Tracking disease at the world’s largest religious festival

This article was originally published by the Harvard TH Chan School of Public Health.

September, 24, 2015 — From July through September this year, up to 30 million people are traveling to the cities of Nashik and Trimbakeshwar in India to bathe in the holy waters of the Godavari River, as part of the Kumbh Mela Hindu religious festival. Amidst this mass gathering—supported by acres and acres of temporary parking lots, police stations, fire stations, health clinics, streetlights and toilets—a small band of health and IT experts from the U.S. and India has introduced a new mobile health surveillance system to help keep the millions of visitors healthy while they’re at the festival.

The Harvard South Asia Institute’s Jana Swasthya Project (“Jana Swasthya” means “public health” in Hindi), has two goals: One is to conduct disease surveillance in real time to help health workers at the festival nip potential outbreaks in the bud and allocate health resources wisely. Another is more long-term: to conduct a mass screening program for oral health and hypertension for visitors and workers at the festival.

Tracking disease

The surveillance system, implemented in late August, proved useful right away. For example, after data gathered by the system revealed a recent surge in cases of diarrhea, “within two hours the government had deployed someone to test all the water,” said team leader Satchit Balsari, research fellow at Harvard T.H. Chan School of Public Health’s FXB Center for Health and Human Rights and chief of the Weill Cornell Global Emergency Medicine Division. “That’s an example of a real-time application.”

Health workers are trained to use EMcounter.

Health workers are trained to use EMcounter.

The disease surveillance system, called EMcounter, has an easy-to-use dashboard that offers helpful visualizations of data. When a patient visits one of the temporary clinics at Kumbh Mela, health care workers enter that person’s health information into the system using a government-issued tablet. They can then view graphs and charts that pool patients’ health data from throughout the festival, in real time. This data can be sorted by age, date, time, diagnosis, and other demographic information, enabling users to detect unusual illness patterns or to determine which festival locations need more doctors, nurses, or medical supplies.

In July, Jana Swasthya team members met with hundreds of doctors, nurses, and pharmacists in Nashik to talk about the rationale behind the project, even though the tablets and software weren’t ready yet. “We were told that many doctors wouldn’t see the point of using a system like this, thinking it would be cumbersome,” said Balsari. “We didn’t agree. We felt it was important to explain the system’s potential for providing useful information in real time, and involve the clinicians in the design process, even if they have not used something like it before.”

In late August, the team distributed a tablet, charger, and operation manual to every health care worker and gave them hands-on training.Once health workers and government officials started using the system, they responded enthusiastically, Balsari said. The first day the tablets were used, more than 2,000 patient visits were logged at the 35 busiest clinics throughout the Kumbh Mela. By late September, that number had soared to 30,000.

Screen time

Another component of the Jana Swasthya Project is a mass screening program for oral health and hypertension focused on those who spend the most time at the festival—holy men and security forces. After the festival is over, the plan is to use robocalls or texts to follow up with those whose screenings revealed a problem.

The Jana Swasthya Project team

The Jana Swasthya Project team

The current effort builds on Harvard’s extensive research at the 2013 Kumbh Mela held in Allahabad (the festival is held every few years in one of four cities in India), where experts studied everything from sanitation to environmental impacts to commerce. At that event, a Harvard team co-led by Balsari transcribed doctors’ written notes into iPads, hoping to demonstrate proof-of-concept of their e-surveillance system. This year—convinced of the system’s potential benefits—the regional government of Maharashtra, India sponsored its implementation.

Next, Balsari and his team—which includes Harvard Chan School alumni Clay Heaton, SM ’06, and Ajay Nair, MPH ’07—will work with public and nonprofit private hospitals in Maharashtra and Andhra Pradesh, to equip them with the next iteration of the surveillance tool. “The idea is to institutionalize the system, to mainstream it into regular daily processes,” he said. Given the Kumbh Mela medical officers’ overwhelmingly positive response, Balsari is encouraged about introducing the system in new settings.“Our experience at Kumbh Mela showed that people are ready to use this technology,” he said. “They’re just not being presented with the opportunities to do so.”

— Karen Feldscher

Learn more about the project.

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