International Journal of Current Medical And Applied Sciences, 2017, August, 15(3),149-152.

ORIGINAL RESEARCH ARTICLE

Mass Gatherings - A Public Health Perspective

1 2 Cynthia Subhaprada S. & Kalyani P.

1Associate Professor, 2 Postgraduate students, Department of Community Medicine, Kurnool Medical College, Kurnool-518002. Andhra Pradesh. . ------Abstract: Background: India, a land of spirituality and philosophy, is home to a large number of religious gatherings and pilgrimages such as Pushkaras, Kumbh melas, Rath Yatra, Ramzan and . So, understanding the can highlight the health challenges faced and provide crucial lessons for the management of mass gatherings. Objectives: To describe the health problems among the pilgrims and the public health measures during an event of mass gathering Methods: This descriptive study conducted from July to August, 2016, used the in Srisailam, Kurnool district, as a case study to provide an overview of the medical planning for an event of mass gathering. This festival, held from 12, August to 23, August, 2016 is observed once in twelve years, along the banks of River Krishna. The data from the pilgrims who voluntarily presented themselves to the outpatient booths allocated to the interns from the Department of Community Medicine, Kurnool Medical College, Kurnool, posted at the site, as part of the medical team, was collected to analyze the common symptoms encountered and medical services made available. Results: Among the study subjects, majority (40%) had respiratory ailments of which 45.8% were reported among under 5 children and there were a few (10%) with non-communicable diseases. Conclusions: It is necessary to better understand health risks among pilgrims for a unified approach to create awareness among pilgrims, public health personnel and community during mass gatherings. Keywords: Mass gathering, public health.

Introduction: According to the World Health Organization (WHO), a large attendance, duration of the event & security mass gathering (MG) is ‘‘any occasion, either organized concern [4]. or spontaneous, that attracts sufficient numbers of Most of MGs are planned in advance and recurrent, people to strain the planning and response resources of taking place at the same location like religious the community, city or nation hosting the event’’ [1]. ceremonies (e.g. Hajj) or in a different location These have the potential to overwhelm health services comprising a wide range of activities such as sport as a result, mass gatherings require careful planning. events (e.g. the FIFA World Cup, the Olympic Games), The magnitude is widely contextual, from a couple of social events (e.g concerts), although some events such thousand to a few million [2]. The term special event as Pope’s funeral occur spontaneously. These may also medical care has also been used and has been defined as include some other public events like cultural, “the provision of preventive measures or definitive educational activities and even political rallies. primary care, or hospital referral to persons attending the mass gathering events [3]. Characteristics of mass gatherings that impact public health services include

Address for correspondence: Dr. Cynthia Subhaprada S Associate Professor, Access this Article Online Department of Community Medicine, Kurnool Medical College, Website: Kurnool-518002. Andhra Pradesh. India www.ijcmaas.com EmailHow: to cite this article: [email protected] Cynthia Subhaprada S. & Kalyani P. : Mass Gatherings - A Public Health Perspective International Journal of current Medical and Applied Subject: sciences; 2017, 15(3),149-152. Medical Sciences Quick Response Code

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Cynthia Subhaprada S. & Kalyani P.

In Hindu festivals, worshiping rivers once in twelve little attention to public health [9-11]. This makes it years along each river is called Pushkaram and in imperative to take a critical look at the public health Telugu, it is called as Pushkaralu, an Indian festival. It risks, such as infectious diseases, that could severely constitutes a large number of people gathered at a disrupt the management of MGs [12]. specific place and time. Attracting such a significant Hence the present study was conducted during the number of pilgrims, as well as support staff, the Krishna Pushkaralu, Srisailam, Kurnool district, to event has the potential to place additional pressures describe the health problems among the pilgrims on local health services, making it important to have and the public health measures during such an event appropriate medical care provided on-site. of mass gathering. Health promotion through public health messages should be the core work stream in any mass Materials and Methods: gathering planning to minimize the Public Health This descriptive study conducted from July to risk. This potential of using such events for health August, 2016, used the Pushkaram in Srisailam, promotion is largely untapped. Health problems Kurnool district, as a case study to provide an associated with changes in population dynamics and overview of the common health problems behaviors during MGs have drawn the attention of encountered and the Public Health measures in such Public Health authorities. Mass gathering events a mass gathering event. pose critical health challenges, especially for the is one of the largest rivers in India control of diseases. The rising population, better after , Brahmaputra and Godavari. It has a connectivity, and scope of travel have increased the length of about 1300 kilometers, originating from frequency and magnitude of mass gatherings and Western Ghats of Mahabaleshwar and it flows underscore the need to shift the discourse from through the states of , Karnataka and reacting to the public health issues they throw up to Andhra Pradesh before merging in the Bay of Bengal taking active steps in preventing them based on at Hamasaladeevi in Andhra Pradesh. According to evidence, through research. Hindu mythology it is believed that all deities and MGs are of great importance from an rishis/holy men take a holy dip in the rivers, hence epidemiological point of view, because of the pilgrims from all over India descend on the banks of potential risk of transmission of infectious diseases. Krishna River to have a holy dip with the belief that Firstly, the participants may themselves play a role they would be relieved of all sins, and perform as a source of infection among the people (e.g. cases rituals to departed souls. Pushkaram has been an age of undiagnosed tuberculosis) or they may be old practice in southern states of Andhra Pradesh, susceptible to infectious agents which are in Karnataka and Telangana. In 2016, the celebrations circulation at the location (for example people not started on 12 August and ended on 23 August, along vaccinated against measles traveling to a country the banks of River Krishna in Patala Ganga Ghat, with an ongoing disease outbreak). Secondly, mass Srisailam [13]. gathering puts a severe strain on the health care Patients who self-presented to the outpatient booths system of the host countries and communities. In were considered as the study subjects for this study. such a complicated situation, a combination of Thus, the study subjects were the pilgrims who factors such as overcrowding, restricted accessibility, voluntarily presented themselves to the outpatient insufficient crowd control, and lack of on-site booths allocated to the interns from the Department medical and health care predictions can lead to of Community Medicine, Kurnool Medical College, catastrophic consequences [5]. Another Kurnool, posted at the site, along with the medical characteristic of MGs is the dispersion of participants team of specialists from Government General and pilgrims almost immediately following the Hospital, Kurnool, during the above period, in gathering, which increases the risk of spreading of Srisailam. No personal identifying information on communicable diseases within their country/place of individual patients was collected. Data was collected origin. With regard to the nature of population regarding the common presenting symptoms among movement that takes place in MGs, traditional com- the study subjects and medical services made municable diseases surveillance systems are not able available. to efficiently capture all the information needed for disease control and management activities [6]. Observations & Results: MGs may also have considerable implications in relation to other acute public health incidents such The Krishna Pushkaralu, like other religious events, as pandemics and disasters, which also require was largely an organized, low-adrenaline event, with planning, preparedness, and management, and an fixed rituals and practices. The role of the medical increase in the capacities of the health systems [7]. team was to attend to the emergency cases, provide However, resource materials and studies on how to primary care to the pilgrims and support staff. prepare for and manage health risks during MGs Among the study subjects, majority (73.6%) were have not been developed fully [7, 8]. Most of the males and a maximum number of subjects were from existing guidelines on MG events focus mainly on the age group of 0-10 years (Table 1). crowd control and the prevention of stampedes; with

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Table1: Demographic profile of the study subjects: Characteristic No. (%) N=1600 Percentage Gender Male 1178 73.6% Female 422 26.4% 0-10 821 51.31% Age- 11-20 50 3.12% Group 21-30 265 16.56% 31-40 215 13.43% 41-50 147 9.2% 51-60 82 5.13% 61-70 20 1.25%

Table 2: Common Health problems among study subjects: Disease Frequency % Respiratory diseases 1525 40.76% Diarrheal diseases 110 2.94% Diabetes 376 10.05% Hypertension 381 10.18% Fever 265 7.08% Allergic disorder 296 7.91% Body pains 692 18.49% Injuries 95 2.53% Snake bite 1 2.67%

Among the study subjects, the common health Pushkaram had resulted in overcrowding, with the problems encountered were respiratory diseases potential to lead to stampedes and crush injuries, and diarrhoeal disorders, out of the communicable though such incidents were not encountered. diseases. Table 2 also shows that there were some Professional swimmers were also present for search who had been suffering from a chronic non- and rescue operations in case of any drowning communicable disease and approached the episodes, apparently none occurred around this outpatient booths for management of a complaint of time. acute exacerbation associated with that particular chronic condition or a misplaced prescription. Discussion: The outpatient booths had first aid kits and essential The collection of patient presentation data and medicines required to manage and treat these analysis of the presentation rate is variable and conditions. Those who needed secondary and author dependent. Zietz et al found that over a 9-day tertiary medical care were provided free ambulance agricultural show, patient presentations totaled service to the nearest higher centers without delay. 1,028 persons [14]. It is difficult to create definitive A Community health centre was present within a patient estimates for mass gathering events because reach of 15 km from the ghat where emergency cases of unique variables like prevalent environmental were treated to some extent. Recognizing the conditions and crowd demographics functional at importance of water, sanitation, and hygiene in such events. Public Health information is essential to minimizing health risks, the government had taken enable the public to take any necessary precautions substantial measures such as sanitizing the ghat to protect their health and enjoy the mass gathering areas every 2 hours, checking the bacterial levels safely. So the key messages to the public during mass once every 2 hours and chlorinating accordingly, gathering event should be very clear, appropriate providing free mineral water and food, mobile toilets and utilize media channels that are appropriate. installed at every ghat, taking cultural preferences Community involvement is important to ensure into consideration, with adequate quality and appropriate health behaviour and health quantity of water. communication strategies are implemented. As the event involved bathing in the river, of a few Planners should work with local communities to fully lakhs of people, there was an increased risk of water- understand public priorities and needs. borne infections, respiratory infections and also Interventions and communications should be tested sexually transmitted infections which were prior to implementation and barriers should be underreported. The sheer density of people identified and addressed to enable the public to descending on the river banks at Srisailam benefit from health promotion interventions.

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References: Conclusion: 1. World Health Organization. Communicable The data generated during the study shows that disease alert and response for mass gatherings. Public health and mass communication professionals Technical workshop. Geneva, Switzerland, April were engaged in planning this mass gathering event 29–30, 2008. 2. Memish ZA, Stephens GM, Steffen R, Ahmed QA. so as to ensure that public health risks and health Emergence of medicine for mass gatherings: promotion opportunities are identified and realized. lessons from the Hajj. Lancet Infect Dis Many of the health needs of the pilgrims, safe water 2012;12:56–65. and sanitation services had been addressed. While 3. Baker WM et al. Special event medical care :the there is more that can be done, the overall health 1984 Los Angeles Summer Olympic experience. risks associated with Pushkaralu have come down Annals of emergency medicine,1986 ,15:185-190. considerably. The process of evolution towards 4. Franaszek.J. Medical care at mass gatherings. better outcomes, challenges faced, lessons learnt, Annals of emergency medicine, 1986, 15:.600- and strategies used in a low-resource setting need to 601. 5. Soomaroo L, Murray V. Disasters at mass be better documented and evaluated. gatherings: lessons from history. PLoS Curr. The most common communicable diseases during 2012;4: RRN1301. this event were respiratory infections, diarrheal 6. Yom-Tov E, Borsa D, Cox IJ, Mc Kendry RA. diseases. The findings of this study would help in Detecting disease outbreaks in mass gatherings providing solutions and making recommendations using Internet data. J Med Internet Res. 2014;16. for prevention and management of infectious 7. World Health Organization. Global mass diseases during mass gathering event. Awareness on gatherings: implications and opportunities for prevention by vaccination, community measures, global health security. Geneva: WHO; 2011. infection prevention and control practices for 8. Lombardo JS, Sniegoski CA, Loschen WA, Westercamp M, Wade M, Dearth S, Zhang G. pilgrims apart from early diagnosis and prompt Public health surveillance for mass gatherings. treatment was stressed upon and relevant health Johns Hopkins APL Tech Dig 2008;27:347–55. education messages were provided. 9. Health and Safety Executive. The Event Safety The war against travel-related infections is a shared Guide: The purple guide to health safety and responsibility. Interstate collaborations and welfare at music and other events. Norwich, UK: networks should focus on preventive measures by Health and Safety Executive; 1999. health care professionals and community groups. 10. National Disaster Management Authority of India. Creating a multi-disciplinary consortium that can Managing crowds at events and venues of mass- share data, engage in research, and develop gathering: a guide for state governments, local authorities, administrators and organizers. New guidelines is the way forward in addressing health Delhi, India: NDMA; 2014. related issues in an event of mass gathering. 11. Federal Emergency Management Agency. Special events contingency planning: job aids manual. Acknowledgement: Washington DC, USA: FEMA; 2005. The authors take this opportunity to thank Dr. G. S. 12. Khan K, Memish ZA, Chabbra A, Liauw J, Hu W, Rama Prasad M.D (Paed, PGIMER, Chandigarh), Janes DA, et al. Global public health implications Professor of Paediatrics and Principal, Kurnool of a mass gathering in Mecca, Saudi Arabia during Medical College, Kurnool, Dr. A. Sreedevi MD, the midst of an influenza pandemic. J Travel Med 2010;17:75–81. Professor and HOD of Community Medicine, Kurnool 13. Krishna Pushkaralu - Wikipedia. Medical College, Kurnool and the interns posted in https://en.wikipedia.org/wiki/Krishna_Pushkara the department during July-August 2016, for their lu. co-operation to carry out this study. 14. Zeitz KM, Schneider DPA, Jarrett D, Zeitz CJ. Mass gathering events: retrospective analysis of patient presentations over seven years. Prehosp Disaster Med 2002;17(3):147. ------

Conflict of interest: None declared Source of funding: None declared

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