Call to avert acceleration of COVID-19 from India’s Sabarimala pilgrimage of 25 million devotees

Call to avert acceleration of COVID-19 from India’s Sabarimala pilgrimage of 25 million devotees

Journal of Travel Medicine.

Published: 5 September 2020

On August 7, 2020, India emerged as the third largest contributor to COVID-19 cases globally. India is also facing significant challenges to COVID-19 mitigation from the Monsoon rain-related evacuations due to floods and landslides, emigrant returnees within India, and from international repatriations. Adding to the challenges would be the forthcoming Sabarimala annual Hindu pilgrimage of 41 days duration normally held during the months of November to December at the Sabarimala peak, at 4,133 ft above sea level in the state of Kerala. The event is attended by an average 25 million pilgrims, though pilgrim volume of 40 million were reported for some years. As the Sabarimala pilgrimage calls for pious observance, most pilgrims refrain from the use of formal accommodations (and rest at temples, roadside shaded areas, or camps) and transportation means, adhere to a minimalist vegetarian diet during the preceding 41 days, trek barefoot the mandatory 5 kilometres of ascent to the peak of the mountain in addition to walking the entire distance from their home locations for several weeks, and queue for the divine sighting of the deity often for 8-12 hours. The majority (65%) of pilgrims originate from the neighbouring States of Tamil Nadu, Karnataka, and Andhra Pradesh. Data on the health challenges of the Sabarimala mass gatherings are emerging. Poor sanitary conditions and makeshift accommodations en-route predisposes pilgrims to respiratory (39%), and gastrointestinal (22%) conditions. In addition to the general health challenges of this arduous pilgrimage, if allowed to proceed status-quo in 2020, and even if some pilgrims self-select not to participate, the event stands to erase the gains achieved by the host State of Kerala’s storied and fragile COVID-19 mitigation success. Additional implications include spill over transmission from pilgrims that will potentially add to the already escalating outbreak in other states of India and in countries with significant international commercial links to Kerala State.

Currently, for the routine non-mass gathering visits to Sabarimala, the State Government requires all pilgrims to submit a negative SARS-CoV-2 antigen test result through the online queue system. But this may be impractical and insufficient when 25 million devotees or more congregate during the annual pilgrimage. Unlike the Hajj pilgrimage which is international and quota based and restricted through the visa process, being a domestic event, participation in Sabarimala pilgrimage is uncoordinated and required no registration for participation until last year. We welcome the Kerala state government decisions to make the virtual queue system into a mandatory requirement for this year’s pilgrimage and to restrict the number of pilgrims in Sannidhanam (the main temple premise) to 50 at a time. However, without a blanket restriction on number of pilgrims who can register through the queue system, even this may result in stranding of thousands of registered pilgrims elsewhere on the way to temple. Also, the pilgrimage site being located in a forest, illegal routes may be formed by eager pilgrims.

If held unrestricted, disease importation can happen via pilgrims originating from majority pilgrim contributing States that also hold 2nd, 4th and 5th places in COVID-19 burden in India.  Event cancellation is the best option to avoid all event related transmission of COVID-19,8 and the least expensive option as it only requires manpower to block access to the Sabarimala peak and risk communication. However, if the authorities prefer an alternate option, a highly restricted event by reducing the number of pilgrims to 5,000 over the 42 day period selected using a lottery method, to fully comply with COVID-19 mitigation principles is recommended while respecting the religious sentiments surrounding the event.

This recommendation is based on the existing World Health Organization guidelines on mass gathering in general and based on the criteria used during the restricted Hajj2020. The Hajj mass gathering normally accommodates over 3.5 million pilgrims but was restricted to 1,000 this year. The Hajj 2020 implemented pre- and post-event testing and quarantine, supervised transportation, and monitoring of mitigation by health authorities. The authors of this paper are cognizant of the enormous logistical and financial burden to host a managed event that fully respects public health principles. Kerala State’s legacy of steering the COVID-19 mitigation offers hope for overcoming such challenges through public private partnerships and civic society engagement.

Written by: K Rajasekharan Nayar , Chief Fellow – Santhigiri Research Foundation, Principal – Global Institute of Public Health