. 2021 Mar 11;6:100103. doi: 10.1016/j.resplu.2021.100103

Table 3.

Expert recommendations to improve safety of snorkellers.

Theme	Expert recommendations
Data collection	• Implementation of a drowning fatality database in all countries
	• Use of a standardized case report structure in databases, ideally with drowning-specific components
	• Databases include data on both fatal and non-fatal snorkelling-related drownings
	• Snorkelling-related drownings be reported publicly on a regular basis as its own separate category

Risk factors	• Urgent implementation of educational strategies highlighting the physiological changes and physical challenges of snorkelling and higher risk of injury for certain health conditions
	• Refrain from the use of alcohol or drugs before or during snorkelling^a
	• Universal use of close-contact buddy system^b
	• Floatation aids be utilized by any first-time or inexperienced snorkellers
	• Refrain from hyperventilation before breath-hold diving^a

Recreational snorkellers	• Screen individuals using a medical questionnaire prior to participation in a snorkelling trip or rental of equipment and have standards regarding when to decline participation
	• Provide safety information and training to participants in their fluent language (e.g., by spoken, written, diagrammatic or electronic means)
	• Implement enhanced supervision strategies for those identified as moderate risk but participation still acceptable
	• Implement legislation/regulations by government, in regions where snorkelling is prevalent, that outline safety standards and set financial penalties for breaches
	• Mandate floatation aids for all trips and equipment rentals unless snorkellers demonstrate competency
	• Check rescue and resuscitation equipment and repair/replace as needed at regular intervals^a

Spearfishers	• For breath-holding dives, use the “one-up-one-down” system
	• Where possible, it would be beneficial for regular snorkellers to have basic aquatic rescue, CPR and first aid skills

Rescue and resuscitation	• Discuss with inexperienced and first-time recreational snorkellers how to act if in distress, and how to communicate with their buddy and company staff
	• Provide a lifeguarded area with adequate staff with suitable training in site supervision who are using their services or equipment
	• Train staff to recognize people in aquatic distress and safe response techniques^a
	• Assure staff is proficient in CPR and its variations in circumstances such as drowning^a
	• Have a contingency plan for hospital evacuation in case of an emergency to allow for rapid post-resuscitation carea

CPR - cardiopulmonary resuscitation.

Expert opinion where evidence from the systematic review was inconclusive.

Budd Buddy system - safety system where two or more individuals perform an activity together, so they can monitor and quickly recognize if the other is in distress.