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Safe Sojourns to High Altitudes: The Risks of Annual Religious Pilgrimages in Jammu and Kashmir, India- Clinical Diagnostics and Treatment -Juniper Publishers

Juniper Publishers- Juniper Online Journal of Public Health

Introduction

The increased prevalence of high altitude sickness such as Acute Mountain Sickness (AMS), High Altitude Cerebral Edema (HACE), and High Altitude Pulmonary Edema (HAPE) are related to the increasing popularity of mountain climbing as an adventure sport; and the increasing ease, and decreasing cost of travel to popular climbing tourist destinations. This precludes the usual preparations and adaptations of experienced climbers embarking on extreme ascents. Today, with the exception of these extreme climbing projects, climbers can climb mountains as a weekend activity. However, even moderate ascents can lead to the illness syndromes that are discussed here. Thus, there is an expected increase in high altitude sicknesses presented to mountain guides, first responders, and emergency department physicians located in mountainous areas.

The experienced climbers anticipating a long ascent plans the climb, gets into shape, and climbs on an acclimatization schedule lasting weeks to months. These are not weekend climbers who anticipate climbing to extreme altitudes. The experienced adventurers rarely suffer high altitude sickness; and, always at the extremes of the planned; but, even weekend climbers can climb to altitudes sufficient to cause illness when unprepared. So, those afflicted with high altitude sickness are much more likely to be inexperienced recreational climbers who have allocated less time to acclimate to the environment such as the dramatic change in altitude (Figure 1).

From a public health standpoint, prevention is an essentialactivity through an aggressive public information programincluding pre-climb briefings, and almost certainly inexperiencedclimbers should be required to climb with an experienced guidewho knows how to identify the signs of sickness, knowledge oftreatment, equipped to treat the illness; and, the authority toorder an immediate descent of the climbing group. Like manyenvironmental conditions; prevention, treatment, and survivaldepend largely on intelligent decisions by people affected bothindividually and as a group. Preparation planning is critical asis planning an exit strategy from the hazardous environment. Insome extremes of altitude and terrain, available rescue is almostimpossible especially at extreme high altitudes beyond the safereach of rescue helicopters. And, the time it would take for aclimbing rescue team to reach the scene could arrive too late fora successful outcome (Figure 2).

As adaptation and clinical symptoms and treatment of HighAltitude Diseases are discussed, it is important to note that noone need die if appropriate precautions are taken. Extremeclimbers in the “Death Zone” of Mt. Everest may die because noone can help them down and their often irrational commitmentto summit creates a psychological conflict between the climb ordescend decisions quickly while the afflicted climber can stillwalk. Also at work is the neurological dysfunction that can impairjudgment and decision making at a critical time. Sometimes, thechoice is to force the climber down or write them off as on theirown; and, likely a lost soul on the mountain. There are dozensof frozen bodies on Mt. Everest and other extreme mountains asevidence to this effect.

The Pathophysiology of High Altitude Sickness

According to the barometric formula, air pressureexponentially decreases at increasing altitudes; a phenomenon,which causes high altitude sickness [1]. It occurs as an acute orchronic condition depending on the time and speed of exposureto high altitude. If an acute condition prevails, symptoms canworsen to both a high altitude pulmonary edema (HAPE) [2] anda high altitude cerebral edema (HACE) [3]. Both complicationsare rare; but, life-threatening. Though these disease conditionsare well described, clinically, their partially overlappingpathomechanisms need to be differentiated [4] (Figure 3).

When ascending to high altitudes, the oxygen partialpressure in the lungs is reduced, whereas the carbon dioxidepartial pressure remains constant. Therefore, hemoglobinis less saturated with oxygen, thus leading to generalizedhypoxia. In this situation, pulmonary arteries constrictresulting in hypertension and fluid imbalances. These effectson hemodynamic caused by a hypoxic environment turn outto be pathognomonic in susceptive individuals. Consequently,all compensatory measures of metabolism aim at increasingthe oxygen concentration in the blood. On the one hand, theendocrine system triggers erythropoietin (EPO) excretion fromthe kidney as response to lower oxygenation. EPO stimulates theproduction of erythrocytes in the bone marrow. This hormonesignal seems to be potentiated by hypoxia-inducible factor 1(HIF-1), which takes part in intrinsic formation of nitric oxide, asecond messenger that promotes vasodilation [5].

As hemoglobin biosynthesis is also accelerated, morepotential oxygen binding sites are made available, as indicatedby elevated hematocrite levels and other standard red bloodcell count (RBC) parameters. However, this compensatoryerythrocytosis is known to be reversible. It corresponds withhigher intestinal iron absorption and reticulocytosis [6] but;the expansion of red blood cell volume requires the heart topump at higher rates and making potentially dangerous clotformation more likely. Besides increasing the binding capacity,hyperventilation occurs to increase oxygen absorption in thelungs. However; by this reflex, only carbon dioxide is breathedout more rapidly progressing to respiratory alkalosis [7]. Sinceas a result less carbon dioxide can be converted into carbonicacid, the volatile bicarbonate buffering system in the blood is outof its equilibrium. Due to a reduced concentration of bicarbonateand hydrogen ions buffering capacity is lost, and the arterialblood pH turns alkaline (>7∙38).

Temporarily, this pH shift can be metabolicallycounterbalanced to retain bicarbonates both by renal excretionand decelerating the urea cycle in the liver. Usually, acidbaseimbalances compensated by the kidneys take effect laterthan hepatic mechanisms. The alkaline blood pH lowers thehemoglobin affinity to oxygen, as indicated by a right shift ofthe equilibrium curve with an increased P50. Simultaneously, glycolysis in red blood cells is activated producing more ofthe intermediate 2, 3-disphosphoglycerate (2, 3-DPG), anallosteric regulator of hemoglobin [8]. 2, 3-DPG binds to itspartially deoxygenated state (T conformation), which facilitatesthe release of already bound oxygen molecules. By keepinghemoglobin in a conformation, which is more likely to unloadoxygen, 2, 3-DPG mediates sufficient supply of hypoxic tissuesas long as this is required. Therefore, this allosteric mechanismcontributes to the gradual acclimatization to high altitudes,which proves to be an evolutionary benefit in animals adaptedto such an extreme habitat [9].

It is critical that emergency medical workers located in theshadows of high ascent areas of the world be constantly trainedin the recognition and response to high altitude sickness.An intensive Orientation Course in High Altitude MedicalEmergencies was started for Medical Officers at RIHFW (Figure1). Active Amarnath Ji Yatra Management by Directorate ofHealth Services Kashmir, India led to drastic reductions inpilgrim deaths this year (Figure 4).

In year 2014 Total piligrims visited the holy shrine are:4,53,000 Number of deaths: 48

In year 2015 Total piligrims visited the holy shrine are:3,67,000 Number of deaths : 43

In year 2016 Total piligrims visited the holy shrine are:2,16,000 Number of deaths : 16

Programs of this kind can continue to reduce deaths amonginexperienced tourists and pilgrims seeking a high altitudeascent regardless of purpose [10]. Of course, it is also criticalthat climber’s guides and climbing club managers also exerciseauthority over those who insist on climbing often withoutadequate preparation, skills, or supervision. Of course, thisauthority may be codified and enforced by local governmentregulation and licensing of guides and formal legal approval ofall climbing group expeditions ensuring that all standards andsafeguards have been met (Figure 5).

Travel Safe to High Altitudes

Introduction to Safe Travel

Every year millions of people travel to high altitude forrecreation, religious purposes and for work. Those travellingto altitudes 5500m/18,000 feet, twenty percent of them sufferfrom acute mountain sickness (AMS). This number goes to fiftypercent above 18,000 ft. Most cases of AMS are mild and selflimitingbut some cases become life threatening. Once travellingor planning to travel to high altitude (above 5500M/18,000 feet)knowledge plays an important role in the prevention of AMS. Highaltitude area (HAA) is divided into High altitude, Intermediatealtitude, very high altitude and extreme high altitude dependingon height as explained below (Table 1).

Many religious high altitude travels are being taken bypilgrims all over the globe and one such travel taken every yearin the northern state of India is Jammu and Kashmir is AmarnathJi Yatra where millions of people climb to the holy cave. Everyyear hundreds of deaths of pilgrims occur because of the lack ofknowledge about the risks of travel to high altitudes. In order toreduce the mortality and morbidity new initiatives were takenby the Government of India by the Ministry of Health and FamilyWelfare under the guidance of the Supreme Court (Highest Courtin India) framed guidelines to make the trip of pilgrims safer. Ateam of health professionals which included Chest Specialists,Orthopaedicians, and Public Health Experts visited the valley of Kashmir to train doctors who are to be on duty on the trackof Amarnath Ji Yatra leading to holy cave. A total of 57 MedicalDoctors in batches of three were trained at the training andresearch center for doctors at Regional Institute of Health andFamily Welfare, Dhobiwan, District Baramulla, the Institutewhich is en route to the health resort of the world known asGulmarg. The main objective of the training was managementof high altitude illnesses which include AMS (Acute mountainsickness), HAPE (High Altitude Pulmonary Edema), and HACE(High Altitude Cerebral Edema) (Figure 6).

Conclusion

The world’s breath taking sites exist at high altitudes andwhether one plans an expedition or a religious trip, altitude illnessmust be a factor while planning the trip. This commentary is anintroduction to recognize and respond to high altitude illness.Most of HAI (High Altitude Illness) is mild and self-limiting sobe prepared for discomfort, and be prepared to recognize signsof serious illness. In the year (2012), the total number of deathsrecorded were 120 related to high altitude sickness while as thisyear 2013, the total number of death were 12 [10], and there hasbeen definitely the impact of good training, good infrastructureprovided, and proper planning done by K- RICH (KashmirInnovation Committee for Health Care).

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