key: cord-0844274-7ut6knvx authors: Shuklaa, Saurabh; Khana, Ramsha; Ahmedb, Yusuf; Memishc, Ziad A title: Conducting mass gathering events during the COVID-19 pandemic: A case study of Kumbh Mela 2021 as a potential ‘super spreader event’ date: 2021-10-05 journal: J Travel Med DOI: 10.1093/jtm/taab160 sha: da2cebf43e863c3e8a69ba14fe7b962c321b53a0 doc_id: 844274 cord_uid: 7ut6knvx Background: With the emergence of novel pathogens, there is a debate worldwide on the cancellation or conduction of mass gathering events. Methods: In the current COVID-19 pandemic, this study assesses the challenges in the conduction of the recently held Kumbh Mela mass gathering (MG) which took place from 14th January 2021-29th April 2021 at Haridwar, the capital city of the state of Uttarakhand, India. The correlation between increased cases of COVID-19 and the Kumbh Mela MG has been highlighted through statistical analysis and growth curves using the available data. Results: The Kumbh Mela-2021 emerged as a potential super spreader event with an increase from 37 cases per day to 144 cases per day (276%) in the COVID-19 cases in Haridwar. An increase from 138 to 480 cases per day (236%) and from 45 600 to 92 754 cases per day (92%) was noted in Uttarakhand and India respectively during this MG. A very strong correlation of ‘more than 0.99’ was seen between the number of cumulative cases of COVID-19 in Uttarakhand and Haridwar, and Haridwar and India during the Kumbh Mela in the third wave of the pandemic. Conclusions: The direct influence of Kumbh Mela on the increase in the number of COVID-19 cases is documented. Although, the socio-cultural, psychological, and economical advantages of MGs are considerable, in a developing nation like India organization of such events can be a huge health hazard. The lack of efficient implementation and observance of COVID-19 guidelines increase the necessity of cancellation of such MGs to prevent the outbreak of diseases. Thus, a well conducted risk assessment prior to the hosting of a MG event during a pandemic is required with strict application of precautionary measures during the event to prevent any superspreading events. Concerns about the hazards associated with MGs highlighting the need of proper risk assessment and maintenance of non-pharmaceutical interventions (NPIs) have been raised in previous studies. 1, 2 The MGs associated with religious belief systems have always attracted people across the globe, creating challenges for assuring safety and sanitation to prevent the outbreak of any unwanted hazardous event. 3 The communicable mode of disease transmission through respiratory, blood-borne, faecal-oral, food and water borne, and vectorborne vehicles have been previously recognized and illustrated in Fig. 1 . [1] [2] [3] [4] [5] [6] The potential threat of spread of communicable diseases associated with rituals based on religious traditions and belief systems have been described. 3, 7 The spread of upper respiratory tract infections (URTI) at the Kumbh Mela in the year 2013 and the rapid occurrence of respiratory issues have been reported two days after the ritual of mass holy bathing (Snan). 8 The potential contamination of water through mucus from nose and mouth, and intestinal mucus are noteworthy. The increase in the bacterial load of the river Godavari, Nasik, consequent to the mass bathing ritual at the Kumbh Mela in 2015, and the outbreak of cholera have been highlighted in the Kumbh Mela in the 19 th century. 9 The Kumbh Mela MG witnesses Hindu pilgrims from across the globe, and can potentially act as a 'super spreader event'. The first reported case of COVID-19 in India was from the state of Kerala, and higher transmission rates were reported with the return of migrant workers in large numbers. 10 The hazard of increase in the transmission at religious MGs was highlighted in a study about the Sabarimala pilgrimage in Kerala. 11 The spread of tuberculosis, pertussis, rhinovirus, of global transmission of such diseases are highlighted due to global participation. 3 Communicable and non-communicable diseases and other hazards associated with mass gathering events are summarized in Fig. S1 . A word cloud ( Fig. S1 ) has been compiled using titles and abstracts of published research and review articles. A recent study highlighted the positive impacts of MGs on social, cultural, and psychological upliftment. This includes the potentially positive and motivating benefits of religious beliefs and spirituality on health and wellbeing in addition to the development of optimistic and supportive social relations amongst humans. 9 The employment associated with MGs in the form of local businesses, food stalls, hoteliers, cinema halls, tour guides play a vital role in the economy of the hosting locality specially in low-and middle-income countries. The imposition of lockdowns towards prevention of COVID-19 led to a major shrink of economy across the globe of around 4.4% in the pandemic year 2020. 10 The cancellation of MGs affects the social, and economic well-being. 11 The workers associated with small scale units, and all other enterprises struggled with their means for sustenance. But the novelty of the virus, its rapid national and international spread, and unavailability of any approved medicines meant that imposing the lockdown was one of the most important measures towards saving human lives. 12, 13 Hence, to resume the economic resurgence, some governments decided to lift the restrictions. However, several guidelines for maintaining preventive measures issued by the WHO, including maintenance of social distancing, use of masks, frequent washing of hands, and avoiding public gatherings, were ignored. The mela area was equipped with 11,700 toilets, 6,674 urinals, 157.65 kilometres of roads, and a hospital with 159 beds acquainted with medical facilities. 13, 14 This study attempts to critically assesses the Kumbh Mela-2021 with respect to its impact on COVID-19 cases in India. It aims to highlight the various challenges associated with future and upcoming MGs in the face of an ongoing pandemic and suggest recommendations, especially with the availability of effective vaccines and much more known public health preventative measures. Major databases such as ScienceDirect, PubMed and Google Scholar, were explored with the keywords 'mass gatherings', 'COVID-19', 'Kumbh Mela', 'infections', 'communicable diseases', 'non-communicable diseases', and 'religious gatherings' for this study. Only peer reviewed articles were considered to gather information about the possible impacts of mass gatherings, its associated hazards, and strategies of risk assessment/management. With respect to cumulative number of COVID-19 cases, the assessment period of this study was divided into three phases, viz., phase-I (11 th Further, phase-wise correlation plots and graphs were prepared through Originpro software package, using the online data. April, the number of cases started to increase sharply and the average daily increase from 11 th April-29 th April was found to be 3.30%, resulting in a 252% increase compared to phase-II. The increasing number of pilgrims in Haridwar and subsequent rise in number of COVID-19 cases in Haridwar, Uttarakhand and India, indicates the possibility of these events being interrelated. Various correlation plots were prepared to analyse the correlation between the daily cases of COVID-19 (Fig. 3 ) and the resulting coefficients of correlation (r 2 ) was found to be greater than 0.99. The increase in number of COVID-19 cases in Haridwar was strongly correlated with the increasing cases in Uttarakhand with r 2 >0.99 in all the three phases (Fig. 3a) . The correlation plot also suggest that the best correlation was found between Haridwar and Uttarakhand indicating that attendees returning from Kumbh Mela 2021 might have caused the increase in COVID-19 cases in Uttarakhand as well. The coefficient of correlation between Haridwar-India, and Uttarakhand-India was found to be less than that of Haridwar-Uttarakhand ( Fig. 3a, b, c) , suggesting that increase in number of cases in India had contributions from other sources as well. Additionally, in all the correlation plots i.e., Haridwar-Uttarakhand, Haridwar-India, and Uttarakhand-India, the highest correlation was observed in phase-III (r 2 =0.998), when the mela was attended by the maximum number of pilgrims. The findings suggest that the pilgrims doing holy bathing without strictly following the concern, considering the spike in mortality rate as well. In a developing nation like India, where the sanitation index ranking stands low, lack of vaccines, lack of emergency services including oxygen supplies, COVID specialized hospitals, the conduction of such a MG can be considered a major risk. The planning of environmental security and public health during mass gatherings includes the assurance of the welfare of visitors, working staff from all types of diseases, and injuries. 18 The severity of the spread of infection, particularly in the rural population, was highlighted in a report. 18 The pilgrims included religious and holy men and women from different sects or The restrained spaces and close contact between pilgrims are a considerate cause of such diseases. One Any mass gathering event provides tremendous socio-economic opportunities for a country. It also presents an opportunity to conduct multidisciplinary collaborative research works related to public health. However, since these events have a potential to amplify the risk of outbreak of infectious diseases like COVID-19, it is imperative that planning and organizing committees make special arrangements and follow the WHO recommended risk assessment beforehand including: 3. Capacity to apply prevention and control measures-the ability to implement actions that can reduce the risks associated with the event. It is hoped that the above risk assessment will lead to an evidence-based decision to proceeding with the MG event with the following key recommendations kept in mind: h) The adaptation of social network analysis can be viable tool towards quantification of the social structure of an occurrence. 19 The MGs are an unavoidable part of human civilization. There are no funding sources to be acknowledged. Authors acknowledge the data availability from worldometer.com and various other online sources for compiling the Covid-19 related data. Authors are thankful to the anonymous reviewers who helped in improving the quality of this manuscript. Authors highly acknowledge the constant support of their families during the compilation of this manuscript. SS and RK visualized and designed the study, analysed the data, and wrote the original draft. ZAM gave important suggestions on improving the quality of the analysis. ZAM and YY monitored the study progress as well as contributed to revising the manuscript. All authors contributed to the checking and final processing. All authors reviewed the final version of the manuscript. All authors read and approved the final manuscript. Hajj: Infectious disease surveillance and control Mass gatherings medicine: public health issues arising from mass gathering religious and sporting events. 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The Lancet Lockdown to contain COVID-19 is a window of opportunity to prevent the second wave Effect of COVID-19 lockdown on the water quality index of River Gomti , India , with potential hazard of faecal-oral transmission Cases and Deaths from COVID-19 Virus Pandemic. 2021. 15. mint, Kumbh Mela 2021: 30 sadhus in Haridwar test Covid-19 positive Nearly 1,300 test Covid positive at Kumbh in 5 days, 14 lakh take part in 3rd shahi snan | Dehradun News -Times of India The authors declare that they have no competing interests.