- Email: [email protected]
Seafarers and infectious disease – Directions for future research
Travel Medicine and Infectious Disease (2013) 11, 259e260
Available online at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/tmid
CORRESPONDENCE
Seafarers and infectious disease e Directions for future research For many centuries seafarers, sea passengers and cargoes, were the major route by which infections such as smallpox, plague, cholera and anthrax were carried around the world. It was in the major port cities, such as Hamburg, London, Liverpool and the Eastern seaboard of the USA that the first hospitals and institutes for investigation of tropical diseases were established and these were always closely linked to the infectious diseases found in seamen. The importance of sea transport as a route of transmission of infection has now diminished, but seafarers themselves remain at risk from a wide range of infectious diseases and have a pattern of work, with worldwide sourcing of crews, periods at sea remote from medical care, port visits and leave periods in home countries that leads to a unique set of challenges for the prevention, diagnosis and treatment of infectious diseases. The International Maritime Health Association convened an expert workshop in Singapore in late 2009 to review the challenges posed by infectious diseases to seafarers in the twenty-first century. A series of articles from the workshop have recently been published.1 One of the main undercurrents in all the workshop discussions was the difficulty in obtaining a reliable overview of the scale and distribution of infectious diseases in seafarers. This is a consequence of the range of places where ill seafarers make contact with healthcare facilities. Consultations with telemedical services can provide one perspective.2 These show that a large proportion of the requests for advice are for infections, with skin, gastrointestinal and respiratory predominating while exotic infections are either rare or rarely recognised. Port clinics provide another source, but while in principle port health authorities could do the same only very few countries have good port epidemiological intelligence systems for anything beyond the highly infectious diseases that pose a threat to the onshore population.3 The cruise industry is exceptional as detailed records are held and the quality of diagnosis is higher because of the presence of medical staff on board. Cruise industry studies on a range on infections including gastro-intestinal, influenza and varicella provide good data, but these findings are not readily extrapolated to other
1477-8939/$ - see front matter ª 2013 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.tmaid.2013.03.012
types of vessel.4 Analogies, for instance with patterns of infection on fixed offshore structures, may provide information that is more generally relevant to seafarers.5 Some ‘traditional’ infections are still important. Tuberculosis, even in developed countries, is an avoidable risk at sea even if in most cases infection is likely to be contracted during leave periods.6 Malaria poses particular problems, with the best prophylactic approach hard to determine, as crews often do not go ashore during modern rapid port turnarounds.7 Port areas themselves can, however, be the locus for the breeding of mosquitoes and transmission. What is not in doubt is the serious risk if falciparum malaria develops in a seafarer in mid passage, where no onshore medical care can be accessed. Sexual and body fluid transmitted infections continue to occur, with HIV and non-A hepatitis now prominent.8 The VD stigma remains and large -scale educational campaigns to minimise both the impact of HIV in seafarers and to change attitudes to it are now in progress.9 The management of infectious disease at sea has always been a problem, with issues such as isolation of cases and the adequacy of aids to diagnosis and treatment by officers with limited medical first aid training coming to the fore. There are limitations to the official information on treatment that is currently available and the training of officers for very rare events that have a big overlay of fear and uncertainty is inherently a problem.10 Management difficulties can be compounded, even in the cruise industry where medical expertise is to hand, by unhelpful responses from port health authorities.4 The workshop concluded by identifying a number of key themes for future action: Each type and route of infection needs to be considered separately, there are few over-arching principles that can be applied. Well-defined and fully validated protocols for management of infections in the maritime sector are urgently required. These need to be linked with greatly improved medical guides for use at sea. Methods of diagnosis and treatment at sea will differ from those ashore. Treatment on suspicion with wide spectrum agents is likely to be more expedient than attempting full diagnosis and tailored therapy.11
260 Data collection on infectious disease in seafarers will inevitably need to be based on multiple less than perfect sources. Some are capable of considerable development, for instance a ‘sentinel’ reporting system from the onshore doctors of first contact could bring big benefits. There are important causes of morbidity from infection that need more detailed investigation. These include wound infections and also infections in the fishing sector, where there are a number of unique pathogens. Vigilance needs to be maintained because shipping still has the potential to be an important means of transferring infections from place to place.
References 1. Int Marit Health 2011;62(3):157e99. 62(4): 247e265. 2. Westlund K. Infections on board ship e analysis of 1290 advice calls to the Radio Medical (RM) doctor in Sweden: results from 1997, 2002, 2007, 2009. Int Marit Health 2011; 62:191e5. 3. Verbist R. Respiratory tract infections, in Carter T. Summary of workshop proceedings. Int Marit Health 2011;62:169. 4. Bunyan K. Pandemic planning in the shipping industry e lessons learnt from the 2009 influenza pandemic. Int Marit Health 2011;62:196e9; Bunyan K. Varicella, in Carter T. Summary of workshop proceedings. Int Marit Health 2011;62:169; Acevedo F, Diskin A, Dahl E. Varicella at sea: a two year study on cruise ships. Int Marit Health 2011;62:254e61.
Correspondence 5. Ulven A. The challenge and prevention of epidemics. Experience from offshore petroleum installations and its extrapolation to ships. Int Marit Health 2011;62:262e5. 6. Miller K. Tuberculosis, in Carter T. Summary of workshop proceedings. Int Marit Health 2011;62:169e70; Hansen HL, Henrik Andersen P, Lillebaek T. Routes of M. tuberculosis transmission among merchant seafarers. Scand J Infect Dis 2006;38:882e7. 7. Idnani C, Kotlawski A. The morbidity of malaria: a strategy for seafarer safety. Int Marit Health 2011;62:247e53. 8. Chan R. Sexually transmitted infections, in Carter T. Summary of workshop proceedings. Int Marit Health 2011;62:166; Lim Seng Gee. Viral Hepatitis, in Carter T. Summary of workshop proceedings. Int Marit Health 2011;62:165e6. 9. Nikolic N. AIDS prophylaxis e achievements due to appropriate strategies. Int Marit Health 2011;62:176e82. 10. Horneland AM. Infectious diseases and medical guides for seafarers. Int Marit Health 2011;62:182e5. 11. Dahl E. Wound infections on board ship e prevention, pathogens and treatment. Int Marit Health 2011;62:186e90.
Tim Carter* Norwegian Centre for Maritime Medicine, University of Bergen, UK Maritime and Coastguard Agency, London SW1P 4DR, UK *Tel.: þ44 20 7944 2031; fax: þ44 020 7944 2029. E-mail addresses: [email protected], [email protected]
8 March 2013
Available online at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/tmid
CORRESPONDENCE
Seafarers and infectious disease e Directions for future research For many centuries seafarers, sea passengers and cargoes, were the major route by which infections such as smallpox, plague, cholera and anthrax were carried around the world. It was in the major port cities, such as Hamburg, London, Liverpool and the Eastern seaboard of the USA that the first hospitals and institutes for investigation of tropical diseases were established and these were always closely linked to the infectious diseases found in seamen. The importance of sea transport as a route of transmission of infection has now diminished, but seafarers themselves remain at risk from a wide range of infectious diseases and have a pattern of work, with worldwide sourcing of crews, periods at sea remote from medical care, port visits and leave periods in home countries that leads to a unique set of challenges for the prevention, diagnosis and treatment of infectious diseases. The International Maritime Health Association convened an expert workshop in Singapore in late 2009 to review the challenges posed by infectious diseases to seafarers in the twenty-first century. A series of articles from the workshop have recently been published.1 One of the main undercurrents in all the workshop discussions was the difficulty in obtaining a reliable overview of the scale and distribution of infectious diseases in seafarers. This is a consequence of the range of places where ill seafarers make contact with healthcare facilities. Consultations with telemedical services can provide one perspective.2 These show that a large proportion of the requests for advice are for infections, with skin, gastrointestinal and respiratory predominating while exotic infections are either rare or rarely recognised. Port clinics provide another source, but while in principle port health authorities could do the same only very few countries have good port epidemiological intelligence systems for anything beyond the highly infectious diseases that pose a threat to the onshore population.3 The cruise industry is exceptional as detailed records are held and the quality of diagnosis is higher because of the presence of medical staff on board. Cruise industry studies on a range on infections including gastro-intestinal, influenza and varicella provide good data, but these findings are not readily extrapolated to other
1477-8939/$ - see front matter ª 2013 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.tmaid.2013.03.012
types of vessel.4 Analogies, for instance with patterns of infection on fixed offshore structures, may provide information that is more generally relevant to seafarers.5 Some ‘traditional’ infections are still important. Tuberculosis, even in developed countries, is an avoidable risk at sea even if in most cases infection is likely to be contracted during leave periods.6 Malaria poses particular problems, with the best prophylactic approach hard to determine, as crews often do not go ashore during modern rapid port turnarounds.7 Port areas themselves can, however, be the locus for the breeding of mosquitoes and transmission. What is not in doubt is the serious risk if falciparum malaria develops in a seafarer in mid passage, where no onshore medical care can be accessed. Sexual and body fluid transmitted infections continue to occur, with HIV and non-A hepatitis now prominent.8 The VD stigma remains and large -scale educational campaigns to minimise both the impact of HIV in seafarers and to change attitudes to it are now in progress.9 The management of infectious disease at sea has always been a problem, with issues such as isolation of cases and the adequacy of aids to diagnosis and treatment by officers with limited medical first aid training coming to the fore. There are limitations to the official information on treatment that is currently available and the training of officers for very rare events that have a big overlay of fear and uncertainty is inherently a problem.10 Management difficulties can be compounded, even in the cruise industry where medical expertise is to hand, by unhelpful responses from port health authorities.4 The workshop concluded by identifying a number of key themes for future action: Each type and route of infection needs to be considered separately, there are few over-arching principles that can be applied. Well-defined and fully validated protocols for management of infections in the maritime sector are urgently required. These need to be linked with greatly improved medical guides for use at sea. Methods of diagnosis and treatment at sea will differ from those ashore. Treatment on suspicion with wide spectrum agents is likely to be more expedient than attempting full diagnosis and tailored therapy.11
260 Data collection on infectious disease in seafarers will inevitably need to be based on multiple less than perfect sources. Some are capable of considerable development, for instance a ‘sentinel’ reporting system from the onshore doctors of first contact could bring big benefits. There are important causes of morbidity from infection that need more detailed investigation. These include wound infections and also infections in the fishing sector, where there are a number of unique pathogens. Vigilance needs to be maintained because shipping still has the potential to be an important means of transferring infections from place to place.
References 1. Int Marit Health 2011;62(3):157e99. 62(4): 247e265. 2. Westlund K. Infections on board ship e analysis of 1290 advice calls to the Radio Medical (RM) doctor in Sweden: results from 1997, 2002, 2007, 2009. Int Marit Health 2011; 62:191e5. 3. Verbist R. Respiratory tract infections, in Carter T. Summary of workshop proceedings. Int Marit Health 2011;62:169. 4. Bunyan K. Pandemic planning in the shipping industry e lessons learnt from the 2009 influenza pandemic. Int Marit Health 2011;62:196e9; Bunyan K. Varicella, in Carter T. Summary of workshop proceedings. Int Marit Health 2011;62:169; Acevedo F, Diskin A, Dahl E. Varicella at sea: a two year study on cruise ships. Int Marit Health 2011;62:254e61.
Correspondence 5. Ulven A. The challenge and prevention of epidemics. Experience from offshore petroleum installations and its extrapolation to ships. Int Marit Health 2011;62:262e5. 6. Miller K. Tuberculosis, in Carter T. Summary of workshop proceedings. Int Marit Health 2011;62:169e70; Hansen HL, Henrik Andersen P, Lillebaek T. Routes of M. tuberculosis transmission among merchant seafarers. Scand J Infect Dis 2006;38:882e7. 7. Idnani C, Kotlawski A. The morbidity of malaria: a strategy for seafarer safety. Int Marit Health 2011;62:247e53. 8. Chan R. Sexually transmitted infections, in Carter T. Summary of workshop proceedings. Int Marit Health 2011;62:166; Lim Seng Gee. Viral Hepatitis, in Carter T. Summary of workshop proceedings. Int Marit Health 2011;62:165e6. 9. Nikolic N. AIDS prophylaxis e achievements due to appropriate strategies. Int Marit Health 2011;62:176e82. 10. Horneland AM. Infectious diseases and medical guides for seafarers. Int Marit Health 2011;62:182e5. 11. Dahl E. Wound infections on board ship e prevention, pathogens and treatment. Int Marit Health 2011;62:186e90.
Tim Carter* Norwegian Centre for Maritime Medicine, University of Bergen, UK Maritime and Coastguard Agency, London SW1P 4DR, UK *Tel.: þ44 20 7944 2031; fax: þ44 020 7944 2029. E-mail addresses: [email protected], [email protected]
8 March 2013