Real-Time Surveillance of Infectious Diseases,Injuries,and Chronic Conditions During the 2018 Iraq Arba'een Mass Gathering

Abstract

The Arba'een pilgrimage in Iraq is now the largest annual gathering in a single place worldwide. To monitor and address the health needs of pilgrims in field clinics near the pilgrimage route, a syndromic surveillance system was designed and implemented by Global Health Development/Eastern Mediterranean Public Health Network in collaboration with Iraq Ministry of Health. This study aimed to analyze the effectiveness of the surveillance system and the data it gathered in evaluating the burden of common acute and infectious conditions, chronic conditions, and trauma and injuries during the Arba'een pilgrimage in 2018. Data were collected at 152 field clinics located across 11 governorates in Iraq at strategic points along the Arba'een pilgrimage route from all governorates to Karbala between October 8 and November 3, 2018. A team of 24 surveillance supervisors trained, oversaw, and provided technical support for 304 data collectors. The data collectors recorded data from 338,399 patients (42.5% female and 57.5% male) in the span of 26 days. The vast majority of patients were from Iraq (n = 294,260, 87.6%) and Iran (n = 34,691, 10.3%). Of the 338,399 patients whose data were recorded by the surveillance system, 246,469 (72.8%) reported acute and infectious conditions, 202,032 (59.70%) reported chronic conditions, and 6,737 (2.0%) reported traumas and injuries. Many patients reported several conditions in multiple categories. The most prevalent acute condition treated was influenza-like illness, identified through patients exhibiting a combination of fever and cough symptoms. Findings from this study will help inform future planning efforts so healthcare workers can be better prepared for treating such cases at mass gatherings. With the latest challenges posed by the COVID-19 pandemic, preparations for a possible future outbreak of the novel coronavirus are also discussed. The information from this study serves as a foundation to inform and optimize future planning of wide-scale surveillance efforts and address challenges in health service delivery and health security.

Introduction

Mass gatherings are defined by the World Health Organization as events in which the number of people attending could strain the planning and response resources of the community or country hosting the event.¹ The Arba'een pilgrimage is now the largest annual gathering in a single place worldwide.² During the pilgrimage, over 20 million Shia pilgrims walk hundreds of kilometers to Karbala, Iraq, to the Holy Shrine of Imam Hussain, the grandson of the Prophet Muhammad, to exonerate his martyrdom.^3,4 The Arba'een pilgrimage falls annually on the 20th day of the month of Safar, a lunar month in the Islamic calendar—in 2020, Arba'een began the evening of Wednesday, October 7. Due to the difference between the lunar and solar calendars, the Arba'een pilgrimage occurs approximately 11 days earlier each year. The Arba'een pilgrimage, while not part of the Five Pillars of Islam like the pilgrimage to Mecca, is considered of utmost importance to many Shia Muslims.

This foot pilgrimage is characterized by mourning, pittance, and commemoration of the martyrdom of Imam Hussein.⁵ The path to Karbala is walked by individuals from Iraq, Iran, Saudi Arabia, and over 25 other countries throughout the world. Along the route, tents are set up, meals prepared, and bedrooms emptied in anticipation of those who choose to participate. Pilgrims do not have to carry any belongings with them as it is customary for families living along the route to spend up to 20% of their annual earnings providing for the needs of pilgrims. In this way, the Arba'een pilgrimage is a testament to the solidarity of Shiite Muslims, an example of extreme hospitality, and a symbol of religious devotion. Since 2003, the mass gathering has grown exponentially to reach millions of people.

A review by Gautret and Steffen⁶ noted that some outbreaks occurring at mass gatherings have resulted in the international spread of communicable diseases. Similar to any other mass gathering, the threat of terrorism still exists to Arba'een participants. The abundant need for infrastructure and healthcare resources as well as bolstered security forces and epidemiological control associated with this fluctuation of travelers cannot be sufficiently met with existing systems. In most cases, the health workforce, public health service, and supplies are insufficient given the number of individuals seeking care.⁷ To fill this gap, advances must be made in several interdivisional domains such as mass gathering medicine, epidemiology, and biosecurity. This study aimed to analyze the effectiveness of the surveillance system and the data it has gathered in evaluating the burden of common acute and infectious conditions, chronic conditions, and trauma and injuries during the Arba'een pilgrimage in 2018. These data are valuable in planning resources for future pilgrimages within the framework of the public health approach. The surveillance system used in 2018 will be adapted in subsequent years to also monitor the spread of SARS-CoV-2, the virus that causes COVID-19.

Methods

Data Collection

Data were collected at 152 field clinics located across 11 governorates in Iraq at strategic points along the Arba'een pilgrimage route from all governorates to Karbala.* Each field clinic was assigned 2 data collectors who worked alternating shifts to ensure all patients seen had their symptoms documented. The data collectors were mainly medical and allied health students who were on their school breaks during the mass gathering. This team of 304 data collectors was overseen and technically supported by 24 surveillance supervisors. This field team was regularly supported by a group of technical experts composed of members from the Global Health Development/Eastern Mediterranean Public Health Network (GHD/EMPHNET), Iraq Field Epidemiology Training Program, and Iraq Ministry of Health (MOH).

Training of Data Collectors

GHD/EMPHNET conducted a training of trainers for the team of survey supervisors, which was followed by 16 subsequent trainings conducted by the trained survey supervisors for data collectors. A total of 164 tablets were provided to the field team (1 for each of the 152 field clinics plus an additional tablet on reserve for each governorate in case any tablet device malfunctioned).

Survey Tool

KoBoToolbox was used to collect data on tablet devices via the survey tool. The GHD/EMPHNET information technology team, in collaboration with the technical team in Amman and Baghdad, digitalized the survey tool for real-time surveillance. Two forms (the field clinic survey and case survey) were published online at midnight on October 7, 2018. The official surveillance activity (field data entry) started at 8:00 am on October 8, 2018. For data that still needed to be entered for testing purposes (eg, in case any tablet device malfunctioned), the data collectors were asked to enter “[TEST]” in response to the last question on the final page of the case survey form before submission. Those test entries were later removed from the analysis. A total of 338,399 visits to GHD/EMPHNET- and Iraq MOH-monitored field clinics treating patients who participated in the Arba'een mass gathering were recorded as real-time surveillance.

The survey tool included information on the following symptoms associated with each category of physical illbeing: infectious and acute conditions (watery or bloody diarrhea, vomiting, fever, cough, rash, heat stroke, jaundice, dermatological conditions, blisters), trauma and injuries (laceration, wound, fracture, burn), and chronic conditions (joint pain, hypertension, diabetes, ischemic heart pain, asthma). In all categories, an option of “other” was provided to give data collectors a place to record a specific condition if it was not already included as an option.

Monitoring Data Collection

Surveillance supervisors were asked to provide regular daily briefs to the technical support team. These daily briefs were mainly sent at the end of each day (usually after 5:00 pm) via email. Major highlights of the day—such as patient overcrowding in a field clinic, issues faced by data collectors alongside the remedies suggested by their supervisors' team, and specific challenges in the fieldwork and how support was sought from the central/technical team—were included in these briefs. The surveillance supervising team in Iraq had real-time access to the data collected online, which enabled them to detect trends (of likely outbreaks or inaccuracies in data collection) and take actions, if needed. The field data collection officially ended on November 3 at midnight. Microsoft Excel was used for data management and cleaning. Extensive algorithms and carefully structured formulas were used throughout the dataset to validate and prepare the data for analysis.

Approaching Data for Future Planning

As each data collector filled out a report on a patient, the length of time they spent recording the answers to the questions on the survey was recorded automatically. Documenting the average length of time spent on each survey will help GHD/EMPHNET to ensure future events attain a satisfactory balance between documentation of thorough epidemiological data and the timely delivery of medical services to patients seeking care. The mean duration of time spent to complete a survey was 70 seconds for more than 338,000 interviews conducted at over 150 field clinics across 11 governorates. The amount of time spent was in line with a similar effort in 2016, with a mean duration of 81 seconds, for a total of over 46,000 interviews conducted at 20 field clinics across 2 governorates.⁸ In fact, the data from the previous pilgrimage was crucial for the successful expansion of implementation from 2 to 11 governorates. Similarly, insights from the operational aspects of the real-time surveillance system used in 2018 will contribute to planning for future pilgrimages within the framework of the public health approach and the system will be adapted in subsequent years to monitor the sudden onset and spread of infectious diseases, including COVID-19.

Qualitative Survey

A final qualitative survey of the surveillance effort was conducted with data collectors from all field clinics in all 11 governorates to collect in-depth insights into how well the surveillance effort was conducted. The survey distributed to surveillance teams asked about the positive and negative aspects of the data collection effort and for any other lessons learned in the field. A total of 105 field data collectors (healthcare workers) completed the survey. The data from the survey will provide surveillance teams and the Iraq MOH with information to adequately plan resources for future events.

Data Analysis

Quantitative data were analyzed using IBM SPSS Statistics for Windows, Version 24.0. (IBM Corp, Armonk, NY) Data were described using numbers and percentages. Qualitative data were analyzed using content analysis.

Results

Patient Characteristics

The 304 data collectors recorded information from 338,399 patients (42.5% female and 57.5% male) in the span of 26 days—from October 8 to November 3, 2018—at 152 field clinics located across 11 governorates. The majority of cases (n = 270,697, 80.0%) were recorded in 4 governorates: Babil, Diwaneya, Karbala, and Najaf. About 62.4% (n = 211,267) of the visiting pilgrims were between the ages of 20 and 49 years, with the highest percentage between 30 and 39 years. The vast majority of patients were from Iraq (n = 294,260, 87.6%) and Iran (n = 34,691, 10.3%), although pilgrims came from all continents, including countries such as Australia, Sweden, and the United States. Of the 338,399 patients recorded by the surveillance system, 246,469 (72.8%) reported acute and infectious conditions, 202,032 (59.7%) reported chronic conditions, and 6,737 (2.0%) reported trauma and injuries. Many patients reported several conditions in multiple categories.

Acute and Infectious Conditions Surveillance

A total of 246,469 (72.8%) patients reported acute and infectious conditions. The largest category of cases reported was for influenza-like illness symptoms, such as fever accompanied by a cough, which accounted for 38.3% (n = 94,292) of all acute cases. Other major categories of acute conditions were blisters from walking (n = 81,995, 33.3%), followed by dermatologic conditions (n = 25,488, 10.3%), vomiting (n = 24,245, 9.8%) and acute watery diarrhea (n = 18,233, 7.4%). It is worth noting that conditions reported as “acute other” accounted for 7.9% (n = 27,125) of cases. A total of 289 acute and infectious disease cases were referred to hospitals.

Of the 27,125 cases reported as “acute other,” 19,340 (71.3%) reported specific symptoms. Of these symptoms, the 15 most commonly recorded were headaches (n = 2,987, 15.4%), stomachaches (n = 1,776, 9.2%), tonsillitis (n = 1,704, 8.8%), muscle spasms/cramps (n = 1,665, 8.6%), colic pain (n = 830, 4.3%), diarrhea (n = 820, 4.2%), toothaches (n = 819, 4.2%), gastric acidity (n = 645, 3.3%), irritable bowel syndrome (n = 603, 3.1%), abdominal pain (n = 524, 2.7%), urinary tract infections (n = 461, 2.4%), joint pain (n = 418, 2.2%), coughs (n = 384, 2.0%), bronchitis (n = 318, 1.6%), and allergies (n = 292, 1.5%). These 15 symptoms represented 71.7% of the total “acute other” conditions specified in the dataset.

Chronic Conditions Surveillance

Of all the patients whose data were collected, 202,032 (59.7%) reported chronic conditions. Many of these patients were checked for more than a single condition. The total number of chronic conditions reported was 236,747, which means that each patient reporting a chronic condition was monitored on average for 1.17 conditions. A total of 141,489 (59.8%) patients presented with joint pain. Other major categories of chronic conditions were hypertension and hypotension (if blood pressure was checked; n = 52,661, 22.2%), diabetes (if blood glucose was checked; n = 23,062, 9.7%), asthma (n = 11,605, 4.9%), other chronic conditions (n = 6,450, 2.7%), and ischemic heart pain (n = 1,480, 0.6%).

Table 1 shows the number of patients with chronic conditions who were treated, referred, or whose treatment status was unspecified. The majority of patients were treated at field clinics, but some patients were referred to regional hospitals, including 1.4% of individuals presenting with joint pain, 2.2% with blood pressure issues, 2.3% with blood glucose issues, 6.8% with asthma, 13.1% with ischemic heart pain, and 2.8% with symptoms designated as “other”.

Table 1.

Cases Treated at Health Facilities Along Pilgrimage Route and Referred to Regional Hospitals, by Chronic Condition Type^a

Chronic Condition	Treated n (%)	Referred n (%)	Unspecified n (%)	Total N
Joint pain	136,943 (96.8)	1,954 (1.4)	2,592 (1.8)	141,489
Blood pressure	49,896 (94.7)	1,169 (2.2)	1,596 (3.0)	52,661
Blood glucose	21,888 (94.9)	537 (2.3)	637 (2.8)	23,062
Asthma	10,605 (91.4)	792 (6.8)	208 (1.8)	11,605
Ischemic heart pain	1,218 (82.3)	194 (13.1)	68 (4.6)	1,480
Others	6,052 (93.8)	182 (2.8)	216 (3.3)	6,450

Joint pain was the most commonly diagnosed chronic condition and the most commonly treated condition. Ischemic heart pain was a relatively rare diagnosis, but as the condition is often foretelling of a heart attack, the condition warranted the largest percentage of referrals among the chronic conditions listed in the table.

Trauma and Injury Surveillance

A total of 6,737 (2.0%) patients were reported as having sustained traumas or injuries, although only 5,135 patients specified the cause of the injury. Of all reported specified injury causes, the most common cause of injury was “overcrowd” (n = 1,842 cases, 33.9%). Other major categories of injury causes were “fall” (n = 1,191, 21.9%), “road traffic injury” (n = 444, 8.2%), “trolley accident (mainly due to crowd)” (n = 351, 6.5%), and “all other injuries” (n = 1,607, 29.6%). Of the total 1,842 overcrowd injury cases, 1,592 (86.4%) were reported in Karbala (n = 1,022, 55.5%) and Babil (n = 570, 30.9%).

In these cases, it is important to consider if the injuries were intentional or unintentional when diagnosing the cause. The high number of intentional injuries reported can be attributed to traditional Shiite practices in which pilgrims hit themselves in an act of self-flagellation with swords and nails on the head and back until they bleed, to atone for the pain felt by Imam Hussain when he was beheaded. Table 2 shows the number of each type of injury sustained (eg, burn, fracture, laceration, wound) and whether they were intentional (self-inflected as part of the mourning/ritual) or unintentional. The most common wound sustained by overcrowding was lacerations. Another important conclusion is that a high number of injuries were marked “other” for both the cause and the type; a significant proportion of these injuries seem to be intentional without reporting them as such. Wounds were also sustained in high numbers due to falls and trolley accidents. Fractures were most frequently the result of falls (again, mainly due to overcrowding). Unintentional burns were mainly the result of spilling hot tea or cooking over open fires.

Table 2.

Type of Injury Sustained by Patients: Unintentional, Intentional, or Unspecified

Injury	Unintentional n (%)	Intentional n (%)	Unspecified ^a n (%)	Total N
Unspecified	124 (20.2)	334 (54.3)	157 (25.5)	615
Burn	326 (76.3)	86 (20.1)	15 (3.5)	427
Fracture	246 (76.4)	72 (22.4)	4 (1.2)	322
Laceration	1,548 (76.9)	431 (21.4)	33 (1.6)	2,012
Wound	1,873 (78.9)	455 (19.2)	46 (1.9)	2,374
Other	87 (8.8)	850 (86.1)	50 (5.1)	987
Total	4,204 (62.4)	2,228 (33.1)	305 (4.5)	6,737

In the context of the Arba'een pilgrimage, many of the injuries marked “unspecified” were injuries sustained to the head and back by pilgrims practicing self-flagellation.

Qualitative Findings from Final Evaluation

The feedback received from 105 data collectors from field clinics in 11 governorates concerning the success of the surveillance system was overwhelmingly positive. Responses indicated a heartwarming sense of teamwork and collaboration shared among healthcare workers, data collectors, and visitors. Some of the responses stated that “cooperation was beautiful from all people” and that the patients and “expatriate people” were treated as “distinguished guests.” The largest subcategory of success stories about teamwork and collaboration highlighted the willingness of patients to answer health-related questions, which was perceived to illustrate the patients' value of their input to the surveillance system and future healthcare services to be offered during upcoming pilgrimages.

In one success story, a respondent described the surveillance system as an “effective and excellent monitoring” tool. This sentiment was echoed in many comments, which stated it was “a realistic monitoring process” and “easy to use.” Other individuals remarked on how they were able to plan ahead for treating common diseases presented by patients. This preparation was possible due to surveillance results from the 2016 Arba'een pilgrimage, which were used to predict outcomes for the 2018 Arba'een pilgrimage. Field clinic workers reported feeling well prepared for the number of visitors seeking healthcare, felt they had an idea of how many separators (to ensure patient privacy) would be needed to accommodate visitors, were able to stock up on medicines needed to treat common diseases, and were more likely to accurately diagnose patients. Further responses indicated that the patients themselves were made aware of public health practices such as disease identification and the importance of drinking clean water and eating healthy food. These awareness initiatives may help to further limit outbreaks in the future. Similarly, the insights from this study could serve as both a success story and evidence base for how a large-scale surveillance effort can be successfully operationalized.

When asked to report areas for improvement in the surveillance system, many healthcare workers responded constructively. The most commonly reported opportunity for growth by far was related to poor internet connections that made recording data difficult at many health clinics. Many data collectors reported not being able to record answers to all the survey questions for several patients due to the slowness of the internet connection or complete lack of internet access altogether. Occasionally, data collectors were forced to use pen and paper to record patient symptoms and information during the day, and then attempt to upload the data into the surveillance application at night when the field clinics were less busy. This system allowed for gaps in the data to develop.

In addition to issues with internet connectivity, healthcare workers expressed a clear need for more data collectors and specialized doctors, especially during daylight hours. It was reported that some patients could not be seen in a timely manner and thus left the clinic without receiving care to seek help elsewhere. This is dangerous, as potentially contagious individuals went untreated for long periods of time and walked alongside healthy individuals without having received antibiotics or medication.

With regard to medication, several surveillance participants (data collectors) reported lacking the proper medications to prescribe to patients. Painkillers, medicines for the digestive system, and analgesic drugs were all cited as medications that should be made more readily available at field clinics for future mass gatherings. Additionally, it was requested that clean water be provided at health clinics for patients to drink, and for the local ambulance center in each governorate to be linked with field clinics nearby for the transportation of dangerous referrals to established hospitals.

For future improvements, responses indicated a desire across the board to expand the footprint of GHD/EMPHNET-monitored programs and to increase the services offered to pilgrims. Individuals who responded to the survey asked for increases in the number of field clinics (so pilgrims would not have to travel as far between clinics), the number of data collectors working (especially in Karbala where the whole crowd will eventually gather about 2 days before the Arba'een mass event), the number of days in which monitoring could take place, and the number of separators in each field clinic. In addition to these suggestions for improvement, early preparedness and training—especially for data collectors—was recommended repeatedly. It seems data collectors felt ill-prepared at the beginning of the monitoring process and want a few days of training to precede the arrival of visitors in the future. Health awareness sessions for patients was also suggested.

Suggestions for improving the application used to record data surveillance include condensing the survey so it can be completed in a single interface in under 1 minute and providing the interface in Arabic, with an option to translate the interface into Persian. Respondents also requested an increase in the amount of space provided for each questionnaire field to allow for more detailed responses and for more diseases, accidents, chronic diseases, and injuries options to be provided on the survey. Respondents noted than many transitional disease options were included in the survey, but few options were available in other categories.

Furthermore, several staff members recommended an increase the field epidemiology presence in the regions monitored to ensure real-time intervention. It was suggested that epidemiological monitoring centers be established for laboratory diagnostic testing of certain cases, such as suspected measles or cholera. Upon the discovery of concerning diseases that could lead to outbreaks, communication between centers would be necessary to develop an intervention program to control existing cases and prevent future cases from occurring.

Finally, as mentioned earlier, any improvements must be accompanied by better internet availability. It has been suggested that all SIM cards should be tested and that each field clinic should sign up for a strong internet server recommended by healthcare workers native to each governorate, rather than relying on a single internet provider for all governorates.

Discussion

The real-time surveillance information gathered during the 2018 Arba'een revealed the health threats posed to pilgrims traveling through Iraq to Karbala. Findings from this study show that the majority (80.0%) of cases were recorded in 4 governorates: Babil, Diwaneya, Karbala, and Najaf. The high proportion of patients requiring health services in these governorates can be attributed to their closer proximity to the end of the pilgrimage route at the Holy Shrine of Imam Hussein in Karbala than the other regions where GHD/EMPHNET and Iraq MOH collected and monitored data. Field clinics closer to the end of the route naturally served more patients as pilgrims had been walking for farther distances. These findings suggest that the 4 governorates need extensive planning and preparations around the Arba'een pilgrimage. Similar implications were confirmed by studies of the event conducted in previous years.^7,9-11 Additionally, there is no fixed route all pilgrims take to arrive in Karbala, so more people will congregate in Karbala and its neighboring governorates than in governorates further from the shrine. The number of patients served at field clinics fluctuated greatly by governorate and by the dates leading up to the Arba'een pilgrimage. Karbala served 26.4% of the total patients toward the end dates of the surveillance event, whereas Basrah served only 0.8% of the total patients during the start of the surveillance event. This has implications for planning resources for future mass gathering events.

About three-quarters of patients reported acute and infectious conditions. Flu (fever and cough combined) and blisters from walking were the most common acute and infectious conditions reported. Similar findings were reported by other previous studies.^12-14 In a cross-sectional survey of a sample of 191 Arba'een participants in 2017, Al-Ansari et al¹² found that the most prevalent symptoms were respiratory in nature (runny nose 22.6%, cough 22.5%). Moreover, other studies of different designs reported a high prevalence of foot blisters among Hajj pilgrims,^13,14 especially among women.¹³

The high prevalence of acute and infectious conditions in these 4 governorates can be partially attributed to their proximity to the Holy Shrine of Imam Hussain as pilgrims in these governorates can be assumed to have traveled a longer distance than those reporting health symptoms in governorates farther away from the mass gathering scene in Karbala, Iraq. It was noted that outbreaks of influenza-like illness and mass incidences of blisters seemed to occur in Babil, Diwaneya, Karbala, and Najaf. However, it should also be noted that more field clinics in these 4 governorates reported to the surveillance system than in other governorates. Additionally, the fact that all pilgrims eventually reached these 4 highly crowded governorates may also have contributed to the larger proportions of acute and infectious diseases being reported in Babil, Diwaneya, Kabala, and Najaf compared with Basrah, Diyala, and Missan. There were 22 field clinics reporting to the surveillance system in Karbala, 20 in Babil, 17 in Diwaneya, 17 in Najaf, and only 5 to 13 field clinics per governorate in the remaining governorates where GHD/EMPHNET and Iraq MOH teams operated.

Joint pain was the most common chronic condition reported. Again, this can be explained by the long distance walked by pilgrims on their way to Karbala. The majority of chronic conditions were treated at field clinics, thereby demonstrating that field clinics used by pilgrims were sufficient in meeting the majority of their needs. However, 13.1% of ischemic heart pain cases were referred to regional hospitals, as heart conditions and complex health issues should be treated in clinics with advanced medical technology. Looking toward the future, field clinics should try to reduce the number of cases they refer by increasing the capacity of medical services offered to patients. However, the goal should never be to completely eliminate case referrals as patients with severe or life-threatening cases should always be seen in the environment most able to meet their needs which is almost always an established hospital.

A total of 6,737 (2.0%) patients were reported as having sustained traumas or injuries. The most common cause of injury was overcrowding. A large number of overcrowd cases were reported in both Babil and Karbala. These governorates are close to the mass gathering site, which explains the high prevalence of overcrowd cases in the area. The most common type of wound sustained by overcrowding was lacerations. Another important finding is that a high number of injuries were marked “other” for both the cause and the type.

Although this article describes the cases seen by healthcare workers in field clinics under surveillance by GHD/EMPHNET and Iraq MOH, it does not apply these findings for the purpose of preventing future outbreaks of diseases at mass gatherings. This is issue and others need to be addressed through additional research. Looking toward the future, many questions have yet to be answered. How can cases previously referred to regional hospitals farther from the pilgrimage route be treated in future years at field clinics? How can preventive measures such as vaccinations be used to curb future epidemics? What methods can be undertaken to limit the number of individuals engaging in self-harm practices in the coming years?

In asking these questions, the importance of a surveillance system is clear. The key to treating conditions at field clinics that previously referred cases to regional hospitals is understanding which conditions are currently beyond the capacity of field clinics to treat, and then planning to increase capacity with the provision of personnel and supplies targeting those conditions. Understanding which vaccines would be beneficial for pilgrims to get before or during a mass gathering is possible only when we know which infectious diseases are prevalent among patients. Efficacy in health education programs aimed at reducing self-harm practices among pilgrims is dependent on knowing who is most at risk for practicing self-harm. All of these questions are best answered with data from the past and present. The syndromic disease surveillance system described in this article can provide the necessary data, especially where traditional reporting from established hospitals is not sufficient in describing the state of health in an area during a mass gathering.

Evidence shows that bringing people together from across counties to participate in a mass gathering can increase the risk of spread for both viral and bacterial respiratory tract infections.^7,10,11 Al-Rousan and Al-Najjar¹⁵ reported that further transmission of COVID-19 to the Middle East was due to human mobility. The authors suggest avoiding several religious rites, closing the borders of infected countries, and supporting the infected countries to prevent further transmission. The current COVID-19 pandemic has posed a political, scientific, and public health dilemma to health authorities and governments. Thus, lessons learned about COVID-19 pandemic preparedness and risk reduction will help guide public health efforts related to future mass gathering events.^16,17

The surveillance system described in this article will play a crucial role in detecting COVID-19 cases and containing the spread of the disease in pilgrim and host community populations in future mass gatherings. As recommended by the World Health Organization, setting up communication pathways between all stakeholders—including event organizers, regional and national health authorities, and healthcare workers—before a mass gathering is a valuable part of the planning process.¹⁸ The data collection tool used by field epidemiologists will be modified to track the prevalence of symptoms characteristic of COVID-19 among patients at field clinics in real time. This will enable stakeholders to make educated decisions concerning containment measures. Previously, cases of influenza-like illness were reported whenever a patient exhibited a combination of fever and cough symptoms. Due to the multiplicity of symptoms exhibited by COVID-19 patients, anyone presenting any symptom consistent with a COVID-19 diagnosis should be monitored by healthcare personnel at field clinics and quarantined from healthy individuals.¹⁸ Symptoms of COVID-19 include fever, difficulty breathing, cough, fatigue, muscle aches, headaches, sore throats, nausea, diarrhea, and loss of taste and/or smell.¹⁹ These symptoms will be integrated in the revised tools for the Arba'een pilgrimage in future years. If a patient has trouble breathing, exhibits persistent chest pain, shows signs of new confusion, is unable to stay awake, or has blue lips, they should be referred to a regional hospital for COVID-19 testing and care according to the guidance of national and local health authorities.¹⁹

Any COVID-19 cases diagnosed in patients participating in the Arba'een pilgrimage should be reported to local and national health authorities as well as health authorities in the home country of patients coming from outside of Iraq.¹⁸ Demographic information detailing the nationalities of pilgrims seeking medical assistance along the Arba'een route will be documented within the surveillance system. To promote and reinforce preventive public health measures, field clinics should display visual guidance in the languages of patients (namely Arabic and Persian) that promote hygiene and social distancing practices such as handwashing and respiratory etiquette.¹⁸

Similar to other large-scale efforts, our real-time surveillance had its own limitations and challenges in field-level implementation. Data were collected for a substantial number of cases (>338,000), from a large number of field clinics (n = 152), across 11 governorates, and over a short period of time. This may have caused challenges that could have affected the quality of the collected data. A total of 304 data collectors worked across 11 governorates. Although a training of trainers was conducted before the 16 subsequent cascade training events, the training exercises in the governorates may have varied slightly, which could have led to inconsistencies in the training, field supervision, and overall approach to data collection. This may have also affected data quality during the large-scale data collection effort. It is possible that data collectors may have used their own understanding of some cases instead of the case definitions provided, which may have affected the quality of data for some rare or hard-to-define cases. Although the data collectors only entered data via tablet devices, tapping answer choices on screen and swiping to the next question, large caseloads during crowded times of the day may have affected the quality of data input. However, such trends were not consistently observed during high caseload hours in the mostly crowded field clinics closer to Karbala Governorate. The most commonly reported challenge was poor internet or SIM connections, which made recording data difficult at many of the field clinics. The primary solution was to record symptoms on paper, then attempt to upload data into the surveillance application at night when internet connections were less stressed. This approach, however, may have allowed for gaps in the data to develop.

Conclusions

The use of a surveillance system enabled healthcare professionals to collect patient information about acute and chronic conditions treated during the Arba'een pilgrimage in 2018. The data collected and lessons learned will help inform resource planning as governments and other entities prepare for future mass gatherings. The COVID-19 pandemic has highlighted the importance of preparing for epidemics to prevent the unnecessary spread of highly contagious infectious diseases. Those planning mass gathering events should also consider the seasonality of certain prevalent conditions, such as flu-like symptoms that may be expected more often during relatively colder months, and diarrheal and food poisoning cases that may be expected more during warmer months. Every 3 years the Arba'een pilgrimage will occur a month earlier, gradually entering into warmer weather. The findings from this study serve as a foundation for further syndromic surveillance research, planning, operationalization, and analysis. More research should be done to explore how field clinics can better provide for the health security of people participating in future Arba'een pilgrimages.

Footnotes

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