Public Health Response for the 1996 Olympic Games

IN 1990, the International Olympic Committee declared Atlanta, Ga, host for the 1996 Centennial Olympic Games. This event presented a unique combination of challenge and opportunity for local, state, and federal public health agencies. The challenge consisted of preventing illness and injury during one of the world's largest gatherings. The opportunity consisted of developing a systematic, coordinated approach that would serve not only the 1996 Summer Olympics, but also would provide a model for future massive public events.

The last Olympic Games held in the United States were in Los Angeles, Calif, in 1984. The Los Angeles County Health Department prepared extensively and monitored health events during the 1984 Games¹ ; there were no major disease outbreaks and the most commonly reported health condition was heat-related illness (HRI). However, the Atlanta experience was different for a number of reasons. In Los Angeles, the event venues were widely scattered over southern California, whereas in Atlanta, the majority of events occurred within an 8-km-diameter circle known as the "Olympic Ring." As the Centennial Olympic Games, the Atlanta Games involved more countries, athletes, and spectators than any previous Olympics (Table 1).² Further, the average daily temperature, humidity, and heat index in Atlanta in July and August were significantly higher than in Los Angeles.

In addition to the traditional athletic events, the Atlanta Committee for the Olympic Games (ACOG) conducted a parallel Cultural Olympiad; constructed a large urban park, Centennial Olympic Park, which attracted huge crowds every day; and, in addition to official Olympics activities, a large number of parallel activities occurred, such as street vendors of prepared food products, alcohol vendors, various municipal festivals, and cultural events.

This article presents an overview of public health preparations, activities, and results for the 1996 Centennial Olympic Games.

The state health agency began planning for the 1996 Centennial Olympic Games immediately after the announcement that Atlanta would be the host city. The public health preparation and activities are categorized into the broad public health functions that were highlighted by the Institute of Medicine in 1988³ : assessment, policy development, and assurance.

Surveillance. Under usual circumstances, Georgia, like most states, conducts surveillance for a variety of diseases and health conditions. Disease reporting is done by physicians and other clinicians, laboratories, and hospitals. An augmented surveillance system was implemented for health conditions that occurred outside of Olympic venues and did not involve members of the Olympic family (ie, the "outside the fence" surveillance system) (Figure 1). This system included augmented laboratory surveillance and systems to monitor all emergency department encounters in 8 sentinel hospitals. At the request of ACOG, the Centers for Disease Control and Prevention established a system to enumerate clinical encounters in Olympic venues and at contract hospitals for Olympic athletes, official Olympic staff, and national delegations (ie, the "inside the fence" system).⁴ Daily reporting of health encounters inside the Olympic fence and of surveillance data outside the fence allowed monitoring of trends.

Victims of the Centennial Olympic Park bombing episode were enumerated through active case finding for the 3 days following the incident. All hospitals in the metropolitan Atlanta area were contacted or visited in case finding. Data were obtained from the hospitals on each patient, including demographics, type of injury, and final disposition on leaving the emergency department.

Environmental Health Services Monitoring. Standardized, daily reports were obtained from field environmental health staff for the purpose of monitoring type, intensity, and location of environmental health staff activities.

Environmental Health Regulations. Six sets of environmental health regulations were either created or modified in anticipation of the Olympics and the problems that were foreseen.

Special Food Service,--Regulations were enhanced to allow for an immediate supervisory suspension of a food service permit, an expedited review of a suspension or other regulatory action, and allowed for the permitting of "semi-permanent" food establishments that would be in place for more than the 14 days previously allowed for temporary establishments.

Water Supply. Potable water was required to be available at all special gatherings.

Solid Waste. The number of containers required at a special event was specified, based on projected attendance. Regulations also provided for the maintenance of the containers to prevent an insect or rodent control problem or an odor problem.

Tourist Accommodations. Accommodations were defined and special provisions were made for bed and breakfast establishments.

Swimming Pools. Water quality standards were specified for all pools and recreational waters at Olympic venues and at all public pools.

Special On-site Sewage Disposal. Provisions were made for the required number of portable toilets at a special event, based on projected attendance, and the required maintenance and cleaning of the portable toilets.

Planning for Response to Public Health Emergencies. Predictions were that the Olympics would be associated with a huge influx of visitors, closed or congested roads, potentially overloaded telephones and other communication methods, and a high risk of disease outbreaks. Further, the state health agency recognized that any significant public health crisis could represent a significant public relations problem for the state, for local government, and for ACOG. Therefore, the state health agency decided to establish a formalized system to ensure a rapid and coordinated response to all public health issues during the Olympics (Figure 2). The center of the system was the Public Health Command Center. The Command Center was a physical location, staffed 24 hours per day by public health professionals and federal emergency response staff. Its primary function was to coordinate response to all public health issues, including media, disease outbreaks, food safety, and prevention services. Each county with an Olympic venue was asked to establish public health response teams that were available on-call 24 hours per day. Data from the augmented surveillance system were reviewed and disseminated each day by the Command Center.

Emergency Medical Services Planning. Emergency medical services (EMS) personnel in Georgia are regulated by the state public health agency. Three major issues drove planning relative to EMS: (1) the need for ACOG to contract with EMS personnel to provide emergency services in Olympic venues and the possibility that vehicles and EMS personnel would be unavailable because of these responsibilities; (2) the possibility that traffic congestion could impede vehicle movement and transport; and (3) the need to develop protocols to avoid having EMS personnel occupied with predictable conditions that might be common, such as mild HRI.

Medical Disaster Planning. According to the state disaster plan, the Georgia Division of Public Health has primary responsibility to coordinate medical response in a disaster situation. Plans are in place for standard disaster measures such as evacuation, mass shelter, and transportation. However, for the Olympics, the concern centered more on the management of mass casualties that could occur from a terrorist incident. The small but real possibility of a chemical or biological terrorist incident was of particular concern. Federal government resources were instrumental in preparing for these possibilities.

The US Public Health Service regional health administrator was responsible for coordinating federal mass casualty preparedness. Working with the state public health agency and state and local emergency response officials, the following preparations were made: (1) prepositioning of federal medical teams with expertise in responding to chemical and biological incidents; (2) placement of pharmaceutical agents in hospitals to manage mass chemical exposures; (3) training of hospital and emergency response personnel in decontamination and treatment for victims of mass casualties; and (4) development of a tabletop exercise in mass casualty response for state, local health, and emergency response officials.

HRI Prevention. The approach to HRI was comprehensive (Table 2).

One of the 6 sets of administrative rules established for the Olympics addressed water supply at special events, which were defined as any commercial event with 50 or more participants anticipated. The regulation required that drinking water be available to participants. Thus, water was available in ACOG venues and in the special event venues. Special EMS protocols were intended to allow for some on-site management of mild heat-related symptoms and avoid having emergency response teams occupied with unnecessary patient transports.

In cooperation with the City of Atlanta and the Red Cross, the state public health agency strategically placed HRI prevention stations in areas that were expected to have high pedestrian traffic. Each station had a visibly marked tent structure, tables, educational posters, and at least 5 volunteer staff. Stations were equipped with portable military water tanks. Pedestrians were given free sunscreen packets; wide-brimmed, cloth hats with neck protectors; water in paper cups or in personal containers; and health education literature. State public health and other agency staff were assigned to stations in 4-hour shifts for a total of 12 hours per day. The locations of stations were modified as the Games proceeded and needs changed. For example, by the end of the Games, stations were in place at both the Centennial Olympic Park and the Stadium Plaza shared by Olympic Stadium and Atlanta Fulton County Stadium.

Public health education materials were distributed, including a wellness brochure. Heat-related illness incidence was monitored through the Olympic Medical Encounter System, operated by ACOG and the Centers for Disease Control and Prevention, and through the state-augmented reportable diseases surveillance system.⁵

Environmental Health Enforcement. Environmental health enforcement in Georgia is a responsibility of county health departments. A training and certification program for environmentalists who would work at the Olympics was established approximately 2 years before the Games. The numbers of county environmentalists were supplemented with environmentalists from non-Olympic counties, other states, and federal agencies, including the Food and Drug Administration and the Indian Health Service.

Enforcement of food service, solid waste, swimming pool, and other environmental regulations was aggressive. Agreements were made with ACOG to place an environmental supervisor and team in each venue, so that monitoring could be done throughout the day. Outside of Olympic venues, teams were assigned to specific areas to ensure that temporary and semipermanent food vendors had the appropriate permits, monitor the food-handling practices of establishments on a regular basis, track solid waste problems, and enforce other environmental regulations.

Public Education and Information. ACOG asked the state public health agency to coordinate the production of a health promotion brochure that was mailed with ticket information to all Olympic visitors who participated in the ticket lottery. Sponsored by Blue Cross/Blue Shield, the brochure covered the following topics: physical fitness, HRI and injury prevention, health care and insurance, and tobacco use. Another means of disseminating health information was conducted by the Fulton County Health Department, which distributed human immunodeficiency virus prevention information via packets on hotel room doors throughout the Olympic Ring.

Staff members from the state health agency office of communications were an integral part of the Public Health Command Center (Figure 2), where they handled media inquiries and prepared daily press releases.

No system was in place to prospectively gather the personnel costs associated with Olympic planning and operations. However, personnel costs were estimated retrospectively for the following functions that involved staff reassigned from usual duties: EMS planning and implementation, HRI prevention activities, and operation of the Public Health Command Center. The total cost of supplies purchased for prevention activities was available. Cost estimates for Fulton and DeKalb counties, the 2 counties that contain the City of Atlanta, were obtained retrospectively. Costs associated with other public health system planning at the state and county level were not available. Other county health department costs were also not available.

Overall, emergency department visits to hospitals that were part of the augmented surveillance system remained stable and did not show the expected increase, given the large influx of visitors (K.E.T., unpublished data, 1996).

A total of 215 environmentalists received special training and certification designed for Olympic environmental health staff at Olympic venues, and an additional 135 worked in areas outside of Olympic venue sites. They worked a total of 22223 hours, issued permits for an additional 2194 food service establishments, conducted a total of 13024 inspections or monitoring visits of vendors, conducted 56577 inspections of portable toilets, 75495 inspections of solid waste collection and storage sites, and made 10798 water site inspections.

Emergency department visits increased for people with gastrointestinal symptoms during the first week of the Olympic Games (K.E.T., unpublished data, 1996). Within the first few days of the Olympic Games, the Public Health Command Center also received numerous reports of probable mishandling of food by large catering operations. Typical of the reports was that boxed lunches with high-risk foods were arriving at room temperature, and that some meals had signs of spoilage. However, no discrete clusters of gastrointestinal illness were detected and found to be associated with these problems. Meetings were held with state public health officials, ACOG officials, federal health officials, and the food preparation managers. Plans for correction included monitoring procedures, documentation of cold chain adherence, and more frequent inspections.

A total of 645000 cups of water, 600000 hats, 395000 sunscreen packets, and 162000 fans were distributed from the heat stations. There were no deaths related to HRI during the Olympic Games. The number of sentinel hospital emergency department visits for HRI decreased during the Olympics. Heat-related illness accounted for only 2% of the emergency department visits in sentinel surveillance hospitals during the Games. Only 15 patients required hospitalization, 94% of whom were Georgia residents (E. H. Barrett-Cramer, K.E.T., R. Fagan, S. Zaza, S. Wetterhall, unpublished data, 1997).

Injuries related to the bombing incident at Centennial Olympic Park represented the only significant disease outbreak detected in venue counties during the Olympic Games. A total of 106 people were seen in emergency departments of 11 hospitals for injuries resulting directly from the Centennial Olympic Park bomb explosion. There were 21 hospital admissions. There was 1 death from the bombing and 1 journalist sustained a cardiac arrest near the bomb scene.

Cost estimates are available for many of these public health activities. The cash outlay for prevention supplies, primarily for HRI prevention, was $368000. The following personnel costs were related to staff that were diverted from usual responsibilities. The state Office of EMS incurred estimated personnel costs of $151000. Personnel costs for HRI prevention were estimated at approximately $127500. Costs for operating the Public Health Command Center were approximately $51940. Personnel involved in surveillance activities outside the fence were all usual epidemiology staff, and their duties were considered to be part of usual epidemiology responsibilities. Thus, total estimated cost, not including costs to individual county health departments, was $689440. Costs to individual county health departments was largely due to environmental health regulation, including food service, tourist accommodations, and swimming pools. Estimated expenditures for Fulton and DeKalb counties were $742048. However, fees were charged for permits, and fees collected for Olympic environmental health functions were approximately $661347. The net expense for these 2 counties was $80701.

Public health planning and response for the Olympics provides a unique case study of public health system response to large events and demonstrates the role public health should have as an integral part of the health care system.

The primary objectives of the public health response system were as follows: (1) to detect and respond rapidly to disease outbreaks or unusual increases in health conditions; (2) to prevent HRI; (3) to prevent foodborne and waterborne infectious diseases; (4) to assure that medical response to individual emergencies and possible mass casualties would be timely and of high quality; and (5) to take advantage of the Olympics as an opportunity to promote healthy lifestyle choices and other prevention messages.

Two key factors in addressing these responsibilities were early planning and the engagement of key partners from ACOG, county health departments, city officials, federal public health colleagues, emergency response officials, and others.

A combination of special regulations that were implemented specifically for the Olympic Games, special training of environmental health staff, and the good working relationship with ACOG allowed for an aggressive approach to monitoring and inspection of food service establishments. A major limitation of the environmental health planning was failure to anticipate the need to permit and monitor the numerous large-scale, contract catering services that were established to provide food to groups such as law enforcement, the military, and Olympic volunteers.

It is not possible to definitively attribute the increase in gastrointestinal illness detected by the augmented surveillance system to the difficulties with large commercial food preparation establishments. However, environmental health teams quickly evaluated the food production sites and found numerous breaks in accepted food-handling practices. Food-handling irregularities are a well-documented risk factor for institutional outbreaks.^{6 - 8}

It was necessary to plan for the potential public health and medical consequences of a disaster,⁹ including unexpected number of deaths, injuries, or illnesses in the affected community, exceeding the capacities of local health services and requiring external assistance; adverse environmental effects, with increased risk for communicable diseases and environmental hazards; disruption of local health infrastructures; and large population movements.

Even without a catastrophic event, the Centennial Olympic Games were anticipated to potentially have some of the characteristics of a "planned disaster," including disruption of routine health services, mass migration, and environmental threats. Many of the public health management strategies were modeled after those used in disasters.

The public health system was modeled on the emergency operations center used in disaster management and included on-site federal partners. The Georgia Emergency Management Agency and the governor established the State Olympic Law Enforcement Command, which engaged in statewide emergency response planning for the state and functioned as a 24-hour per day operations center during the Olympics. Public health staff was an integral part of this planning and execution and served as members of the State Olympic Law Enforcement Command staff.

In many jurisdictions, including Georgia, public health is identified as the agency responsible for the coordination of medical response in a disaster. However, public health does not have the additional resources needed for many disaster situations. Special disaster medical teams and teams to respond to the medical effects of terrorism are federal resources.¹⁰ Nonmedical state resources are generally under the control of state and local emergency response staff.

Engagement of key partners and early planning were important for the establishment of a workable emergency response capability. Federal disaster response resources were coordinated with public health, acute care providers in the community, ACOG, and state and local emergency response teams. Communication began well before the summer of 1996 and continued with daily briefings during the Olympics that included the Centers for Disease Control and Prevention, the US Public Health Services regional health administrator, the Food and Drug Administration, state and local public health leaders, and ACOG.

A valuable activity was a "tabletop" disaster exercise that was held about 2 weeks prior to the start of the Olympics. At the request of the state health agency, the US Public Health Service arranged for a consultant to create and conduct this daylong exercise. Most relevant agencies participated, including county emergency management, state emergency management, state and local public health agencies, US Public Health Service representatives, and local fire and law enforcement agencies.

Public health response teams were mobilized numerous times during the Olympic Games to investigate possible disease outbreaks, to enumerate bomb disaster victims, and to address environmental health issues. The system (Figure 2) proved to be an efficient and responsive approach to addressing the variety of public health issues likely to arise in an event of this magnitude.

Past episodes of mass HRI are well documented,^{11 - 13} as are approaches to the prevention of HRI, including hydration.¹⁴ Heat-related illness was considered by public health officials to be one of the most likely significant public health problems. We believe that the attention given to the threat of HRI before and during the Olympics increased the level of public awareness. Whether or not the extensive public health efforts contributed to the relatively low incidence of severe HRI is not known. The actual average high and average daily temperatures in Atlanta during the Olympic Games were 31.8°C (89.3°F) and 27.0°C (80.7°F), respectively (National Weather Service, Atlanta, oral communication, March 1998). Although these were both above the historical averages, the high temperature was 35°C (95°F) or greater for only 5 of the 17 days. The administrative regulations that were put in place to ensure the availability of water at events (including Olympic events) was helpful in getting organizers to make water available both within Olympic venues and in other special event areas.

A major obstacle to implementation of a comprehensive HRI prevention strategy was initial resistance on the part of ACOG to make water available and to develop a prevention plan for "inside the fence." The implementation of regulations requiring that water was available at all special events was helpful in overcoming this obstacle. The medical staff planning for ACOG also were committed to preventing HRI and persuaded ACOG to allow development of an HRI prevention strategy. The public health agencies were consistent in emphasizing the risk of HRI, both in real health terms, and in regard to the possible image problems that could result from a high prevalence of HRI.

The interventions implemented to prevent HRI typify a major limitation involved with a one-time event of this type. The interventions were costly, but the cost-effectiveness of these interventions is unknown.

The estimated cost to the state and the 2 large counties in which the City of Atlanta lies was nearly $800000. Not included are some planning costs and costs to other counties. These data provide an estimate of resources that public health agencies that might have to deal with similar future large-scale mass gatherings may need to anticipate. Certain supplies and equipment, such as computer network capabilities and radio communication capabilities, already were in place in the aftermath of past disasters and therefore did not require new expenditures. The source of state funds for materials and supplies (eg, for the HRI stations) was previously budgeted supply dollars that were redirected and no new appropriation was necessary. Most personnel were redirected from other activities and, although a cost, also did not require new funding. However, many states would need to consider seeking supplemental appropriations. Counties in Georgia are authorized to charge for their enforcement activities, and they were able to recoup most costs through fee collections.

The single biggest error in public health preparations at the state level was the failure to secure funding in advance for these activities. A major reason for this was that, in many ways, the system of public health response evolved over more than 2 years of planning. It was not known in advance what the system ultimately would consist of and cost could not be estimated. State funds were made available for Olympic law enforcement activities, which were given high priority in planning overall at the state level.

A major potential threat to the success of the Olympics or many mass gatherings is an epidemic. In this case, considerable attention was given to preventing HRI and foodborne diseases, and to the system of medical and public health response to mass casualties or terrorism. It is impossible to attribute a causal relationship between those public health interventions and the incidence of various health conditions. Nevertheless, we believe that the attention given to the potential problem of HRI was likely an important factor in achieving a low incidence of severe HRI. Similarly, the aggressive approach to environmental health concerns, through both rule making and enforcement, should be considered in future events of this magnitude. Finally, public health agencies should play a lead role in organizing and implementing the system to respond to disasters and mass casualties.

The systematic integration of assessment tools, policies, and assurance of implementation developed for the Atlanta Olympic Games demonstrates responsiveness and flexibility in the public health system. We believe that many of the approaches used in Atlanta can provide a model to serve as a foundation for public health planning in future Olympic cities worldwide.