title: Mass Gatherings and Respiratory Disease Outbreaks in the United States - Should We Be Worried? Results from a Systematic Literature Review and Analysis of the National Outbreak Reporting System.
abstract: BACKGROUND
  Because mass gatherings create environments conducive for infectious disease transmission, public health officials may recommend postponing or canceling large gatherings during a moderate or severe pandemic. Despite these recommendations, limited empirical information exists on the frequency and characteristics of mass gathering-related respiratory disease outbreaks occurring in the United States.
  
  
  METHODS
  We conducted a systematic literature review to identify articles about mass gathering-related respiratory disease outbreaks occurring in the United States from 2005 to 2014. A standard form was used to abstract information from relevant articles identified from six medical, behavioral and social science literature databases. We also analyzed data from the National Outbreaks Reporting System (NORS), maintained by the Centers for Disease Control and Prevention since 2009, to estimate the frequency of mass gathering-related respiratory disease outbreaks reported to the system.
  
  
  RESULTS
  We identified 21 published articles describing 72 mass gathering-related respiratory disease outbreaks. Of these 72, 40 (56%) were associated with agriculture fairs and Influenza A H3N2v following probable swine exposure, and 25 (35%) with youth summer camps and pandemic Influenza A H1N1. Outbreaks of measles (n = 1) and mumps (n = 2) were linked to the international importation of disease. Between 2009 and 2013, 1,114 outbreaks were reported to NORS, including 96 respiratory disease outbreaks due to Legionella. None of these legionellosis outbreaks was linked to a mass gathering according to available data.
  
  
  CONCLUSIONS
  Mass gathering-related respiratory disease outbreaks may be uncommon in the United States, but have been reported from fairs (zoonotic transmission) as well as at camps where participants have close social contact in communal housing. International importation can also be a contributing factor. NORS collects information on certain respiratory diseases and could serve as a platform to monitor mass gathering-related respiratory outbreaks in the future.
authors.affiliation: Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, GA, United States of America.
authors.forename: Jeanette J
authors.initials: JJ
authors.lastname: Rainey
authors.affiliation: Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, GA, United States of America.
authors.forename: Tiffani
authors.initials: T
authors.lastname: Phelps
authors.affiliation: Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, GA, United States of America.
authors.forename: Jianrong
authors.initials: J
authors.lastname: Shi
mesh_terms: D004196:Disease Outbreaks / Q000706:statistics & numerical data*; D006801:Humans; D008399:Mass Behavior; D011159:Population Surveillance; D012140:Respiratory Tract Diseases / Q000453:epidemiology* / Q000209:etiology; D014481:United States / Q000453:epidemiology