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Public Health Aspects of the Rainbow Family of Living Light Annual Gathering—Allegheny National Forest, Pennsylvania, 1999
JAMA. 2000;283:3065-3066.
MMWR. 2000;49:324-326
The Rainbow Family of Living Light (RFLL) is a loosely organized group that developed out of the late 1960s counterculture movement. RFLL has had a 2-week "Gathering for World Peace and the Healing of the Earth" in a different national forest each summer since 1972. For the June 21-July 10, 1999, gathering, RFLL selected the Allegheny National Forest in Pennsylvania. The site was not accessible by vehicle and was an hour's walk to the nearest road. No sanitary facilities were available, and water from streams was consumed without treatment. Approximately 20,000 persons attended from the United States and several foreign countries. The state health department requested federal assistance to establish and maintain public health surveillance and to advise on outbreak prevention and control. This report describes the public health aspects of the gathering and presents recommendations for the management of health risks at large outdoor events.
RFLL was asked by the state health department's epidemiologists to conduct or permit surveillance for persons with injuries, vomiting, and diarrhea at the RFLL clinic, the Center for Alternative Lifestyles Medicine (CALM). CALM was predominately staffed by herbalists, faith healers, and acupuncturists. CALM did not maintain records of patient visits but stocked supplies for obtaining stool samples if the staff encountered large numbers of patients with diarrhea. Public health workers visited the CALM clinic daily to inquire about the number of patients and spectrum of diseases encountered; CALM staff requested that these interactions be informal and not involve written records.
Surveillance for injuries and diseases was conducted at the 15 hospitals and clinics within a 75-mile radius of the Pennsylvania gathering. Emergency department (ED) directors of the 15 facilities were informed in person or by telephone about the gathering and were asked to inform their staff about the gathering. From June 27 to July 7, the peak period of attendance, ED staff asked all persons seeking care at their facility whether they were affiliated with the gathering, and if they were, to record on a provided form the participant's age, sex, reason for visit, and medical disposition. Facilities were requested to return the form by fax each day. Telephone calls to all ED directors were made at the end of the surveillance period to verify data completeness.
Five facilities in the surrounding area reported caring for 115 persons affiliated with the gathering; 112 were attending the gathering, and three were local law enforcement officers detailed to the event. The median age of patients was 23 years (range: 1-70 years) and 69 (60%) were male. Fourteen (12%) of the 115 persons required hospital admission. Twenty-eight (24%) of the 115 sought care for apparent infections, including nine cases of diarrheal illness for which no pathogen was identified. Twenty persons (17%) had musculoskeletal injuries related to falls or altercations; 17 (15%) sought care for soft tissue injuries, 12 of which were bites (e.g., four brown recluse spider bites, two dog bites, and one rattlesnake bite). One death occurred as the result of complications from a myocardial infarction. Other reasons for seeking care included 13 (11%) psychiatric conditions, seven (6%) motor-vehicle–related injuries, five (4%) environmental exposures (e.g., severe sunburn and lightning strike), and obstetric/gynecologic, noninfectious gastrointestinal, neurologic, allergic, and neoplastic conditions (less than 5% each). Although not a presenting complaint, lice infestation and illicit substance abuse among RFLL members were reported by medical staff.
Outbreak prevention measures included hygiene and health information provided by public health staff, and training sessions for clinic staff about risks for infectious diarrhea, Lyme disease, and rabies. Signs were posted on the grounds describing appropriate latrine use, handwashing, and water treatment. In addition, the state agency that certifies commercial kitchens in Pennsylvania provided a courtesy "walk-through" to reinforce safe foodhandling practices in the kitchens.
Reported by:
D Fapore, P Lurie, MD, M Moll, MD, A Weltman, MD, J Rankin, DVM, State Epidemiologist, Pennsylvania Dept of Health. Epidemiology Program Office; and an EIS Officer, CDC.
CDC Editorial Note:
Mass outdoor gatherings can occur in settings with inadequate sanitary facilities and potable water. Crowded conditions increase the potential for food and water contamination, and foodborne and waterborne outbreaks.1-3 Although guidelines are available for public health management of displaced persons,4-5 guidelines have not been published for managing the health of persons attending special outdoor events in the United States.
This report is subject to at least two limitations. First, no formal surveillance existed within CALM; therefore, the number of persons seeking health care and the spectrum of illnesses and injuries cannot be determined. Second, persons seeking care in the surrounding medical centers identified through surveillance may have had more serious illnesses than those reporting to CALM. The number of these persons may have been underestimated because they may not have been asked or they did not identify themselves as affiliated with RFLL.
Effective public health planning for special event gatherings can be achieved through collaboration among the event's planners; community representatives; and local, state, and/or federal agencies responsible for health and safety. Plans should include (1) assessing the size of the event and the likely health needs of participants; (2) learning about local environmental hazards and diseases (e.g., rabies, Lyme disease, giardiasis, and vectors); (3) estimating local response capacity for laboratory diagnosis and emergency medical treatment; and (4) preparing triage and evacuation systems. Epidemic diarrheal diseases are a concern at outdoor gatherings where there are no sanitary facilities or safe sources of water; therefore, plans for preventing enterically transmitted diseases should include providing clean water, sanitary facilities, personal hygiene information, and surveillance for the prompt detection of epidemics.4
REFERENCES
1. Horwitz MA, Pollard RA, Merson MH, et al. A large outbreak of food borne salmonellosis on the Navaho Indian Reservation: epidemiology and secondary transmission. Am J Public Health. 1977;67:1071-6.
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2. Lee LA, Ostroff SM, McGee HB, et al. An outbreak of shigellosis at an outdoor music festival. Am J Epidemiol. 1991;133:608-15.
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3. Wharton M, Spiegel RA, Horan JM, et al. A large outbreak of antibiotic-resistant shigellosis at a mass gathering. J Infect Dis. 1990;162:1324-8.
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4. CDC. Famine-affected, refugee, and displaced populations: recommendations for public health issues. MMWR. 1992;41(no. RR-13).
5. Medecins Sans Frontieres. Refugee health: an approach to emergency situations. Hanquet G, ed. Kowloon, Hong Kong: Macmillan Education Ltd, 1997.
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