/influenza like illness, chiken pox, measles, bacillary dysentery, conjunctivitis, skin diseases and Non-communicable risks, including heat-related illness, accidents, drowning, dog bite, snake bite and burn. In addition, rituals in religious events, such as rolling on the floor, or bathing naked in the river early in the morning, may predispose to skin, respiratory, gastrointestinal and genitourinary infections [5].

From the previous four year data of all these identified diseases and events in the area are under the threshold level. On the basis of previous data available, the prone diseases were identified. Though, the event is of national and international concern, the communicable diseases which were prevalent at national and international level were also taken into consideration for alert.

To know the situation of vectors more specific in the study area, a pilot survey in the six zone distributed area of Ujjain was conducted to identify the risk associated with vector born diseases. The Master Trainers reveal the survey and found the House Index of 6.5, Container Index 1.34 and Bretaeu Index 7.70.

As per the guidelines of Vector Born Disease Control Programme (VBDCP), these indices shows certain amount of risk in the area. On the basis of pilot survey, mass surveillance activities in the Ujjain city to minimize the risk regarding the Vector Born Disease was carried out, it includes the Fair area.

The rational and objectives of the study

The most basic rationale of the study is to replicate the best practices in many of the mass gathering events in different setup.

The objectives of the study are as follows-

1. To know the disease trends in a huge event.
2. To know the risk factor triggered by the surveillance system
3. To assess the importance of health planning and monitoring in a mass gathering
4. To provide a pathway to future endowers

Plan of action- From the four year data analysis of city Ujjain , if we restrict it to one month i.e. the same main Fair period, 21 April to 22 May, the disease pattern of the Ujjain city shown in the Fig. 1.

Period and flow of data collection- The period of the data collection of the study was 21 April to 22 May 2016. A stipulated proforma was designed for daily reporting. The flow of reporting was like Sectors to Zones and Zones to District than SSU and CSU as shown in Fig. 3. It was insured that all outbreaks must reported immediately. Analysis and forecasting of the data would be done simultaneously.

Fig.-2: Surveillance during Simhastha Fair –Flow Chart of data flow

Data Collection- The data collected on the daily basis. Data were compiled and validated every day. They were analyzed and summarized on the same day. Any trigger mark in trends of disease data, initiated an action for the field to investigate the actual situation. Whether it is clustering of cases in a specific area or all are scattered cases. This was the prime importance of the whole study. Vector prevention activities were also carried out through these data inferences.

A total of 3,21.841 patients were screened in OPD and 19178 patients were treated as IPD. The OPD includes the Ghat OPD of 52957 patients. In the Fair period there is no death due to any disease and no epidemic erupted. Highest number of cases recorded of fever i.e. 18,700 (6.95%), followed by acute respiratory infection (ARI), 15,834 (5.89%), Acute diarrheal disease (ADD) 14,715 (5.47%), skin disease 3089 (1.15), heat stroke 1225 (0.46%) and rest shared by injuries 1143 (0.42%), conjunctivitis 823 (0.31%), bacillary dysentery 320 (0.12%), malaria 62 (0.02%), Jaundice/Viral hepatitis 58 (0.02%), chicken pox 21 (0.01%). The cases of dog bite were 504 (0.19%), snake bite 6 (0.01%), Burn 84 (0.03%) and drowning 18 (0.01%). There were no case reported of dengue and measles. All these are shown in Table 2 & Fig. 3.

From the past years metrological data of Ujjain city the temperature of the city varies from 41 to 46 degree Celsius in summer. In total screened patients about 20% were suffered from heat related illness. In the study period only three outbreak were reported. This shows the best efforts done in terms of public health concern.

The planned health infrastructure, availability of safe drinking water, good sanitation facilities, proper crowed control were the key to success. The basic idea of “pilgrims never become patient” gives the health officials and health workers a road map to deal with every situation.

Mass gathering have been associated with significant morbidity and deaths. A large outbreak of meningococcal disease was reported among pilgrims from 12 countries who contracted the disease while attending the Hajj in Mecca [10]. Ehresmann KR et al reported an outbreak of measles in the United States at the International Special Olympic Games (1991) involved athletes, spectators and volunteers [11].

In 1996 about 10000 cases of malaria were reported to be imported into the European Union (EU) [12]. Rowbotharn TJ explains the cruise ships berthed in harbours near mass-gathering venues have the potential for experiencing outbreak of disease, including gastroenteritis, Legionnaires disease, influenza and tuberculosis [13].

In large congregations, many people go missing, and in some cases die in instances such as stampedes, fires and collapse of buildings. For example, during 1997 and 2005, several hundred Hajj pilgrims died of fire or stampede (Yamin, 2005). The things have been no different in Indian perspective. Table 1 shows some of the major mishaps that caused people loss of lives and damage to property [14].

The referral and district hospital labouratory network was also used for different type of testing of human samples. Thirteen Stool samples were sent for testing of cholera to referral lab Mahatma Gandhi Medical College, Indore and found 2 cholera positive. A study in 2003 reported encouraging results from the use of telemedicine during the Fair for evading cholera epidemics [15].

As per the triggers given by surveillance, the water samples around 3754 were collected and tested. Among these samples 1442 samples found less than 0.5 ppm Residual Chlorine. Action were initiated according to the situation.

During the event time three outbreaks were reported. The first outbreak was of food poisoning in a ashram where 30 people eaten contaminated food at night. Eight of the person admitted in hospital through 108 facility. No death registered. After treatment patients were discharged. The second outbreak was of heat stroke.

The event happened after bathing in holy river Kshipra, 41 Japanese and European people got heat stroke. All were admitted in two govt. hospitals and discharges after treatment. No death registered.

Disease surveillance, diagnosis, treatment and prevention will become more targeted if doctors and public health officials are aware of the common health risks involved during the pilgrimage. The disease pattern of the Simhastha shows the clear picture of role played by the surveillance. The area was on high alert to do the public health activities. If prevention is better than the next burden will be half.

The authors offer sincerest gratitude to Principal Secretary, Health Mrs. Gauri Singh who has supported us in every aspects and inspired to write this paper. Authors are also acknowledge the support of Director, NIMR, New Delhi, Director, NCDC and EIS officers.

Authors are thankful to JD, Ujjain Division, Dr. Nidhi Vyas, CM& HO, Dr. N. K. Trivedi for their meaningful cooperation. It was a team effort and in the last but not the least the acknowledgement goes to the whole study team which consists of Divisional Entomologist Dr. C. S. Sharma, six District Malaria Officers, Seven District Epidemiologists and six Vector Born Disease Consultants.