentio - arch in the area . nal contamination of restaurant salad bars. JAMA. 1997;278:389-95. - MGs represent an opportunity to strengthen intersec - 11 Cenciarelli O, Rea S, Carestia M, D’Amico F, Malizia A, Belleci C, et toral and cross-nation collaboration in order to increa - al. Bioweapons and bioterrorism: A review of history and biological agents. Defence S&T Tech Bull. 2013;6:111-29. se the capacity of health infrastructure, as well as to 12 Cariappa MP, Singh BP, Mahen A, Bansal AS. Kumbh Mela 2013: He - promote healthy behaviours in the population, given althcare for the millions. Med J Armed Forces India. 2015;71:278-81. 13 Grange JT, Baumann GW, Vaezazizi R. On-site reduce am - the interest and impact of this type of events in the bulance transports at mass gatherings. Prehosp Emerg Care. media. 2003;7:322-6. - In the review we have not found any publication rela - 14 Salhanick SD, Sheahan W, Bazarian JJ. Use and analysis of field triage criteria for mass gatherings. Prehospital Disaster Med. 2003;18:347-52. ted to Spain, so we should encourage research in this 15 Feldman MJ, Lukins JL, Verbeek PR, Burgess RJ, Schwartz B. Use of field of emergency medicine given the relevance of treat-and-release medical directives for paramedics at a mass gathe - the topic and the development of research at the in - ring. Prehosp Emerg Care. 2005;9:213-7. 16 Zeitz KM, Zeitz CJ, Arbon P. Forecasting medical work at mass-ga - ternational level. thering events: Predictive model versus retrospective review. Prehosp Disast Med. 2005;20:164-8. 17 Lund A, Turris SA, Wang P, Mui J, Lewis K, Gutman SJ. An analysis of patient presentations at a 2-day mass-participation cycling event: Conflicting interests The ride to conquer cancer case series, 2010-2012. Prehospital Di - saster Med. 2014;29:429-36. 18 Hardcastle TC, Samlal S, Naidoo R, Hendrikse S, Gloster A, Ramlal The authors declare no conflict of interest in relation to this article. M, et al. A redundant resource: A pre-planned casualty clearing sta - tion for a FIFA 2010 stadium in Durban. Prehospital Disaster Med. 2012;27:409-15. 19 Bledsoe B, Songer P, Buchanan K, Westin J, Hodnick R, Gorosh L. Financing Burning man 2011: Mass gathering medical care in an austere envi - ronment. Prehosp Emerg Care. 2012;16:469-76. The authors declare the non-existence of external financing of this 20 Feldman MJ, Lukins JL, Verbeek PR, Burgess RJ, Schwartz B. Use of article. treat-and-release medical directives for paramedics at a mass gathe - ring. Prehosp Emerg Care. 2005;9:213-7. 21 Bortolin M, Ulla M, Bono A, Ferreri E, Tomatis M, Sgambetterra S. Holy shroud exhibition 2010: Health services during a 40-day mass- Ethical Responsibilities gathering event. Prehospital Disaster Med. 2013;28:239-44. 22 Yazawa K, Kamijo Y, Sakai R, Ohashi M, Owa M. Medical care for a mass gathering: The suwa onbashira festival. Prehospital Disaster All authors have confirmed the maintenance of confidentiality and Med. 2007;22:431-5. respect for patients' rights in the author's responsibilities document, pu - 23 Grant WD, Nacca NE, Prince LA, Scott JM. Mass-gathering medical ca - blication agreement and assignment of rights to EMERGENCIAS. re: Retrospective analysis of patient presentations over five years at a multi-day mass gathering. Prehospital Disaster Med. 2010;25:183-7. 24 Johnsson KMC, Örtenwall PA, Kivi ALH, Hedelin AHE. Medical sup - port during the European Union Summit in Gothenburg, Sweden, Article not commissioned by the Editorial June 2001. Prehospital Disaster Med. 2006;21:282-5. Committee and with external peer review 25 Zeitz KM, Zeitz CJ, Kadow-Griffin C. Injury occurrences at a mass ga - thering event. J Emerg Prim Health Care. 2005;3.

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