Mass gatherings events (MGEs) of all kinds are becoming more frequent in our communities. It is projected that the music MGEs in Canada alone will produce revenues of over 1 billion US dollars by 2025. 1 An important number of these MGEs are organized under the structure of music festivals, and take place in the larger cities of Canada located in the eastern provinces (Quebec and Ontario) and western provinces (British Columbia and Alberta). 2 These gatherings sometimes reach over 100,000 attendees and occur over multiple days. Sporting events such as marathons or sport tournaments are also becoming more and more prevalent and lucrative, with estimated revenue of over 1 billion of dollars in Canada alone for 2022. 3 The MGE crowds are mostly composed of healthy, young athletes or young adults considered “well persons,” but statistically have proved to be associated with a greater prevalence of injury and illness than in the general population. Reference Arbon4
MGEs can cause a burden on health systems. In addition to higher proportions of injury and illness, deaths have also been reported at MGEs. Reference Turris and Lund5 These deaths may be due to specific activities at MGEs that attendees participate in, or as a result of accidental disasters or intentional acts of harm. Reference Turris and Lund5–Reference Glick, Rixe and Spurkeland8 The recent coronavirus disease 2019 (COVID-19) pandemic also shed light on the high risks of infectious diseases spreading during mass gatherings. Reference Ranse, Beckwith and Khan9 Due to the factors mentioned above, MGEs can create additional resource challenges for health-care systems that are often already overburdened. Reference Milsten, Seaman and Liu10–Reference Almalki, Hart and Issa12 The Canadian health-care system has been suffering from an increase in overcrowding over the past 15 y, Reference Pearce, Marchand and Shannon13,Reference Affleck, Parks and Drummond14 with many factors contributing to this phenomenon, including an overall increase in the number of patients, as well as the unpredictability of medical needs. Reference Rowe, McRae and Rosychuk11 To alleviate this burden on health systems and provide appropriate care at MGEs, in-event health service (IEHS) professionals should be able to provide a certain standard of care, within a defined scope of practice, and be held accountable as other health providers.
There is a need to have MGE organizers and IEHS providers regulated. Over the past 3 decades, many articles have been published globally regarding MGEs, with most being single case reports or descriptive studies. These studies lack definitions and reporting of patient outcomes, therefore, limiting comparison between MGEs. Reference Turris, Rabb and Munn15–Reference Ranse, Hutton and Turris19 The paucity of literature, combined with a lack of standardized approach to data reporting on MGEs limits IEHS in the way they can draw conclusions and plan MGEs accordingly. Reference Guy, Prager and Turris16,Reference Turris, Rabb and Chasmar20 Thus, IEHS and MGE organizers are left without guidance on how they should prepare for MGEs. Reference Lund, Turris and Rabb21 To compensate for a lack of evidence, legislation and regulations should be provided for what constitutes the provision of reasonable IEHS at MGEs. To draft legislation, an understanding of the existing legislation on MGE IEHS provision would provide insight as to what constitutes a minimum requirement for MGEs. Reference Jaslow, Drake and Lewis22
This study aims to determine the existence and details of legislation, regulations, and guidance in Canada. Understanding Canadian legislation regarding MGEs will then inform the requirements for future legislation in both Canadian jurisdictions, and international jurisdictions, without legislation.
Methods
Study Design
This research was a cross-sectional descriptive study among the 10 provinces and 3 territories of Canada to determine if there are any acts, regulation, or guidelines that exist relating to MGE medical care.
Setting
This research is set in Canada, a federation, whereby the federal government, 10 provinces, and 3 territories all have different legislative requirements and oversight of different aspects of law. This oversight also includes oversight for MGEs. Municipal regulations are outside the scope of this study.
Sample
The sample for this research is any Act, Regulation, and/or Guideline that stipulates MGE medical care from any of the Canadian provinces and territories. For this study, an Act, also called a statute, is a law enacted by the Legislative Assembly. A regulation is delegated legislation, and is made by a person or body under the authority of an Act passed by the Legislature. 23 A guideline is not bound by any legal frameworks, rather, a guideline provides general principles and recommendations. However, aspects of a guideline are not enforceable by law.
Ethical Considerations
This review aimed to find any document that would be publicly available, as is normally the case for legislation. Contacts by means of agency e-mails and/or phone numbers that were available on the province government or agencies websites, were only used to guide the research and obtain the documents in a more pro-active manner. As such, the individuals that answered our requests were not considered research participants; none of their personal data or contact information were obtained.
Data Collection
Contact information for provincial and territory Emergency Medical Service (EMS) governing bodies were obtained by means of their respective websites, as shown in Table 1. Provincial and territorial agencies were then contacted by e-mail to determine if they were aware of any federal, provincial/territory, or regional MGE medical care legislation, regulations, and/or guidelines. Up to 2 e-mail reminders were sent, and if no response was received by means of e-mail, EMS governing bodies were then contacted by means of phone, for a maximum of 2 attempts. In some cases, inquiries were transferred to departments of ministries of health responsible for legislation. If e-mails and phone calls were not returned, a review of the published legislation was performed, by means of the Nahum Gelber Law Library. Data collection took place between October 16, 2022, and March 15, 2023.
Table 1. Contact information for provincial and territory EMS governing bodies
Abbreviation: EMS, Emergency Medical Service; N/A: not available.
Data Analysis
Data analysis was undertaken using descriptive statistics, such as frequencies. Data were analyzed directly into Microsoft Word tables.
Results
Of the 13 jurisdictions that were contacted, 10 replied. This represents a response rate of 76.9%. An overview of the laws, Acts, Regulations, and/or guidelines from each province and territory is outlined in Table 1.
Governance Structure for Regulations in Canada
The Canadian structure for governance is briefly summarized as follows. Federal government, as the highest level of governance, can issue legislations that will apply throughout the whole country; it is the case for immigration laws, for instance. Within the boundaries of these legislations, provinces can further implement more specific legislations or regulations. The federal government can also entrust provinces to governate on specific matters. If so, the legislative assembly of a province or territory has full power to enforce legislation, within boundaries of which localities can implement their own regulations; it is the case for Health, for instance.
Acts, Legislation, and Regulations
There were no laws or Acts identified that related to MGE medical response. However, it is noted that most of the jurisdictions that replied (n = 6; 60%) had clauses in their Public Health Acts relating to MGEs. Reference Justice25–30 These clauses were public health specific and not related to MGE medicine or IEHS; in fact, they do not contain any provision on acute health services or first responder-type activities. The Public Health Acts contain information related to public health aspects such as water access, sanitation, clean and sanitary aspects of MGEs. These Public Health Acts include broader aspects, such as when to cancel an event, and were referred to during the COVID-19 pandemic. However, no information or requirement as to a minimum standard specifically regarding the medical response or health infrastructure needed for MGEs was noted. Regulations on the topic of mass gatherings were enforced at the municipal level; therefore, their more in-depth analysis and comparison were outside the scope of this study.
Guidelines
Although no laws or Acts were identified specifically relating to IEHS at MGEs, nearly a third (n = 4; 30.8%) of the jurisdictions had some form of regulation. Guidelines were the most common form of governance document located, with 5 (38.5%) jurisdictions having some form of guideline. Of these 5, 3 were established event planning guidelines, 31–33 1 was pending and should be available sometime in 2024, and the remainder was an online workshop. Of the MGE guidelines, 3 provided suggestions for MGE management, of which also included IEHS aspects. 31–33 These suggestions included considerations for weather, size of the crowd, mass casualty incident protocols and emergency planning. These guidelines cover broad topics regarding general risk assessments of MGEs. However, only 1 guideline 33 contains a detailed section on risk and vulnerability assessment. Alberta’s Mass-Gathering Guidebook provides numerous charts, a risk assessment matrix, and a step-by-step approach to evaluating categories of MGE hazards. It also contains a specific chapter that briefly covers emergency plans and what to consider for specific scenarios such as lost children, mass casualty, bomb threat, etc. Nova Scotia’s guidelines also provide a sample worksheet for risk assessment but does not provide details and tools to adequately assess each of the components needed to complete the assessment. British Columbia’s guide is the only 1 that provides a stepwise approach to elaborating a medical plan for a MGE. 32 The 3 guidelines, although heterogeneously, cover key components of what should constitute a thorough risk assessment according to the WHO. 34 None of the guideline’s mandate or enforce any type of IEHS. The 3 guidelines were authored by provincial working groups, composed of stakeholders with a variety of MG expertise important to the organization of a major event: government, law enforcement, fire services, emergency medical services, environment, and weather services. None of the 3 guidelines provide specific information as to how the regulating organizations would provide authorizations for the event to take place.
Discussion
Absence of Legislation
This study demonstrates that, although there are some legislative requirements for MGEs from a public health perspective, there are no legislative requirements in Canada from an IEHS perspective. In a cross-sectional survey of states in the United States of America in 1999, Reference Jaslow, Drake and Lewis22 Jaslow et al. showed that only 6 states had specific guidance on IEHS provision at MGEs. The legislation of these 6 states were grouped in 2 categories, either public health and hygiene elements, or medical care elements. This first category shares many similarities with the Public Health Acts reported in this Canadian study. Arguably, both public health and IEHS are focused on protecting the health of MGE attendees and those in the communities where MGEs occur. As such, it would be reasonable to have legislation for IEHS and MGE organizers. Future research on this matter could include a Delphi study to identify most important areas to orient lawmakers in developing pertinent legislation. Many studies have been published to identify important aspects to consider in planning a mass gathering medical response, but a strong consensus on the way to address these issues is lacking.
Guidelines
Guidelines normally outline the interplay between factors that may influence the risk of patient presentations to an IEHS and the transport to hospital from an MGE. These factors can broadly be described as biomedical, psychosocial, environmental, public health, command and control, and security. Reference Hutton, Ranse and Zimmerman35 Internationally, many guidelines or considerations are primarily based on expert opinion rather than evidence. However, it could be argued that some guidelines bring a false sense of security to MGE organizers and attendees, while missing important parts of the risk assessment. It is also possible that focusing on the requirements without tailoring the plan to a specific MGE will lead to a lack of important resources to adequately respond during the event. The provincial guidelines described in this study use a descriptive approach to detail the important aspects of mass gatherings planning, rather than suggest ways to respond to or mitigate hazards.
Although it has been demonstrated that the presence of an IEHS on-site during an event may influence risky behaviors among attendees, Reference Hutton, Munn and White36 it has not been shown to influence the rate of patient presentation and severity of medical emergencies in any ways. Reference Goldberg, Maggin and Molloy37 Given the above, there is no consistency; the medical response is not evidence based and primarily based on resource allocation depended on the budget of the event organizer rather than the health needs of the attendees or communities where MGEs are being held. Guidelines are not enforceable; however, guidelines may be used to inform contracts and general IEHS provision. In the absence of legislation, guidelines should be in place in all jurisdictions. Guidance for similar MGEs could be a place to commence standardization for MGEs. Engaging with MGE industries, organizations, and associations would be a reasonable place to start developing standardized guidelines.
Contracts
In the absence of legislation and guidelines, MGE organizers and IEHS providers will still develop MGE plans, considering health issues and providing a medical response for attendees. In this situation, MGE organizers’ obligations are not enforced by law, instead agreed to within contracts between MGE organizers and IEHS providers. Contracts are often agreed upon between these parties to provide health support at MGEs. This study did not explore individual contacts between IEHS providers and MGE organizers. However, contracts often include an agreed upon cost for providing IEHS, usually in the form of an agreement between parties on the minimal standards of IEHS provision at an MGE. These standards are negotiated between parties and vary between MGE types, while also taking into consideration the financial means of both parties. The downside of this situation is that these contractual clauses can be very broad and not specific without taking into consideration many crucial aspects of the planning related to a particular MGE. Financial considerations may also overly influence the planning and response process. While these considerations may mean that many MGE have some IEHS provision, standardized legislation to ensure that all MGEs have a basic, minimum response plan in place would protect MGE attendees and the health resources in the communities where MGEs are being held.
Despite some jurisdictions having some legislation relating to public health aspects of MGEs, no jurisdictions had specific IEHS provision or MGE organizer requirements. As such, MGE organizers and IEHS providers may rely on guidance documents, which are limited to 3 jurisdictions. As a result, IEHS providers and MGE organizers essentially determine, on an individual MGE basis what the minimum IEHS provision will be. This provision is often embedded within contracts. Legislation is required to ensure a standardized approach to IEHS provision with consequences when adequate services are not provided. Legislation would be an important step in providing safer MGEs.
Limitations
This research was conducted in 1 country. The legislative requirements of other countries may also provide insight for Canada. Therefore, future research should explore legislation internationally to inform practice locally. A further limitation was the collection of data directly from EMS in each jurisdiction. In some jurisdictions, our inquiries were transferred to deputy ministers or communication officers within the ministry of health, whereas in some others we got feedback by means of EMS directors or other field representatives. Finally, our research strategy did not access municipal legislations or guidelines. It may be that some municipalities may have guidelines for MGE organizers.
Conclusions
The lack of MGE legislative requirements demonstrated in this study may result in attendees and host communities of MGEs being at risk of avoidable morbidity and mortality. Guidelines are heterogeneous and provide variable guidance in different provinces and territories. Strengthening legislation and guidelines may strengthen health outcomes for event attendees and communities where events are held.
Authors contributions
Marc-Antoine Pigeon had the original idea for the research. Marc-Antoine Pigeon, Attila Hertelendy, and Alexander Hart designed the protocol. Marc-Antoine Pigeon conducted the data collection and analysis. All authors equally contributed in writing and reviewing the manuscript.
Funding statement
None of the authors received funding to participate in this study.
Competing interests
Adam Lund has been working as a medical director for many events and medical coverage companies for many years, although none of them provided funding for this research. Marc-Antoine Pigeon volunteers as medical director for many events and as provincial commissioner for St-John Ambulance Canada, Council of Quebec, and did not receive any funding for this research.
