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BRIEF RESEARCH ARTICLE
Year : 2020  |  Volume : 64  |  Issue : 2  |  Page : 198-200  

Public health surveillance during Simhastha Kumbh, a religious mass gathering in Ujjain district, Madhya Pradesh, India, 2016


1 Directorate Health Services, Bhopal, Madhya Pradesh, India
2 National Centre for Disease Control, New Delhi, India
3 Centers for Disease Control and Prevention, Delhi, India
4 DGHS, GoI, India

Date of Submission05-Feb-2019
Date of Decision18-May-2019
Date of Acceptance06-May-2020
Date of Web Publication16-Jun-2020

Correspondence Address:
Meera Dhuria
Division of Epidemiology, National Centre for Disease Control, 22 Shamnath Marg, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_53_19

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   Abstract 


A daily surveillance for disease detection and response at the Simhastha Kumbh Mela, in Ujjain, Madhya Pradesh, April–May 2016, was established. Existing weekly reporting of the Integrated Disease Surveillance Programme (IDSP) was modified to report 17 diseases or events from 22 public hospitals and three private hospitals in Ujjain. Water samples were also tested for fecal contamination in areas reporting diarrhea. We identified 56,600 ill persons (92% from government hospitals and 8% from private hospitals): 33% had fever, 28% acute respiratory infection, and 26% acute diarrheal diseases. There were 15 deaths (12 injury and 3 drowning). We detected two diarrhea outbreaks (Mahakaal Zone with 9 cases and Dutta Akhara Zone with 42 cases). Among 26 water samples, eight showed fecal contamination. This was a large implementation of daily disease surveillance in a religious mass gathering in India by IDSP. We recommended laboratory confirmation for diseases and similar daily surveillance in future mass gatherings in India.

Keywords: Kumbh, mass gathering, outbreak response, surveillance


How to cite this article:
Goel P, Dhuria M, Yadav R, Khasnobis P, Meena S, Venkatesh S. Public health surveillance during Simhastha Kumbh, a religious mass gathering in Ujjain district, Madhya Pradesh, India, 2016. Indian J Public Health 2020;64:198-200

How to cite this URL:
Goel P, Dhuria M, Yadav R, Khasnobis P, Meena S, Venkatesh S. Public health surveillance during Simhastha Kumbh, a religious mass gathering in Ujjain district, Madhya Pradesh, India, 2016. Indian J Public Health [serial online] 2020 [cited 2020 Jul 2];64:198-200. Available from: http://www.ijph.in/text.asp?2020/64/2/198/286822



Mass gatherings, the concentration of people at a specific location for a specific purpose over a set period of time, have the potential to strain the health planning and response resources of the community.[1] In 1991, a measles outbreak occurred at the International Special Olympics,[2] and in 2000, a meningococcal outbreak occurred after the Hajj Pilgrimage.[3] Mass gatherings pose many additional challenges beyond communicable diseases, such as lack of food hygiene, inadequate waste management, and poor sanitation, crowd management, security, and medical emergency preparedness for causalities.[4] Outdoor events are associated with complications of exposure, dehydration, sunburn, heat exhaustion, and stampedes. On October 13, 2013, casualties due to stampede were reported during a religious mass gathering in Madhya Pradesh, India.[5]

Kumbh Mela is a Hindu religious mass gathering which attracts millions of people from across the country and world, creating immense pressure on the host city's resources.[6] Simhasth Kumbh Mela was held in Ujjain, Madhya Pradesh, on the banks of Shipra River. Ujjain, a city of a half million people, hosted an estimated 50 million people during the Simhastha Kumbh between April 22, and May 21, 2016. A temporary city with additional infrastructure was established in 4000 hectares around the Ujjain city to accommodate the pilgrims.

The Integrated Disease Surveillance Programme (IDSP), India's national program for disease surveillance, collects information on health events from participating health facilities weekly. A risk assessment team found the existing weekly surveillance system insufficient to meet the requirements of this large mass gathering. Thus, IDSP set up daily surveillance for public health events to analyze disease trends, rapidly detect outbreaks and health emergencies during the Ujjain Simhastha. This report describes the established surveillance system and its findings.

Ujjain, including the permanent and temporary city, was divided into six administrative zones (KaalBhairav, Mangalnath, Dutta Akhara, Mahakaal, Chamunda Mata, and Triveni). Zones were further divided into 22 sectors. A centralized control room was set up for various departments involved in Mela response including public works, municipal corporation, home security, and health.

Temporary health facilities were set up in all the zones and sectors of Mela area with additional staff deployed for providing primary health care to the visiting pilgrims.

We developed a standardized daily reporting format for public health surveillance during the Simhastha Kumbh event in Ujjain. Formats were modified from the existing weekly reporting formats of IDSP. A total of 17 public health events including 11 events already under IDSP (fever, acute respiratory illness/influenza like Illness (ILI), acute diarrheal disease, dog bite, dysentery, malaria, jaundice/viral hepatitis, chicken pox, snake bite, dengue/dengue hemorrhagic fever/dengue shock syndrome, and measles) and 6 events added specifically for this mass gathering (skin disease, heat stroke/heat exhaustion, major injury/trauma, conjunctivitis, burn, and drowning) were included for surveillance. We also established a media scanning cell and a 24-h call center.

There were 39 reporting units: 1 district, 5 zonal, 16 sectoral, 7 satellite town hospitals, 1 medical college in public sector, and 9 volunteering private hospitals. The reporting unit collected information from outpatient and inpatient registers and shared reports with district epidemiologist at District Surveillance Unit (DSU) via paper, E-mail, or WhatsApp by 2 pm daily.

A daily summary report was shared by DSU after evening control room meeting with the state's Principal Secretary (Health), Director of Health Services, and District's Chief Medical Officer. Surveillance team members visited the sites on the basis of day's analysis showing any clustering of cases to check data quality and completeness, sensitization of staff about case definitions, and to conduct water testing (residual chlorine and fecal contamination) wherever acute diarrheal disease (ADD) cases were reported. Zonal outbreak rapid-response teams were formed comprising a district epidemiologist, surveillance team member, and first aid team.

There were 298,465 patients seen, 279,287 (94%) patients in outpatient and 19,178 (6%) patients admitted in hospitals of Simhastha area between 16 April and 22 May 2016 [Figure 1]. Among these, 56,600 ill persons (92% from government hospitals and 8% from private hospital) reported at least one of the 17 public health events under surveillance. Among these 17 public health events, fever, acute respiratory infection (ARI)/ILI, and ADD cases together accounted for about 87% of the reported conditions [Table 1].
Figure 1: Number of cases reported in public health surveillance during Simhastha Kumbh Ujjain Madhya Pradesh, April–May 2016.

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Table 1: Health event reported in public health surveillance during Simhasth Kumbh Ujjain Madhya Pradesh, April-May 2016 (n=56,600)

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There were 15 deaths reported (12 from injuries and 3 from drowning). An increase in the number of patients attending health facilities was observed as the Mela progressed. Two referral hospitals (district and Madhav Nagar hospital) from Chamunda Mata zone reported 20,459 (36%) cases and had the most fever (7,193, 39%), ARI (6,225, 39%), and ADD (5397, 37%) cases. Overall, 39 reporting units submitted reports with 100% timeliness and 66% (947/1443) completeness. We tested 26 water samples from places reporting large number of ADD cases; eight (30%) showed fecal contamination.

The results were shared everyday with Mela health authorities and departments such as public health engineering and disaster management to review resource requirement, outbreak detection, and planning for next day priorities and for better coordination of public health response.

Media scanning covering regional and local newspapers did not capture any outbreak or health-related event.

On April 29, 2016, eight students were admitted to the district hospital with complaints of abdominal pain, diarrhea, and vomiting from a residential school in Mahakal Zone. On 30 April 2016, rapid response team investigated and identified 9 cases with a median age of 14 years (range 12–19) and attack rate of 29% (9/31) in school. We could not identify any common food item association through food history. The drinking water source was through a bore well located inside the campus. We tested water from two sites (mess and hostel building) through hydrogen sulfite test and found both positive for fecal contamination. Sample of food, stool, or vomitus could not be collected. Advice was given to consume freshly prepared food and maintain hand hygiene during food preparation and consumption.

On 11 May 2016, 42 international pilgrims (41 Japanese and 1 Russian) were admitted in the district hospital with complaints of abdominal pain, fever, vomiting, and headache from a camp in Dutta Akhara Zone. Pilgrims could not be interviewed as they were discharged next day and left Ujjain. Among five stool samples taken at admission, no growth on culture was observed. Next day, the Rapid Response team visited the affected to conduct active search for cases but did not find any new case.

On 5 May 2016, there was heavy rain with thunderstorms, during which 7 people died and 50 were injured due to the collapse of temporary structures mostly in Mangalnath zone. Information regarding injuries and causality was immediately shared with nearest zonal teams for quick response.

This report describes a large-scale, temporary, daily surveillance system successfully implemented by IDSP in one of the largest religious mass gatherings in the world. The system provided policy makers with daily data for planning purpose and response to multiple public health events during the event. Being a partner in the Global Health Security Agenda for a safer and secure world under the International Health Regulations, this response demonstrated India's effort toward enhanced disease surveillance for detection and response.

The state initiated the planning for clinical services much in advance but setting up systematic public health surveillance was initiated only 1 month in advance in March 2016. Ideally, such surveillance systems should be planned when the preparations for the mass gathering event begins. During Athens Olympic held in August 2004, preparation for public health surveillance started over a year in advance in February 2003.[7]

This was the first time IDSP coordinated the surveillance activities for a large religious mass gathering. This demonstrated the flexibility of IDSP to be adapted and customized (from weekly to daily reporting) for such events.[8] This experience will guide future efforts for daily surveillance during other mass gathering in India.

Medical care is an important component of mass gathering preparedness. This surveillance system helped administration and other stake holders to understand disease patterns in this mass gathering and to prepare for future needs. Fever, ARI/ILI, and ADD are common public health events in religious mass gatherings in India[9] and were commonly found in this event. Simhastha was celebrated during peak summer season which resulted in more heat-related illnesses. In Simhasth, as in many religious gatherings in India, people take a holy dip in the river, so there was an important risk of drowning.

Limitations of this mass gathering public health surveillance included nonrepresentativeness of private health sector and passiveness of surveillance.

Mass gatherings, particularly religious gatherings, in India are increasingly recognized for their public health importance. Continued government commitment and willingness to engage in preparedness and collaborate with other sectors will ensure safe mass gatherings in future. For surveillance during mass gatherings, we recommend advanced planning and coordination with other governmental and nongovernmental sectors. Use of the latest digital technologies for the surveillance of infectious disease at mass gathering events could be used to facilitate timely data collection.

Acknowledgment

We thank doctors - K. L. Sahu, N. K. Trivedi, Sanket Kulkarni, Nishant Kumar, Ranjeet Prasad, C. S. Moghe, Parul Goel, Sushma Chaudhary, Dipu Lowang, Prasoon Sheoran, Naveen Rastogi, Biswaprakash Dutta, Rajesh Sahu, Ulhas Jayant, C. S. Agarwal, Sandip Jogdand, Amol R. Patil, Rajeev Sharma, Samir V. Sodha, Shailendra Singh, Sudhir Kumar Jain, Sujeet Kumar Singh, malaria officers, malaria inspectors, pharmacist, staff nurses, and other health professionals of Department of Public Health and Family Welfare, Madhya Pradesh. We are also thankful to private hospitals for their continuous support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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World Health Organization. Public Health for Mass Gatherings: Key Considerations. World Health Organization; 2015. Available from: http://www.who.int/about/licensing/copyright_fo rm/en/index.html. [Last accessed on 2019 Jan 22].  Back to cited text no. 1
    
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Ehresmann KR, Hedberg CW, Grimm MB, Norton CA, MacDonald KL, Osterholm MT. An outbreak of measles at an international sporting event with airborne transmission in a domed stadium. J Infect Dis 1995;171:679-83.  Back to cited text no. 2
    
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Aguilera JF, Perrocheau A, Meffre C, Hahné S, W135 Working Group. Outbreak of serogroup W135 meningococcal disease after the Hajj pilgrimage, Europe, 2000. Emerg Infect Dis 2002;8:761-7.  Back to cited text no. 3
    
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Memish ZA, Zumla A, Alhakeem RF, Assiri A, Turkestani A, Al Harby KD, et al. Hajj: Infectious disease surveillance and control. Lancet 2014;383:2073-82.  Back to cited text no. 4
    
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Reply Government of India. Ministry of Home Affairs in Lok Sabha on; 17th December 2013.  Back to cited text no. 5
    
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Kasthala S, Lakra HS. Mass religious gatherings and disaster preparedness: A planning perspective institute of town planners. India J 2015. p. 1-17.  Back to cited text no. 6
    
7.
Tsouros AD, Efstathiou PA. Mass Gatherings and Public Health the Experience of the Athens 2004 Olympic Games. Available from: http://www.euro.who.int/__data/assets/pdf_file/00 09/98415/E90712.pdf. [Last accessed on 2017 Dec 08].  Back to cited text no. 7
    
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About IDSP. Integrated Disease Surveillance Programme (IDSP). Available from: http://idsp.nic.in/inde×1.php?lang=1 and level=0 and linkid=313 and lid=1592. [Last accessed on 2017 Dec 08].  Back to cited text no. 8
    
9.
Tracking Disease in a Tent City Harvard Gazette. Available from: https://news.harvard.edu/gazette/story/2013/03/t racking-disease/. [Last accessed on 2017 Dec 08].  Back to cited text no. 9
    


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