Public health risk assessment of a cultural mass gathering: The International Festival of Sahara, Douz, Tunisia

Background Mass gathering events that combine cultural activities, animal exposure, and limited healthcare infrastructure remain underrepresented in public health research. The International Festival of Douz (Tunisia) — a four-day annual Saharan event attracting 25,000 to 40,000 attendees — exemplifies this gap, as it has never been the subject of a structured risk assessment. Methods We conducted a mixed-methods public health risk assessment using retrospective data (2016–2021) from hospital emergency records, archives, field observations, and stakeholder consultations. Risk assessment integrated the Swiss Samaritans Association (SSA) checklist, the Klaus Maurer algorithm, and a semi-quantitative 5×5 risk matrix. Results Nineteen hazards were prioritized across four domains. Primary risk pathways included post-event mixed traffic flows (pedestrians, vehicles, animals), racing circuits lacking physical barriers separating spectators from vehicles or animals, camel/horse racing, motorized sports, and intentional security threats. These seven hazards were classified as high risk. Eight additional hazards—including MERS-CoV zoonotic transmission via dromedary contact, crowd surge during peak hours, and dromedary combat—were classified as significant risk. The Klaus Maurer algorithm (score: 65.2) and SSA Tier 3 classification validated this major-risk designation. Conclusion The International Festival of Douz constitutes a complex major-risk mass gathering requiring coordinated public health preparedness. This assessment highlights the importance of aligning emergency medical resources, surveillance systems, and intersectoral coordination with the specific risk profile of this mass gathering. Routine pre-event public health risk assessment, strengthened multi-sectoral collaboration, and integrated surveillance should become standard components of planning for comparable cultural mass gatherings in rural and resource-limited settings worldwide.