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Background: Via ferrata (VF) climbing is an increasingly popular mountain activity in the European Alps. The purpose of this study was to determine the nature of injuries incurred by VF climbers and to understand the extent of their First Aid (FA) knowledge and training. Materials and methods: A questionnaire-based cohort study was performed at two alpine locations. Data included basic data (age, gender, climbing activities, exercise), 18 multiple choice questions with 5 answers each concerning First Aid (FA) knowledge and a self-rating of FA knowledge. Statistics were performed with non-parametric tests. Results: 391 questionnaires were completed. Sunburns (23.9%), contusions (17.7%), open wounds (13.1%), and exhaustion-related injuries were the most reported incidents. Exhaustion was the most common emergency call. Only 52% of climbers wore helmets and gloves, less than 25% had adequate physical conditioning, and 28.1% reported having no FA training. The most common causes of emergencies were weather conditions (19%), stumbles (18.6%), falls (13.4%), and fatigue and deficiency in concentration (13.4%). Only 11 of the surveyed climbers scored 75% on their FA knowledge questions. VF climbers showed significant less FA knowledge than alpine mountaineers. They scored quite high on questions related to general FA but low on questions related to high altitude sickness, back, and thoracic injuries. Conclusions: VF climbers should seek out FA training every two years with an emphasis placed on sunburns, contusions, open wounds, and exhaustion injuries. The training should also emphasize the prevention of back and thoracic trauma and developing rescue strategies.

Background: The effect of sleeping positions during acclimatization to high altitude on Acute Mountain Sickness (AMS) and High Altitude Pulmonary Edema (HAPE) is unknown. We tested whether sleeping with the upper body raised by 5° reduces prevalence and severity of symptoms of AMS as well as of elevated pulmonary artery systolic pressure (PASP) values as a risk factor of HAPE. Methods: Randomly assigning trekking tourist volunteers n = 44 (25 m, 19 f; mean age 42.9 yr) sleeping at 4280 m or 5170 m to the experimental group (upper body elevated by 5°), or to the control group. After exclusion of other reasons for AMS-like symptoms those assumed to be related to AMS were rated by Lake Louise Score questionnaire in the evening and the following morning of the study. Transthoracic echocardiography was performed on both occasions to estimate PASP. Results: In the study group, symptoms of AMS were significantly reduced in younger subjects (p = 0.021), prevalence of AMS was reduced in women (p = 0.156), and PASP values were significantly reduced in older subjects and men (p = 0.032; p = 0.031 respectively). Conclusion: Results suggest that sleeping with the upper body in elevated position during a high altitude ascent may benefit those suffering from AMS or at risk of HAPE due to elevated PASP values.

This year the meeting included again a wide variety of topics. Beside of ‘typical’ ones like malaria (Rothe) or actual aspects concerning vaccinations (Burchard, Kling) other lecturers reported about international aid in the case of catastrophies (Schad), polar regions (Kohlberg), volcano tourism (Heggie), diving medicine (Koonen and Schröder), rare diseases like naegleria (Heggie), and even work in space (Ewald). A session focused tricky cases from daily routine travel medicine. There was also a special invitation to young scientists, students and clinicians with a specific event. Poster presentations added topics for discussions. The presented abstracts include lectures and posters and are listed in alphabetical order of the first author. The presented abstracts include lectures and posters and are listed in alphabetical order of the first author.

The monitoring of physiological parameters using wearable (bio-) sensors of military personnel is a progressing process within the military environment. It sets high demands on such devices, in order to support healthcare and performance of the personnel. To get an ovierview of the current status of the use, the evaluation and the implementation in the military, in May 2021, the Multinational Medical Coordination Centre / European Medical Command has organized an expert workshop about ‘Biosensors Supporting Healthcare in Missions’. Three thematic clusters were addressed: ‘Human Performance and Readiness’; ‘Health and Medical Management Applications’ and ‘Ethical and Legal Aspects of the Use of Biosensors’.

Portable hyperbaric chambers are a therapeutic option for altitude disease in the mountains. By an increase of the oxygen partial pressure the patient’s symptoms ameliorate significantly. Portable hyperbaric chambers may be used as ‘stand alone therapy’ as well as in combination with other therapeutic options. Here we present the recommendation how to use the device and how to avoid problems. The recommendation has been agreed by all members of the medical commission of the world umbrella organization Union Internationale des Associations d’Alpinisme (UIAA MedCom).

This year the Annual Meeting in Berlin (September 15th to 17th) was the 25th one of the German Society of Travel Medicine and therefore it included some celebration. The scientific part included a wide variety of topics. Beside of ‘typical’ ones like malaria prevention and new vaccines there were lectures about space tourism (Prof. R. Gerzer), environmental risks (earthquakes – Dr. J. Lauterjung, altitude medicine – Dr. S. Baniya, and poisonous snakes – Dr. C. Pechmann). Prof. M. Tannheimer discussed quick ascents to extreme altitude by pre-acclimatized climbers while Dr. Kattner reported news about tick borne diseases. Yellow fever (Dr. K. Kling) and Hepatitis B in Nepal (Dr. A.S. Menner) were discussed intensively. Another topic was different aspects of cruise shipping (Prof. T.W. Heggie, C. Kopp, L. Damm). Prof. T. Küpper touched a ‘hot iron’: Ethical considerations in travel medicine. There was a special invitation to young scientists, students and clinicians with a specific event. Poster presentations added topics for discussions. The presented abstracts include lectures and posters and are listed in alphabetical order of the first author.

Antarctica is one of the last great wilderness areas on Earth. Early Antarctic expeditions during the Heroic Age of Antarctic discovery (1895–1922) returned reports of frostbite, scurvy, snow blindness, and death. Today, over 50,000 people travel to the Antarctic each year via research expeditions, commercial cruise ships (tourism), and research cruises. This study reviewed the existing research reporting the health challenges encountered during modern day travel to Antarctica. The results identified a transition from the Heroic Age when death was common to a contemporary time when death is an uncommon event. The review identified musculoskeletal and soft tissue injuries resulting from moving equipment and supplies to be the most common health challenge encountered by long-term land expeditions. Digestive issues such as constipation and dyspepsia were also common in during the coldest months. For tourist oriented commercial cruise ships, motion sickness resulting from rough seas was most prominent. Specifically, the small nature of the cruise ships made them prone to rough seas in Drakes Passage. During scientific cruises where research is primarily conducted aboard the ship, dermatological conditions (viral, fungal, bacterial) such as dry skin, dry lips, eczema are the most common health challenge. Musculoskeletal and soft tissue injuries are also common given the physical challenge associated with strenuous research.

Background: Water quality for tourists visiting South Luangwa National Park and other less developed regions is of the utmost importance in order to avoid gastrointestinal infections; one of the most common diseases among tourists. It is also important to the health of the local tourist accommodations and the local tourist economy. Methods: Water quality samples assessing microbiological contamination were taken from the borehole and point of use in 14 tourist lodges and camps. Turbidity was assessed optically with a DelAlgua turbidity tube. For microbiological analysis, samples were incubated in the DelAgua Dual Incubator at 37°C and 44°C. Thermotolerant Escherichia coli (E. coli) was used as the indicator bacterium for fecal pollution. Water samples were classified based of risk levels for pollution determined by the World Health Organization (WHO). Results: Fifty percent of borehole samples showed no contamination. Two were found to be at high risk and the others ranged between low and intermediate risk. At the point of use, 80% of the samples were clean and compliant with WHO guidelines. Water contamination generally improved from the borehole to point of use. Turbidity at borehole samples were clear in 75% of possible samples. At the point of use, turbidity was clear in 81% of samples. Conclusion: This study establishes the first baseline water quality data for tourist facilities at South Luangwa National Park in Zambia. While water quality at most sites is clean for human use, a regular monitoring system accompanied by maintenance is recommended.

While the epiphyseal stress fracture of the finger’s middle phalanx is a known sport-specific injury occurring only in adolescent climbers, and in other locations it’s rare, no femoral neck stress fracture (FNSF) in sports climbing has yet been reported. An experienced female sport climber (37y, 160 cm, 45 kg, BMI 17.5) suffered from pain in the left inguinal region while climbing, and later, also required a stick to walk. Routine radiography missed the FNSF and it was many weeks before a MRI accurately provided that diagnosis. The time between the X-ray and MRI should have been minimized as it resulted in a delayed diagnosis, unnecessary pain and delayed healing. In this situation the initial clinical investigation, the patient’s history and the X-ray did not lead to a clear diagnosis, and the initial treatment was ineffective. Further investigation by MRI and / or CT scans should have taken place sooner and would have been essential.

Introduction: Extreme levels of sleep deprivation, fragmentation and management, are major problems in many sportive disciplines, ultramarathons, polar or extreme altitude expeditions, and in space operations. Material and methods: Polysomnographic (PSG) data was continuously recorded (total sleep time and sleep stage distribution) in a 34-year-old male whilst performing the new world record in long-term downhill skiing. He napped only during the short ski lift rides for 11 days and nights. Results: After an initial period of complete sleep deprivation for 24 hours, total sleep time and the total times of non-REM and REM achieved during the lift rides returned to standard values on the second day. PSG data revealed an average sleep time per 24 hours of 6 hours and 6 minutes. During daylight sleep was rarely registered. The subject experienced only two minor falls without injury and immediately resumed skiing. Conclusion: In a healthy, trained, elite male athlete, sleep fragmentation over 11 consecutive days did not significantly impair the sleep, motor or cognitive skills required to perform a continuous downhill skiing world record after an initial adaptation phase

About the Meeting This year the Annual Meeting off the German Society of Travel Medicine took place in Bremerhaven, September 16th to 18th. This traditional harbour town where thousands of Germans were embarking hundred years ago facing an uncertain future, the so-called “climate house” (an exihibtion about several aspects of the world’s climate) and the Alfred-Wegener Institute for Arctic Research were a fantastic setting for the meeting’s motto “traveling under extreme conditions”. After a brillant introduction by Stefan Kröpelin about research in the Sahara two weeks away from the next pharmacy and a fascinating lecture by Eberhard Kohlberg how to organize expeditions to Antarctica and how to work and to live there several lecturers illuminated a wide field of travel medicine in more or less extreme conditions.

Background: Ski mountaineering is a competitive sport that has gained popularity during the last years. As most competitions are held in altitudes between 1500 m and 3500 m, a considerable amount of training occurs at various hypobaric hypoxia degrees. It was establishing a sport-specific cardiopulmonary exercise protocol using standard ski mountaineering equipment on a treadmill. This study investigated altitude’s effects on a self-regulated incremental exercise field test at 3100 m with this protocol. Methods: Six athletes were tested (24.2 ± 4.2 years) from the German Ski Mountaineering National Team with a portable telemetric cardiopulmonary exercise test equipment. First, an incremental indoor step test with skis on a treadmill (altitude 310 m) and four days later outdoor on glacier snow (3085 m) after three days of acclimatization. All athletes were exposed to repetitive intermittent hypoxia during the weeks before the test. Standard cardiopulmonary exercise parameters were recorded while individual training zones were defined according to ventilatory thresholds. Results: In highly trained athletes, mean V̇O2peak (72/ml kg KG/min) was reduced by 25% or 9% per 1000 m altitude gain and by 18% and 23% at the first and second ventilatory thresholds, respectively. Mean maximum heart rate and the heart rate at the ventilatory thresholds were reduced at altitude compared to sea-level, as was the O2pulse. Conclusion: Due to distinctive individual reactions to hypoxia, cold, etc., an individual and sport-specific field performance analysis, representing the daily training environment, is highly useful in world-class athletes for precise training control. Our self-regulated cardiopulmonary field protocol could well prove to serve in such a way.

Safe water is still a major problem for travellers in many countries worldwide. In the last decade several new technical developments were made and more data exist about traditional procedures to produce safe water. This update includes such data with special regard to UV-C and held devices and SODIS.

Introduction: The Borg Scale for perceived exertion is well established in science and sport to keep an appropriate level of workload or to rate physical strain. Although it is also often used at moderate and high altitude, it was never validated for hypoxic conditions. Since pulse rate and minute breathing volume at rest are increased at altitude it may be expected that the rating of the same workload is higher at altitude compared to sea level. Material and methods: 16 mountaineers were included in a prospective randomized design trial. Standardized workload (ergometry) and rating of the perceived exertion (RPE) were performed at sea level, at 3,000 m, and at 4,560 m. For validation of the scale Maloney-Rastogi-test and Bland-Altmann-Plots were used to compare the Borg ratings at each intensity level at the three altitudes; p < 0.05 was defined as significant. Results: In Bland-Altmann-Plots more than 95% of all Borg ratings were within the interval of 1.96 x standard deviation. There was no significant deviation of the ratings at moderate or high altitude. The correlation between RPE and workload or oxygen uptake was weak. Conclusion: The Borg Scale for perceived exertion gives valid results at moderate and high altitude – at least up to about 5,000 m. Therefore it may be used at altitude without any modification. The weak correlation of RPE and workload or oxygen uptake indicates that there should be other factors indicating strain to the body. What is really measured by Borg’s Scale should be investigated by a specific study.

Background: Occupational physicians work directly with individual employees regarding diseases that has been caused or exacerbated by workplace factors. However, employees are increasingly required to travel for their work, including to tropical countries where they risk exposure to diseases they would not normally encounter at home (i.e., malaria). Such disease/s may also take days to months to incubate before becoming symptomatic, even after their return home, thus delaying and complicating the diagnosis. Proving this was an occupational disease with respective sick leave entitlement or compensation can be challenging. There is a lack of data concerning occupational diseases caused by tropical infections. Material and methods: Employee case records for the period 2003-2008 from the State Institute for Occupational Health and Safety of North-Rhine Westphalia in Germany were analysed and assessed within Germany’s regulatory framework. These records included Germany’s largest industrial zone. Results: From 2003-2008the suspected cases of “tropical diseases and typhus”, categorized as occupational disease “Bk 3104” in Germany, have decreased significantly. A high percentage of the suspected cases was accepted as occupational disease, but persistent or permanent sequelae which conferred an entitlement to compensation were rare. Conclusion: There is scope to improve diagnosis and acceptance of tropical diseases as occupational diseases. The most important diseases reported were malaria, amoebiasis, and dengue fever. Comprehensive pre-travel advice and post-travel follow-ups by physicians trained in travel and occupational health medicine should be mandatory. Data indicate that there is a lack of knowledge on how to prevent infectious disease abroad.

Introduction: Fellow trekkers are often the first responders to their comrades in remote settings. Not everyone undertakes First Aid (FA) training when travelling to remote settings away from comprehensive healthcare, whether travelling independently or in a group. The syllabus of standard urbanised FA courses does not fully cover the needs of such trekkers (ie altitude illnesses). We evaluated the FA and emergency knowledge of trekkers en route in the remote Nepalese Himalayas. Material and methods: A questionnaire about FA, trekking emergencies and water hygiene knowledge was completed by a cohort of 453 trekkers passing through Manang (3,519 m), Nepal, who volunteered their participation. A previously validated questionnaire consisted of 20 multiple choice questions (each using a five-point Likert scale) was used, followed by a subjective self-assessment of 17 key topics using a 5-point rating scale from very good to unsatisfactory knowledge. Demographic data including FA and climbing experience was also collected. Results: The participants generally showed a poor knowledge in FA and trekking emergencies, even though 20.8% had some occupational medical training. In total 59.5% of possible answers were answered correctly. On average each participant managed to answer only one out of 20 questions (5.4%) completely correct. The most unsatisfactory results concerned the following topics, each with only 2.4% correct answers: hypothermia/resuscitation, rescue strategies and rip fractures. The best results were for HACE 33.8%, cranio-cerebral injury 33.6%, angina pectoris/heart attack 31.8% and hypovolemic shock 28.7%. The majority of participants had very limited experience of climbing mountains, rock climbing or ice climbing. Conclusions: This study provides essential data identifying deficiencies in standard FA courses that are targeted for urban settings, and not for trekkers in a remote setting far away from comprehensive health care and rescue. There is a need to develop readily accessible FA curriculums specific to trekkers that would provide education on preventative care prior to, during, and after treks, and to improve their knowledge of medical care of trekking injuries and emergencies.

Aim of the study: The purpose of this work is to show the possibility to use a recuperative design of a heat and moisture exchange face mask (HME). Such HME are used as cold weather face masks for Arctic expeditions and conditioning of air for long-term intubated patients. Common regenerative HME have the disadvantage of increasing airway resistance and airway volume (dead space). In recuperative devices, the separation of inspired and expired airflow could reduce dead space and resistance. Materials and methods: Prototype HMEs were built using two concentric ducts of aluminium or cotton. A valve ensures that expired and inspired air are led through either the inner or the outer tube. The inner tube’s wall transmits heat and water. The HMEs were tested in a simulated Arctic environment using a breathing simulator and characterized in terms of heat and moisture exchange efficiency. The new design was also tested at room temperature in order to simulate the conditions of long-term intubation. To compare the results, the relative difference in temperature (Performance Coefficient PC) between the expired and the inspired air was calculated. Results: During the experiments, the ambient temperature was −37°C and therefore the absolute water content was about zero. The recuperative HME conditioned the air to 21°C and 10.7 mg/l water (61% relative humidity), giving a PC of 82%. At room temperature the recuperative mask showed a PC of 62%. Conclusion: The recuperative HME shows great potential. It might be of use in clinical conditions and Arctic expeditions.

Background: Trekking in Nepal is popular and generally safe. However preventable trekking injuries and deaths are often the result of poor risk managementand lack of skills – i.e. acute mountain sickness (AMS) and specific First Aid (FA). Shlim and Gallie’s reviews in 1992 and 2004 of trekking deaths here found a fivefold higher risk for fatal outcomes in organized trekking tours (OT) compared to independently organised trekkers (IT), including preventable deaths (i.e. AMS). Our survey sought to identify the AMS, FA and risk management knowledge/skills of OT and IT whilst trekking in Nepal. Methods: Based on previous pilot studies at the Khumbu region in Nepal, and on risk management information provided by leading German trekking operators, a survey was conducted using two questionnaires: one each for OT and IT.The study site was Manang (3,500m) in Annapurna region, Nepal. All trekkers passing through this site who volunteered their participation were included. For evaluation descriptive statistical methods and non-parametric tests were used. Results: 442 questionnaires were completed (155 OT; 287 IT). Mean agewas 36.4 +/– 12.0y and 61% were male. Mountaineering experience was low and FA training was scarce in both groups. IT (92.7%) followed acclimatization recommendations and 59.2% carried AMS medication, compared respectively to OT at 63.2% and 25.2%. Only 27.1% of OT had repatriation plans for a medical emergency. Conclusions: Most of OT and IT were inexperienced in mountaineering and in mountain emergencies. The preparedness of OT overall was inadequate and over-reliant on the organisers whose skills may also be inadequate when responding to an emergency. Responsible trekking should require that more than one person in a group have adequate, up-to-date riskassessment/management and FA skills specific to the trek, and in particular an understanding of altitude profile, AMS, and individual abilities.

Introduction: The hygienic conditions during trekking or mountaineering at high altitudes are reduced, especially regarding defecation and hand hygiene. An additional problem exists in regions above the snowline, especially in highly frequented regions: snow may be contaminated by faecal microbes, causing diarrhea. Prevention against faecal-oral infections must include not only disinfection of drinking water, but hand disinfection, too, e.g. by a water-free hand gel. The practicability of this measure was tested during a Himalaya expedition on the way to Mt. Everest. Material and methods: 10 participants were instructed to use Stokosept-Gel, an alcohol based skin disinfectant, at least prior to meals, after using a toilet and after handling boot-laces and to note each use (including additional occasions). Results: A very good practicability of using the hand gel, which was absorbed quickly (ca. ¼ min) was reported. 100 ml were sufficient for at least 2 weeks and there were no side effects or problems at the skin. During the mountaineering phase which included a total of 250 person days in the field no diarrhea occurred. Conclusion: We conclude that using such hand gels is – additional to other procedures – a very practical prevention against diarrhea in mountaineering at high altitude.

Legionnaire’s disease is a life threatening respiratory tract infection that is commonly associated with a stay in communal accommodations such as hotels, hostels, guesthouses and camping sites. In the European Alps and some other areas of the world mountain refuges and huts can sometimes accommodate over 100 guests in almost hotel like comfort. Such a “hut” may have cramped dormitories with multi-occupancy bunks and a basic water supply system possibly with hot water. Some will have showers. The water supply may be limited by the environment. As such these may pose a high risk for transmission of Legionellosis. In an environment of a hut which is more difficult to control than others. Unfortunately countries differ in their guidelines for the prevention of Legionnaire’s disease transmission within tourist accommodation. The aim of this paper is to propose a set of simple and pragmatic rules that can prevent the development of Legionella infections in mountain huts and other accommodations situated in the wilderness environment.

This suggested contract document attempts to clarify the rights and obligations of the tour operator (referred to herein as “organization”, OR), the ED and the EX to avoid trouble and misunderstandings during the trip. Being an Expedition or Trekking Doctor (referred to herein as “Expedition Doctor”, ED) is more than being merely a member which advises others in case of a health problem during the trip and who may get a discount on organized trips! An ED has specific responsibilities, has to provide special skills, and must always accept responsibility for any diagnosis made, whether right or wrong. Both, the tour operator and the participants of the Expedition (referred to herein as “Expedition”, EX) have their individual and often conflicting interests to which the ED’s own mountaineering interests must also be added. However, to minimize the possible multiple risks associated with these conflicts of interest, the rights, obligations and priorisation of medical and expedition scheduling should be made clear well in advance of the expedition. The following is a model text which may be adapted to an EX’s specific demands. In this text, EX includes the organizers of the trip, the expedition’s leaders and the participants.

Introduction: Young people serving as volunteers in international projects show a different risk profile to “normal” travellers. Data are scarce. While infectious risks were published elsewhere we focus now on non-infectious risks. Material and methods: 153 questionnaires, obtained from volunteers returning from their project were evaluated. Questions included age, situation abroad (living space and work), travel experience, region of the project, language skills, pre-travel advise, type of problems abroad (accidents, traffic, violence, robbery, sexual assault, psychosocial stress etc.). Results: Several factors, normally not included in pre-travel advice, cause significant psychosocial stress which decreases a bit during the stay. Special problems are insufficient language skills, (subjective) safety at night, traffic / transport, and violence. Psychosocial stress was the most important reason to stop the activity and to return home ahead of schedule (4% of all volunteers). Conclusions: Pre-travel advice of young volunteers should include psychosocial factors and other topics additional to infectious diseases, vaccination, and hygiene. Sufficient training in common but minor medical problems (headache, sunburn, minor wounds) is a “must”. A comprehensive advice and training may need two days and may be realized in groups of 5 to 12 participants. Health and safety should become a more important topic of all projects.