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Home Eurosurveillance Monthly Release  2006: Volume 11/ Issue 12 Article 9
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Eurosurveillance, Volume 11, Issue 12, 01 December 2006
Surveillance report
Epidemiologic surveillance system implemented in the Hautes-Alpes District, France, during the Winter Olympic Games, Torino 2006

Citation style for this article: Franke F, Coulon L, Renaudat C, Euillot B, Kessalis N, Malfait P. Epidemiologic surveillance system implemented in the Hautes-Alpes District, France, during the Winter Olympic Games, Torino 2006. Euro Surveill. 2006;11(12):pii=671. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=671

 

F Franke1, L Coulon2, C Renaudat1,3, B Euillot2, N Kessalis2, P Malfait1

1. Cellule inter régionale d’épidémiologie Sud, Marseille, France
2. Direction départementale des affaires sanitaires et sociales des Hautes-Alpes, Gap, France.
3. Programme de formation à l’épidémiologie de terrain PROFET

 


Some of the competitions of the Olympic Winter Games in Torino, 10 to 26 February 2006, were organised in France near the city of Briançon, in the department of Hautes-Alpes.
An epidemiologic surveillance system was set up by the local health authorities. The goals were to detect in a timely fashion any phenomenon which could justify prevention or sanitary control action, and to guide interventions in the case of outbreak or environmental pollution.
Surveillance was implemented from 30 January to15 March 2006 in the Briançon area.
Mortality was tracked using by analysing the number and cause of deaths.
A sentinel network of general practitioners was set up and reported the frequency of acute gastroenteritis, influenza-like illness and measles. Medical laboratories provided data about the analyses they undertook. Hospital emergency department and emergency ambulance service activities were followed up. Statutory notification diseases and toxic effects of carbon monoxide surveillances were reinforced.
Analysed data were transmitted daily to the health authorities. A French/English report was sent weekly to all participants.
The participation rate was close to 100%, and data transmission deadlines were respected. No adverse health event was identified.
The strong acceptability of this surveillance system comes from its good understanding by the participants. This surveillance, structured around routine and ad-hoc systems, allowed the establishment of the foundations of a network to be used in case of outbreak or environmental pollution.


 
Background
The Olympic Winter Games 2006 took place from 10 to 26 February 2006 in Torino, Piemonte, Italy. This event was followed by the Paralympic Games, held from 10 to 19 March. An integrated epidemiological surveillance and response system, set up by the regional and national Italian health authorities during the Games, had as its goal the early detection of any adverse health events (particularly clusters of communicable diseases) [1].
As some of the competitions were held at Sestriere, close to the French-Italian border, with the nearest French city being Briançon, in the Hautes-Alpes department, it was judged that many spectators would choose to find accommodation on the French side, particularly in and around Briançon. The French health authorities considered that there was a possibility of health hazards related to such mass gatherings, because of [2]:
- large numbers of people gathering in the same place, which could increase the risk of disease transmission;
- possible saturation of healthcare structures;
- installation of temporary restaurants with potentially precarious hygiene conditions despite reinforcement of hygiene inspetions;
- mobility of the population concerned.
Only a small number of adverse health events, such as diseases or outbreaks, had been detected during previous mass gatherings [3-5], but the large concentration of people expected in a very limited area heightened the necessity of developing a surveillance strategy.
An epidemic intelligence mass gathering system was set up by the local public health authorities: the Direction départementale des affaires sanitaires et sociales (Ddass) des Hautes-Alpes, and the Cellule interrégionale d’épidémiologie Sud (Cire Sud). The aim was the early detection of any event that could justify prevention or sanitary control measures, and to guide interventions in the case of outbreak or environmental pollution.

Methods
Surveillance was implemented from 30 January to 15 March 2006, a period of time which covered the Games and the French school holidays in the Briançon area [FIGURE 1].


The system aimed to complement to the Italian system; surveillance targeted diseases with strong infectious epidemic potential (such as meningitis, legionellosis and gastroenteritis) or events which could represent a specific risk in the area under surveillance (such as very low environmental temperatures or carbon monoxide poisoning). Reinforcement of the carbon monoxide poisoning monitoring was carried out, because private residences with poor quality heating equipment were known to be available to rent during the Games.
Surveillance was based partly on existing surveillance systems that were enhanced during the Games and partly on systems set up for the occasion. Surveillance allowed indicators of mortality, morbidity and activity to be tracked.
The system collected the following information:
- Mortality was monitored daily through deaths recorded by the Town Hall in Briançon, and the analysis of the causes reported on the death certificates sent to the Ddass.
- Acute gastroenteritis, influenza-like illness, and measles surveillance was carried out through a sentinel network of general practitioners (GPs) set up especially for this period. The two private and public microbiology laboratories in Briançon provided test result data for stool cultures, hepatitis A serology and methaemoglobinaemia. Daily data were collected and reported once a week.
- The activities of Briançon Hospital’s Emergency Department and the Hautes-Alpes Emergency Ambulance Service (SAMU) were followed daily through the routine non-specific surveillance system implemented by Cire Sud.
- Selected complaints (acute gastroenteritis, carbon monoxide poisoning and illness related to low environmental temperatures) recorded in Briançon Hospital’s Emergency Department were followed up via the French national surveillance network of hospital emergency departments. Data collection began on 9 February; the delay was due to logistical problems.
- Surveillance data for mandatory notifiable diseases [6] and carbon monoxide poisoning were reported daily, as usual, and communication channels were reinforced.
- Preventive measures were also taken in and around Briançon: monitoring the quality of food and accommodation services, in accordance with statutory food hygiene standards, intensification of routine water quality checks and adjusted and reinforced water treatment, public information campaigns about legionellosis and carbon monoxide poisoning, and enhanced controls of quality standards for personal skiing equipment.
Ad hoc tools were created: computerised data collection sheets for Ddass and Cire, standardised forms for GPs and laboratories. Some data were collected by the Ddass and some by the Cire Sud [FIGURE 2].


Two analysis systems were implemented: one based on historical data (not available for all the indicators) – threshold built on the upper limit of the 95% confidence interval – and one based on the method of the control charts for individual measurements [7].
Every day, data collected were analysed jointly by the Cire Sud and the Ddass. In addition, the Cire Sud consulted the daily report published by the Italian Epidemiological Consultation Team [1].
In case of unexpected events, the concerned Italian regional (Piemonte) and national health authorities, the European Centre for Disease Control and Prevention (ECDC), and the French National Institute for Public Health Surveillance (InVS) would have been alerted.
Once a week, all the data were merged by the Cire Sud [FIGURE 2].
A weekly report in both French and English was sent every Friday to the data providers, the regional and national Italian health authorities, the ECDC, and the InVS [FIGURE 2]. It was made available on the internet [8].
The surveillance system was evaluated through a satisfaction survey of the Gs sentinel network and the completeness of data and transmission deadlines.

 

Results
Twenty nine deaths were registered by the town hall in Briançon. There was no excess of deaths compared with the previous year. Two deaths due to mountain accidents in the area under surveillance, but not related to the Games, were identified by the analysis of the causes of death reported on death certificates.
During the period of surveillance, the daily average number of cases recorded by the SAMU was 94 (range: 46 – 161). The overall volume of activity was 12% higher than during the same period in the previous year [Figure 3]. However, the activity recorded in 2006 was more specifically higher than 2005 after 16 February.
The daily average number of cases recorded by the emergency department at Briançon Hospital was 58 (range: 36 – 85), with an overall volume of activity 7% lower than the previous year at the same period. There was a daily average of 16 admissions to hospital after a consultation at the emergency department (range: 9-27), 18% lower than the number registered during the same period in 2005. On average, one patient in three was admitted to hospital after a consultation at the emergency department. Among the 2024 consultations for which selected complaints were recorded, only 24 acute viral gastroenteritis, 11 influenza-like illnesses and three cases of illness related to low environmental temperatures were reported. Most admissions were related to trauma.


Of the consultations of the GP Sentinel network, 6% were for acute gastroenteritis and 12% for influenza-like illness. Only one consultation for measles was recorded. Peak of visits for influenza-like illness were observed during weekends.
No cluster of cases was detected by the two public and private microbiology laboratories in Briançon during the period of surveillance. Among the 91 stool cultures and the 31 hepatitis A serologies recorded, 6 and 2, respectively. were positive. No methaemoglobinaemia tests were requested.
No mandatory notifiable diseases and no carbon monoxide poisoning were reported in the area. An outbreak of severe gastroenteritis due to Mycobacterium avium paratuberculosis in a ski resort was recorded, but this diagnosis was refuted after investigation.
Data transmission deadlines were met. The satisfaction survey of the GP sentinel network showed that GPs were satisfied with the organisation of the system, because of the simplicity of the procedures, the limited number of collected variables, the modes of data transmission and the content of weekly reports. Completeness of data transmitted by the GP’s was 89%. For other systems, completeness was 100%, mostly because of automatic computerised data transmission.

Discussion
The 2006 Olympic Winter Games had a very limited impact on illness and adverse events in the neighbouring French department of Hautes-Alpes. No alert was issued by the French epidemiological surveillance system. In Italy, no increase was seen during the Games in visits to healthcare facilities in the area where the games were held [9].
Surveillance was based on the mandatory diseases system and the routine non-specific surveillance system used by the Cire Sud, collecting data from hospitals, emergency ambulance services and mortality statistics collected by the local municipal authority, completed by GPs and medical Iaboratories. In this limited geographical area under surveillance, the high number of participants involved in the system, covering all different sectors of medical activities, would probably have detected any health event which could reveal a potential risk for the population.
The surveillance system was found to have been adapted successfully to its assigned objectives by both data providers and decision makers. The system implemented was a good complement to inspection and control measures, and allowed the establishment of the foundations of a network to be used in case of outbreak or environmental pollution. 

Acknowledgements
The Cire Sud and the Ddass acknowledge all participants for their cooperation and time devoted to this surveillance.


References

1. Epidemiological Consultation Team. Surveillance system in place for the 2006 Winter Olympic Games, Torino, Italy, 2006. Euro Surveill 2006;11(2):E060209.4. Available from: http://www.eurosurveillance.org/ew/2006/060209.asp#4
2. Coulombier D, Malfait P, Ballereau M. Dispositif de veille sanitaire pour la coupe du monde de football, 1998. Bulletin Epidémiologique Hebdomadaire. 1998;22:95.
3. Jorm LR, Thackway SV, Churches TR, Hills MW. Watching the Games: public health surveillance for the Sydney 2000 Olympic Games. J. Epidemiol. Community Health. 2003;57;102-8. Available from:
http://jech.bmj.com/cgi/content/full/57/2/102
4. Wetterhall SF, Coulombier DM, Herndon JM, Zaza S, Cantwell JD. Medical care delivery at the 1996 Olympic Games. Centers for Disease Control and Prevention Olympics Surveillance Unit. JAMA. 1998;279:1463-8.
5. Allen T, Jolley S, Cooley V, Winn R, Harrison J, Price R, Rich J. The epidemiology of illness and injury at the alpine venues during the Salt Lake City 2002 Winter Olympic Games. J Emerg Med. 2006;30(2):197-202.
6. Institut de veille sanitaire. Le dispositif de surveillance des maladies à déclaration obligatoire. Updated 21 July 2006. Accessed 14 August 2006. Available from from: http://www.invs.sante.fr/surveillance/mdo/index.htm
7. NIST/SEMATECH e-Handbook of Statistical Methods. Accessed on 29 November 2006. Available from: http://www.itl.nist.gov/div898/handbook/pmc/section3/pmc322.htm
8. Cellule interrégionale d’épidémiologie Sud. Dispositif de veille sanitaire dans le département des Hautes-Alpes durant les Jeux Olympiques d’hiver de Turin, 2006. Accessed on 29 November 2006. Available from: http://www.invs.sante.fr/surveillance/jo_turin/index.htm
9. Epidemiological Consultation Team. Results from the integrated surveillance system for the 2006 Winter Olympic and Paralympic Games in Italy. Euro Surveill. 2006;11(8):E060817.5. Available from: http://www.eurosurveillance.org/ew/2006/060817.asp#5

 



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