Public health perspectives from the biggest human mass gathering on earth: Kumbh Mela, India

Short-term impacts of a large cultural event on the microbial pollution status of a pre-alpine river

Rivers are impacted by microbial faecal pollution from various sources. We report on a short-term faecal pollution event at the pre-alpine Austrian river Traisen caused by the large cultural event FM4 Frequency music festival, with around 200,000 visitors over 4 days. We observed a massive increase of the faecal indicator bacteria (FIB) intestinal enterococci during the event, while Escherichia coli concentrations were only slightly elevated. This increase poses a significant potential health threat to visitors and people recreating downstream of the festival area. A plausible explanation for the uncoupling of the two FIBs may have been a differential persistence caused by a combination of factors including water temperature, solar radiation, and the excessive presence of personal care products (PCPs) in the river water. However, a potential impact of PCPs on FIB assay performance cannot be ruled out. Our observations are relevant for other intensively used bathing sites; detailed investigations on persistence and assay performance of the FIB in response to different ingredients of PCPs are highly recommended. We conclude that for future festivals at this river or other festivals taking place under similar settings, a more effective management is necessary to reduce deterioration in water quality and minimise health risks.

Syndromic surveillance system during mass gathering of Panchkroshi Yatra festival, Ujjain, Madhya Pradesh, India

Background

The health implications surrounding a mass gathering pose significant challenges to public health officials. The use of syndromic surveillance provides an ideal method for achieving the public health goals and objectives at such events. In the absence of published reports of systematic documentation of public health preparedness in mass gatherings in the local context, we describe the public health preparedness and demonstrate the operational feasibility of a tablet-based participatory syndromic surveillance among pilgrims during the annual ritual circumambulation- Panchkroshi Yatra.

Methods

A real-time surveillance system was established from 2017-2019 to capture all the health consultations done at the designated points (medical camps) in the Panchkroshi yatra area of the city Ujjain in Madhya Pradesh. We also surveyed a subset of pilgrims in 2017 to gauge satisfaction with the public health measures such as sanitation, water, safety, food, and cleanliness.

Results

In 2019, injuries were reported in the highest proportion (16.7%; 794/4744); most numbers of fever cases (10.6%; 598/5600) were reported in 2018, while 2017 saw the highest number of patient presentations of abdominal pain (7.73%; 498/6435).

Conclusion

Public health and safety measures were satisfactory except for the need for setting up urinals along the fixed route of the circumambulation. A systematic data collection of selected symptoms among yatris and their surveillance through tablet could be established during the panchkroshi yatra, which can complement the existing surveillance for detecting early warning signals. We recommend the implementation of such tablet-based surveillance during such mass gathering events.

Healthcare Research in Mass Religious Gatherings and Emergency Management: A Comprehensive Narrative Review

Religious mass gatherings, especially pilgrimages of various faiths, involve overcrowding and the international movement of people, exposing individuals to significant health risks, such as the spread of infectious diseases, crowds, exposure to bad weather, physical stress, or risks due to pre-existing medical conditions. This paper aims to review the literature related to health care research on religious mass gatherings, with special reference to the role of awareness creation, training, and risk awareness for individuals during Hajj. The results indicated that the research on health risks associated with large-scale gatherings showed that some countries (which witness religious gatherings) follow effective preventive measures to reduce health risks, while some countries did not (and linked this to its poor infrastructure and the low standard of living in it, such as India). It also showed that most studies overlooked identifying the causes of infectious diseases and determining the perceptions of participants in mass gatherings. While it showed that environmental factors strongly influence the emergence of infectious diseases among individuals, the results also showed the scarcity of research that revolves around the awareness of community members, the health risks of mass gatherings, preventive measures against diseases, and the main effects on individuals' perceptions of risks. The results also showed a lack of research evidence on how pilgrims perceive risks, adopt information, and interact with their willingness to be trained in preventive measures.

Distribution of self-reported health in India: The role of income and geography

An important new large-scale survey database is brought to bear on measuring and analysing self-reported health in India. The most important correlates are age, income and location. There is substantial variation of health across the 102 'homogeneous regions' within the country, after controlling for household and individual characteristics. Higher income is correlated with better health in only 40% of India. We create novel maps showing regions with poor health, that is attributable to the location, that diverge from the conventional wisdom. These results suggest the need for epidemiological studies in the hotspots of ill-health and in regions where higher income does not correlate with improved health.

Emerging and Re-Emerging Viral Infections: An Indian Perspective

Emerging and re-emerging viral infections pose a constant threat, especially in healthcare settings. Viral infections can be thought of as an ecological system, like a forest or a pond, with different species competing for resources. Pandemics tend to occur when there is a disruption to this ecosystem, such as introducing a strain of virus into humans or animals that they have no immunity against. Around 60% of human infectious diseases and 75% of emerging infections are zoonotic, with two-thirds originating in wildlife. There is an ongoing risk of viral diseases as the human population continues to grow and the rate of urbanization increases. The emergence and re-emergence of viral diseases are influenced by a variety of virologic and environmental factors. These factors can be roughly categorized as affecting humans, the environment and/or ecology, and viruses. The spread of zoonotic diseases among humans can be prevented by reducing the transmission risk associated with wildlife and exotic pets through education, legislation, and behavioral change programs that target individuals at risk for exposure.

A Review of Infectious Diseases Associated with Religious and Nonreligious Rituals

Rituals are an integral part of human life but a wide range of rituals (both religious and non-religious), from self-flagellation to blood brotherhood to ritual sprinkling of holy water, have been associated with transmission of infections. These infections include angiostrongyliasis, anthrax, brucellosis, cholera, COVID-19, cutaneous larva migrans, Ebola, hepatitis viruses, herpes simplex virus, HIV, human T-cell leukemia virus (HTLV), kuru, Mycobacterium bovis, Naegleria fowleri meningoencephalitis, orf, rift valley fever, and sporotrichosis. Education and community engagement are important cornerstones in mitigating infectious risks associated with rituals.

Knowledge and transmission risk awareness of tuberculosis among the pilgrims attending a religious mass gathering in India: a cross-sectional study

Background

Tuberculosis infection accounts for more annual deaths than any other single infectious disease, except the Corona Virus infection. It is a significant global issue and India is one of the most affected countries. Religious mass gatherings congregate millions of pilgrims at one place. Over-crowding is a high-risk factor for the transmission of tuberculosis. Knowledge and awareness of the disease are proven prerequisites for the spread-prevention and early diagnosis of tuberculosis. The present study was designed to explore the knowledge of tuberculosis and awareness of disease transmission risk among pilgrims attending a religious mass gathering, the Kumbh Mela (2016) in Ujjain, India.

Methods

Self-reported data on the pilgrims’ tuberculosis-knowledge were collected using a cross-sectional study design. A contextual, pre-tested questionnaire was used, using the convenience sampling method. In addition to the anonymous descriptive analyses, a composite knowledge-score was developed to enable comparisons between demographic groups.

Results

In total, 1665 pilgrims participated in the study with 38.8 years of mean age and 59% literacy rate. The most recognized symptoms of tuberculosis were “Cough for more than 15 days with sputum” (94%) and “Blood in sputum” (81%). Most participants knew that tuberculosis is an infectious disease (93%) and not hereditary (91%). Additionally, 84% considered it is a potentially lethal disease that requires extensive treatment. However, vaccine awareness was poor (4%). “Direct contact with tuberculosis patient” (78%) and “To be in a crowded area” (4%) were considered as the most important risk factors for tuberculosis transmission. For the composite knowledge-score, a significantly higher mean score was seen among those with at least ten years of schooling compared with illiterates (p <  0.001). Occupation and residency also affected the mean score.

Conclusion

Most pilgrims attending the Kumbh Mela had basic knowledge of the characteristics of tuberculosis, but some important knowledge gaps concerning the transmission risks associated with crowded situations existed. These gaps need to be addressed in future policies to enable safer mass gatherings and to end the TB epidemic, globally.

Easy Access to Antibiotics; Spread of Antimicrobial Resistance and Implementation of One Health Approach in India

Antimicrobial resistance (AMR) is a global public health concern because of its fast spread. India, one of the world's top consumer of antibiotics and second most populated country has its unique constraints of social, cultural and economic strata. The continual self-medication, use of antibiotics for the growth promotion in animals, and accumulation of residual antibiotics in the environment challenge the implementation of AMR containment policy. Hence, the present review attempts to delineate the influence of antibiotics abuse on the human, animal and environmental health under the realm of one health. It was based on the literature search using public databases to highlight the rapid surge in the burden of AMR in India affecting various sectors and/or ecosystems in India. It was found that the irrational and overuse of antibiotics in different sectors have led to the emergence of extended antimicrobial resistance wherein the environment acts as a reservoir of antibiotic resistance genes (ARGs); completing the cycle of contamination and recontamination. There are efforts by government policy makers to reduce the burden of AMR in the country to reduce the health risks, through the One Health approach. Parallel efforts in educating healthcare professionals, strict legislation for pharmacies and pharmaceutical companies should be prioritize. At the same time surveillance of newly emerged AMR pathogens, prioritising research focusing on AMR, and awareness camps or programs among the local population is critical while addressing the consequences of spared of AMR in India.

Public health risks threatening health of people participating in mass gatherings: A qualitative study

Background

Mass gatherings (MGs) have made many problems for the health system and potentially threaten the health of those participated in these gatherings. MGs account for a range of public health risks including communicable diseases, waterborne diseases, water treatment, and outbreaks.

Objectives

The present study aimed to identify public health risks threatening the health of people participating in MGs in Iran.

Methods

A qualitative study was designed using a conventional qualitative content analysis approach. Participants were selected using a purposive sampling method among the managers and staff who have experiences in the field of health in MGs in Iran. Subjects were interviewed through individual in-depth interviews after obtaining informed consent. Semi-structured interviews were used to collect the data from December 2018 to February 2019. To analyze the data, the content of recorded interviews was written verbatim. Preliminary data were repeatedly and simultaneously retrieved to give a general understanding of them.

Results

The main theme emerged from data analysis on 16 interviews was related to public health risks involving the following categories: food hygiene deficiencies, communicable diseases risks, defects in health supervision, and the risk of environmental contamination.

Conclusion

It is of paramount importance to identify the risks threatening the health of people participating in MGs. In the present study, the main public health risks were detected.

Extended Ecological Restoration of Bacterial Communities in the Godavari River During the COVID-19 Lockdown Period: a Spatiotemporal Meta-analysis

The unprecedented COVID-19 pandemic has had major impact on human health worldwide. Whilst national and international COVID-19 lockdown and travel restriction measures have had widespread negative impact on economies and mental health, they may have beneficial effect on the environment, reducing air and water pollution. Mass bathing events (MBE) also known as Kumbh Mela are known to cause perturbations of the ecosystem affecting resilient bacterial populations within water of rivers in India. Lockdowns and travel restrictions provide a unique opportunity to evaluate the impact of minimum anthropogenic activity on the river water ecosystem and changes in bacterial populations including antibiotic-resistant strains. We performed a spatiotemporal meta-analysis of bacterial communities of the Godavari River, India. Targeted metagenomics revealed a 0.87-fold increase in the bacterial diversity during the restricted activity of lockdown. A significant increase in the resilient phyla, viz. Proteobacteria (70.6%), Bacteroidetes (22.5%), Verrucomicrobia (1.8%), Actinobacteria (1.2%) and Cyanobacteria (1.1%), was observed. There was minimal incorporation of allochthonous bacterial communities of human origin. Functional profiling using imputed metagenomics showed reduction in infection and drug resistance genes by - 0.71-fold and - 0.64-fold, respectively. These observations may collectively indicate the positive implications of COVID-19 lockdown measures which restrict MBE, allowing restoration of the river ecosystem and minimise the associated public health risk.

Mass gatherings: a review of the scope for meningococcal vaccination in the Indian context

The risk of meningococcal transmission is increased with crowding and prolonged close proximity between people. There have been numerous invasive meningococcal disease (IMD) outbreaks associated with mass gatherings and other overcrowded situations, including cramped accommodation, such as student and military housing, and refugee camps. In these conditions, IMD outbreaks predominantly affect adolescents and young adults. In this narrative review, we examine the situation in India, where the burden of IMD-related complications is significant but the reported background incidence of IMD is low. However, active surveillance for meningococcal disease is suboptimal and laboratory confirmation of meningococcal strain is near absent, especially in non-outbreak periods. IMD risk factors are prevalent, including frequent mass gatherings and overcrowding combined with a demographically young population. Since overcrowded situations are generally unavoidable, the way forward relies on preventive measures. More widespread meningococcal vaccination and strengthened disease surveillance are likely to be key to this approach.

Exploring the allochthonous pollution influence on bacterial community and co-occurrence dynamics of River Ganga water through 16S rRNA-tagged amplicon metagenome

River Ganga is one of the largest and most sacred rivers of India. This river is largely affected by anthropogenic activities causing significant increase in water pollution. The impact of drains discharging polluted water on the bacterial community dynamics in the river remains unexplored. To elucidate this, the targeted 16S rRNA V3-V4 variable region amplicon sequencing and bioinformatic analysis were performed using water from upstream, drain, and downstream of river Ganga. Analysis revealed significant difference in relative abundances of bacterial communities. The increase in bacterial abundance and alpha diversity was detected in the downstream compared to the upstream. Environmental factors were found significantly different between upstream and downstream water. At the phyla level, highly abundant taxa such as Proteobacteria, Actinobacteria, Planctomycetes, Bacteroidetes, and Verrucomicrobia were observed. Bacterial genera like Prevotella, Bacteroides, Blautia, and Faecalibacterium (fecal indicator) had higher abundance in the downstream site. Network co-occurrence revealed that bacterial communities have a modular profile with reduced interaction in drain and downstream water. The network of co-occurring bacterial communities consists of 283 nodes with edge connectivity of 6900, 7074, and 5294 in upstream, drain, and downstream samples, respectively. Upstream communities exhibited the highest positive interaction followed by the drain and the downstream sites. Additionally, highly abundant pathogenic species such as Acinetobacter baumannii and Prevotella copri were also detected in all samples. This study suggests the drain to be allochthonous pollution vector that significantly contributes to bacterial community enrichment. From the results of this study, it is apparent that the lotic water may be used as the ecological reference to understand and monitor the variations in the bacterial communities and their co-occurrence dynamics in the fresh water ecosystems.

Religious factors affecting death anxiety in older adults practicing Hinduism

The aim of the study was to examine the influence of religion on death anxiety in older adults (N = 105) practicing Hinduism and visiting the Kumbh pilgrimage. Standardized questionnaires and brief interviews were administered in participants' native language. Pilgrims with higher religiosity had lower death anxiety compared to pilgrims with lower religiosity. Greater belief in the cycle of rebirth, an increased presence of meaning in life, and less continued search of meaning in life were significantly associated with lower death anxiety. The findings provide support for incorporating religious and spiritual awareness for older adults in community health settings.

Disease surveillance during a large religious mass gathering in India: The Prayagraj Kumbh 2019 experience

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At Kumbh Mela 2019, disease surveillance was established for 22 acute diseases and syndromes.

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Among the reported illnesses, 95% were communicable diseases such as acute respiratory illness (35%), acute fever (28%), and skin infections (18%).

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The incident command centre generated 12 early warning signals from indicator-based and event-based surveillance: acute diarrheal diseases (n = 8, 66%), vector-borne diseases (n = 2, 16%), vaccine-preventable disease (n = 1, 8%), and thermal event (n = 1, 8%).

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There were two outbreaks (acute gastroenteritis and chickenpox) that were investigated and controlled.

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Implementation of disease surveillance facilitated early outbreak detection and response.

Background

Mass gathering (MG) events are associated with public health risks. During the period January 14 to March 4, 2019, Kumbh Mela in Prayagraj, India was attended by an estimated 120 million visitors. An onsite disease surveillance was established to identify and respond to disease outbreaks.

Methods

A health coordination committee was established for planning. Disease surveillance was prioritized and risk assessment was done to identify diseases/conditions based on epidemic potential, severity of illness, and reporting requirement under the International Health Regulations (IHR) of 2005. A daily indicator and event-based disease surveillance was planned. The indicator-based surveillance (IBS) manually and electronically recorded data from patient hospital visits and collected MG area water testing data to assess trends. The event-based surveillance (EBS) helped identify outbreak signals based on pre-identified event triggers from the media, private health facilities, and the food safety department. Epidemic intelligence was used to analyse the data and events to detect signals, verify alerts, and initiate the response.

Results

At Kumbh Mela, disease surveillance was established for 22 acute diseases/syndromes. Sixty-five health facilities reported 156 154 illnesses (21% of a total 738 526 hospital encounters). Among the reported illnesses, 95% (n = 148 834) were communicable diseases such as acute respiratory illness (n = 52 504, 5%), acute fever (n = 41 957, 28%), and skin infections (n = 27 094, 18%). The remaining 5% (n = 7300) were non-communicable diseases (injuries n = 6601, 90%; hypothermia n = 224, 3%; burns n = 210, 3%). Water samples tested inadequate for residual chlorine in 20% of samples (102/521). The incident command centre generated 12 early warning signals from IBS and EBS: acute diarrheal disease (n = 8, 66%), vector-borne disease (n = 2, 16%), vaccine-preventable disease (n = 1, 8%), and thermal event (n = 1, 8%). There were two outbreaks (acute gastroenteritis and chickenpox) that were investigated and controlled.

Conclusions

This onsite disease surveillance imparted a public health legacy by successfully implementing an epidemic intelligence enabled system for early disease detection and response to monitor public health risks. Acute respiratory illnesses emerged as a leading cause of morbidity among visitors. Future MG events should include disease surveillance as part of planning and augment capacity for acute respiratory illness diagnosis and management.

The Impact of Mass Gatherings on Emergency Department Patient Presentations with Communicable Diseases Related to Syndromic Indicators: An Integrative Review

BACKGROUND

Mass-gathering events (MGEs) are commonly associated with a higher than average rate of morbidity. Spectators, workers, and the substantial number of MGE attendees can increase the spread of communicable diseases. During an MGE, emergency departments (EDs) play an important role in offering health care services to both residents of the local community and event attendees. Syndromic indicators (SIs) are widely used in an ED surveillance system for early detection of communicable diseases.

AIM

This literature review aimed to develop an understanding of the effect of MGEs on ED patient presentations with communicable diseases and their corresponding SIs.

METHOD

An integrative literature review methodology was used. Online databases were searched to retrieve relevant academic articles that focused on MGEs, EDs, and SIs. Inclusion/exclusion criteria were applied to screen articles. The Standard Quality Assessment Criteria for Evaluating Primary Research (QualSyst) assessment tool was used to assess the quality of included papers.

RESULTS

Eleven papers were included in this review; all discussed the impact of an MGE on patient presentations with communicable diseases at EDs/hospitals. Most included studies used the raw number of patients who presented or were admitted to EDs/hospitals to determine impact. Further, the majority of studies focused on either respiratory infections (n = 4) or gastrointestinal infections (n = 2); two articles reported on both. Eight articles mentioned SIs; however, such information was limited. The quality of evidence (using QualSyst) ranged from 50% to 90%.

CONCLUSIONS

Limited research exists on the impact of MGEs on ED presentations with communicable diseases and related SIs. Recommendations for future MGE studies include assessing differences in ED presentations with communicable diseases regarding demographics, clinical characteristics, and outcomes before, during, and after the event. This would benefit health care workers and researchers by offering more comprehensive knowledge for application into practice.

Welcome to Wonderland? A Population Study of Intimate Experiences and Safe Sex at a Transformational Mass Gathering (Burning Man)

Transformational festivals are socially immersive artistic mass gatherings that are said to promote a strong feeling of belonging and experiences of personal transformation. The purposes of the present study were (1) to investigate the social and intimate experiences of Burning Man participants and (2) to study the factors predicting safe sex practices in the context of that transformational festival. The study was based on data from two consecutive cycles (2013 and 2014) of the yearly post-event online survey done in collaboration with the Burning Man Project. Participants consisted of people who attended the event (N = 19,512). The results were weighted based on the sociodemographic characteristics of the population. A typology of social and intimate experiences was created using a k-means cluster analysis. Predictors of having had unprotected sex with someone met during the event were identified using a nested logistic regression. Five profiles of social and intimate experiences were identified. Profiles with high levels of emotionally and physically intimate experiences were associated with a strong feeling of belonging and a high proportion of personal transformation. Predictive analyses showed that unprotected sex was mainly predicted by variables associated with one of three factors: (1) a lower lever of preparation and practice in using protection, (2) sex education and/or subcultures, and (3) the perceived costs and benefits associated with protection. The results also indirectly suggest a positive effect of the event on safe sex. Implications in terms of public health intervention are discussed.

Opportunities and challenges for cholera control in India

The Indo Gangetic delta is homeland for cholera for almost two centuries now and there is evidence of global spread from this area. With migration of people to more urban areas within the country and increase in international travel, it is time for action against cholera in India, given its capacity to present itself in epidemic proportions. The Global roadmap to end cholera by 2030 was launched by the WHO Global Task force for Cholera Control which has led to renewed vigor and convergence of stakeholders across the world against the disease. There is also an emphasis on cleanliness and improved sanitation by the current government. The article discusses the unique opportunity for India in the current scenario, to act against diseases like cholera and challenges that are anticipated in deployment of interventions due to suboptimal surveillance and shortage of vaccines.

Mass gatherings medicine: public health issues arising from mass gathering religious and sporting events

Mass gathering events are associated with major public health challenges. The 2014 Lancet Series on the new discipline of mass gatherings medicine was launched at the World Health Assembly of Ministers of Health in Geneva in May, 2014. The Series covered the planning and surveillance systems used to monitor public health risks, public health threats, and experiences of health-care providers from mass gathering events in 2012 and 2013. This follow-up Review focuses on the main public health issues arising from planned mass gathering events held between 2013 and 2018. We highlight public health and research data on transmission of infectious diseases and antibiotic-resistant bacteria, mass casualty incidents, and non-communicable diseases, including thermal disorders. In the events discussed in this Review, the combination of a large influx of people, many from countries with outbreak-prone infectious diseases, with a high degree of crowd interactions imposed substantial burdens on host countries' health systems. The detection and transmission of antibiotic-resistant bacteria in pilgrims attending the Kumbh Mela and the Hajj raise concern of possible globalisation from mass-gathering religious events. Priorities for further investments and opportunities for research into prevention, surveillance, and management of these public health issues are discussed.

Qualitative study of health system preparedness for traumatic incidents in a religious mass gathering

BACKGROUND AND OBJECTIVES

Traumatic incidents may occur during religious mass gatherings. A lack of preparedness by the health system to respond to traumatic incidents may increase the mortality rate. This study investigated the factors that affect the preparedness of a health system to respond to traumatic incidents, and we provide appropriate suggestions for improving the response to such incidents during religious mass gatherings.

METHODS

A qualitative research method was used with a conventional content analysis approach. In total, 22 semi-structured interviews were conducted employing the content analysis method. The data were analyzed based on the means of the meaning units, condensed meaning units, sub-themes, themes, and codes.

RESULTS

Four main categories and nine sub-categories emerged from the data: factors that increased or decreased the occurrence of incidents (with three sub-categories comprising risk perception and fatalism, pilgrims' responses to incidents, and health system response to traumatic events); medical infrastructure (with two sub-categories comprising medical infrastructure in the host country and medical structures in border cities); organizational resource category (with two sub-categories comprising manpower, and equipment and facilities); and coordination of responsible organizations (with two sub-categories comprising inter-organizational coordination and inter-agency collaboration). All of the data were extracted from the experiences of the participants.

CONCLUSION

Similar to other mass gatherings, Arbaeen requires multi-sectoral and international planning, organizing, and management. The key factors that could improve the preparedness to respond to traumatic events in Arbaeen include training, increasing the perception of risk, changing the attitudes and behavior of pilgrims, developing a national strategic plan of the health system preparedness for policymakers, and implementing scenario-based exercises for executives.

Emerging/re-emerging viral diseases & new viruses on the Indian horizon

Infectious diseases remain as the major causes of human and animal morbidity and mortality leading to significant healthcare expenditure in India. The country has experienced the outbreaks and epidemics of many infectious diseases. However, enormous successes have been obtained against the control of major epidemic diseases, such as malaria, plague, leprosy and cholera, in the past. The country's vast terrains of extreme geo-climatic differences and uneven population distribution present unique patterns of distribution of viral diseases. Dynamic interplays of biological, socio-cultural and ecological factors, together with novel aspects of human-animal interphase, pose additional challenges with respect to the emergence of infectious diseases. The important challenges faced in the control and prevention of emerging and re-emerging infectious diseases range from understanding the impact of factors that are necessary for the emergence, to development of strengthened surveillance systems that can mitigate human suffering and death. In this article, the major emerging and re-emerging viral infections of public health importance have been reviewed that have already been included in the Integrated Disease Surveillance Programme.

World's Largest Mass Bathing Event Influences the Bacterial Communities of Godavari, a Holy River of India

Kumbh Mela is one of the largest religious mass gathering events (MGE) involving bathing in rivers. The exponential rise in the number of devotees, from around 0.4 million in 1903 to 120 million in 2013, bathing in small specified sites can have a dramatic impact on the river ecosystem. Here, we present the spatiotemporal profiling of bacterial communities in Godavari River, Nashik, India, comprising five sites during the Kumbh Mela, held in 2015. Assessment of environmental parameters indicated deterioration of water quality. Targeted amplicon sequencing demonstrates approximately 37.5% loss in microbial diversity because of anthropogenic activity during MGE. A significant decrease in phyla viz. Actinobacteria, Chloroflexi, Proteobacteria, and Bacteroidetes was observed, while we noted substantial increase in prevalence of the phylum Firmicutes (94.6%) during MGE. qPCR estimations suggested nearly 130-fold increase in bacterial load during the event. Bayesian mixing model accounted the source of enormous incorporation of bacterial load of human origin. Further, metagenomic imputations depicted increase in virulence and antibiotic resistance genes during the MGE. These observations suggest the striking impact of the mass bathing on river ecosystem. The subsequent increase in infectious diseases and drug-resistant microbes pose a critical public health concern.

Seasonal Variations in Water-Quality, Antibiotic Residues, Resistant Bacteria and Antibiotic Resistance Genes of Escherichia coli Isolates from Water and Sediments of the Kshipra River in Central India

OBJECTIVES

To characterize the seasonal variation, over one year, in water-quality, antibiotic residue levels, antibiotic resistance genes and antibiotic resistance in Escherichia coli isolates from water and sediment of the Kshipra River in Central India.

METHODS

Water and sediment samples were collected from seven selected points from the Kshipra River in the Indian city of Ujjain in the summer, rainy season, autumn and winter seasons in 2014. Water quality parameters (physical, chemical and microbiological) were analyzed using standard methods. High-performance liquid chromatography⁻tandem mass spectrometry was used to determine the concentrations of antibiotic residues. In river water and sediment samples, antibiotic resistance and multidrug resistance patterns of isolated E. coli to 17 antibiotics were tested and genes coding for resistance and phylogenetic groups were detected using multiplex polymerase chain reaction. One-way analysis of variance (ANOVA) and Fisher tests were applied to determine seasonal variation.

RESULTS

In river water, seasonal variation was significantly associated with various water quality parameters, presence of sulfamethoxazole residues, bacteria resistant to ampicillin, cefepime, meropenem, amikacin, gentamicin, tigecycline, multidrug resistance and CTX-M-1 gene. The majority of the Extended Spectrum Beta-Lactamase (ESBL)-producing E. coli isolates from river water and sediment in all different seasons belonged to phylogenetic group A or B1.

CONCLUSIONS

Antibiotic pollution, resistance and resistance genes in the Kshipra River showed significant seasonal variation. Guidelines and regulatory standards are needed to control environmental dissemination of these “pollutants” in this holy river.

Corynebacterium godavarianum sp. nov., isolated from the Godavari river, India

A Gram-stain-positive, rod-shaped, non-motile bacterium, strain PRD07^T, was isolated from Godavari river, India during the world's largest spiritual and religious mass bathing event 'Kumbh Mela'. Molecular analysis using 16S rRNA gene sequencing and phylogenetic analysis reveals the distinct phylogenetic positioning of strain PRD07^T within the genus Corynebacterium. The strain demonstrated highest sequence similarity to Corynebacterium imitans DSM 44264^T (97.9 %), Corynebacterium appendicis DSM 44531^T (97.1 %) and <96.7 % with all other members of the genus Corynebacterium. The G+C content of PRD07^T was 68.5 mol% (Tm) and the DNA-DNA hybridization depicts 61.09 % genomic relatedness with C. imitans DSM 44264^T. Chemotaxonomic assessment of strain PRD07^T suggested presence of C16 : 0 (31.6 %), C18 : 0 (3.5 %) and C18 : 1ω9c (58.6 %) as the major cellular fatty acids. The major polar lipids of strain PRD07^T were phosphatidylglycerol, diphosphatidylglycerol and glycophospholipid. Differentiating molecular, phylogenetic and chemotaxonomic characteristics of strain PRD07^T with its closest relatives necessitated the description of strain PRD07^T as a novel species of genus Corynebacterium for which the name Corynebacteriumgodavarianum sp. nov., has been proposed. The type strain is PRD07^T (=MCC 3388^T=KCTC 39803^T=LMG 29598^T).

Anthropogenic Activities Induce Depletion in Microbial Communities at Urban Sites of the River Ganges

The Ganges is the largest river of India, worshiped by Hindus with a belief that bathing in the river causes the remission of sins and is considered very pure. It is heavily polluted by the unrestricted human usage including ritual practices, urbanization, and industrialization. Such perturbations may subsequently influence the bacterial community composition and ecosystem functioning. Here, we applied targeted amplicon sequencing to determine the impact of spatial variation on the microbial community assemblage of the Ganga River. The river bacterial community demonstrates taxonomic variability across the sites with accumulation of Firmicutes (20.9%) Verrucomicrobia (6.09%), Actinobacteria (4.51%), and Synergistetes (1.16%), at rural site while Proteobacteria (49.4%) and Bacteroidetes (12.7%) predominate at urban sites. Furthermore, sites under study establish the unique taxonomic signature which could represent the impact of spatial variation on the microbial community assemblage.

A Three-Year Follow-Up Study of Antibiotic and Metal Residues, Antibiotic Resistance and Resistance Genes, Focusing on Kshipra-A River Associated with Holy Religious Mass-Bathing in India: Protocol Paper

BACKGROUND

Antibiotic resistance (ABR) is one of the major health emergencies for global society. Little is known about the ABR of environmental bacteria and therefore it is important to understand ABR reservoirs in the environment and their potential impact on health.

METHOD/DESIGN

Quantitative and qualitative data will be collected during a 3-year follow-up study of a river associated with religious mass-bathing in Central India. Surface-water and sediment samples will be collected from seven locations at regular intervals for 3 years during religious mass-bathing and in absence of it to monitor water-quality, antibiotic residues, resistant bacteria, antibiotic resistance genes and metals. Approval has been obtained from the Ethics Committee of R.D. Gardi Medical College, Ujjain, India (No. 2013/07/17-311).

RESULTS

The results will address the issue of antibiotic residues and antibiotic resistance with a focus on a river environment in India within a typical socio-behavioural context of religious mass-bathing. It will enhance our understanding about the relationship between antibiotic residue levels, water-quality, heavy metals and antibiotic resistance patterns in Escherichia coli isolated from river-water and sediment, and seasonal differences that are associated with religious mass-bathing. We will also document, identify and clarify the genetic differences/similarities relating to phenotypic antibiotic resistance in bacteria in rivers during religious mass-bathing or during periods when there is no mass-bathing.

What is the experience from previous mass gathering events? Lessons for Zika virus and the Olympics 2016

All previous experiences from different mass gathering show that vaccine preventable diseases is the most important infections like influemza, hepatitis A, polio and meningitis. Three mass gathering held in Africa during the Ebola outbreak accepted participants from West Africa and was able to handle the theoretical risk without any incident. Therefore we believe that the Olympc games in Rio de Janeiro should not be canceled. The number of visitors to the games is a tine fraction (1%) of other visitors to Zika endemic con tries and it will have no measurable effect on the risk of spreading Zika virus, if the games was cancelled.