For Orthodox Christians in Ethiopia, August 7 marks the start of Tsome Filseta, or the “Fast of Assumption”, a sixteen-day period of fasting that coincides with the assumption of the Holy Virgin Mariam into heaven. During this time, followers of this religion travel to various sites across the country to take up residence for up to three weeks, where they abstain from certain foods and engage in reflection, prayer and singing. Tsome Filseta is a milestone in the Orthodox Tewahedo calendar that provides immensely meaningful experiences for those taking part.
Like many religious and cultural gatherings around the world, Tsome Filesta presents public health challenges, as increased interactions among large groups of people provides new opportunities for the spread of illness. As Tsome Filesta approached in August 2024, Ethiopia was already in the throes of a surge in cholera cases, part of a wider outbreak sweeping across the region. Part of the reason for the Tsome Filseta pilgrimages is to gain access to sacred holy water sites, where water is consumed or poured onto people for its healing properties. The rainy season, coupled with confined living conditions, limited infrastructure, and high mobility of pilgrims from cholera-affected areas, significantly increases the likelihood of cholera transmission during these gatherings.
Enhanced situational awareness prompts timely action
With this context in mind, the Ethiopian Public Health Institute (EPHI) and Amhara Public Health Institute (APHI) took early and preemptive action to prevent disease transmission before the first case was even detected at holy water sites, resulting in record lows of cholera cases during this year’s Tsome Filesta. This approach, known as enhanced situational awareness, or ESA, is an ongoing effort by EPHI, working in partnership with Resolve to Save Lives to take timely actions that prevent the spread of disease. ESA focuses on risks that indicate a surge in disease cases could be imminent—like the mass gatherings of people participating in Tsome Filseta—and encourages leaders to act based on those risks during a small window of opportunity before an outbreak has a chance to take hold.
Before the fasting season, EPHI met with APHI and regional public health emergency managers in Bahir Dar, the capital of Amhara, which was selected due to the high number of holy water sites in the region. Together with Resolve to Save Lives, EPHI made the case to their regional colleagues that enhanced situational awareness—activities focused on prevention, rather than detection and response—could serve as a useful addition to their public health toolkit. During a two-day convening, the team discussed cholera and other diseases with heightened risk during the fasting season, and developed a joint preparedness and prevention plan while delegating roles and responsibilities.
“Enhanced situational awareness facilitates data-driven and risk-informed actions to reduce the impact of outbreaks before a first case has been detected,” said Rahel Yemanaberhan at Resolve to Save Lives, who has been partnering with EPHI to implement this approach. “We’re pleased with the promising results following this year’s Fast of Assumption and look forward to continuing our partnership with EPHI to replicate this success during future mass gatherings.”
In previous years, during Tsome Filesta or other religious gatherings like Irrecha and Kulubi Gebreal, EPHI has ensured those participating can access essential health services via mobile teams, a safe water supply, new latrines and handwashing stations, and important messages about the risk of disease. For Tsome Filesta, water, sanitation and hygiene (WASH) interventions are of particular importance to minimize public health risk, as the rainy season increases the risk of cholera transmission through contaminated food and water. While this work has been taking place under the stewardship of EPHI for decades, the addition of enhanced situational awareness has placed additional emphasis on when these activities are completed and who is engaged to provide support.
Engaging local leaders
Like other fasting seasons, an important part of the team’s plan was community engagement—reaching as many pilgrims as possible to help them understand and minimize their risk of getting infected with cholera. Central to this effort was engaging religious leaders, important figures in the orthodox community who could help spread the message about the increased risk posed by the ongoing cholera outbreak and encourage pilgrims to participate in the fast while forgoing some of the rituals associated with consuming holy water. After the initial meeting with regional colleagues, the team hosted a workshop with around 80 religious leaders and other stakeholders, and selected 22 holy water sites with the highest risk, so they could target their messaging effectively ahead of the fast.
“We targeted the highest risk holy water sites, including those hosting the most pilgrims, those with limited WASH infrastructure, and those furthest from health facilities,” said Hanna Mekonnen at EPHI. “We have good relationships with local religious leaders, who supported our efforts by communicating tailored messages about the risk of cholera to pilgrims, thereby minimizing the number of cases.” By working with religious leaders, EPHI was able to share important public health messages with pilgrims through channels they trust, thereby increasing their reach and impact.
In addition to partnering with religious leaders, APHI also deployed 88 multidisciplinary experts—including environmental specialists, psychiatrists, nurses, and surveillance officers—across the 22 targeted sites, to ensure the necessary resources for outbreak prevention and response were prepositioned before the onset of any cases.
Scaling for success
Hanna Mekonnen confirmed that enhanced situational awareness was a huge success at this year’s Tsome Filseta. In previous years, most of the 22 holy water sites reported surges in cholera cases during the fast, whereas this year only five sites reported any cases. She added that the cases were also fewer in number, and therefore easier to manage than the larger surge in cases witnessed in previous years. “It’s amazing that we’ve seen so few cases this year, and we can say with confidence that this is a direct result of our new approach,” she said.
Based on these successes, EPHI plans to scale these activities outside of Amhara Region, and to other mass gatherings. Hanna Mekonnen is confident that modifying EPHI’s existing approach to incorporate enhanced situational awareness will prove fruitful in helping to minimize the number of infectious disease outbreaks. “Taking actions before cases have been identified will prevent any outbreaks from occurring—saving time, resources and, most importantly, lives.”