Enteritis during mountaineering above the snow line – how to practice prophylaxis?

1. Enteritis during mountaineering above the snow line – how to practice prophylaxis? (preliminary results) Robert Adamek (1), Beate Kraft (2), Michael Pietsch (2) and Hans-Volkhart Ulmer (1)1) Institute of sports science, Johannes Gutenberg-Universität, Mainz, Germany2) Department of hygiene, Universitätsklinikum Mainz 4th international Symposium: “High altitude influence on human performance: science and praxis” – Bohinjska Bela (Slovenia) Sept. 8-13, 2009 ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

2. Introduction, aim, methods, results, discussion, final conclusions INTRODUCTION ZOCHOLL (2008) described, that diarrhea by infection with faecal bacteria under difficult hygienic conditions above the snow-line is a typical problem in mountaineering Faeces contain many pathogenic and non pathogenic microorganisms, –> enteritis ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

3. Introduction, aim, methods, results, discussion, final conclusions Introduction Enteritis –>diarrhea: Loss of water and electrolytes, negative for physical and psychic performance capacity ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009 3

4. Introduction,aim, methods, results, discussion, final conclusions Mountaineering in high altitudes: No WC, only „SC“ („snow closet“) with an alternative: Clean mountain can ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

5. Introduction,aim, methods, results, discussion, final conclusions „SC“ (snow closet) using the „clean mountain can“ in the Mt McKinley region Foto: M. Tannheimer Hier Foto ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

6. Introduction,aim, methods, results, discussion, final conclusions „Clean mountain can“: Rigorous reglementation of use with supervision after return Only in the Mt McKinley-region (Alaska) ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

7. Introduction,aim, methods, results, discussion, final conclusions Process of infection by faeces during mountaineering in high altitudes above the snow line: 1) Defaecation only possible in snow (better in the clean mountain can) 2) Snow used for melting water 3) Melting water: Potential of infection with pathogenic microorganisms, if not disinfected, risk of diarrhea ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

8. Introduction,aim, methods, results, discussion, final conclusions To prevent infection with pathogenic microorganisms from faeces, usually snow water is boiled or disinfected chemically or physically (filter) as prophylaxis against enteritis ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

9. Introduction,aim, methods, results, discussion, final conclusions For boiling gas is used – problem of additional weight for transportation Chemical disinfection – less weight for transportation, but needs effecting time Physical disinfektion – also weight of filter-systems for transportation ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

10. Introduction,aim, methods, results, discussion, final conclusions PIETSCH (2008) – specialist of hygiene – argued, however: The risk of infection by the own hands could be more important than the risk of infection by melted snow Therefore disinfection of the hands would be very important ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

11. Introduction,aim, methods, results, discussion, final conclusions • AIMS • Check • – melted snow and • – gloves • Basal consideration: • Coliform bacteria etc. are an indicator for faecal contamination and so for the risk of enteritis • 2) Check practicability of hand disinfection in high altitude ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

12. Introduction, aim, methods, results, discussion, final conclusions • METHODS • Bacteriological check for faecal bacteria (usual bacteriological procedure similar as for drinking water) of • melted snow from the Muztagh Ata region (Kunlun-mountains – brought by B. HONKA): 4 steps between 4400 and 6800 m, 25 snow specimens, each August 2008 ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

13. Introduction,aim, methods, results, discussion, final conclusions Bacteriological check 2. of melted snow for comparison: 3 specimens from Kleinwalsertal (touristic region with many restaurants, cottages etc, 1500 m), Jan. 2009, snow ca. 1 week old 3. of a pair of gloves, used 14 days before during mountaineering ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

14. Introduction, aim, methods, results, discussion, final conclusions Test of typical hand-disinfection with alcohol tampons during mountaineering above the snow line (Kleinwalsertal, Jan 2009, environmental temperature ca. – 10 until 0 °C, ca. 2000 m, no storm) ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

15. Introduction, aim, methods, results, discussion, final conclusions RESULTS (preliminary) In 21 of 100 Kunlun specimens coliform bac- teria or escherischia coli were found, the higher, the lesser: Table: Frequency of coliform bacteria or e. coli ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

16. Introduction, aim, methods, results, discussion, final conclusions In the other 3 specimens from the Kleinwalsertal (touristic region): No faecal bacteria ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

17. Introduction, aim, methods, results, discussion, final conclusions – Also in all fingers of one pair of gloves faecal bacteria (enterococcus faecalis) were found – The use of typical alcohol tampons under mountaineering conditions was very difficult or not practicable, due to cold and wind, e.g. coordination problems by cold fingers and additional cooling effect of the alcohol. Needed time: ca. 1 – 1½ min ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

18. Introduction, aim, methods, results, discussion, final conclusions DISCUSSION Methodical mistake in taking off the snow probes etc? – The expedition leader HONKA was precisely instructed about the procedure (also the coauthor Adamek) , – they used professional equipment for analyses of drinking-water – the bacteriolical analyses were performed in a professional lab So we are shure: no methodical mistakes ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

19. Introduction, aim, methods, results, discussion, final conclusions Incidence of other pathogenic microorganism? We only looked on coliform bacteria, e. scherischia coli and enterococcus faecalis as indicator for faecal contamination ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

20. Introduction, aim, methods, results, discussion, final conclusions Check ofmelted snow: The exemplary results show already, that a relevant part of the melted snow (Kunlun) was contaminated with faecal bacteria The amount/ml is irrelevant: Coliform bacteria indicate faecal contamination and so the risk of enteritis To prevent infection (enteritis) by melted water it should be disinfected further on ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

21. Introduction, aim, methods, results, discussion, final conclusions In the touristic region Kleinwalsertal with many people and many WC in restaurants, cottages etc. the contamination of snow with faeces would be a rarity Even, if we had only 3 specimens, this exemplary finding underlines the importance of defaecation during mountaineering in high altitudes ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

22. Introduction, aim, methods, results, discussion, final conclusions In 6800 m water boils at 77 °C. Sufficient? Boiling with bubbles at least 1 min is sufficient until 8.900 m Küpper et al., 2008), but needs lot of gas Alternative for high altitudes: Disinfection of melted snow : chemically or physically with micropore filters ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

23. Introduction, aim, methods, results, discussion, final conclusions Check of one pair of gloves: Infection by gloves – until today not discussed: A possible relevant problem, too, even if only one pair of gloves could be tested In contrast to coli-bacteria enterococus faecalis (e. f.) can survive in dry environment e. f. not effects enteritis, e. f. low pathogenetic potential, but e. f. indicates also faecal contamination inside of the gloves with other potential pathogenic mikroorganisms ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

24. Introduction, aim, methods, results, discussion, final conclusions If the gloves are contaminated, the hands are contaminated, too. But which consequence? ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

25. Introduction, aim, methods, results, discussion, final conclusions Hand-disinfection with alcohol tampons: Even under mild climatic conditions for mountainee-ring (ca. 2000 m, environmental temperature ca. – 10 until 0 °C, no storm) classical hand disinfektion was hardly or not practicable Recommendation: Perhaps it could be possible after special training inside of a tent, at least after every defaecation ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

26. Introduction, aim, methods, results, discussion, final conclusions Prevention of infection by own hands: Avoid infection of the food with the own hands by handling all food carefully. ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

27. Introduction, aim, methods, results, discussion, final conclusions FINAL CONCLUSIONS Process of infection by faeces during mountaineering in high altitudes above the snow line: Defaecation only possible in snow, (mountain clean can: not realistic world wide) Snow is used for melted water Melted water: risk of infection, if not disinfected Own hands: Also Pay attention to risk of infection by faecal microorganisms ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

28. Introduction, aim, methods, results, discussion, final conclusions But all these recommendations need time, and so prevention of enteritis by melted snow is a question of risk balance. The higher the used snow, the lesser the risk The knowledge about the ways of infection may help for the risk balance ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

29. Introduction, aim, methods, results, discussion, final conclusions • Literature • Küpper, T.E.A.H., Schöffl, V. and Milledge, J. S.:Water disinfection in the mountains – state of the art recommendation paper of the Union Internationale des Associations d'Alpinisme Medical Commission • http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7578-4V4KCB5-1&_user=10&_coverDate=01%2F31%2F2009&_rdoc=1&_fmt=high&_orig=browse&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=f81de86e6e24ab91f24efa0605bbfd00 • 2) Backer, A: Water disinfection for international and wilderness travelers. Clinical infectious diseases, 34, Issue 3, 2002, 355-364. • http://www.scopus.com/record/display.url?eid=2-s2.0-0036467140&view=basic&origin=inward&txGid=oehk2myPywygC80wxWmgjME%3a2#corrAuthorFooter ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009 29

30. Acknowledgment • The authors are very obliged to • Mr. B. Honka (Deutscher Alpenverein, Section Mainz) for collecting snow-probes in the Kunlun-region • and • to Mr. O. Schneider (Deutscher Alpenverein, Section Wiesbaden) for his support in the Kleinwalsertal. ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009

31. The end ___________________________________________________________ Adamek et al.: Enteritis above the snow line. 4th Symposium: Altitude & praxis, 2009