Mass gatherings medicine: international cooperation and progress
Authors: Ziad A Memish, Alimuddin Zumla, Brian McCloskey, David Heymann, Abdullah A Al Rabeeah, Maurizio Barbeschi, Richard Horton
Journal: The Lancet (2014)

In July, 2012, we discussed plans to move the complex public health issues surrounding mass gatherings into a formal scientific discipline, and to create a global network for mass gatherings research, training, and capacity development.1Al Rabeeah A Memish ZA Zumla A et al.Mass gatherings medicine and global health security.Lancet. 2012; 380: 3-4Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 2The LancetMass gatherings health—creating a public health legacy.Lancet. 2012; 380: 1Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar We believed that it was important for this network to be led by Saudi Arabia, since the country has extensive experience through many decades of managing millions of pilgrims from 184 countries at the largest yearly recurring religious mass gathering in the world—the Hajj. Subsequently, the Saudi Government and WHO3Ministry of HealthKingdom of Saudi ArabiaWHO General Assembly embraces the Saudi proposal of creating a program for mass gathering medicine.http://www.moh.gov.sa/en/Ministry/MediaCenter/News/Pages/news-2012-05-27-001.aspxDate: May 27, 2012Google Scholar strongly supported mass gatherings medicine as a scientific discipline, establishing the Saudi Global Center for Mass Gathering Medicine (GCMGM), with its headquarters in Riyadh and membership from other Gulf countries,4Global Center for Mass Gathering Medicinehttp://gcmgm.com/Google Scholar and a virtual research network linked with other WHO collaborating centres for mass gatherings. This network has brought together global academic and public health institutions with complementary expertise to gather and translate the most appropriate public health policy evidence for use by countries that host, or plan to host, mass gathering events. The GCMGM consists of an overarching board chaired by the Saudi Minister of Health, with a membership of experts from WHO, University College London, Public Health England, the London School of Hygiene & Tropical Medicine, the Saudi Council for Health Specialties, and King Abdulaziz City for Science and Technology (the national research funding agency in Saudi Arabia). In its continued commitment to supporting the Global Mass Gatherings Network, The Lancet is publishing a Series of reports about different mass gatherings: the London 2012 Olympic and Paralympic Games;5McCloskey B Endericks T Catchpole M et al.London 2012 Olympic and Paralympic Games: public health surveillance and epidemiology.Lancet. 2014; (published online May 21.)http://dx.doi.org/10.1016/S0140-6736(13)62342-9Google Scholar the 2012 European Football Championship (Euro 2012),6Smallwood CAH Arbuthnott KG Banczak-Mysiak B et al.Euro 2012 European Football Championship Finals: planning for a health legacy.Lancet. 2014; (published online May 21.)http://dx.doi.org/10.1016/S0140-6736(13)62384-3Google Scholar hosted jointly by Poland and Ukraine; and Hajj 2012 and Hajj 2013.7Memish ZA Zumla A Alhakeem RF et al.Hajj: infectious disease surveillance and control.Lancet. 2014; (published online May 21.)http://dx.doi.org/10.1016/S0140-6736(14)60381-0Google Scholar These reports, led by board members of the GCMGM, set out the planning and surveillance systems used to monitor public health risks, and describe the public health experiences and lessons learnt for the planning of future events. For all of these events, the host countries and international public health agencies undertook major planning activities to assess and build capacity, and to develop effective strategies for public health services and health messaging. All the events in question took place without major disease outbreaks or public health issues.5McCloskey B Endericks T Catchpole M et al.London 2012 Olympic and Paralympic Games: public health surveillance and epidemiology.Lancet. 2014; (published online May 21.)http://dx.doi.org/10.1016/S0140-6736(13)62342-9Google Scholar, 6Smallwood CAH Arbuthnott KG Banczak-Mysiak B et al.Euro 2012 European Football Championship Finals: planning for a health legacy.Lancet. 2014; (published online May 21.)http://dx.doi.org/10.1016/S0140-6736(13)62384-3Google Scholar, 7Memish ZA Zumla A Alhakeem RF et al.Hajj: infectious disease surveillance and control.Lancet. 2014; (published online May 21.)http://dx.doi.org/10.1016/S0140-6736(14)60381-0Google Scholar These reports show that rapid and effective information sharing and early exploitation of knowledge networks can optimise the planning and delivery of effective public health services during major events. The London 2012 Olympic and Paralympic Games5McCloskey B Endericks T Catchpole M et al.London 2012 Olympic and Paralympic Games: public health surveillance and epidemiology.Lancet. 2014; (published online May 21.)http://dx.doi.org/10.1016/S0140-6736(13)62342-9Google Scholar and Euro 2012 Football Championship6Smallwood CAH Arbuthnott KG Banczak-Mysiak B et al.Euro 2012 European Football Championship Finals: planning for a health legacy.Lancet. 2014; (published online May 21.)http://dx.doi.org/10.1016/S0140-6736(13)62384-3Google Scholar were the culmination of years of careful preparation to manage acute public health risks with potentially global effects. Public health planning started several years before these events, as laid out by WHO8WHOCommunicable disease alert and response for mass gatherings—key considerations. World Health Organization, Geneva2008http://www.who.int/csr/Mass_gatherings2.pdfGoogle Scholar in 2008, taking into account the experiences of previous host cities. The report about the Hajj7Memish ZA Zumla A Alhakeem RF et al.Hajj: infectious disease surveillance and control.Lancet. 2014; (published online May 21.)http://dx.doi.org/10.1016/S0140-6736(14)60381-0Google Scholar details the extensive public health planning, surveillance systems used to monitor public health risks, and health services provided and accessed during Hajj 2012 and Hajj 2013. The continued success of infectious diseases alert and response planning at the Hajj is attributed to the many decades of experience of the Saudi Government in providing health care at the yearly pilgrimage. The experience of planning and risk management from all three mass gathering events5McCloskey B Endericks T Catchpole M et al.London 2012 Olympic and Paralympic Games: public health surveillance and epidemiology.Lancet. 2014; (published online May 21.)http://dx.doi.org/10.1016/S0140-6736(13)62342-9Google Scholar, 6Smallwood CAH Arbuthnott KG Banczak-Mysiak B et al.Euro 2012 European Football Championship Finals: planning for a health legacy.Lancet. 2014; (published online May 21.)http://dx.doi.org/10.1016/S0140-6736(13)62384-3Google Scholar, 7Memish ZA Zumla A Alhakeem RF et al.Hajj: infectious disease surveillance and control.Lancet. 2014; (published online May 21.)http://dx.doi.org/10.1016/S0140-6736(14)60381-0Google Scholar presents an opportunity to improve future public health management of mass gatherings, in terms of investment for capacity building, targeted health interventions, risk management strategies, and training in mass gatherings medicine. There is an urgent need to address health issues related to mass gatherings such as the need for systems and adequate capacity to be in place to receive and analyse information rapidly from surveillance, reporting, and intelligence systems, and to identify and respond to any potential public health threat. The reports5McCloskey B Endericks T Catchpole M et al.London 2012 Olympic and Paralympic Games: public health surveillance and epidemiology.Lancet. 2014; (published online May 21.)http://dx.doi.org/10.1016/S0140-6736(13)62342-9Google Scholar, 6Smallwood CAH Arbuthnott KG Banczak-Mysiak B et al.Euro 2012 European Football Championship Finals: planning for a health legacy.Lancet. 2014; (published online May 21.)http://dx.doi.org/10.1016/S0140-6736(13)62384-3Google Scholar, 7Memish ZA Zumla A Alhakeem RF et al.Hajj: infectious disease surveillance and control.Lancet. 2014; (published online May 21.)http://dx.doi.org/10.1016/S0140-6736(14)60381-0Google Scholar show that these lessons have become embedded as a direct legacy of these events, and will be used by organisers of future mass gatherings such as the 2016 Olympic Games and Hajj 2014. Mass gatherings medicine provides an opportunity to generate a wealth of knowledge and expertise, and sharing the experiences of organisers can assist in shaping a positive legacy and provide valuable lessons for organisers of future events. The value to planners of mass gatherings and their governments in sharing best practices is clear, as is the need for new operational research into mass gatherings, with systematic collection and analysis of data to inform planning activities for future events. Through provision of scientific evidence, the GCMGM aims to drive the best health promotion and prevention guidelines and practice, including health education for attendees of mass gatherings across different contexts. The Hajj provides an ideal model for research into mass gatherings that recur yearly in the same location, and the very large sporting events provide a different context and complementary opportunities for research and training. Substantial gaps in research remain, particularly in relation to mass gatherings in low-resource settings and in unplanned or spontaneous mass gatherings. The GCMGM could have a major positive public health legacy through the development of an evidence base for improvements in health systems and services at mass gatherings. For example, our experiences have shown that effective planning for mass gatherings can be used to improve the public health systems of host countries. The potential benefit of the GCMGM became evident when, in September, 2012, a serious respiratory disease caused by a novel betacoronavirus (later named Middle East respiratory syndrome or MERS-CoV) emerged in Saudi Arabia.9Zaki AM van Boheemen S Bestebroer TM Osterhaus AD Fouchier RA Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia.N Engl J Med. 2012; 367: 1814-1820Crossref PubMed Scopus (4220) Google Scholar, 10McCloskey B Zumla A Stephens G Heymann DL Memish ZA Applying lessons from SARS to a newly identified coronavirus.Lancet Infect Dis. 2013; 13: 384-385Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar International media attention focused on MERS-CoV after the detection of fatal cases in France, Germany, and the UK, all of which had a connection with the Arabian Peninsula. A WHO emergency committee on MERS-CoV was formed,11WHOWHO IHR Emergency Committee concerning Middle East respiratory syndrome coronavirus (MERS-CoV).http://www.who.int/ihr/ihr_ec_2013/en/Date: 2013Google Scholar which included a GCMGM board member. In view of the impending Hajj in November, 2013, during which an estimated 3 million pilgrims were expected to visit Saudi Arabia, the possibility that MERS-CoV could occur in pilgrims and then spread as they returned home, causing a worldwide epidemic, was a major concern. Extensive research done under the remit of the GCMGM MERS-CoV study group led to the rapid definition of hospital outbreaks, identification of the mode of transmission,12Memish ZA Zumla AI Al-Hakeem RF Al-Rabeeah AA Stephens GM Family cluster of Middle East respiratory syndrome coronavirus infections.N Engl J Med. 2013; 368: 2487-2494Crossref PubMed Scopus (375) Google Scholar, 13Assiri A McGeer A Perl TM et al.Hospital outbreak of Middle East respiratory syndrome coronavirus.N Engl J Med. 2013; 369: 407-416Crossref PubMed Scopus (950) Google Scholar and the development of specific recommendations for Hajj 2013.12Memish ZA Zumla AI Al-Hakeem RF Al-Rabeeah AA Stephens GM Family cluster of Middle East respiratory syndrome coronavirus infections.N Engl J Med. 2013; 368: 2487-2494Crossref PubMed Scopus (375) Google Scholar, 13Assiri A McGeer A Perl TM et al.Hospital outbreak of Middle East respiratory syndrome coronavirus.N Engl J Med. 2013; 369: 407-416Crossref PubMed Scopus (950) Google Scholar, 14Memish ZA Al-Rabeeah AA Public health management of mass gatherings: the Saudi Arabian experience with MERS-CoV.Bull World Health Organ. 2013; 91 (99A): 899Crossref PubMed Scopus (31) Google Scholar, 15Assiri A Al-Tawfiq JA Al-Rabeeah AA et al.Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study.Lancet Infect Dis. 2013; 13: 752-761Summary Full Text Full Text PDF PubMed Scopus (1113) Google Scholar, 16Cotten M Watson SJ Kellam P et al.Transmission and evolution of the Middle East respiratory syndrome coronavirus in Saudi Arabia: a descriptive genomic study.Lancet. 2013; 382: 1993-2002Summary Full Text Full Text PDF PubMed Scopus (251) Google Scholar, 17Memish ZA Zumla AI Assiri A Middle East respiratory syndrome coronavirus infections in health care workers.N Engl J Med. 2013; 369: 884-886Crossref PubMed Scopus (138) Google Scholar, 18Memish ZA Al-Tawfiq JA Makhdoom HQ et al.Screening for Middle East Respiratory Syndrome Coronavirus infection in hospital patients and their health care worker and family contacts: a prospective descriptive study.Clin Microbiol Infect. 2014; (published online Jan 24.)https://doi.org/10.1111/1469-0691.12562Summary Full Text Full Text PDF Scopus (112) Google Scholar No MERS-CoV cases were detected at either Hajj 2012 or Hajj 2013, and none have been reported from the pilgrims' home countries after return.18Memish ZA Al-Tawfiq JA Makhdoom HQ et al.Screening for Middle East Respiratory Syndrome Coronavirus infection in hospital patients and their health care worker and family contacts: a prospective descriptive study.Clin Microbiol Infect. 2014; (published online Jan 24.)https://doi.org/10.1111/1469-0691.12562Summary Full Text Full Text PDF Scopus (112) Google Scholar Case-control studies to investigate various hypotheses about the source of MERS-CoV infection have not yet been done, but such studies are being planned. As the events around the MERS-CoV outbreak show, mass gatherings will constantly face new issues8WHOCommunicable disease alert and response for mass gatherings—key considerations. World Health Organization, Geneva2008http://www.who.int/csr/Mass_gatherings2.pdfGoogle Scholar and will continue to provide serious public health challenges—but these challenges can be met through effective collaborative research, education, training, and capacity building. ZAM, AZ, BM, DH, AAAR, and MB are board members of the Global Center for Mass Gathering Medicine. Hajj: infectious disease surveillance and controlReligious festivals attract a large number of pilgrims from worldwide and are a potential risk for the transmission of infectious diseases between pilgrims, and to the indigenous population. The gathering of a large number of pilgrims could compromise the health system of the host country. The threat to global health security posed by infectious diseases with epidemic potential shows the importance of advanced planning of public health surveillance and response at these religious events. Saudi Arabia has extensive experience of providing health care at mass gatherings acquired through decades of managing millions of pilgrims at the Hajj. Full-Text PDF London 2012 Olympic and Paralympic Games: public health surveillance and epidemiologyMass gatherings are regarded as potential risks for transmission of infectious diseases, and might compromise the health system of countries in which they are hosted. The evidence for increased transmission of infectious diseases at international sporting mass gatherings that attract many visitors from all over the world is not clear, and the evidence base for public health surveillance, epidemiology, and response at events such as the Olympics is small. However, infectious diseases are a recognised risk, and public health planning is, and should remain, a crucial part of the overall planning of sporting events. Full-Text PDF Euro 2012 European Football Championship Finals: planning for a health legacyThe revised international health regulations offer a framework that can be used by host countries to organise public health activities for mass gatherings. From June 8, to July 1, 2012, Poland and Ukraine jointly hosted the Union of European Football Associations European Football Championship Finals (Euro 2012). More than 8 million people from around the world congregated to watch the games. Host countries and international public health agencies planned extensively to assess and build capacity in the host countries and to develop effective strategies for dissemination of public health messages. Full-Text PDF Ziad Memish: father of mass gatherings medicineZiad Memish is currently the Deputy Minister of Health for Public Health for the Government of Saudi Arabia. The son of a diplomat with the Saudi Foreign Office, he grew up travelling with his parents, living and studying in different countries. "I have always admired what my father used to do helping Saudi citizens in need abroad. My first ambition was to be a diplomat like my father, but seeing my older brother train as an invasive cardiologist in Canada persuaded me to change into medicine", he says. Full-Text PDF