Novel Cricket World Cup Mass Gatherings Surveillance for Event-Based Surveillance in the Caribbean Region

Abstract

Objective

To proactively identify and respond to potential health threats during mass gathering (MG) events using the regional MG Surveillance Framework across host countries for the 2024 T20 Cricket World Cup.

Designs/Methods

This framework, using multiple data sources, including the MG Surveillance module, provided daily intelligence and threat analysis to host nations. Specifically, the module allowed on-the-field data entry and immediate analysis; its infrastructure featured an Alerting mechanism built upon thresholds customized for MG events. Alerts were generated once thresholds were passed, notifying the relevant stakeholders immediately.

Results

Thirty-one MG and Health Facility Sites were registered onto the system and surveillance teams across the host countries were able to digitally capture 146 cases (generating 17 syndromic cases; 14 acute gastroenteritis-related and 3 fever with respiratory symptoms). The system reported non-communicable health issues like accidents/injuries (33 cases) and heat-related illnesses (22 cases).

Conclusion

The MG surveillance module illustrated its ability to provide health care practitioners and decision-makers with real-time data, syndromic alerts and analytics. The early warning and response mechanism facilitated early identification, communication and response to disease threats emanating from these events, and consequently reduce the risk of outbreak events that can overwhelm the health systems in the Caribbean.

Background

Mass gatherings (MG) are defined as events with large numbers of individuals, inclusive of visitors, gathered in a specific area for a specific purpose [1]. Given the magnitude of these crowds and the close proximity people are to one another, these events represent an increased risk of illness spread, outbreaks and other health impacts [1–4] for which countries need to be prepared to prevent and respond to in a rapid/real-time manner. As the number and closeness of persons in a mass gatherings event increase, the risk of illness spreads through person-to-person transmission, and other health impacts increases. Effective surveillance of mass gatherings is an essential component of public health and safety planning [3, 4].

Existing surveillance systems in the communities hosting large-scale mass gathering events should be enhanced to monitor and respond to any foreseeable and, to an extent, unforeseeable issues which may arise in such situations. Proper mass gathering or event surveillance necessitates electronic surveillance with in-built alert mechanisms to promptly identify and respond to health threats and ensure the safety and well-being of attendees and the surrounding community. It also plays a vital role in pandemic preparedness and response, as large gatherings can facilitate the rapid spread of infectious diseases. MG can be associated with disruptive impacts on health services, including overwhelming the response capacity of the host country’s health system [4, 5].

The International Cricket Council (ICC) Men’s T20 World Cup (CWC), held in the USA and Caribbean in June 2024, with 20 international cricket teams that participated in 55 matches in six Caribbean countries (Antigua and Barbuda (ATG), Barbados (BAR), Guyana (GUY), Trinidad & Tobago (TTO), St. Lucia (SLU), St. Vincent & the Grenadines (SVG)) [6, 7] provided the ultimate test of the region’s capability to manage the potential health threats brought by large MG events. These events posed an increased risk of infectious diseases introduction and spread given the high number of players, officials and spectators attending from all continents, amount of matches scheduled, accompanying social events and complexity of movement, coupled with the increasing trends of infectious diseases being reported globally. This was further exacerbated by the porosity of Caribbean borders, ease and high levels of travel between the islands and the lack of institutionalized health surveillance systems [8] at strategic sites that enable rapid detection and response to these events.

The Caribbean Public Health Agency (CARPHA), given its regional mandate for public health response [9], developed and successfully implemented a novel, regional daily Mass Gathering Surveillance System (MGSS) across the six (6) CWC host countries for the 2024 T20 World Cup, via a multipronged approach, to proactively identify and respond to potential health threats emerging due to the games [10–15]. CARPHA also coordinated the regional health response to CWC with CARPHA Member States (CMS), Cricket West Indies /ICC, the CARICOM Security Cluster (CDEMA, IMPACS, RSS), PAHO, the UKHSA and the CDC to protect the health of the Caribbean people and its visitors whilst ensuring regional health security.

The resounding success of the MGSS, particularly the electronic MG surveillance module used at the match sites that facilitated real-time data capture, syndromic alerts and analytics that triggered rapid responses and the daily regional and national health, safety and security intelligence reports, that proved vital to rapidly identifying and mitigating potential threats, presents a golden opportunity to be expanded to facilitate effective, real time event-based surveillance in the region for other MG events such as carnival, sports and festivals. Collaboration, coordination, building of trust and capacity, timely daily information sharing with countries, regional and international agencies played a pivotal role in the success of the MGSS.

CARPHA’s Mass Gathering Surveillance System (MGSS)

MGSS Framework

CARPHA’s MGSS is an innovative framework, involving the collaboration and support of many partners at the national, regional and international level (Fig. 1), that all contribute towards obtaining a better understanding of the public health environment in the region. With this enhanced evidence and knowledge, public health risk reduction strategies and interventions can be developed and targeted to address potential threats. It involves continuous inputs and data sources from countries (ramped up to daily for the CWC) including – national syndromic surveillance data, event-based incidence reports, visitor-based surveillance data (tourism), MG surveillance data (the latter two received through Tourism and Health Information System (THiS) platform) and laboratory data. In addition to this level of data, other key data inputs included environmental scanning data gathered from daily reports by the UK Health Security Agency (UKHSA) and the US Center for Disease Control and Prevention (CDC), Advanced Passenger Information System (APIS) from CARICOM’s Implementation Agency for Crime and Security (IMPACS), the Caribbean Disaster Emergency Management Agency (CDEMA), security incidents and threat reports from the Regional Security System (RSS), CARPHA regional surveillance data and media scanning from CARPHA and the Pan American Health Organization (PAHO).

Fig. 1.

Showing the mass gathering surveillance system framework

The MGSS framework provided daily intelligence and threat analysis to Chief Medical Officers (CMOs) of host countries. This gave the host countries a comprehensive source of advanced information to prepare for potential health, safety and security threats during the games (Fig. 2).

Fig. 2.

Showing stakeholder collaboration for the CWC mass gatherings

A key component of the MGSS and a vital contributor to its success during the CWC is the electronic mass gathering surveillance module built to capture cases of ill persons in the field during the MG events. The system also provided real-time analysis of the data captured, sent immediate alerts to key Ministry of Health (MoH) staff in the event a syndromic threshold has been met or exceeded and facilitated coordination of all sites with the MoH epidemiology/ surveillance unit. The CARPHA team built upon the existing THiS platform that already possessed several features that were needed to facilitate on-the-spot data collection capabilities, real-time alerts and enabled both MG site and country users to visualize the data collected immediately.

During the development process, given the various scenarios put forward by countries and their specific requirements, a third module was added to the platform that targeted established Health Centres/ Polyclinics that were earmarked to provide additional support to the MG site. This module also encompassed private clinics and Field Hospitals activated for the tournament. The data collection tool for both new modules was also customized based on discussions held with CWC host countries and the recommendations received, and as such the tool was expanded to include an optional section to capture identifiable patient information and an expanded list of symptoms that reflected the health issues typically found in a MG setting, e.g. accident/ injury causing trauma, burns, inebriation, heat-related illness/ heat stroke. Both additions were deemed essential given that the primary users in the field were surveillance doctors and/or nurses, and greater details were needed to meet the surveillance requirements for this purpose.

With this current development, the THiS infrastructure now has the capacity to support electronic health surveillance within the Tourism Sector, Mass Gathering Events as well as Polyclinics/ Heath Centers all linked to the CMO and Surveillance Team at the Ministry of Health (Fig. 3).

Fig. 3.

Real-time electronic surveillance modules built upon the THiS platform

Mass Gathering Surveillance during the CWC Event

Pre-CWC Infrastructure

Prior to the surveillance activities implemented for the CWC, in addition to developing and testing the Mass Gathering and Health Facility modules, the CARPHA team embarked on a series of training, sensitization and consultation sessions with key stakeholders from the MoH in each of the six (6) Host countries on the Mass Gathering Surveillance System. This session allowed buy-in to be garnered for the system’s use by the CMO and their surveillance team, key surveillance personnel trained and registered onto the system and contributions made to the system’s development in its current state. Some of the activities undertaken included: Mass Gathering Training, System Demonstration & Training with members of the Epidemiology and Surveillance Team and establishment of key communication linkages.

In addition to these activities, CARPHA also provided tablets to each of the host countries to enable data collection in the field. These tablets have been set up to allow for quick and easy access to the surveillance platform in addition to being outfitted to protect the device and facilitate mobility whilst in the field. The Agency developed, printed and disseminated multiple promotional materials (posters & flyers) to countries to help sensitize persons and build awareness of prevention and control activities to reduce the risk of contracting an infectious disease in a MG setting. The posters also illustrated a unique QR code that allowed spectators at the events to easily self-report onto the MGSS if feeling ill. These factors have allowed for significant country capacity to be built for continued MG surveillance.

Data Collection & Response

During the month long T20 World Cup, 31 Mass Gathering and Health Facility Sites were registered onto the system and through those sites the surveillance teams across the six (6) host countries were able to digitally capture 146 cases. This allowed for on-the-field data entry and immediate analysis resulting in greater efficiencies and less paper utilization. These cases generated 17 syndromic cases; 14 being acute gastroenteritis (AGE) related and 3 being Fever with Respiratory. Furthermore, the system reported on other noteworthy non-communicable health issues such as Accidents/Injuries causing Trauma (33 cases) and Heat-related Illnesses (22 cases). These reports allow the key decision makers at MoH to quickly adapt and adjust some of their public health strategies to reduce the risk of future public health threats. This ability was showcased in the lead up to the T20 CWC Final where recommendations were made to set up cooling and hydration areas at the stadium due to the number of Heat-Related Illnesses recorded at the stadium during the previous daytime matches.

The system’s infrastructure also has an Alerting mechanism built upon thresholds customized for each of the three (3) modules on the platform, with the ones for the MG and Health Facility modules being also adapted for the unique setting of Mass Gathering events (See Fig. 4). Determining a threshold for an electronic surveillance system poses significant challenges, as highlighted in the WHO’s Key Recommendations for MG [16, 17]. These thresholds are inherently event and denominator specific, prompting most systems to initially adopt conservative thresholds. Without access to two years’ worth of data to adjust the threshold accordingly, the enhanced mass gathering surveillance module faces unique obstacles, including (i) combining multi-country data is complex due to variations in disease, demographics, and tourist influx rates, and (ii) the occurrence of MG is distinct within THiS, requiring separate consideration from typical tourist data. Currently, the only available set thresholds are regarding Acute Gastroenteritis outbreaks (not MG specific) and the UNHCR [18], which align with established thresholds for THiS regarding certain diseases, such as Respiratory Infections and Viral Haemorrhagic Fevers.

Fig. 4.

Breakdown of the alert thresholds developed for the MG and health facility modules

At the T20 CWC, two (2) AGE alerts were generated at two match sites in two (2) CMS. The surveillance team onsite as well as the MoH team offsite were immediately notified of the possible threat via the Email Alert mechanism. This allowed for immediately identification, speedy communication with the MoH team offsite and rapid response to each alert, resulting in no reported spread of illness at the game site.

Reporting

At the country level, CMOs, National Epidemiologist and other designated representatives possessed a confidential access to view key analytics for all modules on the THiS platform for their respective country. To facilitate accurate and timely reporting, particularly for the enhanced surveillance needed during the period of the CWC, a time-filtered reporting feature was also added to the Country Module. This feature gives the country users the ability to generate reports between any given time period based on their specific needs and provides a quick aggregate snapshot of case information captured through any of the three (3) modules now on the THiS platform (Fig. 5). National Epidemiologists/ Surveillance Officers from each host country were able to generate instant aggregated data reports from each of their sites (Tourism, MG & Health Facilities). This allowed for faster data verification for the country, earlier analysis with timelier decision-making capability and quicker daily submissions to CARPHA for daily regional reporting.

Fig. 5.

Dynamic report generating feature in the THiS platform for countries

Expanding the MG Surveillance System for all Event-based Surveillance

The CWC constituted an amalgam of various events (matches, fan parks, parties) that brought together many people (both local and visitor), heightening the potential risk to public health. Information received through the electronic surveillance systems developed for the CWC was rapidly captured and assessed for the risk the event posed to public health, provided data analytics and an alert notification (if needed) thus enabling an appropriate response. These elements outlined are in congruence with the core components of event-based surveillance as defined by the WHO [16]. Consequently, given the alignment of CARPHA’s MGSS with the goal of event-based surveillance and in conjunction with the systems developed and experience gained through the MG surveillance activities conducted during the CWC, there is a clear opportunity for the system to be easily adapted and adopted for regional events-based surveillance.

To add further support for the establishment of such system, participants at the August 2024 Pandemic Fund workshop – which included CMOs, National Epidemiologists and Lab Directors – indicated that their major expectations from an Early Warning and Response Systems (EWRS) were Real-Time Alerts, User-Friendliness, Interoperability, and availability of Analytics and Reporting tools. These characteristics identified are core parameters of the existing THiS platform and shape the backbone of all development activities. EWRS are critical to pandemic preparedness and response, which each module in the platform is geared towards and as such will aid CMS in efficiently expediting plans and decisions at the national level for improved public health.

The region has many varying MG events that can potentially lead to adverse public health situations on an annual basis, including: CPL Cricket, Carnival, Music and Cultural Festivals, Regional and International Conferences and Culinary events. This system being proposed has been successfully tested within the Caribbean for the Caribbean and possess the following advantages over other similar systems:

• It is a fully digital, real-time early warning system developed on a web-based platform to allow for easy accessibility. The electronic data collection forms are developed to allow for quick and seamless data entry.

• Contains an in-built alert system that immediately sends an email Alert notification when any of the six (6) Syndromes being monitored meet or exceed their set thresholds.

• All the modules are linked to the CMO and the national surveillance unit allowing for easy sharing and visualization of data from all sites nationally to get a more detailed picture of the wider national public health situation. Also, the CMO and national focal points are also linked to the Alert notification thus allowing them to identify the areas of concern immediately and respond to the issue. This early identification and response will result in the reduction and avoidance of large outbreaks in the region.

• Technical knowledge and capacity have already been built in six (6) CMS through the MG training conducted and the experience gained from already using the system, therefore minimal additional learning will be required. Furthermore, 14 additional CMS are aware of the original THiS platform, thus making the transition easier.

• Through the initial groundwork done, a level of trust has also been built between the country users and the CARPHA team inclusive of what the system provides.

• Infrastructure and communication network is already established via email and WhatsApp groups with key focal points identified to facilitate coordination which includes data sharing, system recommendations, troubleshooting and response.

• Tablets were provided to six (6) CMS for easy and immediate data entry while on the field. These tablets should be used further data entry to any of the modules on the THiS platforms for future events.

• The platform comes at no cost to CARPHA Member States (CMS) as this is a public health good for the enhancement of regional health security.

• Provides a feature for instant report generation thus allowing country users to quickly verify the data collected, share aggregated data and visualise pattern and trends in the data.

• The system was successfully used for CWC and customized to include much more data elements than just syndromes (e.g. injuries, heat-related illnesses, etc.). These were added to capture all health-related issues that are common in a MG setting and would be applicable to most events. Also to note, the system has a level of customizability that allows for relatively quick and easy additions/adjustments to be made.

In addition to these specific advantages, CARPHA has built the platform on a very secured and robust IT infrastructure and facilitates the ongoing maintenance, and upgrades as deemed necessary. Furthermore, the CARPHA team possess sound technical and development competencies to facilitate the continued advancement of the system and assist all CMS with adopting and transitioning to this system for events-based surveillance.

Conclusion

The success of the MG surveillance module utilized across the 6 host countries for the 2024 T20 World Cup, shown by its ability to provide health care practitioners and decision-makers with real-time data, syndromic alerts and analytics, has provided the evidence for continued and expanded use in other MG events across the region throughout the year such as Carnival, Conferences, Sports and Festivals. The early warning and response mechanism enabled by the system will facilitate early identification, communication and response to disease threats emanating from these MG event in addition to the already functioning Tourism Sector and consequently reduce the risk of outbreak events that can overwhelm the health systems in our small island developing states.

The advantages of this system (real time, early warning digitalized system, flexibility, confidentiality, ease of use, instant analysis and reports, in built alerts, established infrastructure, technical capacity, trust, data entry tools) and the ability to enhance the various modules facilitated through CARPHA’s robust development support, allows the platform to be further developed as an Early Warning and Response Event-Based Surveillance (EBS) System for the region that can be utilized in the wider public health space. This will further expand the region’s ability to identify health threats quickly and respond promptly to reduce the impact on our member states and the region at large. The CARPHA team is buoyed by this potential opportunity and is eager to continue working with our Member States to strengthen our region’s surveillance systems.

Author Contributions

K.D, L.I. and S.K. contributed to the writing of the the main manuscript text. K.D, S.K and M.E. contributed to the abstract. K.D. prepared figures 3, 5; S.K. prepared figures 1, 4 and M.E. prepared figure 2. All authors reviewed and edited the manuscript.

Funding

This work was supported the Pandemic Fund Project (RG-T4387), International Health Grants Program (Aviation Biosecurity Partnership Project) and 11th European Development Fund (EDF) (Programme of Support for Health Security Strengthening for Prevention and Control of Outbreaks of Communicable Diseases in the Caribbean). The funding bodies did not have any influence on the study design, study conduct, preparation of the manuscript, or decision to publish.

Data Availability

Data is provided within the manuscript.

Declarations

Ethical Approval

Not applicable.

Competing Interests

The authors declare no competing interests.