Today, mass gatherings (MGs) are commonly held events throughout the world. According to the World Health Organization (WHO), an MG is an event in which the participants affect the capacity of the available resources to support their health needs and to successfully deliver health services.Reference Lund and Turris1 Each year, religious, sport, and various festival MGs are held at the national and international levels. Public health issues of MGs are becoming more complicated in national and international levels.Reference Shafi, Booy and Haworth2 Important implications of MGs to health security risks such as infectious diseases, outbreaks, noncommunicable diseases, and injuries have encouraged research.Reference Eberhardt, Vinnemeier and Dehnerdt3–Reference Wilson and Chen6
People who participate in MGs may be threatened by communicable diseases such as water and foodborne infectious diseases, respiratory infectious diseases, injuries, terrorism, and bioterrorism.Reference Al-Tawfiq, Gautret, Benkouiten and Memish7–Reference Zeitz, Zeitz and Kadow-Griffin11 In addition, noncommunicable diseases and accidents are other concerns in MGs for participants and health systems.Reference Steffen12 The health of the people in MGs may be affected by the interaction of the biologic, environmental, psychological, and social factors.Reference Arbon13 So the characteristics of participants such as age, sex, and chronic underlying disorders are determinants of health in MGs.Reference Steffen12
In recent years, health and safety provisions for participants in these MGs have been raised as 1 of the major concerns of governments, as well as national and international organizations.Reference Al-Tawfiq and Memish8, Reference Locoh-Donou, Guofen and Welcher9, Reference Gautret and Steffen14 The occurrence of communicable and noncommunicable diseases in an MG is related to the presence of risk factors during the event. Accordingly, the identification of such risk factors in each MG can be useful in the planning of preventive actions.Reference Tam, Barbeschi and Shapovalova15 Moreover, based on WHO recommendations, the hosts of international and large MGs should have the preparedness to respond appropriately to preventable diseases and injuries and to manage potential threats effectively during MGs.Reference Karami5, Reference Riccardo, Manso and Caporali16
To date, several studies have been published regarding the health threats among participants during MGs. Some of these studies evaluated the required health care of participants in MGs. However, the more precise knowledge regarding the potential risk factors of prevalent diseases and injuries can be useful for planning preventive interventions during the MGs. Therefore, the aim of this review was to assess and identify the health threats in MGs based on the type of the MG, type of risk factors, and types of diseases and injuries.
METHODS
Searching and Eligibility Criteria
This systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).Reference Moher, Liberati, Tetzlaff and Altman17 We designed a search strategy using the key words: mass gathering, health, diseases, illness, infectious diseases, emerging diseases, re-emerging diseases, and injuries. The major international scientific databases – Web of Science, Medline, and Scopus – were searched up to August 2018, using the mentioned key words. In addition, to obtain more articles, the reference lists of included studies were scanned.
All epidemiologic studies that investigated the health threats of participants in MGs were included in the review. The studies regarding the required health care in MGs were excluded from the review. In addition, review articles, editorials, and letters to the editor were excluded.
Two authors (ADI, ZB) were responsible for screening the retrieved articles. In the first step, the title and abstract of articles were scanned independently. Any disagreement between authors in the selection of the studies was resolved by discussion and the judgment of the third author (MK). In the next step, the full text of selected articles was assessed based on the eligibility criteria. Finally, 2 authors (ADI, ZB) extracted from the selected studies these data: (1) first authors, (2) year of publication, (3) date of the MG, (4) location of the MG, (5) type of study, (6) alternation in the MG holding, (7) number of participants in the MG, (8) type of MG, (9) type of health threats or risk factors, (10) tools of data gathering, (11) type of surveillance system during the MG, and the (12) main results of the study.
The Microsoft Excel program was used for extraction and the management of extracted data from the included studies. The selected studies in the review were categorized based on the type of the MG, type of health threats, and the time and location of the MG.
RESULTS
Description of Studies
A total of 1276 references were obtained from the electronic search of international databases. After finally checking the eligibility criteria, 45 articlesReference Eberhardt, Vinnemeier and Dehnerdt3, Reference Riccardo, Manso and Caporali16, Reference Abdullah, Sharkas and Sabri18–Reference White, Saketa and Johnson62 regarding the health issues in the MGs were included in the review (Figure 1). The characteristics of the included study are shown in Table 1.
FIGURE 1 A Flow Diagram for the Process of Study Selection in the Review.
TABLE 1 Characteristics of Included Studies in the Review
MG = mass gathering; UTI = urinary tract infection.
Types of MGs
In terms of the types of MGs, the 3 main types – religious, festival, and sport – were reported by the included studies.
Religious MGs
Fifteen articles were related to the religious MGs. Infectious diseases were the most common health threat in these MGs. Infectious diseases, such as respiratoryReference Alqahtani, BinDhim and Tashani19, Reference Hassan, Imtiaz and Ikram35, Reference Khan, Khan and Asima60, Reference Sokhna, Mboup and Sow61 and gastrointestinal,Reference Hassan, Imtiaz and Ikram35, Reference Youbi, Dghoughi and Akrim55 were the most reported public health concerns. Middle East respiratory syndrome-related coronavirus was assessed during the 2013 Hajj in Saudi Arabia, but it was not detected in the samples tested in the pre-Hajj and post-Hajj screening.Reference Memish, Assiri and Almasri44
Injuries, such as road traffic accidents,Reference Abdullah, Sharkas and Sabri18, Reference Hassan, Imtiaz and Ikram35, Reference Sindy, Baljoon and Zubairi52, Reference Youbi, Dghoughi and Akrim55 injury caused by marine creatures, drowning,Reference Abdullah, Sharkas and Sabri18, Reference Youbi, Dghoughi and Akrim55 falls, riots,Reference Hassan, Imtiaz and Ikram35 intentional injuries,Reference Youbi, Dghoughi and Akrim55 and crowded disaster-related injuries,Reference Joseph, Babu, Dev and Pradeepkumar40 were the most reported injuries in the religious MGs.
Asthma was another health problem among participants in the religious MGs.Reference Hassan, Imtiaz and Ikram35, Reference Mirza, Fillimban and Maimini45, Reference Sindy, Baljoon and Zubairi52 The higher risk of asthma attack was observed among women and people ages 40–60 years. Other noncommunicable diseases, such as hypertension, ischemic heart disease, and diabetes mellitus, were the major health problems during MGs, especially for elderly participants.Reference Hassan, Imtiaz and Ikram35 Environmental problems, such as hygiene conditions, water sanitation, number of persons per toilet, drainage,Reference Baranwal, Anand and Singh23 and exposure to cold weather,Reference Gocotano, Dico and Calungsod33 were the most reported health problems in these MGs.
Sport MGs
Sixteen articles were related to sporting events. Injuries were the most common health problems in these MGs.Reference Athanasopoulos, Kapreli and Tsakoniti22, Reference Burton, Corry, Lewis and Priestman26, Reference Chen, Zhang and Wan27, Reference Dutch, Senini and Taylor29, Reference Piat, Minniti and Traversi50, Reference Anikeeva, Arbon and Zeitz59, Reference White, Saketa and Johnson62 Athletes and participants both were affected by injuries in the sport MGs. During the 2004 Olympic games, the most common site of injuries was the thigh, knee, and lumbar spine, respectively.Reference Athanasopoulos, Kapreli and Tsakoniti22 Motor vehicle accident and drowning were reported in the Athens 2004 Olympic and Para-Olympic games.Reference Hadjichristoulou, Mouchtouri and Soteriades34 During the 2002 FIFA World Cup, the most prevalent traumatic injuries included blisters, scrapes, bruises and fractures, sprains, and lacerations.Reference Morimura, Katsumi and Koido46 Soft tissue, head, laceration, fracture, fall, dislocation, leg and hands, dermal, eye injuries, traffic accidents, and burns were the other reported injuries in the sport MGs.Reference Burton, Corry, Lewis and Priestman26, Reference Dutch, Senini and Taylor29, Reference Selig, Hastings and Cannon51, Reference Todkill, Hughes and Elliot53, Reference Milsten, Seaman and Liu54, Reference Varon, Fromm and Chanin56
Infectious diseases were another health threat in the sport MGs.Reference Chen, Zhang and Wan27 In the London 2012 Olympic and Para-Olympic games, a syndromic surveillance system was established. In this surveillance system, the indicators of gastrointestinal and respiratory infection symptoms peaked during December 2010.Reference Elliot, Hughes and Hughes30 During the Athens 2004 Olympic games, traveler’s diarrhea, foodborne and waterborne diseases, and sexually transmitted diseases were the high-risk potential public health concerns.Reference Hadjichristoulou, Mouchtouri and Soteriades34 Lim et al.Reference Lim, Cutter and Lim42 reported a successful experience in the prevention of influenza H1N1 during the Asian Youth Games in Singapore in 2009. During this event, 7 cases of influenza H1N1 were confirmed.Reference Lim, Cutter and Lim42
Alcohol and drug-related disorders were another reported public health concern.Reference Eberhardt, Vinnemeier and Dehnerdt3, Reference Burton, Corry, Lewis and Priestman26, Reference Morimura, Katsumi and Koido46, Reference Todkill, Hughes and Elliot53 The proportion of alcohol intake during the 2014 FIFA World Cup in Brazil among travelers to the games and regular travelers was 71.74% and 40.53%, respectively.Reference Eberhardt, Vinnemeier and Dehnerdt3 During the 2002 FIFA World Cup in Korea/Japan, 0.7% of illness/injuries were related to alcohol and drug use.Reference Morimura, Katsumi and Koido46
Casual sex encounters were reported as a risky behavior during the 2014 FIFA World Cup. The proportion of casual sex occurrences among the FIFA World Cup travelers and regular travelers was 8.76% and 2.59%, respectively.Reference Eberhardt, Vinnemeier and Dehnerdt3
Festival MGs
Eleven articles reported health issues in the festival MGs. Alcohol/drug-related problems were commonly reported in these MGs.Reference Friedman, Plocki and Likourezos32, Reference Hawkins and Brice36, Reference Hutton, Ranse and Verdonk38, Reference Hutton, Savage and Ranse39, Reference Yazawa, Kamijo and Sakai63 In music festivals, alcohol, drug, and combined alcohol and drug-related presentations were commonly reported as 32.8%, 17.7%, and 16.4%, respectively.Reference Hutton, Ranse and Verdonk38
Injuries were another health problem in this type of MG. The commonly reported injuries were trauma, soft-tissue injuries, burns, lacerations, sprain/strain, head injury, and a foreign body in the eye.Reference Bledsoe, Songer and Buchanan24, Reference Hawkins and Brice36, Reference Hutton, Ranse and Verdonk38, Reference Hutton, Savage and Ranse39, Reference Yazawa, Kamijo and Sakai63
Infectious diseases affected the health of participants in 2 festivals. The first one was at the 11th festival of Pacific Arts in the Solomon Islands, where an enhanced syndromic surveillance was used. In this MG, the most important reported syndromes were influenza-like illness (44%), prolonged fever (24%), non-watery diarrhea (23%), and acute fever and rash (12%).Reference Hoy, Saketa and Maraka37 Influenza (H1N1) was confirmed in 62 participants in the second music festival.Reference Loncarevic, Payne and Kon43
Other MGs
Other MGs in this review were related to fairs such as trade, book, and agricultural fairs. Like the previously mentioned MGs, injuries, illness, and infectious diseases were the main health problems reportedReference Riccardo, Manso and Caporali16, Reference Crabtree, Mo and Ong28, Reference Pakravan, West and Hodgkinson48, Reference Perez-Gomez, Ramos-Zuniga and Gutierrez-Padilla49 (see Table 1).
DISCUSSION
Included studies in this review were related to three types of MGs – religious, sport, and festivals. The major public health threats in these MGs were determined. In the religious MGs, infectious diseases, injuries, road traffic accidents, and environmental health problems were the main problems for participants. In addition, noncommunicable diseases such as asthma, hypertension, ischemic heart disease, and diabetes mellitus, especially among elderly people were the other health problems. In the sport MGs, injuries were the most common problems. In addition, infectious diseases such as influenza were an important problem. The high-risk behaviors such as alcohol drinking, drug use, and illicit sexual behaviors were reported in the sport MGs. At the festivals, alcohol drinking, drug use, injuries, and communicable diseases were the main health problems.
The findings of this review show that religious MGs are more prevalent in Asian countries than in other regions. There are numerous published studies regarding the Hajj, which is the most important religious MG for Muslims. In addition to concerns regarding infectious diseases and noncommunicable diseases among older people,Reference Hutton, Brown and Verdonk64, Reference Algarni, Memish and Assiri65 especially in recent years, injuries were the most important problems for participants.Reference Ganjeh and Einollahi66 Apart from the mentioned health conditions, environmental risk factors such as sunburn, foot burns, and heat-related problems threaten the health of participants during their pilgrimage.Reference Hutton, Brown and Verdonk64, Reference Noweir, Bafail and Jomoah67 Likewise, these same conditions threaten the health of participants in other religious MGs.Reference Abdullah, Sharkas and Sabri18, Reference Baranwal, Anand and Singh23, Reference Bortolin, Ulla and Bono25, Reference Hassan, Imtiaz and Ikram35
Injuries, communicable diseases, and some risky behaviors were reported as the main concerns in the sport and festival events. Alcohol misuse is prevalent during sport MGs,Reference Leeka, Schwartz and Kloner68–Reference Merlo, Ahmedani and Barondess71 and alcohol misuse and drug use are prevalent in the festivals,Reference Hutton, Brown and Verdonk64, Reference van Gemert, Dietze and Gold72 which would explain the prevalence of alcohol-related complications among participants of sport and festival MGs. In addition, other factors such as age, gender, type of event, and weather conditions have an important role in the patient presentation and required health care.Reference Goldberg, Maggin and Molloy73
The results of our review indicate that the health conditions of participants in the MGs are related to the type of MG. On the other hand, it seems that the basic characteristics of participants in each type of MG are different. For example, the participants of the Hajj are older than those in other MGs, therefore, chronic diseases may be an additional threat for these participants and health care providers. Also, because participants of sport and festival MGs are younger than participants in religious MGs, high-risk behaviors may be more prevalent in the former.
According to our results and a previously published review,Reference Hutton, Brown and Verdonk64 the health organizers of MGs should have specific health planning for each type of MG. Health managers should know the characteristics of each type of MG, such as the characteristics of participants, the environmental conditions, the epidemiology of prevalent infectious diseases, and the cultural conditions in the location of the event. In the reviewed articles, there was not a standard tool used for data collection. Different tools such as researcher designed questionnaires, patients’ records, and medical records were used in some MGs. Nevertheless, in some MGs, a standard minimum data set was based on the syndromic surveillance system,Reference Elliot, Hughes and Hughes30 and the Ranse and Hutton minimum data setReference Hutton, Ranse and Verdonk38, Reference Hutton, Savage and Ranse39 was used.
The appropriate knowledge and, consequently, management of health conditions during the MGs are required in order to collect the higher quality data and information. The health-related data can be very useful for the planning of preventive interventions and delivery of needed health services during future MGs. The quality of data gathering is an important issue in the reporting of health problems. Human, logistic, and environmental factors can affect the quality of data gatherings.Reference Guy, Prager, Turris and Lund74 So it seems for each type of MG a standard specific tool is needed for data collection.
As a new insight for reducing MG-related health threats, published literature provides advice for public health authorities of host countries to consider preventive and fundamental activities, including “implementation of syndromic surveillance systems or enhanced surveillance systems, educating participants on occurred health events, and other activities according to relevant guidelines in light of the situation.”Reference Karami75
CONCLUSION
According to the results of this review, the health threats are different based on the type of the MG. Religious MGs are more affected by infectious diseases and injuries. Injuries and high-risk behaviors, such as alcohol drinking and illicit sexual behaviors, are more common in sporting events in comparison with other MGs. Festivals are more affected by alcohol and drug-related problems and injuries.
Acknowledgments
The authors would like to thank, Dr. Saeid Bashirian, the Vice Chancellor for Research and Technology, Hamadan University of Medical Sciences, for supporting this study, as well as Drs Mahmood Soroush, Behzad Amiri, Hossain Akbari, and Mohammad Jaber Huwail for their kind help in conceiving the idea for the study.
Conflict of Interest Statement
The authors declare no conflicts of interest.
Funding
This study was supported by the Vice Chancellor for Research and Technology, Hamedan University of Medical Sciences (Grant No. 9603091590 and 960129639).
