This article was downloaded by: [22.214.171.124]
On: 26 August 2015, At: 21:44
Publisher: Taylor & Francis
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: 5 Howick Place,
London, SW1P 1WG
Publication details, including instructions for authors and subscription information:
Reducing the risk of public health emergencies for the
world’s largest mass gathering
, Mark Keim
, Yongchao He
, Mollie Mahany
& Zheng'an Yuan
Shanghai Municipal Center for Disease Control & Prevention; Shanghai Municipal Health
Bureau; Shanghai, P.R. China
National Center for Environmental Health; Centers for Disease Control & Prevention;
Atlanta, GA USA
Published online: 01 Jan 2013.
To cite this article: Xiaodong Sun, Mark Keim, Yongchao He, Mollie Mahany & Zheng'an Yuan (2013) Reducing the risk of public
health emergencies for the world’s largest mass gathering, Disaster Health, 1:1, 21-29, DOI: 10.4161/dish.22537
To link to this article: http://dx.doi.org/10.4161/dish.22537
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in
the publications on our platform. Taylor & Francis, our agents, and our licensors make no representations or
warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Versions
of published Taylor & Francis and Routledge Open articles and Taylor & Francis and Routledge Open Select
articles posted to institutional or subject repositories or any other third-party website are without warranty
from Taylor & Francis of any kind, either expressed or implied, including, but not limited to, warranties of
merchantability, fitness for a particular purpose, or non-infringement. Any opinions and views expressed in this
article are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The
accuracy of the Content should not be relied upon and should be independently verified with primary sources
of information. Taylor & Francis shall not be liable for any losses, actions, claims, proceedings, demands,
costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in
connection with, in relation to or arising out of the use of the Content.
This article may be used for research, teaching, and private study purposes. Terms & Conditions of access and
use can be found at http://www.tandfonline.com/page/terms-and-conditions
It is essential that you check the license status of any given Open and Open Select article to confirm
conditions of access and use.
www.landesbioscience.com Disaster Health 21
Disaster Health 1:1, 21–29; January/February/March 2013; © 2013 Landes Bioscience
*Correspondence to: Mark Keim; Email: firstname.lastname@example.org
Submitted: 09/21/12; Accepted: 10/11/12
The Shanghai Expo was the largest mass gathering in world his-
tory. Over 240 nations and international organizations took part
in the exhibition. The Expo was held in Shanghai, China from
May 1st to Oct 31st and lasted 6 mo (182 d). The event attracted
70 million visitors to a city of 20 million people. The site of the
exposition (Expo Park) was 5.3 km
(530 hectares) or two square
miles (1280 acres) and accommodated an average of 400,000 visi-
tors per day, with 700,000 on most peak days and 1,003,000 per-
sons as a record high for daily attendance. An estimated 3–5% of
these visitors were expected to travel from abroad and 50% were
expected to arrive from provinces other than Shanghai.
The long duration and the large number of visitors, together
with a history of relatively high incidences of endemic seasonal
intestinal and respiratory infections during summer and autumn
months in Shanghai, contributed to concerns that the event
Mass Gatherings and Public Health
Mass gatherings are highly visible events with the potential for serious health and political consequences if not managed
carefully and eectively.
Mass gatherings have been reported to have signicant impact upon public health systems
throughout the world.
International mass gathering events, such as those associated with the Olympic Games,
often carry high political signicance and have a historical risk for terrorist attacks.
Mass gatherings ranging from
the subnational level to the international level have also been associated with outbreaks and subsequent spread of
communicable diseases. These events have included outbreaks of foodborne shigellosis occurring at an outdoor music
festival in the United States.
The annual Hajj pilgrimage in Saudi Arabia has been plagued by public health threats
such as res, stampedes and an outbreak of meningitis.
Inuenza outbreaks were also reported during the 2008 World
Youth Day mass gathering in Australia.
Local, provincial and national public health and medical agencies are frequently
involved before, during and after a major event. Therefore, disaster risk reduction is a key element for the eective
management of mass gatherings.
Disaster Risk Reduction
Throughout the world, the overall approach to emergencies and disasters has recently shifted from post-impact activities
(i.e., ad hoc relief and reconstruction) to a more systematic and comprehensive process of risk management.
risk management includes pre-impact disaster risk reduction (i.e., prevention, preparedness, and mitigation) as well as
post-impact response and recovery.
While planners may not always have the ability to prevent health hazards from
occurring at mass gathering events, the health sector can play an important role in preventing the public health impact
of such hazards. This manuscript describes a comprehensive approach for disaster risk reduction as implemented by
those entities responsible for health security associated with the 2010 Shanghai World Exposition (Shanghai Expo).
Reducing the risk of public health emergencies
for the world’s largest mass gathering
2010 World Exposition, Shanghai, China
* Yongchao He,
and Zheng’an Yuan
Shanghai Municipal Center for Disease Control & Prevention; Shanghai Municipal Health Bureau; Shanghai, P.R. China;
National Center for Environmental Health; Centers for
Disease Control & Prevention; Atlanta, GA USA
Keywords: public health response, mass gatherings, 2010 World Exposition, public health, disaster management
could impose great challenges on the public health security of
Shanghai. Anticipated medical problems included heat illness,
injuries, communicable disease, food borne illness and mass
During the Shanghai Expo, the Shanghai Municipal Center
for Disease Control and Prevention (SCDC) established a special
unit to coordinate public health and medical services within and
outside the Park. These services included the following ten key
• Risk assessment
• Medical assistance
• Disease surveillance
• Vector surveillance
• Laboratory testing
• Risk communication
• Health education and interventions
Downloaded by [126.96.36.199] at 21:44 26 August 2015
22 Disaster Health Volume 1 Issue 1
and natural disasters or other emergencies. For each of the four
rounds, the risk assessment was performed by an expert group
using a standard risk assessment methodology based on the AS/
NZ 4360:2004 Standard for Risk Assessment,
according to advice provided by the US Centers for Disease
Control and Prevention (CDC). Assessments were performed
one year prior to the start of the Expo; one month prior to the
start; at the mid-term; and then again one month prior to the
ending. These risk assessments identiﬁed and prioritized the pri-
mary threats to public health during the Expo.
The ﬁrst three assessments used the same methodology and
resulted in no signiﬁcant change in any of the assessment scores.
Compared with the previous three rounds, the fourth and ﬁnal
risk assessment focused speciﬁcally on the increased number of
visitors that were expected at Expo Park during the ﬁnal two
months of the event. In September 2010, SCDC performed the
fourth round risk assessment and identiﬁed the following risks:
• Extreme (high) temperature
• Infectious disease
• Food poisoning
• Shortage of medical resources within Expo Park
• Occupational risks for working staff
After the fourth risk assessment, SCDC provided updated
recommendations to the Organizing Committee of the World
Exposition 2010 Shanghai China for public health security
activities that would better accommodate the expected increase
in event census. These recommendations included the following
• Enhancing medical and rescue personnel within Expo Park.
• Strengthening sanitation inspection of food and drinking
water within Expo Park.
• Continuing with health education and issuing health advi-
sories in a timely manner.
Medical assistance at Expo Park. Five medical service cen-
ters located inside Expo Park provided medical care and ﬁrst aid
services for visitors, working staff (including volunteers) and the
exhibitors (See Fig. 1). These medical stations were staffed by
a total of ten physicians and ten nurses as well as 15 Red Cross
staff and 15 emergency medical technicians. There was a physi-
cian, a surgeon, two nurses, a Red Cross staff and several emer-
gency medical technicians placed in every medical station. Each
• Food safety
• Water safety
In this paper we review the SCDC medical and public health
response for the Shanghai Expo.
Organizational structure. The SCDC began preparing for the
Shanghai Expo two years in advance of the opening day. SCDC’s
subsequent public health response had three main goals as fol-
lows: (1) maintain public health security with efﬁciency; (2)
ensure the clarity and accuracy of information submitted to the
Shanghai Municipal Health Bureau; (3) respond to infectious
diseases and other public health related events in a timely man-
ner. To accomplish these goals, SCDC established an Ofﬁce of
Public Health Security for the Shanghai Expo as the core of the
public health organization system related to Expo issues. This
central ofﬁce was in charge of routine work, and was supported
by 5 working groups: the Comprehensive Coordination Group,
the Expo Park Working Group, the Surveillance and Analysis
Group, the Laboratory Group and the Logistical Support Group.
The role of each group is listed in Table 1.
Coordination and communication. Public health security
for the Shanghai Expo relied upon coordination among differ-
ent organizations and sectors. During the Expo, SCDC held
regular public health security meetings once a week among all
working groups. During the week leading up to the opening of
the Expo, (April 30th ~May 4th), the frequency of the meeting
was increased to once daily. In addition, SCDC purchased a tele-
phone conference system to ensure that on-duty working staff
and those working in the ﬁve medical service centers in the Park
could also participate in the meetings and communicate with
other working groups. Moreover, during the course of the Expo
SCDC held a total of 18 video conferences with the Zhejiang
Municipal, the Jiangsu Municipal and the Chinese Center for
Disease Control and Prevention in order to share information
regarding any infectious disease or public health emergency situ-
ations during the Expo.
Risk assessment. In order to develop updated plans for
emergency preparedness and response activities related to the
Shanghai Expo, SCDC performed four dynamic risk assessments
from April 2009 to September 2010. These assessments con-
sidered risks related to infectious disease, injury, lab bio-safety
Table1. SCDC public health workgroups established for the Expo response
Working group Function
Comprehensive Coordination Group Coordinate all the other public health working groups within and outside Expo Park.
Expo Park Working group
Assist the physicians in the five medical service centers to perform health surveillance in Expo Park
Respond to any public health emergency occurring inside Expo Park
Perform vector surveillance and control within Expo Park
Surveillance and Analysis Group
Integrate comprehensive public health monitoring
Provide regular monitoring reports to the Shanghai Municipal Health Bureau
Laboratory Group Perform diagnostic and confirmatory testing
Logistical Support Group Coordinate material support of public health efforts
Downloaded by [188.8.131.52] at 21:44 26 August 2015
www.landesbioscience.com Disaster Health 23
monitor, identify and evaluate out-of-the-ordinary information.
The surveillance system provided a much-needed capability for
early warning and rapid response in order to control the spread
of infectious diseases in a timely, scientiﬁc and effective manner.
Monitoring content. Public health surveillance data contained
two main elements as follows:
• Key illness: acute gastrointestinal, fever, injury, heat stroke,
upper respiratory tract infection, urgent onset of chronic disease,
• Syndromes: u-like syndrome, gastrointestinal syndrome,
fever with rash syndrome, fever with hemorrhage syndrome, cen-
tral nervous system syndrome and jaundice-like syndrome.
Table 2 describes the case deﬁnitions used for various catego-
ries of syndromic illnesses.
In addition to syndromic surveillance, additional epide-
miological information was also collected for key illnesses such
as: enteric disease, upper respiratory tract infection, fever of
unknown origin, food poisoning, chemical poisoning and injury
(See Table 3).
Prevention and control measures. Enteric disease. During the
Shanghai Expo, 22 patients experiencing diarrhea were detected
using syndromic surveillance. Among the 22 cases, 15 occurred
among one group of visitors. Although they went to the different
medical service centers for treatment, they were traceable through
the epidemiological information. Once detected, the cluster was
then reported to the Shanghai Food and Drug Administration
(SFDA). At the same time, the Expo Park working group
medical station was afﬁliated with two local Shanghai
hospitals. In the case of a serious illness requiring hos-
pitalization, ambulances assigned to each of the medical
stations transported patients to one of the two hospitals
afﬁliated with that particular station.
The Shanghai Municipal Health Bureau also added
11 temporary medical stations (one for every entrance to
Expo Park) to supplement the ve main centers. Because
there were visitors coming from abroad, and many from
other provinces, all the physicians in the medical ser-
vice centers of Expo Park received specialized training
related to imported and emerging infectious diseases.
SCDC also provided reference manuals related to rare,
imported or emerging infectious diseases for each of the
medical service centers.
Public health surveillance. It has been well described
that public health surveillance should be implemented
in mass gatherings to facilitate rapid detection of out-
breaks and other health-related events, and to enable the
groups responsible for public health security to respond with con-
trol measures in a timely manner. Ten public health surveillance
systems were set up to detect emerging outbreaks of infectious
disease. Surveillance activities ranged from passive systems for
detecting speciﬁc infectious disease to the development of a syn-
dromic surveillance system for rapidly identifying unusual clus-
ters of suspicious symptoms. Disease surveillance was established
and maintained for areas both inside Expo Park, as well as for the
Shanghai metropolitan area in general.
SCDC established the real-time surveillance system for
abnormalities among clinic visits within Expo Park in conjunc-
tion with Shanghai Municipal Health Bureau so as to detect
outbreaks which may require a rapid public health response.
Monitoring points included the ﬁve medical service centers in
Expo Park, and the eight special hospitals located in the dis-
tricts where Expo Park was located. The physicians working in
the ﬁve medical service centers of Expo Park directly inputted
their patient data through an online surveillance system on a
daily basis. The following day, SCDC reported the monitoring
data to the Shanghai Municipal Health Bureau. All presenta-
tions to the medical stations were monitored for the incidence
of key illnesses and syndromes that may require a rapid public
health intervention (See Fig. 1).
Daily and cumulative summaries were delivered to the
Shanghai Municipal Health Bureau. The syndromic surveillance
system collected, arranged, analyzed and integrated the informa-
tion of clinic visits from the medical service stations in order to
Figure 1. SCDC sta member reviewing online surveillance data.
Table2. Case definitions used for various syndromic illnesses
Syndrome category Definition
gastrointestinal Diarrhea (3 times or more/day), accompanied with blood in the stool, abdominal pain or vomiting.
flu-like Fever (oral temperature ≥ 38°C) with cough or angina.
fever and rash Fever (oral temperature ≥ 38°C) with papule, macule or maculopapule.
fever with hemorrhage Fever (oral temperature ≥ 38.5°C) with headache, muscular soreness, bleeding tendency or purpuric rash.
central nervous system Fever (oral temperature ≥ 38.5°C) with projectile vomiting or disturbance of domestic peace and security.
jaundice-like Icteric sclera or xanthochromia with anorexia or malaise.
Downloaded by [184.108.40.206] at 21:44 26 August 2015
24 Disaster Health Volume 1 Issue 1
of shade awnings provided at pavilion entrances where visitors
were standing in long queues.
Respiratory infections. Starting in April 2011, Shanghai gov-
ernment departments released health education information
to the public that included precautions that could be taken
against respiratory illness. The information was distributed
in various ways, such as newspapers, internet, mobile media,
etc. Visitors to the Expo had easy access to health education
information about key illnesses such as inuenza, measles and
Vector surveillance and control. During the Shanghai
Expo, especially from June to August, environmental conditions
remained favorable for vector breeding. Also the large inux of
international visitors into Shanghai increased the potential for
intercontinental transmission of emerging and imported infec-
tious diseases. For these reasons, it was important to guard
against the outbreak of vector-borne infectious disease. SCDC
strengthened vector surveillance from May 1st to Oct 31, 2010,
including mosquitoes, ies, mice and cockroaches in Expo Park
(see Fig. 2).
By the end of the Shanghai Expo, SCDC had achieved the
goal of eliminating vector-borne disease in Expo Park and the
city as a whole, thus minimizing the risk of outbreaks and spread
Vector control. SCDC also implemented the following key ele-
ments of prevention and control measures to reduce the number
of various vectors in Expo Park:
• Ensured adequate sewage treatment by strengthened health
supervision and inspection.
• Reduced the mosquito breeding sites.
• Set y traps in public green land, road surrounding areas, etc.
• Implemented ultra-low volume spraying to reduce the mos-
quito density on public green lands, lakes, etc.
• Exterminated rodents within the pavilions and other public
• Set rat traps and poisonous bait stations in the non-open
• Strengthened the supervision and examination of pest con-
Surveillance of disinfection (or infection control) effect
within Expo Park. On an average day approximately 400 patients
presented to the medical centers in Expo Park making infection
immediately deployed staff to carry out epidemiological investi-
gations and emergency response.
Injury. On any given day, there were 300,000–500,000
visitors present in Expo Park. With so many people attending
the Expo at the same time, injuries were quite likely to occur.
Therefore, in order to reduce the incidence of injuries SCDC
performed an assessment of injury risk factors from May 11 to
June 14. The assessment evaluated 16 separate environments/
facilities within Expo Park according to 14 risk factors. It also
evaluated the results of 40 injury cases. Based on the assessment
and evaluation of injuries SCDC recommended that steps be
taken to reduce environmental risk factors, particularly those
associated with the risk of falls, and to strengthen the health
education on site.
Heat illness. Shanghai’s hot and humid summer weather
combined with overcrowding in Expo Park, made prevention of
heat-related illness a major challenge during the Shanghai Expo.
Expo Park was already designed and ﬁtted with multiple water
air-misting stations, shaded rest areas and easy access to drink-
ing water to help visitors keep cool. In order to further decrease
the number of heat-illness cases, the SCDC provided fans free
of charge to visitors at the Expo and recommended that the
Organizing Committee of the World Exposition increase the area
Table3. Epidemiology information collected for various diseases
Disease Category Main content information for tracing to source Remark
General information (address, telephone), past medical history of
chronic diarrhea, dietary history in Expo Park, drinking water information
The tourist groups need to fill in the
contact information of the escort
Upper respiratory tract infection,
fever of unknown origin
General information(address, telephone, etc) None
General information (address, telephone), past medical history of chronic
diarrhea, dietary history in Expo Park, drinking water information
The tourist groups need to fill in the
contact information of the escort
General information (address, telephone), history of exposure
Asked whether other patients have
Injury Injury location, nature, cause, injury intention none
Figure 2. SCDC sta member performing vector surveillance in Expo Park.
Downloaded by [220.127.116.11] at 21:44 26 August 2015
www.landesbioscience.com Disaster Health 25
A total of 843 doses of Hepatitis A vaccine, 2322 doses of
Measles vaccine, 318 doses of seasonal inuenza vaccine, 132
doses of novel H1N1 inuenza vaccine and 2883 doses of cholera
vaccine were given to staff working within Expo sites, includ-
ing medical workers, food handlers and volunteers. In addition,
SCDC also purchased 100 doses of the Japanese Encephalitis
vaccine to hold as an emergency reserve to be used in the event
of a terrorist release.
Risk communication. In order to ensure timely and effective
communication of public health information to the public dur-
ing the World Expo, SCDC established the following risk com-
munication system components:
• A media working group
• A system of spokespersons
• A work plan for information transfer
• A system for measuring public feedback
On April 30th, 2010, (one day before the start of the Expo),
the director of SCDC provided several media interviews. During
these interviews the director discussed the extensive level of
SCDC public health preparedness. The director noted that
although disease outbreak was highly unlikely, it would be neces-
sary to prepare for it. In addition, the SCDC also offered addi-
tional opportunities for tourists to obtain health information
by way of a World Expo column on the SCDC webpage. The
column included Expo news, travel health tips, health educa-
tion and health resources. The Chinese and English interfaces of
World Expo column were both updated on April 30th and June
25th, and then ran without interruption during World Expo. As
of October 31th, the World Expo column had 27,000 visits (see
Health education and interventions. Health education and
health intervention was an important part of public health secu-
rity for the event. To improve the knowledge and skills of local
healthcare providers, SCDC performed training on eight health
control in these centers critical for preventing the spread of infec-
tious disease, maintaining health care quality, ensuring the safety
of patients and medical personnel, and in providing for the public
health security during the Expo. The bacterial count of the air
in the transfusion rooms and therapeutic rooms in the medical
centers was monitored regularly in order to maintain a high level
of quality control.
In addition to the disinfection quality surveillance, SCDC
also provided ﬁt-tested respiratory protection masks for the doc-
tors and other medical personnel who worked in Expo Park in
order to limit potentially infectious exposures among the health-
care staff during patient care. Moreover, according to the relevant
requirements established by the Shanghai Counter-terrorism
ofﬁce, SCDC purchased a stockpile of additional personal pro-
tective equipment, including masks, protective clothing, gloves
and shoes to be used if circumstances warranted.
Laboratory conﬁrmation. To compensate for some spe-
ciﬁc limitations of in-house laboratory testing capacity, SCDC
engaged the support of the World Health Organization (WHO)
and the Chinese Center for Disease Control and Prevention. In
the event that Shanghai CDC did not have diagnostic capability,
arrangements were made in advance for transport of samples to
China CDC or to WHO for laboratory analysis. At the same
time, SCDC established a laboratory referral network including
18 district CDCs, the Institute of Forensic Science Ministry of
Justice P.R. China, the Institute of Forensic Science, Shanghai
Municipal Public Security Bureau, the Institute Pasteur of
Shanghai Chinese Academy of Sciences, the Shanghai Public
Health Clinical Center and the Shanghai Institute for Food and
Vaccination campaign. With assistance from the Bureau of
Shanghai World Expo Coordination, SCDC launched a vaccina-
tion campaign targeting the working Expo staff in order to further
reduce the risk from key infectious diseases within Expo Park.
Figure 3. Screenshots from Chinese and English versions of the SCDC Expo column for World Expo tourists.
Downloaded by [18.104.22.168] at 21:44 26 August 2015
26 Disaster Health Volume 1 Issue 1
meat, dairy products, vegetables, fruit, aquatic products
and edible oil for quick intervention, as necessary.
3. Food security information systems which uses an
electronic label to track storage, production and circula-
tion of the food item, thus allowing for traceability.
4. System for monitoring sampling data analysis
results for bacterial food poisoning and providing early
warning if indicated.
Drinking water safety. During the 2010 Shanghai
World Expo, there were on average about 400,000 people
drinking water in Expo Park on a daily basis. According
to the Shanghai Health Inspection and Supervision
Bureau, there were no outbreaks of waterborne dis-
ease at the Shanghai World Expo Park. In order to
ensure the drinking water safety, Shanghai World Expo
Coordination Board prohibited carrying drinking water
into Expo Park. Inside Expo Park, all beverages provided
by the vendors were pre-designated by the Coordination
Board, and direct drinking water was provided free of
charge at “Direct-Drinking Water Points” (see Fig. 4).
The Shanghai World Expo Coordination Board provided
about 117 Direct-drinking Water Points in Expo Park. In order
to ensure the drinking water safety of Expo Park, Shanghai
Health Inspection and Supervision Bureau implemented the two
following important measures:
• Establishment of 30 real-time surveillance points to monitor
the direct-drinking water all day during the Expo. Results were
transmitted to the Command Center for Health Inspection and
Supervision within 3 to 5 min after testing.
• Twenty Health Inspection and Supervision security staff per-
formed the water quality testing for all the Direct-drinking Water
Points and the complete water distribution system during all
hours of operation at Expo Park, (8:00 a.m. to 12:00 a.m. daily).
Emergency preparedness and response. Taking the results
of the risk assessment and other public health security needs
into consideration, SCDC worked to improve and integrate 30
separate hazard-speciﬁc emergency plans, and then to validate
the plans through a series of emergency exercises from August
to December, 2009. A supplementary document, an all-hazard,
capability-based plan for public health emergencies inside the
Expo site, was also developed. In the event of a public health
emergency occurring in the Expo site, this more generic plan
could be implemented immediately. SCDC also developed three
emergency response teams stationed at SCDC. If a public health
emergency occurring within Expo Park exceeded the capabili-
ties of the Expo Park Working Group, these 12-member rapid
response teams were to be mobilized to facilitate a rapid emer-
gency response. These teams were able to perform activities
concerning investigation of infectious diseases, vector control,
disinfection, acute chemical poisoning and radiation accident
disposal. Finally, 18 district-level CDCs in the greater Shanghai
metropolitan area also built several emergency response teams
as a component of the overall public health response system for
the Shanghai Expo. Each of these district level CDCs coordinate
directly with the SCDC.
education and intervention topics in the ﬁve medical service cen-
ters within Expo Park. The ﬁve topics were: respiratory infectious
diseases; intestinal infectious diseases; vector borne infectious
diseases; the disinfection and infection control of Expo pavilions;
food borne diseases; acute exacerbation of chronic diseases; inju-
ries and heat-stroke.
From May 1st to Oct 31st, 2010 more than 121,500
health education and health intervention materials (includ-
ing hygiene and infection control tips while visiting Expo
pavilions and an intestinal infection prevention and control
manual) were printed out and delivered to the visitors in
the Expo site. In addition, travel health tips for Expo 2010
Shanghai China were also provided in many of the hotels
Food safety. The enormous inux of visitors made food safety
critically important. There were 244 restaurants serving food in
Expo Park, including the public catering units, dining hall and
In order to ensure food safety, the public health and medi-
cal groups of Shanghai World Expo established the Department
of Food Security, which included the Shanghai Food and Drug
Administration (SFDA), the Shanghai Agriculture Committee,
the Shanghai Entry-Exit Inspection and Quarantine Bureau and
The Department of Food Security established four monitor-
ing systems to ensure food safety. These systems including the
1. On-site electronic monitoring system of food safety to col-
lect the real-time temperature data. The system implemented
real-time monitoring of temperatures in the refrigerated ware-
house and the food that required temperature control. If the
monitoring temperature was higher than the set value, the system
would send a warning message.
2. A food safety rapid detection system to carry out the fast
detection and analysis of the food safety. A supervising ofﬁcer
used rapid testing equipment to test tableware, disinfectant,
Figure 4. Expo Park visitor using a direct drinking water point.
Downloaded by [22.214.171.124] at 21:44 26 August 2015
www.landesbioscience.com Disaster Health 27
the 19th week. Despite high seasonal ambient temperatures at
Expo Park, cases of heat illness were less frequent than antici-
pated. In comparison, the peak incidence rate for the entire
2010 World Expo was 3 cases per week (among a weekly aver-
age of 250,000 attendees) and 6.8% of all cases seen onsite for
the entire event, while the peak incidence for the 1996 Olympics
was reported as 24 cases in one day, (among 100,000 attend-
ees), comprising 10% of all cases seen onsite for the entire event.
There were no a major food safety incidents or major outbreaks
of food borne disease. The vector surveillance system detected
no vector-borne infectious disease among the vector populations
in or near Expo Park. Vector density remained similar to that of
previous years for that same location.
Disaster risk reduction as applied to mass gathering events.
Mass gatherings have become high-visibility, international events
with the potential to impact the health of literally millions of peo-
ple as well as national security of the host nation. For this reason,
Medical assistance inside of Expo Park. During the Shanghai
World Expo, 97,708 visitors sought on-site medical care and
97,059 were diagnosed by physicians. Among these patient
encounters, 213 required hospitalization and 3530 required
The most common indication for physician examination
was upper respiratory tract infection (17.8%); enteric disease
was diagnosed in 16.6%. Injuries (including lacerations and
abrasions) were also relatively common during the surveil-
lance period, accounting for 12.8% of patient encounters.
Other reasons for seeking medical care included 6.8% vis-
its for heat-related illness, 6.6% for headache, 4.5% for fever,
5.0% for abdominal pain and 3.1% for acute exacerbation of
chronic disease (e.g., high blood pressure or chest pain). The
onset ages ranged from 0 to 101 y old, and 51% of the cases
were between the ages of 15 to 39 y old. The gender ratio of
males to females was 0.92. There were no deaths during the
event (see Fig. 5).
Disease surveillance. During the Shanghai Expo, there were
no indications of any serious infectious disease outbreaks or
epidemics either inside or outside of Expo Park. There were no
events reported inside Expo Park that involved chemical poison-
ings or severe injuries.
Shanghai Major Metropolitan Area (outside of Expo Park).
Disease surveillance. The incidence rate of notiﬁable infectious
diseases has shown a low level of uctuations in Shanghai from
1950–2008. The major diseases are syphilis, gonorrhea, viral
hepatitis, tuberculosis and dysentery. Sexually transmitted dis-
ease is the major category of infectious diseases, and tubercu-
losis is the leading cause of death due to infectious disease in
Shanghai. According to the surveillance results, the incidence
rate of diseases of a relatively high priority in China remained
at a low level in Shanghai during the Expo. As compared with
the same period last year, the incidence rate of these diseases
decreased 14.4%. Compared with the same period last year, cases
of a similar prioritized disease (hand-foot-and-mouth disease)
increased, but these incidence trends were consistent with trends
in the rest of the nation.
Laboratory surveillance. During the duration of the
Shanghai Expo, a total of 1,020,251 laboratory samples
were tested by SCDC and the 18 district CDCs, includ-
ing emergency samples and monitoring samples. Twenty-
one batches of samples were sent to the Chinese Center
for Disease Control and Prevention for viral testing
(including specimens for polio, measles, inuenza and
Area within Expo Park. Disease surveillance. As depicted
in Figure 6, the incidence rate of injuries decreased every
week after the start of the Expo and reached the lowest
level during the ﬁnal (26th) week. The incidence rate for
upper respiratory tract infections decreased from the ﬁrst
week and reached a peak between weeks 10 – 20.
The incidence of enteric disease and heat-illness begin
to rise from the 10th week, and decreased gradually from
Figure 5. Clinical case composition among visitors presenting to medical
clinics at the 2010 Expo Park, May 1 – October 31, 2010.
Figure 6. Incidence of key illnesses reported inside the World Expo Park, ac-
cording to week of event.
Downloaded by [126.96.36.199] at 21:44 26 August 2015
28 Disaster Health Volume 1 Issue 1
site offered mostly open areas thus minimizing any such bottle-
necks that could contribute to overcrowding or stampedes. Trip
and fall hazards were kept to a minimum. Vehicle trafc was very
limited within the site, and public transportation routes within the
venue were kept separate from areas of pedestrian trafﬁc.
Exposure reduction. Public health disasters are prevented when
populations are protected from exposure to the hazard if in fact it
does occur. As mentioned above, dynamic and ongoing risk assess-
ments allow for identiﬁcation of previously unrealized hazards and
lead to rapid interventions to avoid or mitigate population expo-
sures (such as trip hazards, sun exposure, etc.) at the Expo.
Extensive efforts were made to prevent and control the occur-
rence of infectious disease and injury. In addition to careful
surveillance of vectors and food service, clinical and laboratory
surveillance were used to inform subsequent public health inter-
ventions. These interventions included recommendations regard-
ing physical safety of venue facilities to prevent falls, precautions
against heat illness, measures to ensure food and water safety as
well as vector control. These measures proved successful in pre-
venting the outbreak of disease as well as lessening the incidence
of injuries over time. Clinical care at the venue was also closely
coordinated with local hospital facilities and linked to the public
health coordinating groups.
In order to obtain timely and relevant public health informa-
tion during the World Expo and cope with the challenges posed
by the event, the SCDC constructed ten de novo integrated mon-
itoring systems to ensure the public health security of the Expo.
This comprehensive approach linked the expo venue itself to a
citywide monitoring network for infectious disease and public
health risk factors. This monitoring offered public health ofﬁcials
an effective system for early warning that could then guide rapid
Susceptibility reduction. Within the context of disaster risk
reduction, susceptibility is deﬁned as the likelihood of suffering
an adverse health effect when exposed to a given health hazard.
The transient nature of the population attending the Expo, lim-
ited the ability to reduce susceptibility to illness or injury among
the majority of participants. However, extensive efforts were
undertaken that would reduce susceptibility of Expo workers and
staff to potential disaster hazards. Most notably, key Expo staff
members (medical workers food handlers and volunteers) were
immunized, so as to reduce their susceptibility to communicable
diseases. The staff pool was also intentionally selected and hired,
thus the cohort was also at healthy baseline, thereby minimal-
izing any other vulnerabilities noted in previous disaster stud-
ies, (such as extremes of age, presence of comorbidities such as
chronic disease, etc).
Resilience building. Resilience is dened as the capacity of a
system, community or society to resist or to change in order that
it may obtain an acceptable level in functioning and structure.
This largely involves activities focused around preparedness,
response and recovery.
SCDC began building an effective framework for resilience
by establishing an organizational structure that would be exible,
as well as scalable. Each of the various work groups was assigned
a separate functional area and all of them organized according to
a comprehensive and well integrated approach to disaster risk
management is much more preferable than a system inordinately
focused on preparedness for post-impact crisis management.
Disaster reduction has emerged as a core element of sustain-
The 2002 World Summit on Sustainable
Development concluded that “An integrated multi-hazard, inclu-
sive approach to address vulnerability, risk assessment and disas-
ter management, including prevention, mitigation, preparedness,
response and recovery, is an essential part of a safer world in the
Disaster risk reduction shares some tenets with preventive
As in preventive medicine, risk reduction calls for a
basic attitude shift in the minds of many who traditionally get
sick ﬁrst and seek treatment later. The challenge for disaster risk
reduction as applied to health is to broaden the focus of disas-
ter risk management from that of tertiary prevention, (response
and recovery) to also emphasize primary and secondary preven-
tion, (prevention, preparedness and mitigation).
In the case of
mass gatherings, disaster risk reduction offers a more comprehen-
sive approach to avoiding public health emergencies that could
adversely impact not only health but also impart serious com-
mercial and socio-political repercussions.
Risk reduction activities seek rst to prevent public health
disaster from ever occurring and then seek to prepare for and
mitigate the disaster’s health effects. Public health may not have
the capability to inuence the probability of a hazard occurrence
(i.e., preventing the heat wave itself), but within public health
lies a unique ability and opportunity to lessen human vulnerabil-
ity to the hazard. Given that an environmental hazard is likely
to occur, the risk of a public health disaster is lessened by (1)
reducing human exposures to the hazard by a reduction of human
vulnerability, (2) lessening human susceptibility to the hazard and
(3) building resilience to the impact of the hazard.
Risk assessment for the expo. SCDC performed a series of
extensive and dynamic risk assessments, beginning one year prior
to the start of the Expo and extending throughout the entire dura-
tion of the event. These assessments served to not only identify
potential hazards, but to also recognize key vulnerabilities that
involved both the public health institution, as well as the popula-
tion served. As a result of the risk assessment, SCDC was able
to identify internal and external gaps in capacity and capability
that could be addressed far in advance of the event. SCDC also
used the ongoing risk assessments to identify physical hazards
associated with the various exhibitions, as well as environmental
hazards such as sun exposure for people waiting in line. In both
of these examples interventions that would prevent signiﬁcant
adverse health impact were in place within a very short period of
time after being identiﬁed. The dynamic nature of the risk assess-
ment helped to raise awareness and diligence for recognition of
potential disaster risk.
Risk reduction for the expo. Hazard avoidance. The optimum
strategy for disaster risk reduction is to avoid the presence of haz-
ards altogether. One advantage of the Expo site was that it was spe-
ciﬁcally designed and newly constructed to promote crowd safety.
The venue was located outside of the major metropolitan area that
offered good ventilation and adequate drainage. The layout of the
Downloaded by [188.8.131.52] at 21:44 26 August 2015
www.landesbioscience.com Disaster Health 29
the need for rapid interaction between technical subject matter
experts and decision-makers. SCDC also relied on an extensive
system for coordination among different institutions and sec-
tors. These connections were well-established and tested far in
advance of the Expo event itself.
Medical assistance inside the Expo Park was also well devel-
oped to absorb and respond to casualties. These included con-
tingencies for not only routine care, but also one- to-one direct
linkages between each of the ﬁve medical service centers and ﬁve
corresponding major hospitals. This would allow for signiﬁcant
surge capacity to occur in the event of an emergency medical
response involving mass illness or casualties. This medical system
was also adjusted during the event to accommodate some degree
of variation in the population distribution within the Expo site.
Public health surveillance also contributed signiﬁcantly to the
capacity for resilience. Systems existing both inside and outside
the park were developed and maintained in order to prepare for a
rapid detection and effective response. Small incidents involving
injury patterns as well as heat illness and gastrointestinal illness
were identiﬁed early allowing for rapid response that prevented
what could have resulted in a larger adverse health event.
An extensive system for timely and effective risk communi-
cation and public health information was also developed. The
system would contribute to a resilient and proactive public health
outreach for domestic Chinese as well as international visitors.
The system would also assist in preparing for any potential disas-
ter event that would require extensive public communication.
1. Brennan RJ, Keim ME, Sharp TW, Wetterhall SF,
Williams RJ, Baker EL, et al. Medical and public health
services at the 1996 Atlanta Olympic Games: an over-
view. Med J Aust 1997; 167:595-8; PMID:9418799.
2. Sharp TW, Brennan RJ, Keim M, Williams RJ, Eitzen
E, Lillibridge S. Medical preparedness for a terrorist
incident involving chemical or biological agents dur-
ing the 1996 Atlanta Olympic Games. Ann Emerg
Med 1998; 32:214-23; PMID:9701305; http://dx.doi.
3. Tsouros AD, Lekka M, Minogiannis P, Stergachis A.
Disease prevention and health promotion activities, AD
Tsouros, PA Efstathiou, Editors, Mass gatherings and
public health: the experience of the Athens 2004 Olympic
Games, World Health Organization Regional Office for
Europe, Copenhagen (2007), pp. 253–265.
4. Thackway S, Churches T, Fizzell J, Muscatello D,
Armstrong P. Should cities hosting mass gatherings
invest in public health surveillance and planning?
Reflections from a decade of mass gatherings in
Sydney, Australia. BMC Public Health 2009; 9:324;
5. Wharton M, Spiegel RA, Horan JM, Tauxe RV, Wells
JG, Barg N, et al. A large outbreak of antibiotic-
resistant shigellosis at a mass gathering. J Infect Dis
1990; 162:1324-8; PMID:2230262; http://dx.doi.
6. Lee LA, Ostroff SM, McGee HB, Johnson DR,
Downes FP, Cameron DN, et al. An outbreak of shig-
ellosis at an outdoor music festival. Am J Epidemiol
1991; 133:608-15; PMID:2006648.
7. Wilder-Smith A, Goh KT, Barkham T, Paton NI.
Hajj-associated outbreak strain of Neisseria menin-
gitidis serogroup W135: estimates of the attack rate in
a defined population and the risk of invasive disease
developing in carriers. Clin Infect Dis 2003; 36:679-83;
8. Cobeljić M. Smallpox outbreak in Yugoslavia in 1972.
Vojnosanit Pregl 2004; 61:569-73; PMID:15551812.
9. Ahmed QA, Arabi YM, Memish ZA. Health risks at the
Hajj. Lancet 2006; 367:1008-15; PMID:16564364;
10. Blyth CC, Foo H, van Hal SJ, Hurt AC, Barr IG,
McPhie K, et al.; World Youth Day 2008 Influenza
Study Group. Influenza outbreaks during World
Youth Day 2008 mass gathering. Emerg Infect Dis
2010; 16:809-15; PMID:20409371; http://dx.doi.
11. Clack ZA, Keim ME, Macintyre AG, Yeskey K.
Emergency health and risk management in sub-saharan
Africa: a lesson from the embassy bombings in Tanzania
and Kenya. Prehosp Disaster Med 2002; 17:59-66;
12. Schipper L, Pelling M. Disaster risk, climate change
and international development: scope for, and chal-
lenges to, integration. Disasters 2006; 30:19-38;
13. Standards Australia Committee OB-007. AS/NZS
4360:2004. In: Risk Management. Sydney and
Wellington: Standards Australia International Ltd.,
14. National Science and Technology Council. 1996.
Natural disaster reduction: a plan for the nation.
Washington DC: Committee on the Environment and
Natural Resources, Subcommittee on Natural Disaster
15. UN/ISDR (The United Nations International Strategy
for Disaster Reduction) 2002. World Summit on
Sustainable Development. Geneva. Retrieved
September 20, 2009 from: http://www.worldsum-
16. Sidel V, Onel E, Geiger H, et al. 1992. Public health
responses to natural and human-made disasters. In:
Maxcy, Rosenthal, Last, Editors. Public health and pre-
ventative medicine. 13th ed. Norwalk, CT: Appleton
17. Keim ME. Building human resilience: the role of
public health preparedness and response as an adapta-
tion to climate change. Am J Prev Med 2008; 35:508-
16; PMID:18929977; http://dx.doi.org/10.1016/j.
18. Keim ME. Preventing disasters: public health vulner-
ability reduction as a sustainable adaptation to cli-
mate change. Disaster Med Public Health Prep 2011;
5:140-8; PMID:21402799; http://dx.doi.org/10.1001/
Extensive capacity for emergency preparedness and response
was also developed both within SCDC as well as among its key
partners. All hazard, capability-based plans were established, and
validated by drills and exercises. Public health staff was educated
regarding the principles of disaster preparedness and response.
The 2010 Shanghai World Exposition posed signiﬁcant challenges
for ensuring the medical and public health security of local and
visiting populations. This event was unique among mass gath-
erings in both scale and duration. The success of the Shanghai
Expo depended upon a comprehensive approach for disaster risk
management that included prevention, mitigation, preparedness,
response and recovery Public health played a key role in ensuring
the safety and security of Expo attendees and of Shanghai citi-
zens, in general. Organizers of future such events should consider
early and extensive integration of public health with a focus on
disaster risk reduction for management of the event.
Disclosure of Potential Conﬂicts of Interest
No potential conicts of interest were disclosed.
The ﬁndings and conclusions in this report are those of the
author(s) and do not necessarily represent the views of the US.
Centers for Disease Control and Prevention.
Downloaded by [184.108.40.206] at 21:44 26 August 2015