Abstracts

Introduction

Mass gatherings are situations in which a large number of people come together for religious, sports, cultural, or political events ¹1. Ministério da Saúde. Portaria nº 1.139, de 10 de junho de 2013. Define, no âmbito do Sistema único de Saúde (SUS), as responsabilidades das esferas de gestão e estabelece as Diretrizes Nacionais para Planejamento, Execução e Avaliação das Ações de Vigilância e Assistência à Saúde em Eventos de Massa. Diário Oficial da União 2013; 11 jun.. In mass gatherings, healthcare must be involved throughout the health system’s operational planning, which in turn must be described in a comprehensive action plan. The plan should be structured on an understanding of expected natural or technological hazards and prior needs assessment ²2. Paul A, Bridgewater FHG, Smith C. Mass gathering medicine: a predictive model for patient presentation and transport rates. Prehosp Disaster Med 2001; 16:150-8..

Mass events may differ widely in crowd sizes, type of attendance, and nature of the event (e.g., scheduled events at sports facilities, air shows, rock concerts, outdoor celebrations, and visits by dignitaries), but may be very similar as to the need for in-place capacity and healthcare provision. Preparedness for mass events is conducted in much the same way as for disasters: emergency response based on identification of hazards. Mass events thus provide a practical opportunity to enhance the level of disaster preparedness at the local, regional, and country levels ³3. Enock KE, Jacobs J. The Olympic and Paralympic Games 2012: literature review of the logistical planning and operational challenges for public health. Public Health 2008; 122:1229-38.^,44. Soomaroo L, Murray V. Weather and environmental hazards at mass gatherings. PLoS Curr 2012; 4:e4fca9ee30afc4..

As in disaster preparedness, the World Health Organization recommends the all-hazards approach ⁵5. World Health Organization. Emergency preparedness and risk management. WHO five-year strategy for the health sector and community capacity-building. Geneva: World Health Organization; 2007.. Because preparedness measures are similar irrespective of the nature of the hazard, this approach has the benefits of concerted planning. The higher the level of disaster preparedness, with adequate healthcare structure and trained human resources, the less the effort needed for preparedness in mass events ⁶6. World Health Organization. Global Alert and Response (GAR). London Olympics: enhancing disease surveillance and response. http://www.who.int/csr/mass_gatherings/olympics/en/ (accessed on 15/Oct/2015).
http://www.who.int/csr/mass_gatherings/o... , and hazard identification is a first step for government decision-making involving the health sector.

The identification of priority measures, such as defining available hospital beds and structuring response capacity should then be established1 in order to prepare the health sector for mass gatherings ⁷7. Lund A, Gutman SJ, Turris SA. Mass gathering medicine: a practical means of enhancing disaster preparedness in Canada. CJEM 2011; 13:231-6.. In several previous mass sports events such as the FIFA 2002 and 2010 World Cups and the 2004 Summer Olympic Games in Athens, Greece, calculations were made to model patient presentations and hospital transfers ²2. Paul A, Bridgewater FHG, Smith C. Mass gathering medicine: a predictive model for patient presentation and transport rates. Prehosp Disaster Med 2001; 16:150-8.^,88. Morimura N, Katsumi A, Koido Y, Sugimoto K, Fuse A, Asai Y, et al. Analysis of patient load data related from the 2002 FIFA World Cup Korea/Japan. Prehosp Disaster Med 2004; 19:278-84.^,99. Zeitz KM, Zeitz CJ, Arbon P. Forecasting medical work at mass gathering events: predictive model versus retrospective review. Prehosp Disaster Med 2005; 20:164-8.^,1010. Yancey AH, Fuhri PD, Pillay Y, Greenwald I. World Cup 2010 planning: an integration of public health and medical systems. Public Health 2008; 122:1020-9.. Yancey et al. ¹⁰10. Yancey AH, Fuhri PD, Pillay Y, Greenwald I. World Cup 2010 planning: an integration of public health and medical systems. Public Health 2008; 122:1020-9. also proposed a 2% hospitalization rate in case of mass casualties occurring during mass events.

In Brazil, public hospitals, many of them reference centers, are at the frontline of response efforts. Under Brazilian Unified National Health System (SUS), all Brazilian and foreign citizens are eligible for hospitalization and treatment in public hospitals. Pharmacists should be very much involved in planning health needs, since they are responsible for forecasting, managing, and supplying medicines.

In 2014, 12 cities in Brazil hosted the FIFA World Cup and, in 2016, the city of Rio de Janeiro hosted the Summer Olympic Games. A comprehensive research project called Prepara Brasil aimed to investigate health sector and pharmaceutical services preparedness for mass gatherings in the country, specifically for the 2014 FIFA World Cup and the 2016 Summer Olympic host cities. According to Brazil’s health legislation, in these “national” events, municipalities, states, and the Ministry of Health share the responsibility for coordination, thus highlighting the role of municipal and hospital administrators in operational planning and preparedness efforts ¹1. Ministério da Saúde. Portaria nº 1.139, de 10 de junho de 2013. Define, no âmbito do Sistema único de Saúde (SUS), as responsabilidades das esferas de gestão e estabelece as Diretrizes Nacionais para Planejamento, Execução e Avaliação das Ações de Vigilância e Assistência à Saúde em Eventos de Massa. Diário Oficial da União 2013; 11 jun..

Our objective is to present and discuss the perceptions of health administrators in the host cities of the 2014 FIFA World Cup regarding hazards, and to compare these perceptions with available public hospital infrastructure in these cities at the time of the event.

Method

The study was conducted in all 12 host cities of the 2014 FIFA World Cup. The cities were contacted and asked to identify three key informants: administrators from the Civil Defense Secretariat, the Health Secretariat, and the head of Pharmaceutical Services. In order to also cover hospital administrators (heads of clinical and pharmaceutical services), three hospitals were selected for visits in each city. One reference hospital was selected among the list supplied by the Ministry of Health. The first hospital that responded positively to the invitation was included. Additionally, two general hospitals with emergency care were randomly selected from the municipal inpatient facilities that fit this profile ¹¹11. Shoaf K, Osorio de Castro CGS, Miranda ES. Hospital preparedness in advance of the 2014 FIFA World Cup in Brazil. Prehosp Disaster Med 2014; 29:1-4..

Key informants were asked to respond to a semi-structured interview regarding World Cup events in Brazil, with questions related to each informant’s field of expertise and a general question on hazards to be expected during the sports events.

All the administrators provided informed consent. The project was approved by Institutional Review Board of the Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation (CAAE no. 17796513.6.0000.5240).

Hazards

Hazards are defined as any phenomenon capable of causing damage to individuals or to the environment ⁵5. World Health Organization. Emergency preparedness and risk management. WHO five-year strategy for the health sector and community capacity-building. Geneva: World Health Organization; 2007.. Hazards are sometimes reported together with adverse health outcomes with which they are associated. In order to investigate expectations regarding negative health outcomes associated with mass gatherings, interviewees were asked to cite “possible hazards” and “related outcomes” during mass gatherings. Outcomes were then grouped into main categories.

Data on expected hazards were collected from four groups of respondents: municipal and hospital pharmaceutical services administrators and municipal health and hospital administrators. These were additionally regrouped as all hospital administrators and as all municipal health administrators. We compared each outcome category versus all the other categories for the four different groups. Analyses between types of respondents inside each respondent group were also made.

Data were analyzed quantitatively, using descriptive statistics (frequencies). Tests of differences between proportions and Upton’s chi-square (WinPepi, 2014. http://www.brixtonhealth.com/pepi4windows.html) were used to verify statistical significance at p < 0.05.

Availability of hospital beds for surges and mass casualties

Data were collected on maximum capacity of FIFA 2014 World Cup arenas in each city. Surge and mass casualty calculations were carried out using this parameter. A literature review provided three possible estimates for surges in case of mass gatherings ⁸8. Morimura N, Katsumi A, Koido Y, Sugimoto K, Fuse A, Asai Y, et al. Analysis of patient load data related from the 2002 FIFA World Cup Korea/Japan. Prehosp Disaster Med 2004; 19:278-84.^,99. Zeitz KM, Zeitz CJ, Arbon P. Forecasting medical work at mass gathering events: predictive model versus retrospective review. Prehosp Disaster Med 2005; 20:164-8.^,1010. Yancey AH, Fuhri PD, Pillay Y, Greenwald I. World Cup 2010 planning: an integration of public health and medical systems. Public Health 2008; 122:1020-9.. We chose the rates for the 2010 FIFA World Cup in South Africa (0.5/1,000), considered the closest to the Brazilian context. For mass casualties, surplus beds were calculated according to the 2% rate, calculated over maximum attendance at each sports event ¹⁰10. Yancey AH, Fuhri PD, Pillay Y, Greenwald I. World Cup 2010 planning: an integration of public health and medical systems. Public Health 2008; 122:1020-9..

Hospital inpatient bed availability in each host city was investigated through data available in the CNES database (National Registry of Health Establishments, 2014. http://datasus.saude.gov.br/cadastro-nacional-de-estabelecimentos-de-saude). The CNES base lists all health services in Brazil, classified according to level of complexity, presenting qualitative and quantitative data on services available in each facility. In each city, we only examined the institutions classified as public general hospitals in CNES levels 5, 6, 7, and 8 (more apt to provide emergency care). For each hospital, we collected the theoretical number of available beds (type and number).

In order to refine the numbers and model for hospital capacity at the time of the 2014 FIFA World Cup (in June), hospital occupancy rates for March, April, and May 2014 in each city were calculated (using hospital census data, i.e., patient-days, bed-days, and average hospital stay). Public data were obtained in December 2014 from the Brazilian Hospital Information System (SIH-SUS), through the Brazilian Health Information Department (DATASUS) database (http://www2.datasus.gov.br/). A 6-month gap was required to guarantee data stability (due to daily system updates that tend to wane over time), and averages were calculated. The resulting occupancy rates were applied to the theoretical availability of beds in order to obtain a proxy for actual availability. The number of unoccupied beds was calculated and subtracted from surge and mass casualty needs to obtain surplus beds.

Results

Of the 12 host cities, one refused to participate, leaving a total of 33 municipal health administrators. Of the 36 hospitals that were referred for participation, 35 agreed to receive a visit from the study team. Seventy administrators were interviewed in these hospitals.

When asked about expected hazards during the 2014 FIFA World Cup, the respondents first cited adverse health outcomes and only then associated them with hazards. Four outcome categories were identified during analysis that were linked to various hazards cited by respondents: (i) physical injuries, which included crushing, internal injuries, orthopedic injuries (associated with such expected hazards as alcohol abuse, violence, crowd crushes, automobile accidents, civil unrest, structural collapse); (ii) endemic infectious diseases, including malaria, dengue, tuberculosis, measles, seasonal influenza, or a surge of any prevalent infectious disease in Brazil or vaccine-controlled disease (identified as presence of the infectious agent and crowding associated with the mass gathering); (iii) emerging infectious diseases, such as pandemic influenza and other viral diseases (described by respondents as a consequence of the presence of the infectious agent imported by visitors to the games); and (iv) burns, chemical and radiation injuries and biological contamination, all of which were associated by the interviewees with chemical, biological, radiation, and nuclear incidents (CBRN).

Table 1 shows a preliminary exploratory analysis to determine differences between respondent groups. Differences emerged when we examined respondent sub-groups. Physical injuries (p < 0.000) and endemic diseases (p = 0.001) were mentioned more frequently by pharmaceutical services administrators in hospitals than by their peers in municipal services. Among health administrators, physical injuries (p < 0.000) and emerging infectious diseases (p = 0.007) were much more likely to be mentioned by hospital directors than by municipal health administrators. Pharmaceutical services administrators in hospitals differed from hospital directors in relation to endemic infectious diseases (p = 0.001). Municipal administrators (health and pharmaceutical services) differed in relation to physical injuries (p = 0.013). Hospital directors were concerned about physical injuries and emerging diseases, while hospital pharmaceutical administrators also focused on physical injuries, but on endemic rather than emerging diseases. Regarding total number of responses in all groups, physical injuries ranked first, followed by emerging diseases and endemic diseases. Few respondents cited CBRN incidents.

Table 2 shows the results for availability of beds during surges and mass casualties in public general hospitals only. Baseline occupancy rates were very high (0.93-2.19) in all the cities. This resulted in mostly negative theoretical availability of beds at baseline. The last two columns show total numbers of beds available during surges (764 to -17,191). Only one host city (J) showed theoretical availability for surges. Municipality K showed the largest deficit for surges. In case of mass casualties, the shortages were even greater. All host cities showed hospital bed deficits (-328 to -18.693). Total deficits, in all the cities, ranged from -47,670 (for surges) to -60,569 beds (for mass casualties).

Discussion

The article presents expected hazards and outcomes reported by municipal health administrators, hospital directors, and municipal and hospital pharmaceutical services administrators in the 2014 FIFA World Cup host cities in Brazil. The analysis aimed to estimate the actual availability of public hospital beds to respond to mass casualties, had these hazards materialized. We also analyzed surges, or the baseline demand in case of mass gatherings.

We proposed a simplified estimate of response capacity, given hazards reported by administrators, based on maximum crowd capacity at each sports venue. We also worked with the independent occurrence of mass casualties, in light of the distance between venues and the diverse settings. Lastly, we assumed that calculations for surges and mass casualties would be based on maximum capacity rather than on actual attendance. However, given that nearly 3 million tickets were sold for 2014 FIFA World Cup, an estimated 6,000 people would have made some kind of contact with healthcare services ¹⁰10. Yancey AH, Fuhri PD, Pillay Y, Greenwald I. World Cup 2010 planning: an integration of public health and medical systems. Public Health 2008; 122:1020-9.^,1111. Shoaf K, Osorio de Castro CGS, Miranda ES. Hospital preparedness in advance of the 2014 FIFA World Cup in Brazil. Prehosp Disaster Med 2014; 29:1-4..

Comparisons of responses to hazards were done for sub-groups only. Reporting of expected hazards by administrators in different settings account for their perceptions of how such hazards would impact healthcare provision. Most hospital administrators were worried about trauma, expressed as physical injuries. If one of the hazards they cited (alcohol abuse, civil unrest, outbreaks of violence, motor vehicle accidents, crowd crushes, structural collapses) had occurred, they would have needed emergency health services such as hospital transportation, beds, dialysis, and trauma diagnostic centers to mitigate the consequences ¹²12. Soomaroo L, Murray V. Disasters at mass gatherings: lessons from history. PLoS Curr 2012; 4:RRN1301.. However, by examining the results for available beds, we find that they would be insufficient to accommodate trauma patients. Apart from physical injuries, hospital directors also mentioned emerging infectious diseases, revealing their awareness of possible consequences of mass gatherings and strain on hospital services.

Municipal and hospital pharmaceutical administrators were much more concerned about endemic infectious diseases, perhaps because of the obvious association with ongoing availability and use of medicines (antimicrobials). However, hospital pharmacists reported more expected hazards than did municipal pharmacy administrators. Hospital pharmacists may feel more direct pressure on the pharmaceutical supply, given the present state of antimicrobial resistance in Brazil ¹³13. Rossi F. The challenges of antimicrobial resistance in Brazil. Clin Infect Dis 2011; 52:1138-43. and difficulties in procurement and supply in the public sector ¹⁴14. Pepe VLE, Figueiredo TA, Simas L, Osorio-de-Castro CGS, Ventura M. A judicialização da saúde e os novos desafios da gestão da assistência farmacêutica. Ciênc Saúde Coletiva 2010; 15:2405-14..

The data show a staggering deficit of public hospital beds in host cities in Brazil, due mostly to huge baseline occupancy rates. Only one city showed occupancy below 100%. The public hospital system thus already functions above capacity. Especially in case of mass casualties, additional response capacity (in this case surplus beds) could be very difficult to achieve. However, other possibilities for accommodating response could be devised in emergency situations. Hospital administrators cited cancellation of elective surgeries, activation of empty or underutilized rooms, partnerships with the private sector, and field hospitals (11). The Brazilian Ministry of Health assigned more than 1,500 extra beds to the 12 cities. If a hazardous event had materialized, other response mechanisms would have had to be implemented on an emergency basis ¹⁵15. Secretaria de Vigilância em Saúde, Ministério da Saúde. Preparação e resposta da vigilância em saúde para a Copa do Mundo da FIFA Brasil 2014. Bol Epidemiol (Rio J.) 2014; 45:1-12..

The results also showed little or no planning for surge. Surplus beds were only available for surges in one host city (J). This is a natural and predictable situation ²2. Paul A, Bridgewater FHG, Smith C. Mass gathering medicine: a predictive model for patient presentation and transport rates. Prehosp Disaster Med 2001; 16:150-8.^,33. Enock KE, Jacobs J. The Olympic and Paralympic Games 2012: literature review of the logistical planning and operational challenges for public health. Public Health 2008; 122:1229-38.^,1010. Yancey AH, Fuhri PD, Pillay Y, Greenwald I. World Cup 2010 planning: an integration of public health and medical systems. Public Health 2008; 122:1020-9.^,1616. Castro CF, Simões DCM, Delamarque EV, Pepe VLE. Eventos de massa, desastres e saúde pública. Ciênc Saúde Coletiva 2014; 19:3717-30.. Surges could result from food poisoning or related gastrointestinal problems, high blood pressure (common in high-stress competitive sports events), heat stroke, and alcohol abuse, among others. Administrators only cited alcohol abuse, which they associated with trauma and physical injury. It is reasonable to believe that surges occurred during the 2014 FIFA World Cup. Some accommodation must have occurred in private hospitals, given the unavailability of beds in public hospitals, but we found no records in the literature on surges during the 2014 FIFA World Cup.

We assumed that the calculations would adequately estimate what really happened. However, according to the literature ²2. Paul A, Bridgewater FHG, Smith C. Mass gathering medicine: a predictive model for patient presentation and transport rates. Prehosp Disaster Med 2001; 16:150-8.^,1717. Hartman N. Predicting resource use at mass gatherings using a simplified stratification scoring model. Am J Emerg Med 2009; 27:337-43.^,1818. Milsten AM, Maguire BJ, Bissell RA, Seaman KG. Mass gathering medical care: a review of the literature. Prehosp Disaster Med 2002; 17:151-62., demand is modulated by weather conditions, event types and boundaries, crowd mobility and mood, density, demographics, and alcohol and drug use . Although the FIFA World Cup draws huge crowds in happy or angry moods that may also use alcohol and drugs, no untoward events happened to indicate that these conditions were prevalent during the 2014 World Cup. Moreover, our calculations for surge were based on an empirical study in South Africa ¹⁰10. Yancey AH, Fuhri PD, Pillay Y, Greenwald I. World Cup 2010 planning: an integration of public health and medical systems. Public Health 2008; 122:1020-9., which may have overestimated the actual demand in Brazil. Historical data might have been more adequate, but to our knowledge they were unavailable ⁹9. Zeitz KM, Zeitz CJ, Arbon P. Forecasting medical work at mass gathering events: predictive model versus retrospective review. Prehosp Disaster Med 2005; 20:164-8.. Additionally, although surplus resources are necessary, there is some controversy as to the level of resources actually needed. The literature highlights that most health needs during mass events involve mild cases, and only minimal medical intervention is required ¹⁹19. Locoh-Donou S, Guofen Y, Welcher M, Berry T, O'Connor RE, Brady WJ. Mass-gathering medicine: a descriptive analysis of a range of mass-gathering event types. Am J Emerg Med 2013; 31:843-6.. The most common needs are related to lacerations, dehydration, and falls ²⁰20. Grant WD, Nacca NE, Prince LA, Scott JM. Mass-gathering medical care: retrospective analysis of patient presentations over five years at a multi-day mass gathering. Prehosp Disaster Med 2010; 25:183-7.. Only a small percentage of patients are referred to hospitals ²¹21. Varon J, Fromm RE, Chanin K, Filbin M, Vutpakdi K. Critical illness at mass gatherings is uncommon. J Emerg Med 2003; 25:409-13.. Resource allocation for health needs during mass events should thus be carefully planned by organizers. In Brazil, considering the prospects for more mass events in the future, planning should include availability of on-site health services, based on all of the above.

National inpatient data in Brazil tend to change over time due to progressive validation of health system reimbursement fees (DATASUS. Internações hospitalares. http://www2.datasus.gov.br/DATASUS/index.php?area=2&id=697&assunto=2939). However, even if average occupancy rates were calculated 6 months after actual admissions, residual changes may have occurred after the data were collected. For example, our estimates did not take into account that additional strain can be caused simply by intense turnover or by “stacking” of surge, i.e., if an inpatient admitted during the first sports event is not discharged before another patient is admitted later. Likewise, we did not take into account that in more complex models, patient presentation rates increase where access to health services is difficult ⁸8. Morimura N, Katsumi A, Koido Y, Sugimoto K, Fuse A, Asai Y, et al. Analysis of patient load data related from the 2002 FIFA World Cup Korea/Japan. Prehosp Disaster Med 2004; 19:278-84., since we did not measure access or transportation.

The delivery of emergency medical care is a function of a series of structural and operational components, centrally dependent on a medical action plan ²²22. Jaslow D, Yancey AH. Mass gathering medical care (a position paper of the National Association of EMS Physicians Standards and Clinical Practice Committee). Prehosp Emerg Care 2000; 4:359-60. in which hospital structure and availability must be considered. Moreover, preventive and therapeutic resources must be positioned in relation to expected health outcomes in order to address surge demand and mass casualty situations ¹⁰10. Yancey AH, Fuhri PD, Pillay Y, Greenwald I. World Cup 2010 planning: an integration of public health and medical systems. Public Health 2008; 122:1020-9..

A commitment of the study protocol was to maintain confidentiality as to host cities’ names, which might otherwise identify respondents. Cities differed considerably as to local organization, distribution of urban equipment, transportation, and health resources, which surely affected response capacity. However, a further limitation to the study lies in acknowledging these factors while not being able to discuss them according to each individual host city.

The UK Health Protection Agency (HPA) was intensely involved in planning for the 2012 Summer Olympic Games in London and worked to upgrade health systems and processes. The Agency also strived to make health surveillance data available and to disseminate awareness of possible hazards and related risks ²³23. McCloskey B, Endericks T. Learning from London 2012. A practical guide to public health and mass gatherings. London: Health Protection Agency; 2013.. In Brazil, shortly before the 2014 FIFA World Cup the Ministry of Health published a statement in a Ministry-sponsored journal to disseminate information on health preparedness. Administrators interviewed in all host cities were not uniformly aware of government efforts or of their roles in response ¹¹11. Shoaf K, Osorio de Castro CGS, Miranda ES. Hospital preparedness in advance of the 2014 FIFA World Cup in Brazil. Prehosp Disaster Med 2014; 29:1-4..

Final remarks

The article presented and discussed expected hazards and availability of hospital beds for surges and mass casualties during the 2014 FIFA World Cup in the 12 Brazilian host cities. We recognized the inherent limitations of using secondary data to calculate occupancy rates and the choice of a theoretical model from the literature based on estimations for surges and mass casualties.

There was a widespread shortage of hospital beds in all 12 cities. If hazards had actually materialized as events, the public hospital network in the host cities would have had to work above capacity. Surges must have been partially accommodated by the health system, but shortage of beds is an important constraint in public hospitals and must be considered in planning future mass events in Brazil.

In Brazil, mass gatherings occur every year or have occurred recently, some drawing many more people than the 2014 FIFA World Cup. Examples include Carnival, the New Year’s Celebration on Copacabana Beach in Rio de Janeiro, World Youth Day in 2013, and religious celebrations in many cities. Such mass events have not resulted in mass casualties thus far. However, no historical data have been published to help estimate health needs during future events. Our research, although limited, may be useful in identifying and discussing important issues related to surges and mass casualties, thereby contributing to preparedness for mass gatherings.

Acknowledgments

The authors wish to thank the health administrators and participating institutions for their collaboration and the Brazilian National Research Council (CNPq) for the funding.

References

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