Gaps are considered by reference to the categories listed in Figure 1 in A.3.1
A.1.5.1 At home
Patterns of ill-health in home country
For some countries there is good information on the causes of illness, injury and death in the local population. Unfortunately, this is lacking or not readily available for many of the major crewing countries. This means that comparisons cannot be made between seafarers and comparable groups in other land based populations in the seafarer’s home country.
PEME fitness decisions at the start of a seafarer’s career and periodically
This should be readily accessible information. There are a number of barriers to analysis, except at the level of individual clinics. Very few maritime authorities or health ministries collect, analyse and publish the findings from statutory PEMEs. PEMEs specified by employers and insurers often collect much more detailed data, but this is usually regarded as proprietary information and analysed for internal use only. It is often also collected and disseminated with little regard to the requirements of medical confidentiality (see chapter 4.8 on PEMEs and 2.9 on ethics)
The at-risk population of seafarers
Military seafarers are state employees from a single country and numbers, jobs and demographic information are available. By contrast, merchant seafarers and fishing industry employees are often on casual or other non-standard contracts and frequently come from a range of countries. Few employers hold detailed records and crews are often supplied by agencies. It is difficult to obtain reliable information on seafarer numbers, jobs and demography except at the level of a single ship. This makes the conduct of rigorous studies of the incidence or prevalence of disease or injury expensive and difficult to conduct.
Health information on cadets
Cadets in training at maritime academies provide a ‘captive population’ to study. Investigations of determinants of physical and mental health have been undertaken in this setting. It has the potential to provide more information, at least for officers to be.
A.1.5.2 On board
Medical log book entries at sea
Most incidents requiring health intervention at sea are recorded in medical logs and the more serious events are recorded in the main ship’s logbook. However there have been few studies using this information. There is scope for a wide range of case series and comparative frequency investigations, but there are limitations on formal prevalence or incidence studies because of a lack of information on the overall at-risk seafarer populations. An exception to this is in the cruise industry, where valid single ship studies are feasible because of the large numbers of crew.
A large number of studies have been published on the pattern of contacts with Telemedical Advisory Services. The findings are not very consistent as different national and commercial services have different customs or criteria that determine the pattern of contacts. Communications from ships are not always coherent because of language and other issues. A major problem is the lack of follow up data. This may be because ships that seek advice do not contact the service to provide information on outcomes or it may be because the ill or injured seafarer is referred to a clinic or hospital and there are barriers of medical confidentiality that stop information on outcomes being passed back to ships or to services.
Medical referrals in port
Seafarers with conditions that do not require immediate attention are often referred for investigation or treatment during the ship’s next port call. Following attendance at a hospital or clinic, for investigation or treatment, the seafarer may return to the ship, usually with some form of medical report and treatment plan, provided care can be completed speedily and before the ship leaves the port. Alternatiely, there may be a decision to provide further treatment and then either arrange for the seafarer to fly to re-join the ship at a another port or to repatriate them to their home country. Information from port providers and from ships about such cases has not been analysed. Shipping agents and insurers usually handle repatriations and only a limited amount of information on these cases has been analysed, and then it is often not published.
These normally have TMAS support and are recorded in studies of TMAS referrals.
Self-reports of ill health on leave
There is limited information on ill health during leave periods although some may be found in the few available investigations of mid-career PEMEs. Serious illness may well mean that seafaring careers end. Data on this will only be available if the seafarer has come for a subsequent PEME and been rejected, otherwise the seafarer and their health data are lost to follow up.
A.1.5.4 After employment
Health related reasons for leaving seafaring population
As above, information is available if a seafarer is found to be unfit at a PEME and this is recorded. It is also, in principle, available for deaths and if health grounds are the reason for the formal termination of a seafarer’s employment.
Rehabilitation and return to work
Little information is available in this area. A small number of studies in crewing countries provide some information. In countries with developed and accessible systems of social security, these records can provide such information. However, few studies have been undertaken.
Population of ex seafarers
Details are rarely available, but they may sometimes be found in national statistics comparing death or illness in different occupational groups. Investigations that are more detailed have been reported in a few countries, where welfare organisations provide whole life support and need to assess future demands.
Causes of illness and death in ex seafarers
Data on deaths may be available from national statistics, while pension funds and social security records that have good occupational information can also provide this information. It is also sometimes possible to study particular diseases using the case-control comparison methods summarised in Ch 2.4 on the models for a knowledge base.