Identification of potential health risks in mass gatherings: A study from Sabarimala pilgrimage, Kerala, India
Introduction
A common definition for mass gathering is difficult [1], [2]. Amongst many definitions the one by WHO is widely accepted – it defines a mass gathering as'more than a specified number of persons (which may be as few as 1000 persons although much of the available literature describes gatherings as those exceeding 25,000 persons) at a specific location for a specific purpose (a social function, large public event or sports competition) for a defined period of time' [3], [4], [5], [6]. With the increase in population and urbanization, there has been a quantum jump in the number of people at mass gathering events especially religious congregations in India [6]. Around the world there are about 23 highly crowded religious places visited by more than 250 million people annually, and amongst these nine are situated in India [8]. The Sabarimala shrine in Kerala, where the present study was conducted, is one amongst the nine (Fig. 1).
Mass gatherings have the potential to turn into high morbidity and mortality incidents [9]. Such gatherings can lead to an increase in critical health risks when compared to other natural gatherings with similar number of people present [6]. At mass gatherings the crowd disasters like human stampedes or crush injuries are one of the main causes of mortality [10], [11], [12] and occur frequently with relatively high fatality rate, therefore becoming a matter of concern [9], [13], [14], [15], [16]. Other health-related incidents such as heat or cold related illness [17], food and water-borne illness [18], communicable diseases [19], [20], drugs related illness and injury [21], large outbreak of meningococcal disease [22], and even crimes and terrorist attacks [23], [24] could also occur. It could be said that such events have the potential to disrupt the health care system of the local medical infrastructure and medical community. The impact at the state level or the national level is limited, but the loss of confidence amongst the pilgrims could translate to their reduced inflow, which could impact the local economy to a certain extend [25].
The identification of potential risks is the key factor in every disaster management measure. The present study proposes a methodology adopted and modified from the original Northwest Center for Public Health Practice documents [26] for the potential health risk identification in mass gatherings (MG). The thrust of the study has a disaster management perspective, though it is rooted in the responses of the medical practitioners. Risk assessment is a continuous process that should occur throughout the period leading up to the MG and during the MG itself. It should include ongoing assessment of how the public health system, the health care system and the broader community will cope or are coping with increases in communicable diseases or disease-risk related to the MG. Mass gatherings represent many struggles for health care professionals [27], [28], [29], [30]. The present study deals with the key health considerations for establishing plans and structures to manage health security outbreaks or incidents at mass gatherings. Also the challenges faced by health care professionals in mass gatherings are also a matter of concern.
Section snippets
Research questions
The two main research questions posed in the present study are:
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What are the potential health risks associated with Indian religious gatherings?
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What are the difficulties faced by doctors in a mass gathering?
Materials and methods
A direct in-depth interview was conducted among 46 doctors at district, sub-district level and in the Government Medical College, Kottayam with the help of a questionnaire between January and March 2014. The questionnaire for the interview was prepared based on review of literature and other research instruments used in similar studies. The questionnaire was pilot tested but not subjected to any peer review, except for discussions amongst the team. The questionnaire was mainly open ended and
Results
The response rate of the present study was 94% (n=46). Amongst the doctors 80% (n=37) have direct experience in handling mass gathering emergencies and 62% (n=28) have attended at least one training programme related to mass gathering health management. They work approximately six hours per day in a mass gathering and every so often have work stress due to the overcrowding of patients.
The identified mass gathering health risks associated with Sabarimala pilgrimage includes outbreak of food- and
Discussion
The risk rank identification on the basis of the three identified risk categories outlined in Table 1 have shown that Sabarimala, where more than 30 million pilgrims gather in a short span of time every year and majority of whom are from other states and abroad, the outbreak of person-to-person communicable diseases has a moderate likelihood, but it will have catastrophic consequences. Also human stampedes are one of the major threats in the study area due to the geographic peculiarities of the
Conclusion
Identification of potential health risks can be an essential component in pre-event planning for a mass gathering. The WHO developed the first draft of a comprehensive guidance document for mass gatherings. Though the primary focus of that document is on alert and response to outbreaks of communicable diseases, it is nevertheless valuable in planning other aspects of potential health risks such as non-communicable diseases and physical injury and trauma [3]. The risk ranking tool can be used
Acknowledgements
This work is partially supported by Paristhithi Poshini research fellowship from the Environment and Climatic Change Department, Government of Kerala given to the first author. The incisive and constructive comments by the three anonymous reviewers have helped improve the manuscript considerably, and this is gratefully acknowledged.
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