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Director, Centers for Disease Control

and Prevention

David Satcher, M.D., Ph.D.

Deputy Director, Centers for Disease Control and Prevention

Claire V. Broome, M.D.

Director, Epidemiology Program Office
Stephen B. Thacker, M.D., M.Sc.

Editor, MMWR Series

Richard A. Goodman, M.D., M.P.H.
Managing Editor, MMWR (weekly)
Karen L. Foster, M.A.

Writers-Editors, MMWR (weekly)
David C. Johnson

Darlene D. Rumph-Person
Caran R. Wilbanks

Editorial Assistant, MMWR (weekly)
Teresa Rutledge

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OFFICIAL BUSINESS

During the XVII Central American and Caribbean Games

Puerto Rico, November 1993

To provide medical services at mass gatherings for scheduled special events (e.g., world fairs, music festivals, and athletic competitions such as the Olympics), organizers must have information to anticipate both routine and uncommon situations. In November 1993, approximately 9500 athletes and staff from 31 countries participated in the XVII Central American and Caribbean Games in San Juan, Puerto Rico. To monitor injury- and illness-related morbidity among participants, the schools of public health and medicine at the University of Puerto Rico and the Puerto Rico Olympic Committee established a public health surveillance system designed specifically for this event. This report summarizes selected results from the system, which underscore the usefulness of this approach in planning prevention, medical, and emergency services for similar events.

During the games, 4400 athletes competed in 28 sports at venues located in multiple sites around San Juan; the 5000 staff members included 500 trainers, judges, and delegates, and 4500 volunteers who were support personnel. The athletes lived at the Central American Village of the Caribbean at Camp Santiago in Salinas. Physicians provided medical care at the athletic village hospital, where an epidemiology unit conducted surveillance while the village was open. Staff in the epidemiology unit analyzed data daily and shared reports with games officials.

From November 14 through December 2, a total of 458 (58%) of 794 consultations at the hospital were for athletes, and 336 (42%) were for staff members. The largest numbers of patients were from Puerto Rico (249), Guatemala (49), and Jamaica (46). Most (444 [56%]) of the visits occurred during November 20-25, the peak of competition, when a daily average of 74 patients were evaluated. Among all 794 patients, the most common diagnosis was musculoskeletal injuries (302 [38%]). Among the 229 athletes treated for injuries, the most frequent injury-related diagnoses were contusion (38), sprain (27), strain (27), tendinitis (25), abrasion (15), and myositis (15). The sports accounting for the largest number of injuries were field hockey (25), softball (22), soccer (21), and tae kwon do (21). Other diagnoses among all of those treated included respiratory (180 [23%]), skin (85 [11% ] ), gastrointestinal (56 [7%]), genitourinary (25 [3%]), and other (146 [18%]) problems.

The University of Michigan

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES / Public Health SerDocuments

Center

Public Health Surveillance - Continued

Of 180 patients with respiratory diagnoses, 71 (39%) were athletes whose most frequent diagnoses were upper respiratory tract infection (33) and pharyngitis (23). During the games, acute infectious conjunctivitis was diagnosed in 12 persons, including nine support staff and three athletes. Because of concern about the potential for spread, the nine support staff were provided treatment and asked to leave the games; the three athletes were treated and interviewed by epidemiologists to detect additional cases. Of the 15 cases of acute gastroenteritis, eight occurred in athletes, including three in members of one team. These three and their teammates were monitored by medical personnel for additional cases among teammates.

Of the 794 consultations, 727 (92%) persons received medication, the most common of which were nonsteroidal anti-inflammatory agents (199), analgesics (162), antihistamines (58), and antibiotics (52). A total of 128 procedures were performed, including 26 clinical laboratory tests, 70 radiographic studies, and 32 procedures requiring suturing and local wound care.

Reported by: RV Pérez Perdomo, MD, CA Morell Rivera, AM Mayor Becerra, MD, RA Serrano Rodríguez, Graduate School of Public Health, Univ of Puerto Rico; WR Frontera, MD, School of Medicine, Univ of Puerto Rico, San Juan. E Martin, J Cantwell, MD, Atlanta Committee for the Olympic Games, Atlanta; D Blumenthal, MD, Fulton County Health Dept, Atlanta; P Wiesner, MD, DeKalb County Board of Health, Decatur; K Toomey, MD, State Epidemiologist, P Meehan, MD, Div of Public Health, Georgia Dept of Human Resources. J Clinton, MD, HHS Region IV. Office of the Director, Public Health Practice Program Office; Div of Surveillance and Epidemiology, Epidemiology Program Office, CDC.

Editorial Note: International sports events and other organized mass gatherings bring together large numbers of competitors and support staff from geographically widespread regions into sports venues and lodging facilities. Persons planning such events should recognize the data requirements of health-care and public health officials for providing necessary services during the events (1-3). The public health surveillance system established for the XVII Central American and Caribbean Games was simple and flexible and provided useful information on a timely basis (4). For example, information about patients treated at the hospital was used by the organizing committee's Division of Health Services for daily planning, and the system detected two conditions (conjunctivitis and gastroenteritis) with potential for spread.

Outbreaks of infectious diseases associated with competitive sports events may be transmitted by several modes, including person-to-person, common source, and airborne or droplet spread (5). Basic measures for preventing infectious diseases among athletes participating in such events include diagnosis and follow-up, prevention (e.g., vaccination), education about risk behaviors, and public health surveillance (e.g., prompt disease recognition and reporting). Health-care workers who provide medical care in these settings should recognize the potential risks for transmission of infectious diseases at three levels: the individual athlete, the team and support staff (as a group of individuals in close contact), and spectators or others exposed through viewing or related activities (5). In addition, members of these groups may be at risk for exposure to infectious diseases present among persons in the general community. Although the overall likelihood of transmission during competitive sports events is low, understanding of the levels for potential spread of infectious diseases facilitates rapid detection and intervention by medical and public health officials.

The surveillance system in San Juan focused on athletes but not spectators. At some competitions, particularly those extending over many days and held in

different locations, the provision of medical care for spectators may entail extensive coordination between public health officials and event organizers (2,6,7). Factors to be considered when planning such services include the type and length of event(s), physical facilities, availability of qualified on-site staff and other resources, weather and other environmental factors, local capacity for routine medical care, and relations among groups responsible for organizing the games.

The public health and safety needs for the 1996 Summer Olympics-scheduled for July 19-August 5 in Atlanta, Georgia-are complex and have required close cooperation among the Atlanta Committee for the Olympic Games (ACOG) and the local, state, and federal agencies responsible for these needs. To prepare medical and public health services for these events, ACOG and government agencies have reviewed the experiences of and information from prior events such as the XVII Central American and Caribbean Games, previous Olympics (2,8), and other large gatherings (9). ACOG has worked with the local community to plan medical services for the expected 11,000 athletes, 80,000 staff, and 2.2 million visitors during the 18-day event. These plans have been closely integrated with the operations of existing local, state, and federal public health officials; emergency-management services; environmental health services; and other relevant agencies. Concerns about heat-related morbidity, in particular, prompted extensive planning efforts by ACOG and public health officials to develop for and distribute to the public educational materials regarding prevention measures, and to ensure the availability of adequate water and shade structures both within and outside the Olympic venues.

To monitor the health and safety of athletes, staff, and spectators at the venues and Olympic Village, CDC, at the request of ACOG Medical Services, has coordinated the design and implementation of a surveillance system that will collect information daily from approximately 100 medical assistance sites at the venues. These data will be provided to ACOG, the International Olympic Committee, and state and federal officials. To monitor infectious diseases and other health events that may require intervention in the community, the Division of Public Health, Georgia Department of Human Resources, has enhanced the existing notifiable disease system, which is based on reports from physicians, infection-control practitioners, and statewide laboratories. During the Olympics, the state public health laboratory and a private laboratory will provide daily reports to the state epidemiologist of selected tests requiring immediate public health follow-up. In addition, active surveillance at eight sentinel hospital emergency departments (four hospitals in the metropolitan Atlanta area and one hospital each at venues in Athens, Columbus, Macon, and Savannah) will include reports of potential foodborne illnesses and other infectious diseases, injuries, and heat-related illnesses.

References

1. Thompson JM, Savoia G, Powell G, Challis EB, Law P. Level of medical care required for mass gatherings: the XV Winter Olympic Games in Calgary, Canada. Ann Emerg Med 1991;20:385–90.

2. Baker WM, Simone BM, Niemann JT, Daly A. Special event medical care: the 1984 Los Angeles Summer Olympics experience. Ann Emerg Med 1986;15:185–90.

3. Leonard RB, Petrilli R, Calabro JJ, Noji EK. Provision of emergency medical care for crowds [Monograph]. Dallas, Texas: American College of Emergency Physicians, 1990.

4. Klaucke DN, Buehler JW, Thacker SB, et al. Guidelines for evaluating surveillance systems. MMWR 1988;37(no. S-5).

5. Goodman RA, Thacker SB, Solomon SL, Osterholm MT, Hughes JM. Infectious diseases in competitive sports. JAMA 1994;271:862-7.

6. Weiss BP, Mascola L, Fannin SL. Public health at the 1984 Summer Olympics: the Los Angeles County experience. Am J Public Health 1988;78:686-8.

7. Gustafson TL, Booth AL, Fricker RS, et al. Disease surveillance and emergency services at the 1982 World's Fair. Am J Public Health 1987;77:861-3.

8. Plasencia i Taradach A, ed. Public health at the Olympic games of Barcelona '92 [Catalan and Spanish]. Barcelona, Spain: Area of Public Health, Municipal Institute of Health, 1994.

9. Hnatow DA, Gordon DJ. Medical planning for mass gatherings: a retrospective review of the San Antonio Papal Mass. Prehospital and Disaster Medicine 1991;6:443-50.

Prevention of Perinatal Hepatitis B
Through Enhanced Case Management -
Connecticut, 1994–95, and United States, 1994

Each year, an estimated 20,000 infants are born to women in the United States who are positive for hepatitis B surface antigen (HBsAg). These infants are at high risk for perinatal hepatitis B virus (HBV) infection and for chronic liver disease as adults. To identify newborns who require immunoprophylaxis to prevent perinatal HBV infection (1-4), all vaccine advisory groups have recommended routine HBsAg screening of all pregnant women during an early prenatal visit in each pregnancy. Federal funding to support perinatal hepatitis B-prevention programs became available in 1990, and by 1992, programs had been implemented in all 50 states and the District of Columbia. Specific objectives of these programs are to ensure that 1) all pregnant women are tested for HBsAg, and 2) infants born to HBsAg-positive women receive hepatitis B immune globulin (HBIG) and hepatitis B vaccine at birth, with follow-up doses of vaccine at ages 1 and 6 months (5). This report describes the case-management features of successful hepatitis B-prevention programs in Connecticut during 1994-95 and in the United States during 1994.

Connecticut

In 1992, the Connecticut Department of Public Health implemented a perinatal hepatitis B-prevention program and recommended that 1) HBsAg-positive women be contacted before delivery and educated about HBV infection, 2) the infant's pediatrician and delivery hospital be informed of the mother's HBsAg status, and 3) a tracking system be used to ensure the infant receives appropriate postexposure prophylaxis. Local health departments (LHDs) initially were responsible for providing management to mother/infant pairs.

Enhanced case management (ECM) was implemented in two counties in July 1994 and a third county in April 1995. In addition to use of the basic recommendations, the ECM program employed a full-time nurse (hired by the state) who worked on a flexible schedule to manage all mother/infant pairs in the three-county area and computerbased tracking system to identify pending births to infected mothers and the need for follow-up vaccine doses for infants. To evaluate program effectiveness, outcomes in the ECM program were compared with the LHD programs for HBsAg-positive women identified during 1994-95.