E) Health risks to seafarers

E.11 Dentistry and Oral Health

Details

SUE STANNARD, TIM CARTER

Acute and Long Term Harm

Dental problems affect more than 3.5 billion people around the world[1]. They are highly prevalent in seafarers and account for a large number of consultations with Telemedical Assistance Services and in foreign ports[2] [3]. The results of a 2016 survey also demonstrated the poor oral hygiene of seafarers[4] and looked at the possible reasons for this including a higher than average rate of smoking and poor diet.

Acute problems include dental caries and periodontal disease, whilst lost fillings and lost or broken teeth may also occur on board. Seafarers may present with tooth ache, bleeding from the gums or bad breath.

Poor oral hygiene has also been linked to other health issues including cardiovascular disease[5], respiratory disease, rheumatoid arthritis[6], poor control of diabetes and erectile dysfunction[7].

Risk assessment

The mouth should be examined as part of the examination at PEME, and similar principles applied to oral health as any other health issue. The ‘Guidelines on the Medical Examination of Seafarers’ advise that seafarers should only receive an unrestricted certificate if the ‘teeth and gums appear to be good…’Any seafarer noted to have any dental or oral health problem should be referred to the appropriate health care professional for an assessment and treatment before are given a medical certificate and join a ship[8].

Risk management

Appropriate assessment and completion of any urgent treatment before joining a ship is essential. Ideally seafarers should arrange to have a dental check and any required remedial measures while on leave.The management of dental problems on board is limited and care in foreign ports can be expensive and of varying quality. Seafarers will often end up with a tooth extraction that may have been unnecessary had the problem been managed before sea service. Those with dentures, bridges or other complex dental work should seek advice in advance on what to do should repair be needed.

Crewmembers should be advised to ensure that they have sufficient supplies of toothpaste, brushes, dental floss and other oral hygiene products with them to cover the duration of their time at sea.

In addition seafarers should have access to appropriate health promotion materials on oral hygiene at home and on board the ship. The 2016 survey noted that only 40% of those questioned brushed their teeth twice a day. Seafarers should also have access to a healthy diet and be encouraged to stop smoking and moderate alcohol intake (see xx).

 

[1] https://www.who.int/news-room/fact-sheets/detail/oral-health

[2] Radio Medical Danmark. Annual Report 2010. Esbjerg, 2011.

[3] Tomaszunas S. The work of ship’s doctors of Polish Ocean Lines. Bull Inst Marit Trop Med Gdynia 1985; 36: 51–58

[4] Syed Sarosh Mahdi, Fabio Sibilio, Francesco Amenta. Dental hygiene habits and oral health status of seafarers. Int Marit Health 2016; 67, 1: 9–13

[5] Batty GD, Jung KJ, Mok Y, Lee SJ, Back JH, Lee S, Jee SH. Oral health and later coronary heart disease: Cohort study of one million people. Eur J Prev Cardiol. 2018 Apr;25(6):598-605.

[6] Kriauciunas A, Gleiznys A, Gleiznys D, Janužis G. The Influence of Porphyromonas Gingivalis Bacterium Causing Periodontal Disease on the Pathogenesis of Rheumatoid Arthritis: Systematic Review of Literature. Cureus. 2019 May 28;11(5)

[7] Vijendra P. Singh, Sunil K. Nettemu, Sowmya Nettem, Rajesh Hosadurga, Sangeeta U. Nayak. Oral Health and Erectile Dysfunction. J Hum Reprod Sci. 2017 Jul-Sep; 10(3): 162–166.

[8] https://www.ilo.org/sector/Resources/codes-of-practice-and-guidelines/WCMS_174794/lang--en/index.htm. Accessed January 30th 2022

E.12 Musculoskeletal risks

Details

TIM CARTER

Acute and Long Term harm

There are many tasks at sea that involve physical exertion, sometimes of large muscle groups but often of smaller groups undertaking repetitive tasks or maintaining awkward postures. A single severe episode of overloading can lead to an injury, commonly a sprain or strain. These events are best considered as injuries and safety management principles apply to their prevention. 

However very often pain, swelling or other symptoms develop after repeated demanding actions have been performed and this is often somewhat delayed. Such problems, particularly those affecting the back and upper limbs, are among the commonest causes of temporary disabling illness among seafarers and they may sometimes lead to long-term limitations that can be career threatening.  It can be difficult to distinguish the importance of work as a contributor to such problems, as musculo-skeletal pain is common and is often associated with aging or with other medical conditions. Physique and physical strength may also play a part in determining whether an individual presents with symptoms.

Risk assessment

Similar principles apply to these as for other health risks. However there are few reliable, quantified criteria that can be used to determine risk and preventative action is often initiated because cases have arisen in the past, either when particular tasks are performed or in other situations where similar demands are placed on the musculoskeletal system. The instability and slipperiness of decks and working surfaces on board is an additional risk factor at sea.

Common examples from seafaring include:

  • Handling mooring cables and fuel lines, especially dragging them – back and limb pain
  • Manual handling of food and technical stores, especially when stowing them in hard to access places – back pain
  • Entry and movement through narrow confined spaces – variable joints and muscle groups
  • Serving at table in the cruise industry – upper limb pain
  • Moving passenger luggage in the cruise industry – back and joint pain
  • Deck work in fish catching – back and upper limb pain, sometimes leading to termination of working life
  • Fish processing on board – upper limb pain from gutting and filleting. Back pain from stowing frozen fish blocks                                    

Risk management

There is little evidence that crew selection can reduce musculoskeletal risks, except in those with clear pre-existing disabilities. Reductions in work demands and recognition that these should be further reduced in adverse sea states contribute. Where possible, the use of mechanical aids to limit physical work demands should be adopted. Ergonomic assessment of particular tasks that are suspected contributors to pain will often identify practical solutions.

Case management has an important part to play in preventing the development of chronic pain and limitation of movement. Complete rest and avoidance of all manual tasks rarely helps. Acceptance that work is likely to have contributed to the problem is important as denial often leads to a confrontational situation that delays recovery. Active pain management, with non-sedating analgesics, should be started. As soon as recovery has begun a return to some duties but with reduced workload or avoidance of the heaviest tasks usually speeds full rehabilitation. The onboard medical guide may give advice on this, and TMAS or other clinical help should be obtained if there are severe or continuing symptoms.

E.13 Alcohol and drug abuse

Details

SUE STANNARD, TIM CARTER

Acute and Long Term Harm

Seafarers may use alcohol and drugs that impair their ability to work and these may also have serious acute and long term effects on their health. They may present to medical staff ashore or to colleagues on board whilst under the influence of such substances or suffering withdrawal from them. Withdrawal symptoms are usually seen when a seafarer first joins a ship after a period of leave when they have used a substance regularly and frequently.

The acute and long term health effects of ingestion depend upon the substance that is taken, as do the effects of withdrawal. Of particular concern on board a ship is delirium tremens in the withdrawal from alcohol.

The use of tobacco may not have acute harmful effects but will have negative health effects in the long term.

Abuse of a substance or substance use disorder is defined by the American Psychiatric Association[1] as ‘a complex condition in which there is uncontrolled use of a substance despite harmful consequences.’ This may result in a change of behaviour that is dangerous on board a ship, including issues with judgement, decision making, learning, memory, and behavioral control.

Drugs that are abused include:

  • Alcohol
  • Marijuana
  • Hallucinogens such as LSD
  • Inhalants such as paint thinner or glue
  • Opioid pain killers such as codeine and heroin
  • Sedatives and anxiolytics such as diazepam
  • Stimulants such as cocaine and methamphetamine
  • Tobacco

In addition to the negative health effects, use of a substance may also lead to legal proceedings and loss of employment, for example if the company has a zero tolerance policy for alcohol and drugs and/or an accident occurs at sea whilst the seafarer is under the influence of a substance.

Risk assessment

The use of alcohol, drugs and tobacco should be identified on the self-declaration form used in a pre-employment medical assessment, such as that included in the ‘Guidelines for the Medical Examination of Seafarers.’[2] Additional questions may be asked as part of the history taken by the medical professional and certain behaviours indicating abuse of a substance may be identified.

Other medical conditions, both physical and psychological that may be associated with the use of certain substances should also be identified and an individualized risk assessment carried out.

Testing for the presence of alcohol and drugs during a medical examination does not form part of the international Guidelines[3]. Where it is performed, as a requirement of national authorities or employers, the procedures used should follow national, if available, or international good practice guidelines. These should provide adequate procedural and ethical safeguards for the seafarer. Consideration should be given to the Guiding Principles on Drug and Alcohol Testing Procedures for Worldwide Application in the Maritime Industry, adopted by the Joint ILO–WHO Committee on the Health of Seafarers (Geneva, 10 –14 May 1993), and any subsequent revisions.

Risk management

Appropriate risk assessment at PEME should identify those seafarers with possible alcohol or drug abuse problems. Such seafarers require careful, multi-disciplinary management to be given a medical certificate to work at sea.

All seafarers should be encouraged to stop smoking, limit their alcohol intake, and avoid the use of illicit drugs or the incorrect use of prescription drugs.

Action to stop the use of tobacco, alcohol or drugs should take place when the seafarer is at home with access to appropriate medication and support.

[1] https://www.psychiatry.org/patients-families/addiction/what-is-addiction. Accessed January 27th 2022

[2]https://www.ilo.org/sector/Resources/codes-of-practice-and-guidelines/WCMS_174794/lang--en/index.htm Accessed 27 January 2022

[3] https://www.ilo.org/sector/Resources/codes-of-practice-and-guidelines/WCMS_174794/lang--en/index.htm Accessed 27 January 2022