High altitude pilgrimage medicine

Transforming health in Nepal: a historical and contemporary review on disease burden, health system challenges, and innovations

INTRODUCTION

Nepal witnessed a tumultuous journey over past two centuries, marked by significant political, social, and cultural shifts. From fighting British colonial encroachments in 1800s, the dynastic Rana regime (1846-1951), and democracy movements in the late 1950s, 1990s and 2000s, Nepal became a federal republic in 2008. The main objective of this review is to lay out an interpretative summary on Nepal's epidemiological transition (includes general trends and disease specific topics) followed by discussion on health system development over key periods: historical period (-1950s), modern period (1950-1990), post-democracy (1991-2016), and post-federalization (2016-).

METHODS

We conducted a scoping review of available literature using the Arksey and O'Malley framework to synthesize the key insights. Searches were performed in PubMed (via NLM), Embase and Google Scholar using a combination of search terms related to Nepal's health system, epidemiological transition, disease burden and emerging health issues. A total of 1204 records were identified, of which 123 documents - including peer-reviewed articles, government reports and grey literature - met the inclusion criteria.

RESULTS

Major advances in maternal and child health, nutritional health and reduction of infectious diseases have been observed in recent decades. The maternal mortality ratio (MMR) declined by 55% (1996-2016), and neonatal mortality halved (40 to 20 per 1000 live births) due to improved antenatal care, skilled birth attendance and family planning. Stunting rates fell from 66% (1996) to 25% (2022), yet rising non-communicable diseases (NCDs) pose new challenges. Communicable diseases, once dominant, have declined owing to expanded immunization and tuberculosis control. However, NCDs now account for over two thirds of deaths, driven by urbanization, ageing and lifestyle shifts. Health system gaps persist, with workforce shortages, rural-urban disparities and out-of-pocket health costs limiting access. Addressing rising health inequities, digital health innovations and service expansion is critical to achieving universal health coverage and sustaining Nepal's health gains.

CONCLUSIONS

Nepal's health care landscape has continuously evolved over the past centuries, coinciding with key demographic and political changes. Advances through innovation are necessary for the country's overstretched health system to reduce the cost of health services whilst increasing quality and access.

Impact of capacity building training on emergency medical services for chardham yatra: a pre-test post-test study in a hilly region of North India

BACKGROUND

The Char Dham Yatra in Uttarakhand, India, poses significant healthcare challenges due to high altitude, limited medical infrastructure, and increased risk of emergencies, including high-altitude illnesses and cardiovascular events. To address these challenges, a capacity-building program was implemented for medical officers, aiming to enhance their emergency medicine skills.

METHOD

The study was conducted at the Emergency Medicine and Trauma Surgery Department, AIIMS Rishikesh. The study was conducted for 6 months. A total of 150 medical officers were nominated, with 125 participating. The training involved weekly sessions over three months, comprising didactic lectures and hands-on practical skills, particularly in basic life support. Pre and post-tests comprising 20 questions assessed participants' knowledge, and skill assessments were conducted using a 7-item questionnaire on a 5-point Likert scale.

RESULT

The program resulted in a significant improvement in participants' knowledge, with an average increase of 41% in post-test scores compared to pre-test scores (p < 0.001). Skill assessment showed that 70.4% of participants were rated as "Outstanding" or "Very Satisfactory." The distribution of trained officers was uneven across districts, with Pauri and Tehri having the highest representation.

CONCLUSION

The capacity-building program significantly enhanced the emergency medicine capabilities of medical officers, leading to better preparedness for handling medical emergencies during the Char Dham Yatra. The positive outcomes highlight the importance of continued investment in such training programs to reduce morbidity and mortality. Addressing the uneven distribution of trained officers is crucial for comprehensive emergency medical coverage along the pilgrimage route.

Sacred journeys and pilgrimages: health risks associated with travels for religious purposes

BACKGROUND

Pilgrimages and travel to religious mass gatherings (MGs) are part of all major religions. This narrative review aims to describe some characteristics, including health risks, of the more well-known and frequently undertaken ones.

METHODS

A literature search was conducted using keywords related to the characteristics (frequency of occurrence, duration, calendar period, reasons behind their undertaking and the common health risks) of Christian, Muslim, Hindu, Buddhist and Jewish religious MGs.

RESULTS

About 600 million trips are undertaken to religious sites annually. The characteristics vary between religions and between pilgrimages. However, religious MGs share common health risks, but these are reported in a heterogenous manner. European Christian pilgrimages reported both communicable diseases, such as norovirus outbreaks linked to the Marian Shrine of Lourdes in France, and non-communicable diseases (NCDs). NCDs predominated at the Catholic pilgrimage to the Basilica of Our Lady of Guadalupe in Mexico, which documented 11 million attendees in 1 week. The Zion Christian Church Easter gathering in South Africa, attended by ~10 million pilgrims, reported mostly motor vehicle accidents. Muslim pilgrimages such as the Arbaeen (20 million pilgrims) and Hajj documented a high incidence of respiratory tract infections, up to 80% during Hajj. Heat injuries and stampedes have been associated with Hajj. The Hindu Kumbh Mela pilgrimage, which attracted 100 million pilgrims in 2013, documented respiratory conditions in 70% of consultations. A deadly stampede occurred at the 2021 Jewish Lag BaOmer MG.

CONCLUSION

Communicable and NCD differ among the different religious MGs. Gaps exists in the surveillance, reporting and data accessibility of health risks associated with religious MGs. A need exists for the uniform implementation of a system of real-time monitoring of diseases and morbidity patterns, utilizing standardized modern information-sharing platforms. The health needs of pilgrims can then be prioritized by developing specific and appropriate guidelines.

Mechanisms underpinning sympathoexcitation in hypoxia

Sympathoexcitation is a hallmark of hypoxic exposure, occurring acutely, as well as persisting in acclimatised lowland populations and with generational exposure in highland native populations of the Andean and Tibetan plateaus. The mechanisms mediating altitude sympathoexcitation are multifactorial, involving alterations in both peripheral autonomic reflexes and central neural pathways, and are dependent on the duration of exposure. Initially, hypoxia-induced sympathoexcitation appears to be an adaptive response, primarily mediated by regulatory reflex mechanisms concerned with preserving systemic and cerebral tissue O2 delivery and maintaining arterial blood pressure. However, as exposure continues, sympathoexcitation is further augmented above that observed with acute exposure, despite acclimatisation processes that restore arterial oxygen content (C a O 2 ${C_{{\mathrm{a}}{{\mathrm{O}}_{\mathrm{2}}}}}$ ). Under these conditions, sympathoexcitation may become maladaptive, giving rise to reduced vascular reactivity and mildly elevated blood pressure. Importantly, current evidence indicates the peripheral chemoreflex does not play a significant role in the augmentation of sympathoexcitation during altitude acclimatisation, although methodological limitations may underestimate its true contribution. Instead, processes that provide no obvious survival benefit in hypoxia appear to contribute, including elevated pulmonary arterial pressure. Nocturnal periodic breathing is also a potential mechanism contributing to altitude sympathoexcitation, although experimental studies are required. Despite recent advancements within the field, several areas remain unexplored, including the mechanisms responsible for the apparent normalisation of muscle sympathetic nerve activity during intermediate hypoxic exposures, the mechanisms accounting for persistent sympathoexcitation following descent from altitude and consideration of whether there are sex-based differences in sympathetic regulation at altitude.

Sleep Quality Among Pilgrims at High Altitude: A Cross-Sectional Study From Gosaikunda Lake, Nepal (4380 m)

Introduction Nepal is a touristic country; globally, many people visit Nepal for mountaineering, trekking, sightseeing, and pilgrimages. Gosaikunda, located at an elevation of 4380 m (14,370 ft) in the Rasuwa district, Nepal, is a popular pilgrimage site. At high altitudes, hypobaric hypoxia is the primary cause of sleep disturbances and is characterized by difficulty falling asleep, frequent nighttime awakening, difficulty returning to sleep, and waking up earlier in the morning than desired, ultimately resulting in a reduction in total sleep duration and quality. Objective The primary objective of this study was to evaluate the quality of sleep patterns of pilgrims while undergoing acute high-altitude exposure on their journey to Gosaikunda, Nepal, which is a pilgrimage site situated at an altitude of 4380 meters (14,370 feet) above sea level. Methodology A cross-sectional descriptive study from August 7 to 14, 2022, was conducted among Gosaikunda pilgrims who visited the sacred lake in Rasuwa district in Nepal at an altitude of 4380 m, where weather is unpredictable and adverse climatic events are prevalent. The subjective sleep quality was evaluated by using the Athens Insomnia Scale (AIS). Individual participants rated each item (sleep symptoms) as 0 to 3, 0 = no problem, 1 = slight problem, 2 = marked problem, and 3 = very marked or no sleep at all. The total range of the score is 0 to 24, with a cutoff point score ≥ 6 being considered poor sleep. Results Out of 229 participants, 42 (18%), 24 (11%), and three (1%) of them experienced mild, moderate, and severe insomnia, and 160 (70%) had no sleep disturbances. Based on the Athens Insomnia Scale cutoff points, 69 (30.13%) had a score of ≥ 6, indicative of insomnia, and 160 (69.86%) had a score of less than 6, suggestive of no insomnia. Daytime sleepiness was the most common subjective sleep issue among the pilgrims suffering from insomnia (40, 57.97%) and no insomnia (96, 60%). The majority of pilgrims, 207 (99.12%), stayed overnight while ascending at Gosiakunda (4380 meters). The mean body mass index (BMI) in kg/m2 of pilgrims suffering from insomnia and those not suffering from insomnia was 25.29±5.3 and 24.58±4.47, respectively, with a P-value greater than 0.05. The mean age among pilgrims suffering from insomnia and pilgrims who didn't was 41.64±13.39 and 41.64±13.44, respectively, with a P-value greater than 0.05. The majority of the pilgrims took an average of two days to reach Gosaikunda Lake, of which 207 (99.12%) remained at altitude for one night and 22 (0.96%) stayed for more than one night. Conclusion Acute exposure to high altitude results in frequent arousal due to hypobaric hypoxia, which in turn causes pilgrims to feel mentally and physically fatigued and somnolent due to the poor sleep they experience. An elevated BMI, advanced age, and male sex were associated with poor sleep quality after acute altitude exposure. Further research is needed to better understand the mechanisms underlying these associations and to develop effective interventions to improve sleep quality during rapid ascent.

A Season at the Himalayan Rescue Association Aid Post in Manang

The Himalayan Rescue Association (HRA) has operated high altitude clinics in Nepal for 50 years, with rising visitor numbers, especially from India, China, and Nepal. New roads have eased access and increased the speed of ascent in some areas. Our aim was to provide a description of the activities, clinical problems, and lecture attendees of the HRA aid post in Manang over one season. We also highlight the evolving challenges of providing healthcare and education in the high Himalayan region. We describe the clinical and educational activities of the HRA aid post in Manang from September 24 to December 1, 2023. Prospective clinical data collection included anonymized patient demographics and diagnoses. Lecture data were taken from the attendee register and by daily manual counts of lecture attendees. We saw 376 patients, 62% of whom were Nepalis. Infectious diseases (42%) and altitude illness (16%) were the most common problems. A total of 846 people from 47 countries attended the daily altitude lectures. Only 5% of attendees were Nepali. Electrical supply interruptions and limitations in medical evacuation options were among the challenges of providing care at a high altitude clinic and preventing altitude illness using educational lectures. Altitude illness remains a common and potentially life-threatening problem, with risks increased by rapid ascent enabled by new road access and by ignorance of risks of altitude among travelers, especially Nepalis. Language barriers in educational outreach call for novel approaches and interventions that will ensure the effectiveness of altitude education.

Rapid altitude displacement induce zebrafish appearing acute high altitude illness symptoms

Rapid ascent to high-altitude areas above 2500 m often leads to acute high altitude illness (AHAI), posing significant health risks. Current models for AHAI research are limited in their ability to accurately simulate the high-altitude environment for drug screening. Addressing this gap, a novel static self-assembled water vacuum transparent chamber was developed to induce AHAI in zebrafish. This study identified 6000 m for 2 h as the optimal condition for AHAI induction in zebrafish. Under these conditions, notable behavioral changes including slow movement, abnormal exploration behavior and static behavior in the Novel tank test. Furthermore, this model demonstrated changes in oxidative stress-related markers included increased levels of malondialdehyde, decreased levels of glutathione, decreased activities of superoxide dismutase and catalase, and increased levels of inflammatory markers IL-6, IL-1β and TNF-α, and inflammatory cell infiltration and mild edema in the gill tissue, mirroring the clinical pathophysiology observed in AHAI patients. This innovative zebrafish model not only offers a more accurate representation of the high-altitude environment but also provides a high-throughput platform for AHAI drug discovery and pathogenesis research.

Acute mountain sickness and sleep disturbances differentially influence cognition and mood during rapid ascent to 3000 and 4050 m

The impact of acute mountain sickness (AMS) and sleep disturbances on mood and cognition at two altitudes relevant to the working and tourist population is unknown. Twenty unacclimatized lowlanders were exposed to either 3000 m (n = 10; 526 mmHg) or 4050 m (n = 10; 460 mmHg) for 20 h in a hypobaric chamber. AMS prevalence and severity was assessed using the Environmental Symptoms Questionnaire (ESQ) and an AMS‐C score ≥ 0.7 indicated sickness. While sleeping for one night both at sea level (SL) and high altitude (HA), a wrist motion detector was used to measure awakenings (Awak, events/h) and sleep efficiency (Eff, %). If Eff was ≥85%, individuals were considered a good sleeper (Sleep+). Mood and cognition were assessed using the Automated Neuropsychological Assessment Metric and Mood Scale (ANAM‐MS). The ESQ and ANAM‐MS were administered in the morning both at SL and after 20 h at HA. AMS severity (mean ± SE; 1.82 ± 0.27 vs. 0.20 ± 0.27), AMS prevalence (90% vs. 10%), depression (0.63 ± 0.23 vs. 0.00 ± 0.24) Awak (15.6 ± 1.6 vs. 10.1 ± 1.6 events/h), and DeSHr (38.5 ± 6.3 vs. 13.3 ± 6.3 events/h) were greater (p < 0.05) and Eff was lower (69.9 ± 5.3% vs. 87.0 ± 5.3%) at 4050 m compared to 3000 m, respectively. AMS presence did not impact cognition but fatigue (2.17 ± 0.37 vs. 0.58 ± 0.39), anger (0.65 ± 0.25 vs. 0.02 ± 0.26), depression (0.63 ± 0.23 vs. 0.00 ± 0.24) and sleepiness (4.8 ± 0.4 vs. 2.7 ± 0.5) were greater (p < 0.05) in the AMS+ group. The Sleep− group, compared to the Sleep+ group, had lower (p < 0.05) working memory scores (50 ± 7 vs. 78 ± 9) assessed by the Sternberg 6‐letter memory task, and lower reaction time fatigue scores (157 ± 17 vs. 221 ± 22), assessed by the repeated reaction time test. Overall, AMS, depression, DeSHr, and Awak were increased (p < 0.05) at 4050 m compared to 3000 m. In addition, AMS presence impacted mood while poor sleep impacted cognition which may deteriorate teamwork and/or increase errors in judgement at HA.

Does age have an impact on acute mountain sickness? A systematic review

Acute mountain sickness (AMS) is the most common form of illness at high altitude; however, it is still unclear whether age is a protective factor or a risk factor for the development of AMS in travellers. In recent decades, the number of travellers aged 60 years or older is increasing. Thus, the care of older travellers is a long-standing issue in travel medicine. This study aims to systematically review the current state of knowledge related to the effect of old age on the risk of AMS. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used, and the following databases were consulted: PubMed/Medline, Embase, Europe PubMed Central (EuropePMC), World Health Organization Library Database (WHOLIS) and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS). The search yielded a total of 532 articles, of which 25 met the inclusion criteria, corresponding to 26 reports. Although the approaches, methods and quality were heterogeneous among the included studies, 12 reported a negative correlation between AMS prevalence and age, 11 detected no relationship and three papers indicated that the age of AMS subjects was significantly higher than controls. Despite these differences, old age does not seem to be a contraindication for travelling at high altitude. Thus, the presented synthesis will be useful for health professionals in travel medicine to better tailor their appropriate care for older adults who travel to destinations at high altitude.

The impact of hypoxaemia on vascular function in lowlanders and high altitude indigenous populations

Exposure to hypoxia elicits widespread physiological responses that are critical for successful acclimatization; however, these responses may induce apparent maladaptive consequences. For example, recent studies conducted in both the laboratory and the field (e.g. at high altitude) have demonstrated that endothelial function is reduced in hypoxia. Herein, we review the several proposed mechanism(s) pertaining to the observed reduction in endothelial function in hypoxia including: (i) changes in blood flow patterns (i.e. shear stress), (ii) increased inflammation and production of reactive oxygen species (i.e. oxidative stress), (iii) heightened sympathetic nerve activity, and (iv) increased red blood cell concentration and mass leading to elevated nitric oxide scavenging. Although some of these mechanism(s) have been examined in lowlanders, less in known about endothelial function in indigenous populations that have chronically adapted to environmental hypoxia for millennia (e.g. the Peruvian, Tibetan and Ethiopian highlanders). There is some evidence indicating that healthy Tibetan and Peruvian (i.e. Andean) highlanders have preserved endothelial function at high altitude, but less is known about the Ethiopian highlanders. However, Andean highlanders suffering from chronic mountain sickness, which is characterized by an excessive production of red blood cells, have markedly reduced endothelial function. This review will provide a framework and mechanistic model for vascular endothelial adaptation to hypoxia in lowlanders and highlanders. Elucidating the pathways responsible for vascular adaption/maladaptation to hypoxia has potential clinical implications for disease featuring low oxygen delivery (e.g. heart failure, pulmonary disease). In addition, a greater understanding of vascular function at high altitude will clinically benefit the global estimated 85 million high altitude residents.

Acute mountain sickness (AMS) in a Nepali pilgrim after rapid ascent to a sacred lake (4380 m) in the Himalayas

A 55-year-old female Nepali pilgrim presented to the Himalayan Rescue Association Temporary Health Camp near the sacred Gosainkund Lake (4380 m) north of Kathmandu, Nepal, with a complaint of severe headache, vomiting and light-headedness. She was diagnosed with severe acute mountain sickness. Intramuscular dexamethasone was administered. Paracetamol (acetaminophen in the USA and Canada) and ondansetron were given as supportive management for headache and nausea. Arrangements were made to have her carried down by a porter immediately. After the descent, all her symptoms resolved. High-altitude pilgrims are a more vulnerable group than trekkers and mountaineers. Pilgrims generally have a rapid ascent profile, have low awareness of altitude illness and are strongly motivated to gain religious merit by completing the pilgrimage. As a result, there is a high incidence of altitude illness among pilgrims travelling to high-altitude pilgrimage sites.

High-Altitude-Induced alterations in Gut-Immune Axis: A review

High-altitude sojourn above 8000 ft is increasing day by day either for pilgrimage, mountaineering, holidaying or for strategic reasons. In India, soldiers are deployed to these high mountains for their duty or pilgrims visit to the holy places, which are located at very high altitude. A large population also resides permanently in high altitude regions. Every year thousands of pilgrims visit Holy cave of Shri Amarnath ji, which is above 15 000 ft. The poor acclimatization to high altitude may cause alteration in immunity. The low oxygen partial pressure may cause alterations in gut microbiota, which may cause changes in gut immunity. Effect of high altitude on gut-associated mucosal system is new area of research. Many studies have been carried out to understand the physiology and immunology behind the high-altitude-induced gut problems. Few interventions have also been discovered to circumvent the problems caused due to high-altitude conditions. In this review, we have discussed the effects of high-altitude-induced changes in gut immunity particularly peyer's patches, NK cells and inflammatory cytokines, secretary immunoglobulins and gut microbiota. The published articles from PubMed and Google scholar from year 1975 to 2017 on high-altitude hypoxia and gut immunity are cited in this review.

Seven Passive 1-h Hypoxia Exposures Do Not Prevent AMS in Susceptible Individuals

PURPOSE

The present study evaluated the effects of a preacclimatization program comprising seven passive 1-h exposures to 4500-m normobaric hypoxia on the prevalence and severity of acute mountain sickness (AMS) during a subsequent exposure to real high altitude in persons susceptible to AMS.

METHODS

The project was designed as a randomized controlled trial including 32 healthy female and male participants with known susceptibility to AMS symptoms. After baseline measurements, participants were randomly assigned to the hypoxia or the control group to receive the preacclimatization program (seven passive 1-h exposures within 7 d to normobaric hypoxia or sham hypoxia). After completing preacclimatization, participants were transported (bus, cog railway) to real high altitude (3650 m, Mönchsjoch Hut, Switzerland) and stayed there for 45 h (two nights). Symptoms of AMS and physiological responses were determined repeatedly.

RESULTS

AMS incidence and severity did not significantly differ between groups during the high-altitude exposure. In total, 59% of the hypoxia and 67% of the control group suffered from AMS at one or more time points during the high-altitude exposure. Hypoxic and hypercapnic ventilatory responses were not affected by the preacclimatization program. Resting ventilation at high altitude tended to be higher (P = 0.06) in the hypoxia group compared with the control group. No significant between-group differences were detected for heart rate variability, arterial oxygen saturation, and hematological and ventilatory parameters during the high-altitude exposure.

CONCLUSION

Preacclimatization using seven passive 1-h exposures to normobaric hypoxia corresponding to 4500 m did not prevent AMS development during a subsequent high-altitude exposure in AMS-susceptible persons.

High altitude illness in pilgrims after rapid ascent to 4380 M

BACKGROUND

The goal of the study was to characterize high altitude illness in Nepali pilgrims.

METHODS

We kept standardized records at the Himalayan Rescue Association (HRA) Temporary Health Camp at Gosainkund Lake (4380 m) in the Nepal Himalaya during the annual Janai Purnima Festival in 2014. Records included rate of ascent and Lake Louise Score (LLS). We defined High Altitude Headache (HAH) as headache alone or LLS = 2. Acute Mountain Sickness (AMS) was LLS≥3. High Altitude Cerebral Edema (HACE) was AMS with ataxia or altered mental status.

RESULTS

An estimated 10,000 pilgrims ascended rapidly, most in 1-2 days, from Dhunche (1960 m) to Gosainkund Lake (4380 m). We saw 769 patients, of whom 86 had HAH. There were 226 patients with AMS, including 11 patients with HACE. We treated patients with HACE using dexamethasone and supplemental oxygen prior to rapid descent. Each patient with HACE descended carried by a porter. There were no fatalities due to HACE. There were no cases of High Altitude Pulmonary Edema (HAPE).

CONCLUSIONS

HAH and AMS were common in pilgrims ascending rapidly to 4380 m. There were 11 cases of HACE, treated with dexamethasone, supplemental oxygen and descent. There were no fatalities.

Infectious Diseases at High Altitude

Travel to elevations above 2,500 m is an increasingly common activity undertaken by a diverse population of individuals. These may be trekkers, climbers, miners in high-altitude sites in South America, and more recently, soldiers deployed for high-altitude duty in remote areas of the world. What is also being increasingly recognized is the plight of the millions of pilgrims, many with comorbidities, who annually ascend to high-altitude sacred areas. There are also 400 million people who reside permanently in high mountain ranges, which cover one-fifth of the Earth's surface. Many of these high-altitude areas are in developing countries, for example, the Himalayan range in South Asia. Although high-altitude areas may not harbor any specific infectious disease agents, it is important to know about the pathogens encountered in the mountains to be better able to help both the ill sojourner and the native high-altitude dweller. Often the same pathogens prevalent in the surrounding lowlands are found at high altitude, but various factors such as immunomodulation, hypoxia, poor physiological adaptation, and harsh environmental stressors at high altitude may enhance susceptibility to these pathogens. Against this background, various gastrointestinal, respiratory, dermatological, neurological, and other infections encountered at high altitude are discussed.

Extreme, expedition, and wilderness medicine

Extreme, expedition, and wilderness medicine are modern and rapidly evolving specialties that address the spirit of adventure and exploration. The relevance of and interest in these specialties are changing rapidly to match the underlying activities, which include global exploration, adventure travel, and military deployments. Extreme, expedition, and wilderness medicine share themes of providing best available medical care in the outdoors, especially in austere or remote settings. Early clinical and logistics decision making can often have important effects on subsequent outcomes. There are lessons to be learned from out-of-hospital care, military medicine, humanitarian medicine, and disaster medicine that can inform in-hospital medicine, and vice-versa. The future of extreme, expedition, and wilderness medicine will be defined by both recipients and practitioners, and empirical observations will be transformed by evidence-based practice.