G.3.1 Skin infection and infestations
Wounds are common in seafarers and they can easily become infected in the marine environment and present as impetigo, carbuncles, furuncles, cellulitis, otitis externa and skin abscesses. Dahl emphasizes that most wounds in seafarers must be considered contaminated, with antibiotic treatment started immediately in hand and puncture wounds and if cellulitis occurs. Pre-sea tetanus immunization is essential (1).
G.3.2 Methicillin-resistant staphylococcus aureus
The occurrence of methicillin-resistant Staphylococcus aureus (MRSA) is a recognized cause of nosocomial infection related to the use of antibiotics and poor hygiene practices. Clinical infection is associated with increased morbidity and mortality. Lately, the infection was reported as the cause of community acquired skin infections in individuals without established risk factors. The US Centers for Disease Control name the five C´s of MRSA transmission as follows: crowding, frequent skin-to-skin contact, compromised skin integrity, contaminated items and surfaces and lack of cleanliness (2).
As ashore, MRSA is an emerging medical challenge on ships:
Outbreaks of community acquired MRSA are reported from day-care centres, military quarters, sport-teams and from ships. La Mar et al describe skin infections in two Navy soldiers; 125 mates from the same living quarters on board were examined with nasal swabs, of which 6.4% were asymptomatic MRSA carriers (3).
Lucas et al. performed a chart review on all consultations to the telemedical advice service at George Washington University in the United States of America from the years 2002 to 2006 (4). Their analysis showed that 36% of skin infections in the year 2002 and 74% of skin infections in the year 2006 were clinically suspicious for infection with methicillin-resistant Staphylococcus aureus. They conclude that the number of skin infections reported to their service has increased during the study period and that the proportion of cases with features common to MRSA infection had doubled. No studies are available on the prevalence of the infection and/or colonization in patients and staff of ship hospitals in passenger ships.
The relevance of global travel and transport as vectors of Methicillin-resistant Staphylococcus aureus strains has not been studied so far. In 1993 a tourist returning from travel and medical care in India introduced the resistant strain into British Columbia, Canada which spread to several hospitals and caused 12 cases of disease and 14 colonisations (5). MRSA prevalence in resource-limited countries in Asia and Africa and in the seafarer´s population is ill-defined.
The current evidence suggests that in relapsing or extensive skin infections in seafarers’ methicillin resistant staphylococcus aureus must be considered as a causative agent.
Microbiological resistance testing from wound material should be done whenever possible. In relapsing or extensive infections broad spectrum antibiotics covering MRSA may be justified. Transmission of MRSA among crew is possible. General hygiene measures and precautions in wound care (gloves, hand disinfection) apply.
In 2013 Lekkerkerk described seafarers as a new risk group for methicillin-resistant Staphylococcus aureus (MRSA)’ following their survey of 124 seafarers admitted to the port hospital of Rotterdam in the Netherlands. Screening data showed a prevalence of 5,8% (6).
The relevance of global travel and transport as vectors of MRSA strains has not been studied systematically so far. However case reports suggest that international travel plays a significant role in the transmission of MRSA, potentially contributing to the replacement of existing endemic MRSA with fitter and more transmissible strains (7).
MRSA prevalence in resource-limited countries in Asia and Africa and in the seafarer´s population is ill-defined.
The current evidence suggests that in relapsing or extensive skin infections in seafarers, methicillin resistant staphylococcus aureus must be considered as a causative agent. Microbiological resistance testing from wound material should be done whenever possible. In relapsing or extensive infections broad spectrum antibiotics covering MRSA may be justified. Transmission of MRSA among crew is possible. General hygiene measures and precautions in wound care (gloves, hand disinfection) apply.
 Dahl E. Wound infections on board ship-prevemtiom, pathogens, and treatement. Int Marit Health 2011; 62, 3: 160-163.
 DeLeo FR, Otto M, Kreiswirth BN, Chambers HF. Community –associated methicillin-resistant Staphylococcus aureus. Lancet 2010; 375:1557-156.
(3) LaMar JE, Carr RB, Zinderman C, McDonald K. Sentinel cases of community-acquired methicillin-resistant Staphylococcus aureus onboard a naval ship. Mil Med. 2003 Feb;168(2):135-8. PMID: 12636142.
 Lucas R, Boniface K, Roberts K, Kane E. Suspected methicillin-resistant Staphylococcus aureus infections at sea. Int Marit Health 2007;58:93-102.
 Roman RS, Smith J, Walker M, Byrne S, Ramotar K, Dyck B, Kabani A, Nicolle LE. Rapid geographic spread of a methicillin-resistant Staphylococcus aureus strain. Clin Infect Dis 1997;25:698-705.
(6) Lekkerkerk WS, van Genderen PJ, Severin JA, Peper JP, Storm EF, Vos MC. Letter to the editor: seafarers: a new risk group for meticillin-resistant Staphylococcus aureus (MRSA). Euro Surveill. 2013 Oct 24;18(43):20618. doi: 10.2807/1560-7917.es2013.18.43.20618. PMID: 24176620.
(7) Zhou YP, Wilder-Smith A, Hsu LY. The role of international travel in the spread of methicillin-resistant Staphylococcus aureus. J Travel Med. 2014 Jul-Aug;21(4):272-81. doi: 10.1111/jtm.12133. Epub 2014 Jun 3. PMID: 24894491.
G.3.3 Other (parasitic) skin infections (e.g. Scabies, Tinea corporis, bed bugs, fleas, infected insect bites)
No further publications on seafarers were found concerning infections which are reported to occur in international short and long term travellers and immigrants, such as impetigo, scabies, pediculosis and infected insect bites, fungal infection or rare skin diseases like leprosy and cutaneus diphtheria.
Despite the lack of published data to this topic, every practising port and ship physician is well aware of the relevance of fungal skin infections, that can easily be treated by hygiene measures and topical ointment: mainly tinea corporis (ring-worm), tinea pedis (athlete´s foot), tinea cruris (jock itch).
The author has consulted several sipping companies on pest treatment in ships infested with bed bugs and fleas which put a high burden of discomfort to the crew and cost to the shipowner. There are simple measures to prevent bugs and fleas, such as reducing clutter, cleaning luggage before storing in your cabin and frequent vacuum-cleaning