Curr Infect Dis Rep (2015) 17: 5 DOI 10.1007/s11908-015-0461-1
TROPICAL, TRAVEL AND EMERGING INFECTIONS (L CHEN, SECTION EDITOR)
Water, Sanitation, and Hygiene at the World’s Largest Mass Gathering Michael Vortmann & Satchit Balsari & Susan R. Holman & P. Gregg Greenough
Published online: 18 March 2015 # Springer Science+Business Media New York 2015
Abstract The 2013 Kumbh Mela, a Hindu religious festival and the largest human gathering on earth, drew an estimated 120 million pilgrims to bathe at the holy confluence of the Ganga (Ganges) and Yamuna rivers. To accommodate the massive numbers, the Indian government constructed a temporary city on the flood plains of the two rivers and provided it with roads, electricity, water and sanitation facilities, police stations, and a tiered healthcare system. This phenomenal operation and its impacts have gone largely undocumented. To address this gap, the authors undertook an evaluation and systematic monitoring initiative to study preparedness and response to public health emergencies at the event. This paper describes the water, sanitation, and hygiene components, with particular emphasis on preventive and mitigation strategies; the capacity for surveillance and response to diarrheal disease outbreaks; and the implications of lessons learned for other mass gatherings. Keywords Mass gatherings . Kumbh Mela . Sangam . Nagri . Potable water . Latrine . Wash . E. coli . Fecal coliform This article is part of the Topical Collection on Tropical, Travel, and Emerging Infections M. Vortmann (*) : S. Balsari Global Emergency Medicine Division, Emergency Department, Weill Cornell Medical College, New York, NY, USA e-mail: [email protected] S. Balsari : P. G. Greenough FXB Center for Health and Human Rights, Harvard University, Boston, MA, USA S. R. Holman Global Health Education and Learning Incubator at Harvard University, Cambridge, MA, USA P. G. Greenough Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
Introduction The Kumbh Mela is a large Hindu festival in India, held approximately once every three years, by rotation, in the four cities of Allahabad, Haridwar, Nashik, and Ujjain. The Mela returns to each city once every 12 years, and the festival in Allahabad is considered the most auspicious of them all. The 2013 Kumbh Mela in Allahabad, held over a period of 55 days from January to March 2013, drew an estimated 120 million pilgrims to the holy confluence of the Ganga and Yamuna rivers and was the world’s largest human gathering. The pilgrims came largely from across India, but also from around the world, to bathe at the site, known as the Triveni Sangam. Bathing at the Sangam is said to liberate one’s soul from the perpetual cycle of rebirth [1] and is the unifying purpose of the entire festival. To accommodate the massive numbers (who stay for varying lengths of time) and to manage the flow of people to and from the rivers’ banks, the Indian government constructed a temporary city on the flood plains of the two rivers. Known as the Kumbh Nagri, this 1936-ha city is laid out in a grid with roads and pontoon bridges, electrical and water distribution systems, sanitation facilities and management, a tiered healthcare system, and a vector control program. The Nagri comprises an agglomeration of compounds (akhadas) for various religious sects, meeting spaces for religious discourse and entertainment, living accommodations (mostly tents), communal kitchens, and market places. This phenomenal operation and its impacts have gone largely undocumented. To address this gap in our collective understanding of the making and dismantling of the ephemeral township that hosts the world’s largest congregation of humans, the authors, as part of a large inter-disciplinary team of scholars from India and the USA, undertook an evaluation and systematic monitoring initiative to study preparedness and response to public health emergencies at the Kumbh Mela.
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This paper describes the water, sanitation, and hygiene components at the 2013 Kumbh Mela, with particular emphasis on preventive and mitigation strategies and the capacity for surveillance and response to diarrheal disease outbreaks. This discussion is aimed at building on previous knowledge, investigating and implementing water and sanitation populationbased initiatives, and developing guiding plans for future mass gatherings with a similar population demographic profile and ecological context.
Curr Infect Dis Rep (2015) 17: 5
Kumbh administrative officials, pilgrim participants, sanitation workers, and physicians staffing the Kumbh’s temporary health facilities. Domains of inquiry focused on water provision and sanitation preparations, hygiene, and management of clean and contaminated water flows. This information was then supplemented with direct, on-the-ground observations from a team of American and Indian public health researchers for the entirety of the festival. Water Sampling
Risk of Waterborne Disease at the Kumbh Mela Pilgrims come to the Kumbh Mela from across India, arriving by foot, by road, or by train, often traveling in groups. Though tens of thousands attend the festival every single day, attendance spikes on six Bauspicious^ bathing days. On February 10, 2013, the holiest of all days known as Mauni Amavasya, police estimated 30 million visited the Sangam (PIC 1) [2]. After such high-density mingling, this large and diverse population returns home. The potential for disease transmission to and from the Kumbh Nagri remains a very real threat in this age, as it has been over the centuries. Cholera from the 1817 Kumbh played an incendiary role in the first global pandemic (1817–1824); while Indian pilgrims contributed to the spread across the subcontinent, British naval officers and Hajj pilgrims carried the disease from central India to the Far East and to western Asia and the Mediterranean [3]. A more recent outbreak at the 1948 Kumbh Mela prompted mass cholera vaccination initiatives for the 1960 event [4, 5]. Current healthcare infrastructure in the Kumbh Nagri continues to echo the preparation for the cholera wards in previous Melas. An estimated 80 % of the Mela pilgrims come from rural India, where less than 20 % have access to sanitation facilities, and open defecation is widely practiced [6]. The Mela administration recognizes the risk for waterborne illness in the densely populated urban environment of the Kumbh Nagri, where communal eating, communal bathing, and poor hygiene are the norm [7•]. In 2013, as before, the government went to extraordinary lengths to manage water and sanitation services to mitigate that risk.
Study Method
To determine water quality, we sampled river water for fecal coliform and Escherichia coli (E. coli) counts for two days prior to, the day of, and the day after the most auspicious bathing day. Chosen sample sites were upstream and downstream of major bathing sites (Fig. 1). Samples were collected by lowering standard sterile 10-ml plastic test tubes into the river from the Mela’s pontoon bridges. These were then sealed, kept on ice, and transported to a temporary lab site in the Kumbh Nagri. Sterile water was used to make serial dilutions; the samples were immediately plated on 3M: E. coli/coliform plates and incubated at 99 °F for 24–36 h, per manufacturer instructions. After incubation, photos were taken of the plates and colony counts of E. coli, and coliforms were manually performed. Epidemiological Surveillance The inter-institutional research team assisted the Kumbh medical administration in setting up a syndromic surveillance system at five of the 14 temporary, allopathic, 24-hour-service hospitals constructed for the event, to gather quantitative trends on potential outbreaks [8•]. Planners of other mass gatherings, including those of the recent London Olympics, have similarly instituted surveillance systems [9•]. Four of the chosen surveillance sites were those closest to the main bathing areas and the Sangam confluence where the highest human density of the festival occurs; the fifth was the higher tier central hospital where sicker patients were referred for specialty care (Fig. 1). Physician providers at the surveillance sites daily recorded the chief complaints and medications dispensed for all visits. The research team digitized this information daily, which allowed for instant interpretation and analysis.
The study comprised qualitative in-depth, inquiry-based key informant interviews and direct observation coupled with quantitative measurements of water quality and disease incidence.
Results
Qualitative Observations
Water and Sanitation Infrastructure
The authors gathered information on planning, management, and implementation from key informants, including commissioned
The water and sanitation services are planned and managed by the Mela administration composed of experienced officers
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Fig 1 The crosses mark the sites of four sector hospitals surveilled. The circles mark the vicinity of sites where water was examined for coliform counts. Background map accessed December 10, 2014 at http://kumbhmelaallahabad.gov. in/images/kumbhmalamap.gif
from the local city and state government’s civic services and public works departments. The administration constructs the Nagri’s extensive water and sanitation infrastructure in the three months leading up to the festival, starting at the moment the Ganga has reached its maximally receded level within the flood plain and completing as the first pilgrims arrive. Potable Water In 2013, the potable water system comprised 46 protected piped bore wells, each sunk into the sandy floodplain and attached to submersible pumps with a chlorination tank. The system distributed over 90,000 kl of water daily through 550 km of pipelines and 20,000 taps. Public use taps were placed at major bathing sites in close proximity to religious compounds lining the streets. The compounds were permitted to further extend the network internally to smaller spigots for personal use. Sanitation The administration constructed 35,000 toilets estimated to provide one toilet for every eight to ten people during average attendance. Four types of sanitation facilities were provided and ranged in complexity from open defecation fields to roadside urinals, pit latrines, and bio-digester toilets. All were located at least 15 m away from the rivers. The majority were simple open-air pit latrines and urinals, roofless, semicontained units bounded by 1.5 meter-high corrugated metal, segregated by cloth partitions, and labeled with gender-specific
logos. Earth mounds or bricks allowed the user to squat off the ground; a gravity-fed, non-flushing system of pipes led directly to unlined pits dug into the sand or into hollow drums which were left in place after the event. The human waste was left to decompose naturally or be washed away by the eventual rise of the rivers during the monsoon season. The Planning, Research and Action Institute (PRAI), Lucknow, and Sulabh International Social Service Organization, New Delhi provided water-seal, hand-flush pit latrines. These private stalls contained squatting plates over a pan and trap flush system with a connecting pipe to a pit trench located behind or underneath the structure and required one to two liters of water per flush. According to the administration, 7500 PRAI latrines and 350 ten-seat Sulabh Shauchalaya latrine sheds were installed. Sixty-eight modern bio-digested complexes replaced previously used trench toilets that were notorious for filling up quickly and leaching wastewater into the riverbed. Bio-digesters, designed similarly to the Sulabh pit toilets and presented as part of an effort to Bgreen the Kumbh,^ used Bzero waste^ technology. The bio-digesters used bacterial cultures essential to Bdigest^ human waste, dissolving excreta into odorless and pathogen-free water, which was then allowed to leech into the ground. The resultant bio-methane was released, as for the pit latrines, into the air. The cultures were replenished after every 200 uses. Finally, acknowledging the favored habit of open defecation by many attending the Mela, scattered throughout the Nagri were small gender-specific defecation fields cordoned off by corrugated walls.
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River Water Quality Water quality in India is compromised by inadequately treated sewage and industrial runoff. Upstream from the Nagri and its bathing sites are hundreds of factories, leather tanneries, agricultural fields, and small towns that routinely release chemical and human waste directly into the Ganga. The river receives 1800 million liters/day of industrial and sewage effluent discharge from Uttar Pradesh state alone [10]. Northern Indian cities along the Ganges, including Allahabad, have the capacity to treat only one third of its daily 660 million gallons of sewage prior to being flushed into the river [11]. In the months leading up to the Mela, the state government’s Central Pollution Control Board monitored river water quality daily and implored upstream distilleries, sugar mills, and tanneries to run their water treatment facilities at maximum capacity for the duration of the Mela. Similarly, the city of Allahabad expanded their sewage treatment infrastructure just prior to the event, doubling their capacity from 90 million liters/day (MLD) to 211 MLD. City sewer discharges were redirected downstream of the Sangam for the duration of the festival. Cremations, normally performed at the Sangam throughout the year, remained within the Mela grounds but were moved upstream [12]. Because faster flowing water dissolves more oxygen and purifies by suspending more sediment, the public works administration manipulated upstream dams to discharge water at flow rates that allowed a brisk runoff from the Sangam immediately following heavy bathing days, without making the rivers too rapid for the bathing sites to be unsafe.
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waste. Because these were unlined and the sand would absorb the liquid contents, there was concern about contamination when the river would again fill its flood plain several months hence. PRAI pit latrines were lined with bamboo mesh allowing for liquid elements to be absorbed leaving night soil contents which would either decompose to manure or be suctioned out. All pit latrines were treated with lime and insecticide. Personal hygiene facilities were less available. Sulabh and bio-digester toilets had spigots designated for washing and hand washing stations with soap and towels, respectively. Nonetheless, hygiene supplies were often stolen and not replaced. Local soap brand Lifebuoy launched a novel public health messaging campaign tool, branding one million rotis (flat breads) with the message, BHave you washed your hands with Lifebuoy today?^ Despite such prompts, washing with soap and water remains an uncommon practice in this demographic. Not all who preferred open defecation used the designated defecation fields (billboards encouraged use of toilets in preference to open defecation). To manage open defecation areas along roadsides and public spaces, the administration employed 8000 sanitation workers around the clock to sweep feces into baskets and to deposit bleaching powder in its place (PIC 2). Areas around open pit latrines were sanitized similarly, with little or no sewage odor at pit latrine sites where pipes were not overflowing. Fourteen sanitation officers, one for each Nagri sector and based at the sector health facility, liaised with their respective physician providers. Grey Water
Water and Sanitation Implementation Providing potable water in the context of varying daily population numbers required constant attention. The build-out for 90,000 kl/day proved adequate for typical bathing day populations; however, on high-volume auspicious bathing days, potable water was limited to drinking and cooking only. In addition to public water supplies, corporate donors distributed ultraviolet-treated water dispensers outside sector clinics and at major street intersections. Pit latrine maintenance was an ongoing challenge. Pipelines were easily clogged with debris and a 1000-member maintenance force was available for around-the-clock repairs. Pits that filled quickly, without the time required for anaerobic digestion, needed to be covered or pumped out. No routine system was in place to monitor these; the Kumbh administration simply discovered the problem when pilgrims complained. The bio-digester unit nearest the Sangam was used by hundreds of visitors before sufficient bio-culture was available. Sulabh units near the Sangam were unfinished early in the festival, with loose parts subject to theft. At many roadside simple pit latrines, pipes overflowed with human
Runoff water, waste water, and water deemed unsafe for drinking—Bgrey water^—was segregated into sandbag-lined, open stilling ponds at the margins of the roads. Vector control teams sprayed the ponds with DDT and malathion, and Hindi signage clearly marked the pools as containing non-potable water. The grey water was pumped into tanker trucks that traversed the Nagri and was used to spray down the dusty roads (or less frequently, to put out fires). Despite this system, we observed pools of wastewater gathering in communal cooking and bathing areas that ran into troughs directly to the river. Pilgrims would use this water for bathing and occasionally for drinking. Furthermore, pilgrims would routinely drink river water at the Sangam, given the attributed holiness and purity of water from the Ganga (PIC 3). Measured Water Quality Water was sampled from the Ganga on February 8th, 9th, 10th (Mauni Amavasya), and 11th, at three upstream and two downstream locations from the densest bathing areas. On all days, both upstream and downstream samples demonstrated
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high E. coli and fecal coliform counts ranging 6000 to 50, 000 CFU/100 ml. On February 10, there were too many colonies to count at the 1:10 dilution level suggesting values greater than 50,000 CFU/100 ml (Fig. 2). The temporary disease surveillance system piloted by this research team allowed the tracking of disease presentations to the clinics closest to the Sangam. The number of cases of diarrhea or gastrointestinal complaints rose and fell with the population estimates without a disproportionate spike in the number of cases (Fig. 3). The 20-bed, short-term, inpatient wards, attached to each of the 14 sector hospitals in the Nagri, rarely treated admitted diarrheal cases throughout the duration of the festival. Fig 3 Number of diarrhea cases presenting to one of the five pilot hospitals surveilled. The rise in cases on peak bathing days was comparable to the rise in population and in proportion to rise (and fall) in other presentations
Discussion The 2013 Allahabad Kumbh Mela offered an instructive model with global lessons for other mass gatherings that implement systematic water, sanitation, and hygiene policies that require coordination among administrative sectors. Our observational findings suggest a number of commendable practices that might be used in related events and humanitarian crises, as well as identify challenges and risks that should be addressed in future Melas. In spite of serious concern and significant provision for diarrheal disease outbreaks, including cholera, there was no planned or organized surveillance mechanism in place. Surveillance data collected by our team from four pilot sites suggested that despite measurably elevated E. coli and fecal coliform counts in public bathing water at the Ganga during the height of the festival, there was no demonstrable evidence of a 50
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Fig 2 Measured coliform counts upstream and downstream before, during, and after main bathing days (graphs with dates). Units ×1000 CFU/100 ml. Grey upstream; Black downstream; White missing data
proportional increase in the incidence of water-related diseases (bloody or non-bloody diarrhea) presenting to Nagri hospitals. This finding is especially notable given the known cultural practice of pilgrims drinking river water as part of the religious ritual. The rapid onset of most water-related diarrheal illnesses would make it more likely that pilgrims would become symptomatic prior to leaving the festival and an outbreak readily identifiable. The water quality data are not sufficiently granular to determine whether there was a spike in fecal contamination on the main bathing day of February 10, but the coliform and E. coli counts on all observed days were uniformly outside the ranges the World Health Organization considers safe for drinking or bathing. Although no causal relationship can be definitively established between the river water quality and the paucity of diarrhea cases, these observations may reflect that efforts to improve the quality of the river water, in combination with the provision of distributed potable water and toileting facilities, were sufficient to prevent an outbreak of diarrheal illness. These efforts demonstrate Nagri officials’ commitment to protect public health and prevent a communicable disease catastrophe. Health surveillance data did not identify nationality or place of origin, precluding a subgroup analysis of attendees. While a small minority of foreign visitors attended the Mela for short periods of time, most stayed in Allahabad city or in upscale accommodations in the Nagri that provided worldclass water and sanitation facilities. Foreign tourists tended to access private clinics in Allahabad rather than the Nagri health facilities, precluding systematic surveillance. The Kumbh Mela authorities repeatedly undertook the Herculean task of setting up temporary water and sanitation infrastructure for millions of pilgrims coming from largely rural, illiterate backgrounds. This task was complicated by
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population surges in the millions on main bathing days, a swell that could neither be estimated nor controlled with any precision. Unlike the Hajj or the Olympics, events that require application and/or registration mechanisms that generate population data estimates, the Kumbh Mela has no such estimating devices. As such, administrators default to institutional memory and educated guesses to determine the quantity of water and sanitation facility needs. Future Melas would benefit from using data sources that could provide some predictive population modeling. Toilet facilities drew on a creative combination of technological solutions appropriate to a range of literacy levels and cultural preferences. The diligent, systematic, and continuous collection of feces from roadsides and open public areas and the deposition of lime and vector control agents were effective and commendable. The innovative BGreen Kumbh^ movement focused local and religious activism on environmental respect for the Ganga, including an antilitter campaign and televised cleanup at the Sangam. This portends a critical shift in participant thinking that will be necessary as future Melas will undoubtedly draw increased numbers, raising the capacity for environmental destruction. Toilet signage included environmental messaging and took into account pilgrim illiteracy and gender specificity. However, no signage or messaging addressed personal sanitation and hygiene behaviors or cautionary disease prevention activities. Given ongoing concerns for epidemic diarrheal diseases, the lack of signage or public announcements about water sources, toileting facilities, or hand washing represented a lost opportunity for educating the population. Water pipelines were thoughtfully planned to deliver prodigious amounts of water to the akhadas. Tapped water was clearly readily available in the Nagri’s residential areas. The collection and reuse of runoff to spray down dusty thoroughfares was commendable and consistent with modern water conservation strategies. The availability of commercial ultraviolet-treated water outside clinics and at major intersections was a good example of public-private partnership in provision of a public good. However, large portions of the Sangam bathing areas lacked ready access to piped potable water. Severe crowding on bathing days restricted rapid mobility to access other water or alternative defecation facilities. These areas were key points of contact with contaminated water and where we witnessed pilgrims drinking both non-potable grey water from trucks spraying down the sand and river water as part of their holy ablutions. The inadequacy of the water infrastructure at such key locations is a clear opportunity for improvement at future Melas. Further, monitoring water quality at distribution sites was beyond the scope of the administration’s capacity. Such sites could be easily contaminated. Officials acknowledged problems and risks, and their systematic implementation of contextualized solutions and local
Curr Infect Dis Rep (2015) 17: 5
expertise reflected the benefits of over a half century of administering this fixed and yet unpredictable event. Our surveillance data also identified clear gaps that may offer lessons for the future. While significant effort went into planning the sanitation needs within the urban zone, there was no mechanism to monitor sanitation system use (to reallocate resources as population needs arose) or identify breakdowns and failures. Repair efforts relied largely on ad hoc complaints by the holy men who stay for the duration of the festival. Besides the inventive Lifebuoy soap campaign, there was little evidence of public hygiene messaging strategies. Taken together, we suggest that these risks and constraints offer opportunities for strengthening water, sanitation, and hygiene for ever larger and more high profile future Melas and related events. Especially in light of the increased risks for morbidity and mortality from communicable agents that benefit from high population density and mobility, water, sanitation, and hygiene measures at all mass gatherings may benefit from strengthening strategic planning and implementation practices to mitigate such risk. The 2013 Mela may have, through a combination of will, preparedness, and sheer luck, avoided an epidemic outbreak, but given the ever increasing numbers attending the Mela, faster transportation alternatives available with each passing Mela, and the growing inter-connectedness of our world, future Melas continue to harbor the potential for catastrophic outbreaks, just as they have in the past. Compliance with Ethics Guidelines Conflict of Interest Gregg Greenough, Susan Holman, Satchit Balsari, and Michael Vortmann have no conflict of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by the authors.
References Papers of particular interest, published recently, have been highlighted as: • Of importance
1.
Government of India, Kumbh Mela 2013. Available at: http:// kumbhmelaallahabad.gov.in/english/index.html. Accessed 7 October 2014. 2. Biswas S. India’s Kumbh Mela festival holds most auspicious day. BBC News India, 10 Feb 2013. Available at: http://www.bbc.com/ news/world-asia-india-21395425. Accessed 7 October 2014. 3. Hays JN. Epidemics and pandemics: their impacts on human history. Santa Barbara CA: ABC-CLIO, Inc; 2005. 4. Banks AL. Religious fairs and festivals in India. Lancet. 1961;277(7169):162–3. 5. Bryceson ADM. Cholera: the flickering flame. Proc Royal Soc Med. 1977;70:363–5.
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Nath KJ. Home hygiene and environmental sanitation: a country situation analysis for India. Int J Environ Health Res. 2003;13 Suppl 1:S19–28. 7.• Patel RB, Burke TF. Urbanization—an emerging humanitarian disaster. N Engl J Med. 2009;361(8):741–3. This perspective essay highlights the health and humanitarian risks of rapid urbanization and calls for focused research and action to develop new policies and programs that advance effective healthcare delivery with a focus on urban informal settlements. 8.• Balsari S. Leapfrog technology and epidemiology at the world’s largest human gathering. In: Health and South Asia. Cambridge, MA: South Asia Institute at Harvard University. 2013. Available at http://issuu.com/sainit/docs/healthandsouthasiabook/53. Accessed 18 November 2014. This article describes a mobile, tablet-based, real-time disease-surveillance system, first implemented at the 2013 Kumbh Mela, which successfully monitored potential epidemic risk by gathering and evaluating data from 50,000 patients over 3 weeks; the system has practical relevance for mass gatherings that occur in resource-limited settings 9.• Morbey RA, Elliot AJ, Charlett A, Ibbotson S, Verlander NQ, Leach S, et al. Using pubic health scenarios to predict the utility of a national
Page 7 of 7 5 syndromic surveillance programme during the 2012 London Olympic and Paralympic Games. Epidemiol Infect. 2014;142: 984–93. This study, based on data from the 2012 London Olympic and Paralympic Games, shows how scenario planning can be used to evaluate the effectiveness of syndromic surveillance. 10. Shukla N. Untreated factory waste poisoning the Ganga: Kanpur’s STPs not upgraded to handle tannery discharge. The Times of India, 2 Jul 2014. Available at: http://timesofindia.indiatimes.com/city/ lucknow/Untreated-factory-waste-poisoning-Ganga-Kanpur-STPsnot-upgraded-to-handle-tannery-discharge/articleshow/37632507. cms. Accessed 14 October 2014. 11. Nelson D. India plans 2£bn clean-up of the Ganges. The telegraph. 6 Oct 2009. Available at: http://www.telegraph.co.uk/news/ worldnews/asia/india/6265586/India-plans-2bn-clean-up-of-theGanges.html. Accessed 14 October 2014. 12. Spinney L. Kumbh Mela 2013: Picking flowers. National Geographic. 28 Jan 2013. Available at http://voices.nationalgeographic.com/2013/ 01/28/kumbh-mela-2013-picking-flowers/. Accessed 12 November 2014.
TROPICAL, TRAVEL AND EMERGING INFECTIONS (L CHEN, SECTION EDITOR)
Water, Sanitation, and Hygiene at the World’s Largest Mass Gathering Michael Vortmann & Satchit Balsari & Susan R. Holman & P. Gregg Greenough
Published online: 18 March 2015 # Springer Science+Business Media New York 2015
Abstract The 2013 Kumbh Mela, a Hindu religious festival and the largest human gathering on earth, drew an estimated 120 million pilgrims to bathe at the holy confluence of the Ganga (Ganges) and Yamuna rivers. To accommodate the massive numbers, the Indian government constructed a temporary city on the flood plains of the two rivers and provided it with roads, electricity, water and sanitation facilities, police stations, and a tiered healthcare system. This phenomenal operation and its impacts have gone largely undocumented. To address this gap, the authors undertook an evaluation and systematic monitoring initiative to study preparedness and response to public health emergencies at the event. This paper describes the water, sanitation, and hygiene components, with particular emphasis on preventive and mitigation strategies; the capacity for surveillance and response to diarrheal disease outbreaks; and the implications of lessons learned for other mass gatherings. Keywords Mass gatherings . Kumbh Mela . Sangam . Nagri . Potable water . Latrine . Wash . E. coli . Fecal coliform This article is part of the Topical Collection on Tropical, Travel, and Emerging Infections M. Vortmann (*) : S. Balsari Global Emergency Medicine Division, Emergency Department, Weill Cornell Medical College, New York, NY, USA e-mail: [email protected] S. Balsari : P. G. Greenough FXB Center for Health and Human Rights, Harvard University, Boston, MA, USA S. R. Holman Global Health Education and Learning Incubator at Harvard University, Cambridge, MA, USA P. G. Greenough Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
Introduction The Kumbh Mela is a large Hindu festival in India, held approximately once every three years, by rotation, in the four cities of Allahabad, Haridwar, Nashik, and Ujjain. The Mela returns to each city once every 12 years, and the festival in Allahabad is considered the most auspicious of them all. The 2013 Kumbh Mela in Allahabad, held over a period of 55 days from January to March 2013, drew an estimated 120 million pilgrims to the holy confluence of the Ganga and Yamuna rivers and was the world’s largest human gathering. The pilgrims came largely from across India, but also from around the world, to bathe at the site, known as the Triveni Sangam. Bathing at the Sangam is said to liberate one’s soul from the perpetual cycle of rebirth [1] and is the unifying purpose of the entire festival. To accommodate the massive numbers (who stay for varying lengths of time) and to manage the flow of people to and from the rivers’ banks, the Indian government constructed a temporary city on the flood plains of the two rivers. Known as the Kumbh Nagri, this 1936-ha city is laid out in a grid with roads and pontoon bridges, electrical and water distribution systems, sanitation facilities and management, a tiered healthcare system, and a vector control program. The Nagri comprises an agglomeration of compounds (akhadas) for various religious sects, meeting spaces for religious discourse and entertainment, living accommodations (mostly tents), communal kitchens, and market places. This phenomenal operation and its impacts have gone largely undocumented. To address this gap in our collective understanding of the making and dismantling of the ephemeral township that hosts the world’s largest congregation of humans, the authors, as part of a large inter-disciplinary team of scholars from India and the USA, undertook an evaluation and systematic monitoring initiative to study preparedness and response to public health emergencies at the Kumbh Mela.
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This paper describes the water, sanitation, and hygiene components at the 2013 Kumbh Mela, with particular emphasis on preventive and mitigation strategies and the capacity for surveillance and response to diarrheal disease outbreaks. This discussion is aimed at building on previous knowledge, investigating and implementing water and sanitation populationbased initiatives, and developing guiding plans for future mass gatherings with a similar population demographic profile and ecological context.
Curr Infect Dis Rep (2015) 17: 5
Kumbh administrative officials, pilgrim participants, sanitation workers, and physicians staffing the Kumbh’s temporary health facilities. Domains of inquiry focused on water provision and sanitation preparations, hygiene, and management of clean and contaminated water flows. This information was then supplemented with direct, on-the-ground observations from a team of American and Indian public health researchers for the entirety of the festival. Water Sampling
Risk of Waterborne Disease at the Kumbh Mela Pilgrims come to the Kumbh Mela from across India, arriving by foot, by road, or by train, often traveling in groups. Though tens of thousands attend the festival every single day, attendance spikes on six Bauspicious^ bathing days. On February 10, 2013, the holiest of all days known as Mauni Amavasya, police estimated 30 million visited the Sangam (PIC 1) [2]. After such high-density mingling, this large and diverse population returns home. The potential for disease transmission to and from the Kumbh Nagri remains a very real threat in this age, as it has been over the centuries. Cholera from the 1817 Kumbh played an incendiary role in the first global pandemic (1817–1824); while Indian pilgrims contributed to the spread across the subcontinent, British naval officers and Hajj pilgrims carried the disease from central India to the Far East and to western Asia and the Mediterranean [3]. A more recent outbreak at the 1948 Kumbh Mela prompted mass cholera vaccination initiatives for the 1960 event [4, 5]. Current healthcare infrastructure in the Kumbh Nagri continues to echo the preparation for the cholera wards in previous Melas. An estimated 80 % of the Mela pilgrims come from rural India, where less than 20 % have access to sanitation facilities, and open defecation is widely practiced [6]. The Mela administration recognizes the risk for waterborne illness in the densely populated urban environment of the Kumbh Nagri, where communal eating, communal bathing, and poor hygiene are the norm [7•]. In 2013, as before, the government went to extraordinary lengths to manage water and sanitation services to mitigate that risk.
Study Method
To determine water quality, we sampled river water for fecal coliform and Escherichia coli (E. coli) counts for two days prior to, the day of, and the day after the most auspicious bathing day. Chosen sample sites were upstream and downstream of major bathing sites (Fig. 1). Samples were collected by lowering standard sterile 10-ml plastic test tubes into the river from the Mela’s pontoon bridges. These were then sealed, kept on ice, and transported to a temporary lab site in the Kumbh Nagri. Sterile water was used to make serial dilutions; the samples were immediately plated on 3M: E. coli/coliform plates and incubated at 99 °F for 24–36 h, per manufacturer instructions. After incubation, photos were taken of the plates and colony counts of E. coli, and coliforms were manually performed. Epidemiological Surveillance The inter-institutional research team assisted the Kumbh medical administration in setting up a syndromic surveillance system at five of the 14 temporary, allopathic, 24-hour-service hospitals constructed for the event, to gather quantitative trends on potential outbreaks [8•]. Planners of other mass gatherings, including those of the recent London Olympics, have similarly instituted surveillance systems [9•]. Four of the chosen surveillance sites were those closest to the main bathing areas and the Sangam confluence where the highest human density of the festival occurs; the fifth was the higher tier central hospital where sicker patients were referred for specialty care (Fig. 1). Physician providers at the surveillance sites daily recorded the chief complaints and medications dispensed for all visits. The research team digitized this information daily, which allowed for instant interpretation and analysis.
The study comprised qualitative in-depth, inquiry-based key informant interviews and direct observation coupled with quantitative measurements of water quality and disease incidence.
Results
Qualitative Observations
Water and Sanitation Infrastructure
The authors gathered information on planning, management, and implementation from key informants, including commissioned
The water and sanitation services are planned and managed by the Mela administration composed of experienced officers
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Fig 1 The crosses mark the sites of four sector hospitals surveilled. The circles mark the vicinity of sites where water was examined for coliform counts. Background map accessed December 10, 2014 at http://kumbhmelaallahabad.gov. in/images/kumbhmalamap.gif
from the local city and state government’s civic services and public works departments. The administration constructs the Nagri’s extensive water and sanitation infrastructure in the three months leading up to the festival, starting at the moment the Ganga has reached its maximally receded level within the flood plain and completing as the first pilgrims arrive. Potable Water In 2013, the potable water system comprised 46 protected piped bore wells, each sunk into the sandy floodplain and attached to submersible pumps with a chlorination tank. The system distributed over 90,000 kl of water daily through 550 km of pipelines and 20,000 taps. Public use taps were placed at major bathing sites in close proximity to religious compounds lining the streets. The compounds were permitted to further extend the network internally to smaller spigots for personal use. Sanitation The administration constructed 35,000 toilets estimated to provide one toilet for every eight to ten people during average attendance. Four types of sanitation facilities were provided and ranged in complexity from open defecation fields to roadside urinals, pit latrines, and bio-digester toilets. All were located at least 15 m away from the rivers. The majority were simple open-air pit latrines and urinals, roofless, semicontained units bounded by 1.5 meter-high corrugated metal, segregated by cloth partitions, and labeled with gender-specific
logos. Earth mounds or bricks allowed the user to squat off the ground; a gravity-fed, non-flushing system of pipes led directly to unlined pits dug into the sand or into hollow drums which were left in place after the event. The human waste was left to decompose naturally or be washed away by the eventual rise of the rivers during the monsoon season. The Planning, Research and Action Institute (PRAI), Lucknow, and Sulabh International Social Service Organization, New Delhi provided water-seal, hand-flush pit latrines. These private stalls contained squatting plates over a pan and trap flush system with a connecting pipe to a pit trench located behind or underneath the structure and required one to two liters of water per flush. According to the administration, 7500 PRAI latrines and 350 ten-seat Sulabh Shauchalaya latrine sheds were installed. Sixty-eight modern bio-digested complexes replaced previously used trench toilets that were notorious for filling up quickly and leaching wastewater into the riverbed. Bio-digesters, designed similarly to the Sulabh pit toilets and presented as part of an effort to Bgreen the Kumbh,^ used Bzero waste^ technology. The bio-digesters used bacterial cultures essential to Bdigest^ human waste, dissolving excreta into odorless and pathogen-free water, which was then allowed to leech into the ground. The resultant bio-methane was released, as for the pit latrines, into the air. The cultures were replenished after every 200 uses. Finally, acknowledging the favored habit of open defecation by many attending the Mela, scattered throughout the Nagri were small gender-specific defecation fields cordoned off by corrugated walls.
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River Water Quality Water quality in India is compromised by inadequately treated sewage and industrial runoff. Upstream from the Nagri and its bathing sites are hundreds of factories, leather tanneries, agricultural fields, and small towns that routinely release chemical and human waste directly into the Ganga. The river receives 1800 million liters/day of industrial and sewage effluent discharge from Uttar Pradesh state alone [10]. Northern Indian cities along the Ganges, including Allahabad, have the capacity to treat only one third of its daily 660 million gallons of sewage prior to being flushed into the river [11]. In the months leading up to the Mela, the state government’s Central Pollution Control Board monitored river water quality daily and implored upstream distilleries, sugar mills, and tanneries to run their water treatment facilities at maximum capacity for the duration of the Mela. Similarly, the city of Allahabad expanded their sewage treatment infrastructure just prior to the event, doubling their capacity from 90 million liters/day (MLD) to 211 MLD. City sewer discharges were redirected downstream of the Sangam for the duration of the festival. Cremations, normally performed at the Sangam throughout the year, remained within the Mela grounds but were moved upstream [12]. Because faster flowing water dissolves more oxygen and purifies by suspending more sediment, the public works administration manipulated upstream dams to discharge water at flow rates that allowed a brisk runoff from the Sangam immediately following heavy bathing days, without making the rivers too rapid for the bathing sites to be unsafe.
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waste. Because these were unlined and the sand would absorb the liquid contents, there was concern about contamination when the river would again fill its flood plain several months hence. PRAI pit latrines were lined with bamboo mesh allowing for liquid elements to be absorbed leaving night soil contents which would either decompose to manure or be suctioned out. All pit latrines were treated with lime and insecticide. Personal hygiene facilities were less available. Sulabh and bio-digester toilets had spigots designated for washing and hand washing stations with soap and towels, respectively. Nonetheless, hygiene supplies were often stolen and not replaced. Local soap brand Lifebuoy launched a novel public health messaging campaign tool, branding one million rotis (flat breads) with the message, BHave you washed your hands with Lifebuoy today?^ Despite such prompts, washing with soap and water remains an uncommon practice in this demographic. Not all who preferred open defecation used the designated defecation fields (billboards encouraged use of toilets in preference to open defecation). To manage open defecation areas along roadsides and public spaces, the administration employed 8000 sanitation workers around the clock to sweep feces into baskets and to deposit bleaching powder in its place (PIC 2). Areas around open pit latrines were sanitized similarly, with little or no sewage odor at pit latrine sites where pipes were not overflowing. Fourteen sanitation officers, one for each Nagri sector and based at the sector health facility, liaised with their respective physician providers. Grey Water
Water and Sanitation Implementation Providing potable water in the context of varying daily population numbers required constant attention. The build-out for 90,000 kl/day proved adequate for typical bathing day populations; however, on high-volume auspicious bathing days, potable water was limited to drinking and cooking only. In addition to public water supplies, corporate donors distributed ultraviolet-treated water dispensers outside sector clinics and at major street intersections. Pit latrine maintenance was an ongoing challenge. Pipelines were easily clogged with debris and a 1000-member maintenance force was available for around-the-clock repairs. Pits that filled quickly, without the time required for anaerobic digestion, needed to be covered or pumped out. No routine system was in place to monitor these; the Kumbh administration simply discovered the problem when pilgrims complained. The bio-digester unit nearest the Sangam was used by hundreds of visitors before sufficient bio-culture was available. Sulabh units near the Sangam were unfinished early in the festival, with loose parts subject to theft. At many roadside simple pit latrines, pipes overflowed with human
Runoff water, waste water, and water deemed unsafe for drinking—Bgrey water^—was segregated into sandbag-lined, open stilling ponds at the margins of the roads. Vector control teams sprayed the ponds with DDT and malathion, and Hindi signage clearly marked the pools as containing non-potable water. The grey water was pumped into tanker trucks that traversed the Nagri and was used to spray down the dusty roads (or less frequently, to put out fires). Despite this system, we observed pools of wastewater gathering in communal cooking and bathing areas that ran into troughs directly to the river. Pilgrims would use this water for bathing and occasionally for drinking. Furthermore, pilgrims would routinely drink river water at the Sangam, given the attributed holiness and purity of water from the Ganga (PIC 3). Measured Water Quality Water was sampled from the Ganga on February 8th, 9th, 10th (Mauni Amavasya), and 11th, at three upstream and two downstream locations from the densest bathing areas. On all days, both upstream and downstream samples demonstrated
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high E. coli and fecal coliform counts ranging 6000 to 50, 000 CFU/100 ml. On February 10, there were too many colonies to count at the 1:10 dilution level suggesting values greater than 50,000 CFU/100 ml (Fig. 2). The temporary disease surveillance system piloted by this research team allowed the tracking of disease presentations to the clinics closest to the Sangam. The number of cases of diarrhea or gastrointestinal complaints rose and fell with the population estimates without a disproportionate spike in the number of cases (Fig. 3). The 20-bed, short-term, inpatient wards, attached to each of the 14 sector hospitals in the Nagri, rarely treated admitted diarrheal cases throughout the duration of the festival. Fig 3 Number of diarrhea cases presenting to one of the five pilot hospitals surveilled. The rise in cases on peak bathing days was comparable to the rise in population and in proportion to rise (and fall) in other presentations
Discussion The 2013 Allahabad Kumbh Mela offered an instructive model with global lessons for other mass gatherings that implement systematic water, sanitation, and hygiene policies that require coordination among administrative sectors. Our observational findings suggest a number of commendable practices that might be used in related events and humanitarian crises, as well as identify challenges and risks that should be addressed in future Melas. In spite of serious concern and significant provision for diarrheal disease outbreaks, including cholera, there was no planned or organized surveillance mechanism in place. Surveillance data collected by our team from four pilot sites suggested that despite measurably elevated E. coli and fecal coliform counts in public bathing water at the Ganga during the height of the festival, there was no demonstrable evidence of a 50
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Fig 2 Measured coliform counts upstream and downstream before, during, and after main bathing days (graphs with dates). Units ×1000 CFU/100 ml. Grey upstream; Black downstream; White missing data
proportional increase in the incidence of water-related diseases (bloody or non-bloody diarrhea) presenting to Nagri hospitals. This finding is especially notable given the known cultural practice of pilgrims drinking river water as part of the religious ritual. The rapid onset of most water-related diarrheal illnesses would make it more likely that pilgrims would become symptomatic prior to leaving the festival and an outbreak readily identifiable. The water quality data are not sufficiently granular to determine whether there was a spike in fecal contamination on the main bathing day of February 10, but the coliform and E. coli counts on all observed days were uniformly outside the ranges the World Health Organization considers safe for drinking or bathing. Although no causal relationship can be definitively established between the river water quality and the paucity of diarrhea cases, these observations may reflect that efforts to improve the quality of the river water, in combination with the provision of distributed potable water and toileting facilities, were sufficient to prevent an outbreak of diarrheal illness. These efforts demonstrate Nagri officials’ commitment to protect public health and prevent a communicable disease catastrophe. Health surveillance data did not identify nationality or place of origin, precluding a subgroup analysis of attendees. While a small minority of foreign visitors attended the Mela for short periods of time, most stayed in Allahabad city or in upscale accommodations in the Nagri that provided worldclass water and sanitation facilities. Foreign tourists tended to access private clinics in Allahabad rather than the Nagri health facilities, precluding systematic surveillance. The Kumbh Mela authorities repeatedly undertook the Herculean task of setting up temporary water and sanitation infrastructure for millions of pilgrims coming from largely rural, illiterate backgrounds. This task was complicated by
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population surges in the millions on main bathing days, a swell that could neither be estimated nor controlled with any precision. Unlike the Hajj or the Olympics, events that require application and/or registration mechanisms that generate population data estimates, the Kumbh Mela has no such estimating devices. As such, administrators default to institutional memory and educated guesses to determine the quantity of water and sanitation facility needs. Future Melas would benefit from using data sources that could provide some predictive population modeling. Toilet facilities drew on a creative combination of technological solutions appropriate to a range of literacy levels and cultural preferences. The diligent, systematic, and continuous collection of feces from roadsides and open public areas and the deposition of lime and vector control agents were effective and commendable. The innovative BGreen Kumbh^ movement focused local and religious activism on environmental respect for the Ganga, including an antilitter campaign and televised cleanup at the Sangam. This portends a critical shift in participant thinking that will be necessary as future Melas will undoubtedly draw increased numbers, raising the capacity for environmental destruction. Toilet signage included environmental messaging and took into account pilgrim illiteracy and gender specificity. However, no signage or messaging addressed personal sanitation and hygiene behaviors or cautionary disease prevention activities. Given ongoing concerns for epidemic diarrheal diseases, the lack of signage or public announcements about water sources, toileting facilities, or hand washing represented a lost opportunity for educating the population. Water pipelines were thoughtfully planned to deliver prodigious amounts of water to the akhadas. Tapped water was clearly readily available in the Nagri’s residential areas. The collection and reuse of runoff to spray down dusty thoroughfares was commendable and consistent with modern water conservation strategies. The availability of commercial ultraviolet-treated water outside clinics and at major intersections was a good example of public-private partnership in provision of a public good. However, large portions of the Sangam bathing areas lacked ready access to piped potable water. Severe crowding on bathing days restricted rapid mobility to access other water or alternative defecation facilities. These areas were key points of contact with contaminated water and where we witnessed pilgrims drinking both non-potable grey water from trucks spraying down the sand and river water as part of their holy ablutions. The inadequacy of the water infrastructure at such key locations is a clear opportunity for improvement at future Melas. Further, monitoring water quality at distribution sites was beyond the scope of the administration’s capacity. Such sites could be easily contaminated. Officials acknowledged problems and risks, and their systematic implementation of contextualized solutions and local
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expertise reflected the benefits of over a half century of administering this fixed and yet unpredictable event. Our surveillance data also identified clear gaps that may offer lessons for the future. While significant effort went into planning the sanitation needs within the urban zone, there was no mechanism to monitor sanitation system use (to reallocate resources as population needs arose) or identify breakdowns and failures. Repair efforts relied largely on ad hoc complaints by the holy men who stay for the duration of the festival. Besides the inventive Lifebuoy soap campaign, there was little evidence of public hygiene messaging strategies. Taken together, we suggest that these risks and constraints offer opportunities for strengthening water, sanitation, and hygiene for ever larger and more high profile future Melas and related events. Especially in light of the increased risks for morbidity and mortality from communicable agents that benefit from high population density and mobility, water, sanitation, and hygiene measures at all mass gatherings may benefit from strengthening strategic planning and implementation practices to mitigate such risk. The 2013 Mela may have, through a combination of will, preparedness, and sheer luck, avoided an epidemic outbreak, but given the ever increasing numbers attending the Mela, faster transportation alternatives available with each passing Mela, and the growing inter-connectedness of our world, future Melas continue to harbor the potential for catastrophic outbreaks, just as they have in the past. Compliance with Ethics Guidelines Conflict of Interest Gregg Greenough, Susan Holman, Satchit Balsari, and Michael Vortmann have no conflict of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by the authors.
References Papers of particular interest, published recently, have been highlighted as: • Of importance
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Nath KJ. Home hygiene and environmental sanitation: a country situation analysis for India. Int J Environ Health Res. 2003;13 Suppl 1:S19–28. 7.• Patel RB, Burke TF. Urbanization—an emerging humanitarian disaster. N Engl J Med. 2009;361(8):741–3. This perspective essay highlights the health and humanitarian risks of rapid urbanization and calls for focused research and action to develop new policies and programs that advance effective healthcare delivery with a focus on urban informal settlements. 8.• Balsari S. Leapfrog technology and epidemiology at the world’s largest human gathering. In: Health and South Asia. Cambridge, MA: South Asia Institute at Harvard University. 2013. Available at http://issuu.com/sainit/docs/healthandsouthasiabook/53. Accessed 18 November 2014. This article describes a mobile, tablet-based, real-time disease-surveillance system, first implemented at the 2013 Kumbh Mela, which successfully monitored potential epidemic risk by gathering and evaluating data from 50,000 patients over 3 weeks; the system has practical relevance for mass gatherings that occur in resource-limited settings 9.• Morbey RA, Elliot AJ, Charlett A, Ibbotson S, Verlander NQ, Leach S, et al. Using pubic health scenarios to predict the utility of a national
Page 7 of 7 5 syndromic surveillance programme during the 2012 London Olympic and Paralympic Games. Epidemiol Infect. 2014;142: 984–93. This study, based on data from the 2012 London Olympic and Paralympic Games, shows how scenario planning can be used to evaluate the effectiveness of syndromic surveillance. 10. Shukla N. Untreated factory waste poisoning the Ganga: Kanpur’s STPs not upgraded to handle tannery discharge. The Times of India, 2 Jul 2014. Available at: http://timesofindia.indiatimes.com/city/ lucknow/Untreated-factory-waste-poisoning-Ganga-Kanpur-STPsnot-upgraded-to-handle-tannery-discharge/articleshow/37632507. cms. Accessed 14 October 2014. 11. Nelson D. India plans 2£bn clean-up of the Ganges. The telegraph. 6 Oct 2009. Available at: http://www.telegraph.co.uk/news/ worldnews/asia/india/6265586/India-plans-2bn-clean-up-of-theGanges.html. Accessed 14 October 2014. 12. Spinney L. Kumbh Mela 2013: Picking flowers. National Geographic. 28 Jan 2013. Available at http://voices.nationalgeographic.com/2013/ 01/28/kumbh-mela-2013-picking-flowers/. Accessed 12 November 2014.
