International Maritime Health Foundation Typical Length of Such a Paper Would Be 2000–4000 Words, Not Including Tables, Figures and References

www.intmarhealth.pl nr ISSN 1641–9251 ISSN nr nr eISSN 2081-3252 eISSN nr

Health Maritime Foundation International 2021, Vol. 72, No. 3 No. 72, Vol. 2021, Official scientific forum of the: Official scientific forum Medical Journals Links, Medline, Medical Journals Links, Medline, Ulrich's Periodicals Directory, WorldCat Directory, Ulrich's Periodicals Polish Ministry of Education and Science, Ministry of Education and Science, Polish Polish Medical Bibliography, Scopus, SJR, Medical Bibliography, Polish ESCI, FMJ, Google Scholar, Index Copernicus, Copernicus, Index Google Scholar, ESCI, FMJ, Indexed/abstracted in: CrossRef, DOAJ, EBSCO, EBSCO, Indexed/abstracted DOAJ, in: CrossRef,

International Maritime Health, 2021, Vol. 72, No. 3

217 237 241 245 243 239 223 228

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...... reat ...... of major changes in university ...... king and corruption at the maritime ats due to COVID-19 and actions COVID-19 ats due to affic for detailedfor study of course credit earned as a result w article vie port:th a global health course form based on those findings The need college by and the comprehension of material students LETTERS TO THE EDITOR Yusuf Amuda Tajudeen, Iyiola Olatunji Oladunjoye, Yusuff Adebayo Adebisi diseases and maritime seaport:Zoonotic infectious areas of concern Yusuf Amuda Tajudeen, Iyiola Olatunji Oladunjoye tr Wildlife Yusuff Adebayo Adebisi, Iyiola Olatunji Oladunjoye, Yusuf Amuda Tajudeen, Don Eliseo Lucero-Prisno III Self-medication with antibiotics among seafarers: a public health issue Ali Mohamed Ali Ismail in home: exercise and ocular yogic training Physical control the high-tension options to good alternative of primaryform during the open angle glaucoma ...... waves COVID-19 repeated Yasuyuki Fujita, Ken Inoue, Noriyuki Kawano, Yoshihiro Noso, Nailya Chaizhunusova, Nargul Ospanova, Nursultan Seksenbayev, Timur Moldagaliyev, Aigul Tokesheva, Yersin T. Zhunussov, Nobuo Takeichi, Masaharu Hoshi, Yoshiyuki Ohira VING/UNDERWATER MEDICINE DIVING/UNDERWATER Original articles Peter Germonpré, Pierre Lafère, François Guerrero, Costantino Balestra dry by provided Comparison of insulation or wetsuits water during cold divers among recreational immersion (< 5°C) Re Jarosław Krzyżak, Krzysztof Korzeniewski to dive Medical assessment of fitness after COVID-19 HYPERBARIC MEDICINE Original articles Koc Kubra Ozgok-Kangal, Taylan Zaman, Bayram measures in a hyperbaric The outcomes of COVID-19 centre during the pandemic therapy oxygen

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CONTENTS

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...... ure and health impacts ...... w articles vie "International Maritime Health" is indexed at: CrossRef, DOAJ, EBSCO, ESCI, FMJ, Google Scholar, Index Copernicus, Medical Journals Links, Medline, "International Maritime Health" is indexed at: CrossRef, DOAJ, EBSCO, ESCI, FMJ, Google Scholar, Directory, WorldCat. Polish Ministry of Education and Science, Polish Medical Bibliography, Scopus, SJR, Ulrich's Periodicals to seafarers...... to Fumigation on bulk cargo ships: a chemical threat Fumigation Rune Djurhuus Om Prakash Yadav, Atanu Sarkar, Desai Shan, Arifur Rahman, Lorenzo Moro Occupational noise expos fish harvesters:among ...... a systematic review Re Putri Ayuni Alayyannur, Shintia Yunita Arini and environment work The relationship between occupational accidents among fishermen OCCUPATIONAL MEDICINE OCCUPATIONAL Original articles Face-to-face versus distance versus learning in a seaside Face-to-face ...... point of view area: the teacher's in Indonesian coastal areas Antonella Centonze, Rosa Anfosso, Roberta Pujia, Antonella Centonze, Rosa Anfosso, Roberta Prosperi Porta, Stefania Zampogna, Domenico Sinopoli, Ilaria Emanuele Baldassarre Short communication Sanley Salvacion Abila, Iris Lavalle Acejo Mental health of Filipino seafarers and Clara C. Schlaich, Katharina Lucas, Sophia Sydow, Eike Beyer, Clara C. Schlaich, Katharina Lucas, Sophia Karl P. Faesecke vaccinations Procedural aspects of COVID-19 ...... seafarers ocean-going vessels on for seafarers’ education its implications for Review articles Review Tem Suzie-Solange Mbong, Despena Andrioti Bygvraa Tem Suzie-Solange Mbong, Despena Andrioti Analysis of the implementation of the International theory: using motivation Management Code Safety . views the seafarer's Evaluation of maritime accident reports of Evaluation of main search coordination centre between and rescue cargo ship Aranui 5 Hakan Altıntaş Hüseyin Koçak, Kerim and 2012...... 2001 Jean-Claude Chatard, Jean-Marc Le Gac, Sylvie Gonzalo, Jean-Claude Chatard, Coulange Philippe Vaysse, Mathieu the mixed on board Management of COVID-19 MARITIME MEDICINE Original articles INFORMATION FOR AUTHORS

The International Maritime Health will publish original papers on medical and health problems of seafarers, fishermen, INTERNATIONAL MARITIME HEALTH divers, dockers, shipyard workers and other maritime workers, as well as papers on tropical medicine, travel medicine, Former: Bulletin of the Institute of Maritime and Tropical Medicine in Gdynia, issued since 1949 epidemiology, and other related topics. Owner: International Maritime Health Foundation Typical length of such a paper would be 2000–4000 words, not including tables, figures and references. Its construc- The international multidisciplinary journal devoted to research and practice in the field of: maritime medicine, travel and tropical medicine, tion should follow the usual pattern: abstract (structured abstract of no more than 300 words); key words; introduction; hyperbaric and underwater medicine, sea-rescue, port hygienic and sanitary problems, maritime psychology. participants; materials; methods; results; discussion; and conclusions/key messages. Supported scientifically or financially by: Case Reports will also be accepted, particularly of work-related diseases and accidents among maritime workers. All papers will be peer-reviewed. The comments made by the reviewers will be sent to authors, and their criticism and proposed amendments should be taken into consideration by authors submitting revised texts. Review articles on specific topics, exposures, preventive interventions, and on the national maritime health services will also be considered for publication. Their length will be from 1000 to 4000 words, including tables, figures and references.

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Copyright © 2021 Polish Society of Maritime Tropical and Travel Medicine Printed in the Republic of Poland ISSN: 1641-9251 eISSN 2081-3252 EDITOR-IN-CHIEF: Maria Jeżewska Medical University of Gdańsk, Institute of Maritime and Tropical Medicine, 9B Powstania Styczniowego street, 81–519 Gdynia, Poland, e-mail: [email protected], tel: (+48) 601 67 65 33, fax: (+48 58) 622 33 54 DEPUTY EDITOR-IN-CHIEF: Eilif Dahl NCMDM, Haukeland University Hospital, Bergen, Norway e-mail: [email protected] Stephen E. Roberts School of Medicine Swansea University, United Kingdom e-mail: [email protected] HONORARY EDITOR: STATISTICAL EDITOR: Bogdan Jaremin Paweł Zagożdżon e-mail: [email protected] Department of Hygiene and Epidemiology SECRETARY of the EDITORIAL BOARD: Medical University of Gdańsk, Poland Leszek Mayer e-mail: [email protected] e-mail: [email protected] LANGUAGE EDITOR PUBLISHER EDITOR: Tim Carter Joanna Niezgoda NCMDM, Haukeland University Hospital, Via Medica, Gdańsk, Poland Bergen, Norway e-mail: [email protected] e-mail: [email protected]

EDITORIAL BOARD: Hyperbaric and diving medicine Epidemiology, travel and tropical medicine Marit Grönning Krzysztof Korzeniewski Department of Occupational Medicine, Department of Epidemiology and Tropical Medicine Haukeland University Hospital, Bergen, Norway Military Institute of Medicine, Warsaw, Poland e-mail: [email protected] e-mail: [email protected] Telemedicine, maritime medicine Maritime and travel medicine Alf Magne Horneland Nebojša Nikolić NCMDM, Haukeland University Hospital, Bergen, Norway Faculty of Medicina, University of Rijeka, Croatia e-mail: [email protected] e-mail: [email protected] Francesco Amenta Cardiology, maritime emergencies and accidents CIRM Rome, University of Camerino, Italy Marcus Oldenburg e-mail: [email protected] Department of Maritime Medicine, Institute Epidemiology and occupational medicine of Occupational and Maritime Medicine (ZfAM) Olaf Chresten Jensen University of Hamburg, Germany Centre of Maritime Health and Society, e-mail: [email protected] University of Southern Denmark, Esbjerg, Denmark e-mail: [email protected] Mental health and health promotion Vsevolod Rozanov Jorgen Riis Jepsen Odessa National Mechnikov University, Odessa, Ukraine Centre of Maritime Health and Society, University of Southern Denmark, Esbjerg, Denmark e-mail: [email protected] e-mail: [email protected] Psychology and safety at work Naval medicine, public health Andy Smith Jon Magnus Haga Centre for Occupational and Health Psychology NCMDM, Haukeland University Hospital, Bergen, Norway Cardiff University, United Kingdom e-mail: [email protected] e-mail: [email protected] EDITORIAL ADVISORY BOARD: Wacław Leszek Nahorski Medical University of Gdańsk, Poland Gregory Chan Chung Tsing e-mail: [email protected] National University of Singapore, Singapore e-mail: [email protected] Ralph Nilsson Sahlgrenska University Goteborg, Sweden Ilona Denisenko e-mail: [email protected] IMHA, WISTA, Russian Federation e-mail: [email protected] Marcin Renke Medical University of Gdańsk, Poland Jordi Desola e-mail: [email protected] CRIS-UTH, University of Barcelona, Spain e-mail: [email protected], [email protected] Giovanna Ricci University of Camerino, Italy Lucero Prisno Don Eliseo III e-mail: [email protected] University of Liverpool, UK e-mail: [email protected] Przemysław Rutkowski Department of Nephrology, Transplantology Karl Faesecke and Internal Diseases, MUG, Poland Hamburg Hyperbaric Center, Germany e-mail: [email protected] e-mail: [email protected] Maria Luisa Sanchez Marta Grubman-Nowak K Line Clinic, Manila, Philippines IMTM, MUG, Gdynia, Poland e-mail: [email protected] e-mail: [email protected] Bernd Fred Schepers Christos Hadjichristodoulou German Maritime Health Association University of Thessaly, Larissa, Greece e-mail: [email protected] e-mail: [email protected] Klaus Seidenstuecker Henrik Lyngbeck Hansen Chairman German Maritime Health Association CMHS University of Southern Denmark, Denmark e-mail: [email protected] e-mail: [email protected] Suzanne Louise Stannard Suresh N. Idnani NCMDM, Haukeland University Hospital, Bergen, Norway IMHA, ICSW, Goa, India e-mail: [email protected] e-mail: [email protected] Robert Steffen Dominique Jegaden ISPM, University of Zurich, Switzerland FSMH, Brest University, France e-mail: [email protected] e-mail: [email protected] Agnar Ström Tveten Piotr Kajfasz NCMDM, Radio Medico Norway Medical University of Warsaw, Poland e-mail: [email protected] e-mail: [email protected] Einar Thorsen Jacek Kot Department Occupational Medicine, IMTM MUG, Gdynia, Poland Haukeland University Hospital, Bergen, Norway e-mail: [email protected] e-mail: [email protected] Raymond Lucas Arne Johan Ulven George Washington, University Washington DC, USA NCMDM, Haukeland University Hospital, Bergen, Norway e-mail: [email protected] e-mail: [email protected] Alessandro Marroni Donald A. Velasco DAN Europe, Italy/Malta University of the Immaculate Conception, e-mail: [email protected] Davao City, Philippines Joanne McVeigh e-mail: [email protected] Department of Psychology and Assisting Living Karin Westlund and Learning (ALL) Institute, Maynooth University, Ireland Sahlgrenska University Hospital Gothenburg, Sweden e-mail: [email protected] e-mail: [email protected] Bente Elisabeth Moen Stephen Williams University of Bergen, Norway Institute of Cruise Ship Medicine, Miami Beach, USA e-mail: [email protected] e-mail: [email protected] CONTENTS

MARITIME MEDICINE DIVING/UNDERWATER MEDICINE Original articles Original articles

Jean-Claude Chatard, Jean-Marc Le Gac, Sylvie Gonzalo, Pierre Lafère, François Guerrero, Peter Germonpré, Philippe Vaysse, Mathieu Coulange Costantino Balestra Management of COVID-19 on board the mixed Comparison of insulation provided by dry or wetsuits cargo ship Aranui 5...... 155 among recreational divers during cold water Hüseyin Koçak, Kerim Hakan Altıntaş immersion (< 5°C)...... 217 Evaluation of maritime accident reports of main Review article search and rescue coordination centre between 2001 and 2012...... 163 Jarosław Krzyżak, Krzysztof Korzeniewski

Tem Suzie-Solange Mbong, Despena Andrioti Bygvraa Medical assessment of fitness to dive after COVID-19...... 223 Analysis of the implementation of the International Safety Management Code using motivation theory: the seafarer's views...... 172 HYPERBARIC MEDICINE Review articles Original articles Kubra Ozgok-Kangal, Taylan Zaman, Bayram Koc Clara C. Schlaich, Katharina Lucas, Sophia Sydow, Eike Beyer, Karl P. Faesecke The outcomes of COVID-19 measures in a hyperbaric Procedural aspects of COVID-19 vaccinations oxygen therapy centre during the pandemic...... 228 for seafarers on ocean-going vessels...... 179 LETTERS TO THE EDITOR Sanley Salvacion Abila, Iris Lavalle Acejo Yusuf Amuda Tajudeen, Iyiola Olatunji Oladunjoye, Mental health of Filipino seafarers and Yusuff Adebayo Adebisi its implications for seafarers’ education...... 183 Zoonotic infectious diseases and maritime seaport: Short communication areas of concern...... 237 Antonella Centonze, Rosa Anfosso, Roberta Pujia, Yusuf Amuda Tajudeen, Iyiola Olatunji Oladunjoye Stefania Zampogna, Domenico Sinopoli, Ilaria Prosperi Porta, Wildlife trafficking and corruption at the maritime Emanuele Baldassarre port: a global health threat...... 239 Face-to-face versus distance learning in a seaside area: the teacher's point of view...... 193 Yusuff Adebayo Adebisi, Iyiola Olatunji Oladunjoye, Yusuf Amuda Tajudeen, Don Eliseo Lucero-Prisno III Self-medication with antibiotics among seafarers: OCCUPATIONAL MEDICINE a public health issue...... 241 Original articles Ali Mohamed Ali Ismail Putri Ayuni Alayyannur, Shintia Yunita Arini Physical training and ocular yogic exercise in home: The relationship between work environment and good alternative options to control the high-tension occupational accidents among fishermen form of primary open angle glaucoma during the in Indonesian coastal areas...... 195 repeated COVID-19 waves...... 243 Yasuyuki Fujita, Ken Inoue, Noriyuki Kawano, Review articles Yoshihiro Noso, Nailya Chaizhunusova, Nargul Ospanova, Om Prakash Yadav, Atanu Sarkar, Desai Shan, Arifur Rahman, Nursultan Seksenbayev, Timur Moldagaliyev, Aigul Tokesheva, Lorenzo Moro Yersin T. Zhunussov, Nobuo Takeichi, Masaharu Hoshi, Occupational noise exposure and health impacts Yoshiyuki Ohira among fish harvesters: a systematic review...... 199 The need for detailed study of course credit earned and the comprehension of material by college Rune Djurhuus students as a result of major changes in university Fumigation on bulk cargo ships: a chemical threat course formats due to COVID-19 and actions to seafarers...... 206 based on those findings...... 245

Int Marit Health 2021; 72, 3: 155–162 10.5603/IMH.2021.0031 www.intmarhealth.pl Copyright © 2021 PSMTTM ORIGINAL ARTICLE ISSN 1641-9251 eISSN 2081-3252 Management of COVID-19 on board the mixed cargo ship Aranui 5

Jean-Claude Chatard1 , Jean-Marc Le Gac2, Sylvie Gonzalo3, Philippe Vaysse4, Mathieu Coulange5

1Faculty of Medicine Jacques Lisfranc, University Lyon-Saint-Etienne, France 2Health Simulation Centre of Scorff, Group, C3S-Groupe Hospitalier of Bretagne sud, Lorient, France 3Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France 4Medical Department of Aranui 5, Raiatéa, French Polynesia 5Assistance Publique Hôpitaux de Marseille, Marseille, France

ABSTRACT Background: During cruises, the management of coronavirus disease 2019 (COVID-19) infections poses serious organizational problems such as those encountered in 2020 by the Zaandam, the aircraft carrier Charles de Gaulle or the Diamond Princess. In French Polynesia, the mixed cargo ship Aranui 5 transports both tourists and freight to the Marquesas Islands. The purpose of this article is to show how COVID-19 infections were diagnosed and contained before and after passengers boarded a cruise. Materials and methods: On October 15, 2020, 161 passengers including 80 crew members embarked for a 13-day voyage from Papeete to the Marquesas Islands. Prior to boarding, all passengers underwent a reverse transcriptase-polymerase chain reaction (RT-PCR) test; the tests results were all negative. On Day 0, 3, 5, 8 and 11, Biosynex® rapid antigen diagnostic tests were carried out on all or some of the crew members and tourists who may have had contact with new positive cases. Each day, forehead or temporal temperatures were measured using an infrared thermometer and questions were asked concerning the subjects’ health status. When a subject was positive, the person and their contacts were isolated in individual cabins. The infected person then left the vessel to be received in a communal reception centre on the nearest island. Results: A total of 9 positive cases were observed, including two before departure (a tourist and a crew member). During the trip, 7 crew members tested positive. The patients and their contacts were isolated and then disembarked at the earliest opportunity. At the time of sampling, the subjects were asymptomatic. The patients and their contacts all became symptomatic within 24 to 48 hours after sampling. Conclusions: In total, the voyage could be completed without any transmission on board among the tourists and with a minimum transmission among the crew members, thus maintaining the tourist and economic activity of the islands during the times of COVID-19 pandemic. (Int Marit Health 2021; 72, 3: 155–162) Key words: cruise, crew members, French Polynesia, rapid antigenic diagnostic orientation tests, reverse transcriptase-polymerase chain reaction (RT-PCR), virus infection

INTRODUCTION Diamond Princess. In February 2020, a total of 634 cases During cruises, the management of coronavirus disease of COVID-19 were detected aboard the Diamond Princess (COVID-19) infections poses serious organizational problems among 3,711 passengers forcing the ship to remain in such as those encountered in 2020 by the Zaandam, the dock for 4 weeks in quarantine in Yokohama, Japan [1–3]. Celebrity Apex, the aircraft carrier Charles de Gaulle or the On the Zaandam, after a few days into the cruise 54 of the

Prof. Jean-Claude Chatard, Service de Physiologie Clinique et de l’Exercice, CHU de Saint-Etienne, 42055 Saint-Etienne cedex 2, tel/fax: +33664516017, * e-mail: [email protected] This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

www.intmarhealth.pl 155 Int Marit Health 2021; 72, 3: 155–162

Table 1. Health facilities on the islands located on the Aranui’s route to the Marquesas

Islands Infirmary Medical centre Pharmacy Local hospital Fakarava X Rangiroa X X Bora bora X X Nuku Hiva X X X X Hiva Oa X X Fatu Hiva X Ua Pou X X Ua Huka X Tahuata X

1,800 passengers on board were confirmed positive and 4 passengers died. On the Charles de Gaulle, 70% of the 1,760 crew on board were found to be infected. In French Polynesia, many cruise ships visit the 118 islands spread over an area the size of Europe. Polynesia has many dispensaries but only 4 hospitals, including only one in the Marquesas Islands on the main island of Nuku Hiva (Table 1). Only the Papeete Hospital Centre is equipped to accommodate patients with COVID-19, with 200 beds, including 40 COVID-19 beds among the 60 intensive care beds. October 15, 2020 was the departure date of cruise 16 of the Aranui 5 from Papeete to the Marquesas. At this time, the COVID-19 pandemic was at its highest in Polynesia with an incidence rate of around 500 cases per 100,000 people and Figure 1. The Aranui 5 is a mixed cargo ship that carries both a reproduction rate of 1.4. During the 3 months preceding cruise tourists and cargo to the Marquesas Islands the departure, of the total number of 280,000 inhabitants 3,735 people were infected and 14 died from COVID-19. Many of the infected patients had different comorbidities, e.g.: The purpose of this article is to show how COVID-19 in- overweight, diabetes and high blood pressure. Additionally, fections were diagnosed and therefore contained before a communal lifestyle of the local people, i.e. living in close and after embarking on a cruise to the Marquesas on the proximity to one another facilitated the spread of infection. mixed cargo ship Aranui 5. The mixed cargo ship Aranui 5 carries both tourists and freight to the Marquesas Islands (Figs. 1, 2). The total dura- MATERIALS AND METHODS tion of the cruise is 13 days. Usually, half of the passengers MEDICAL ORGANIZATION ON BOARD are Polynesians and the other half are tourists from abroad. The vessel accommodates a maximum of 335 passen- On October 15, the occupancy rate was around 50% with gers, including 225 tourists and 110 crew members. In accor- only few Western/British tourists due to the travel restric- dance with international regulations, it is equipped with an tions imposed because of the pandemic. infirmary with two hospital rooms, resuscitation equipment The crew was made up mostly of Marquesans. The ma- including a defibrillator, a portable respirator, intubation jority had been confined on board since the date of their last equipment, transportable oxygen bottles and medical bags voyage, 20 days earlier, but a few had had contact outside for shore excursions each containing a defibrillator. the vessel at the dockside. The previous cruise had been A ship’s doctor and a nurse are delegated to manage cancelled for tourists but maintained for freight. Twelve medical emergencies and monitor the health of those on crew members had tested positive, including the captain board. The doctor is the captain’s primary consultant for and his first officer, forcing the vessel to return to port after any particular medical intervention. The medical team is just 1 day of travel. All of the new crew had tested negative reinforced by 4 crew members of the kitchen staff trained and were ready to depart on cruise 16. in first aid in the event of a medical emergency.

156 www.intmarhealth.pl Jean-Claude Chatard et al., Management of COVID-19 on board the mixed cargo ship Aranui 5

Figure 2. Aranui 5 cruise with stops from Papeete to the Marquesas via the Tuamotu and Society archipelagos

During Aranui 5 cruises, the regulation equipment on private company Moana Médex as well as the one on board, board (division D217) is supplemented by sets of personal took samples with a successive deep swab of both nos- protective equipment, but also 300 Biosynex® antigen di- trils. The crew members remained on the aft deck until the agnostic tests giving results in a few minutes. results were given by the doctor and then they returned to On October 15, the Aranui 5 welcomed 161 passengers, their work following a one way circuit to avoid contact with including 81 tourists and 80 crew members, amounting to other crew members (Fig. 3). around 50% of her maximum capacity. To improve the efficiency of the measurements, each tube was numbered from 1 to 80, with a different colour CONTROL OF COVID-19 code for a set of 5 samples. This made it possible to suc- Before boarding. All local tourists had taken a reverse cessively conduct 4 series of 5 samples. Timers were set transcriptase-polymerase chain reaction (RT-PCR) test off after each batch of 5 tests. All the results were collated 2–3 days before boarding in line with the Polynesian regu- in a spreadsheet. When a subject was tested positive, he lations; the tests results were all negative. The other tour- was isolated in an individual cabin as well as the people ists coming from metropolitan France or from abroad had considered to be his contacts, even if they tested negative. presented a negative RT-PCR result on the test taken 3 to During the trip. Every morning, the temporal or frontal 7 days before their departure. They had to take another temperature of crew members was checked by the nurse self-collected RT-PCR test 4 days after their arrival in the using an infrared thermometer. That of tourists was mea- country. This could correspond to the day before or even to sured before each meal, using a thermal sensor installed the very day of the departure at sea. The results of these at the entrance to the restaurant (Fig. 3C) and also before tests were not known. Therefore, Biosynex® rapid antigen each visit ashore. tests were carried out either the day before or immediately On Day 3, 5, 8 and 11, further rapid antigen tests were before departure. carried out by the nurse and the on-board doctor on all or All new crew members had had a negative RT-PCR test re- some of the crew members who may have had contact sult 3 days before departure. A total of 27 crew members who with the new positive cases. The tourists did not undergo had tested negative on the previous trip and were staying on any further tests except when they were symptomatic, as board were not screened as it was considered unnecessary. recommended by the cruise company. After boarding. For all crew members, a one way testing pathway for Biosynex® rapid antigen tests had been pre- RESULTS pared on the aft deck of the vessel by the nurse and the BEFORE LEAVING on-board doctor. Crew members were duly summoned and Two RP-PCR tests were positive in one of the 81 tourists their identity confirmed by the captain or the first officer. and one of the 53 crew members. The crew member had Upon embarkation, temporal or frontal temperatures had contact with 3 sailors who were working ashore at the were measured using an infrared thermometer and ques- embarkation and disembarkation of cargo. Both subjects tions were asked regarding their general condition. A test were asymptomatic. They were excluded from the trip and number was assigned to each person. The nurses of the were not allowed to get on board. The tourist who tested

www.intmarhealth.pl 157 Int Marit Health 2021; 72, 3: 155–162

A B

C D

Figure 3. Nasopharyngeal samples taken on land (A) and in the cabin (B). Whole body (C) or temporal (D) temperature measurements, rapid analysis test (E)

158 www.intmarhealth.pl Jean-Claude Chatard et al., Management of COVID-19 on board the mixed cargo ship Aranui 5

Table 2. Date of sampling, number of people involved and decision taken for those testing positive and contact cases

N subjects tested Positive subjects Decision D0 81 tourists 1 case 1 couple and 1 crew member did not 15 October 35 crew members 1 case embark Before ship’s departure D3 79 crew members 1 Isolated together with 2 cabin contacts. 18 October 43-year-old man All disembarked on Hiva Oa to the isolation centre D5 76 crew members 1 Disembarked on Nuku Hiva 20 October 36-year-old lieutenant with duties in the engine room D8 16 workers in the engine 1 Disembarked on Nuku Hiva. 23 October room and gangway and the 36-year-old machine room The 2 contact cases remained on board 6 staying/accommodated operator in isolation in the same corridor D11 Case testing of contacts with 2 Disembarked at Papeete then isolation 26 October clinical symptoms 32- and 37-year-old men at home

positive had come to Papeete together with his wife and the cabin next to the crew member who had tested positive had been staying with his family for the previous 5 days. His at the previous screening and disembarked on Nuku Hiva wife, although she tested negative, was not allowed on Island in the Marquesas. Two contact cases from his cabin board as well. were placed in separate cabins and remained on board. The crew members who tested positive (on day 3, 5, 8) DURING THE TRIP were asymptomatic at sampling but became symptomatic On Day 3 among all 79 crew members, a 43-year-old after 24 to 48 hours of sample collection. man tested positive. He was isolated in a single cabin, as On day 11, the 2 contact cases aged 32 and 37, who had were 2 sailors aged 40 and 65 who shared his cabin, con- been placed in separate cabins, became symptomatic com- sidered as contact cases. They all disembarked 24 hours plaining of headaches, fever and asthenia; both had positive later in the Marquesas at the Hiva Oa island containment test results. As the end of the trip was only 48 hours away, centre. The 2 crew members subsequently tested positive. they were allowed to stay on board and disembarked on day The 65-year-old sailor had a history of complete cardiac 13 in Papeete and were then placed in isolation at home. arrhythmia due to atrial fibrillation and required oxygen ther- In total, 7 crew members tested positive during the trip. apy at a rate of 2 L/min on the 5th day after disembarkation. Before departure, one crew member and one tourist had On Day 5, of the remaining 76 crew members, a 36-year- also tested positive (Table 2). old lieutenant working in the engine room tested positive, The self-tests which tourists are required to perform, he immediately disembarked in the Marquesas Islands on carried out on the 4th day of arrival on Polynesian territory Nuku Hiva Island. or just before boarding, were deposited at the Nuku Hiva Later, another 4 samples were found to be positive. Hospital, after 6 days of sea travel. Analysed on site, they However, the transmission mode could not be estab- were all negative. lished and as one of the positive patients had already had Of the crew who attended the infirmary, two presented COVID-19 2 months before, the subjects were immediate- with sore throat, which could have been attributed to expo- ly re-sampled and this time tested negative suggesting sure to air conditioning. Their antigen tests were negative. false positive results by contamination of the collection The tourists remained asymptomatic and received no tubes. While handling the swabs, the operator’s gloves further testing. were not changed. All 4 crew members remained on board. On Day 8, a new screening was conducted; this time DISCUSSION targeted at 16 crew members who had had contact with The most important point of this study was to show that the 36-year-old man working in the engine room and on the the sensitivity of rapid antigenic tests was sufficient for the bridge, and the 6 crew members staying in the cabins in the detection of contagious individuals (including 8 crew mem- same corridor and also the engine room. A 36-year-old man, bers and one tourist) and their use prevented transmission was an operator working in the engine room and living in of the COVID-19 infection among the 161 passengers who

www.intmarhealth.pl 159 Int Marit Health 2021; 72, 3: 155–162 boarded the ship. These tests were therefore effective in can also be attributable to collecting the samples too early detecting asymptomatic subjects and above all necessary when the viral load is not yet sufficient to be detectable. to avoid the spread of infection to all passengers as had In such cases, it suffices to repeat the tests to determine been the case with the Diamond Princess cruise ship [1–3] whether or not a person is infected [12]. The salivary or or on the aircraft carrier Charles de Gaulle. On this warship, nasopharyngeal self-tests are easier to use, but their sen- the cabins were dormitories for 40 people, the passage- sitivity is debated. For some researchers, it is high enough ways were very narrow and it was impossible to enforce [13] while for others it is not [14]. This type of tests was not distancing measures. available on the Aranui 5. The 4 false positives were detected very quickly after DETERMINATION OF CONTAGIOUSNESS a re-test. They probably have been linked to contamination After contact with infected individuals, incubation of during handling of samples from the first positive case as COVID-19 lasts an average of 4 to 5 days; (range between 2 and observed under other conditions by Esteve et al. (2020) 14 days with a confidence interval of 97.5% at 12 days [4]). [15]. Then, the person conducting the test sanitised his Right after becoming infected, the tests remain negative hands and used a new pair of gloves as often as possible. for several days, which is how long it takes the virus to Although the tests on Aranui 5 were carried out by a small proliferate and for the viral load to be sufficient to become team and in a timeframe constrained by the crew’s work, detectable on the test. Infected subjects usually become 80 tests were carried out in 2 hours 30 minutes during the contagious 2 to 3 days before the onset of symptoms. In- first session, subsequently 79 tests in 1 hour 30 minutes fectiousness decreases sharply on days 7 and 8 [5]. But in during the second session. Positive results appeared in less the elderly and in immuno-compromised subjects it can last than 2 minutes and consolidated in 15 minutes. up to 3 weeks or even longer. In the case of the Aranui 5 Also considered as false positives are the tests whose ship, the contact cases were tested every 3 days [2] and viral load is sufficient to be detected but insufficient to the infected or sick subjects were isolated in a cabin, or contaminate such as for example after recovery. The tests disembarked at the earliest opportunity to be quarantined remain positive for a few days without the subject being at a communal containment centre on the islands of Hiva contagious [15]. Oa or Nuku Hiva or at home following the World Health Organization (WHO) recommendations [6, 7]. MODE OF TRANSMISSION The investigation into the epidemic on Aranui 5 revealed Apart from non-compliance with containment instruc- that transmission first took place whilst the vessel was tions, non-compliance with preventive measures on board still in dock. Certain crew members had not followed the was also observed in the cabins, in the restaurant and in confinement guidelines and had conversations with other the crew’s rest rooms. sailors and their families. Crew members lived 2 to 3 in a cabin. Distancing more Subsequently, the transmission took place on board. than one metre to avoid getting infected by saliva droplets In fact, all contacts sharing the same cabin tested positive was impossible [16]. The contact time was long, greater and eventually became symptomatic. The positive results than the 15–25 minutes — which is the time required for on rapid antigenic tests were later confirmed ashore by transmission to take place without a mask in a closed, un- RT-PCR tests considered to be more reliable [5]. On the ventilated environment [17]. In practice, all contact cases Diamond Princess, 1/3 of the positive cases had remained staying in the same cabin became therefore infected as asymptomatic over a period of 14 days [3] although they in the case of the Diamond Princess [1]. However, there presented radiologically unequivocal pulmonary signs of was one exception: the case of the lieutenant who was COVID-19 showing that many infected subjects and patients staying in an isolated cabin which adjoined the cabin of may still have had no symptom [2, 8]. On the Aranui 5, it the first case detected on board. The transmission could be was not possible to X-ray the passengers or to test all the explained either by the contact with touch surfaces (hand tourists. The total number of asymptomatic cases cannot rails) or transmission via the ventilation system (the lack of therefore be ascertained. ventilation to the outside). The Biosynex® rapid antigenic diagnostic tests turned In total, special attention was therefore paid to the crew out to be effective. Their sensitivity between 90% and 100% members staying in the cabins in the corridor where the first and specificity between 70% and 99% have been shown to cases had been discovered. The ship owner has decided be similar to RT-PCR tests [9–11]. False negatives were rare. to introduce the following measures on the trips to follow: Most often, they resulted from non-compliance with sample (i) to favour 2-person cabins, bringing together crew mem- collection procedures, e.g. poorly taken nasopharyngeal bers already living together on land, (ii) to hire crew who have swabs, the swab not reaching the back of the nostrils. They recovered from COVID-19 and are therefore immunised,

160 www.intmarhealth.pl Jean-Claude Chatard et al., Management of COVID-19 on board the mixed cargo ship Aranui 5

(iii) to complement the systems of air conditioning with UV were abnormal. Some crew members confessed to having systems and other antimicrobial devices, such as filters [18]. taken paracetamol out of precaution, fearing they would be The crew and the tourists were not completely separated disembarked in case of fever! from one another while eating in a restaurant or staying in the rest room. On the Diamond Princess, this was the main THE PSYCHOLOGICAL CONSEQUENCES site of contamination [1]. The solution then was to wear The psychological consequences could not be effec- a mask, the value of which has been well demonstrated tively evaluated, but some officers were observed to have inside a closed, unventilated room [19]. But on the Aranui 5, symptoms related to high mental stress, such as insomnia, people did not fully respect the requirement to wear face back pain and high blood pressure. The crew perceived masks. It was sometimes worn improperly, i.e. not cover- the confinement on board as a factor of exhaustion. They ing the nose. Duck bill masks have also been reported were looking for companionship as a way to cope with the to interfere with breathing in the engine room where the imposed preventive measures. temperature can reach 40°C. From this observation, better On other cruise ships, several suicides have been re- tolerated surgical masks were made available to the crew. ported following the announcement of confinements or Communication between the medical team, the captain, prolonged quarantines such as on the Regal Princess or his first officer, passengers, other crew members and the the Carnival Breeze. Following the inactivity of 3,000 cruise owner was maintained on a regular basis. Test results and ships for health reasons, the Cruise Line International Asso- modes of transmission were explained in full transparency. ciation reported a clear decrease in the Seafarer Happiness The aim was for everyone to increase their awareness and Index [25], reflecting their psychological suffering. start using preventive measures. The following issues were As for tourists, maintaining group activities, such as raised during the discussions with the crew: the risks of dance and music, has effectively limited the psychological transmission in the crew’s passageways by touching the stress. Sport and relaxation activities were added by the guardrails, or the clothes placed on the guardrails, the risks cruise staff to the usual programme. The massage service from sharing bottles or drinks. Following the discussions, was very busy during the cruise, but alcohol consumption hand sanitizer dispensers were installed, clearly following did not increase. in this the recommendations of Pradhan et al. [20]. Also, For the medical team, discussions with the referring the negativity of the tests was explained and any rumours doctor, the health monitoring office and the cruise man- were ruled out. Part of the crew, for example, believed that ager in Papeete were invaluable in assessing the risks of regular ingestion of kava, a traditional slightly hallucinogenic transmission and in managing evacuations ashore. The Melanesian drink that is obtained from the roots of shrubs progression of the cases could be analysed on daily basis soaked and then squeezed [21] can prevent infection. Those and the adaptation of procedures decided in consultation who perceived themselves as immune, relaxed the preven- with the captain and the medical team. tive measures. The preventive measures applied on the Aranui 5 since CONCLUSIONS February 2020 have been explained clearly on posters Rapid antigenic screening using a deep nasal swab and were the subject of 2 passenger briefings from the helped the detection of COVID-19 on Aranui 5; thus, trans- medical team. mission was limited to 9, out of 161 passengers, including It was recommended that everyone wash their hands 8 crew members and only 1 tourist. These tests proved ef- several times a day [22] even though isolated hand wash- fective in detecting and isolating contagious asymptomatic ing is not considered sufficient to protect against getting subjects. They therefore helped prevent transmission of the infected [19]. Likewise, guardrails, common computer key- infection to all passengers and allowed the continuation boards and control levers were regularly disinfected as of the cruise and the transport of freight to the Marque- recommended by the WHO [23]. Viruses can persist for up sas Islands. to 9 days on certain surfaces, but it is not clear whether the In addition to rapid screening tests, other decisive mea- viral load they constitute is sufficient to be contaminating sures were put in place such as the separating the crew [22–24]. Hydro-alcoholic gel dispensers were installed in members, isolation of the infected persons and contact conspicuous places in resting, transition and meeting areas cases, regular disinfection of cabins, corridors and common for passengers and crew, such as in lifts and stairways. areas, improving the provision of hydro-alcoholic gel sani- The control of temporal or frontal temperatures was diffi- tizer, introducing remote assistance for the management cult to carry out and was limited to the areas of compulsory of the infected persons and placing them in a communal passage: entry and exit by the ship’s gangway at stopovers reception centre after disembarkation under the supervision and entrance to the restaurant. None of the measurements of the island doctors.

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The preventive measures were reinforced and encour- 2020; 30(3): 030901, doi: 10.11613/BM.2020.030901, indexed in aged by the medical team to all the crew and tourists. De- Pubmed: 33071558. 11. Van Honacker E, Van Vaerenbergh K, Boel A, et al. Comparison of spite the effort to communicate the transmission risks and five SARS-CoV-2 rapid antigen detection tests in a hospital setting correct erroneous ideas, the fear of infection remained and performance of one antigen assay in routine practice: a use- a stress factor. Moments of conviviality were sought to avoid ful tool to guide isolation precautions? J Hosp Infect. 2021; 114: moral exhaustion, sometimes with the non-compliance with 144–152, doi: 10.1016/j.jhin.2021.03.021, indexed in Pubmed: confinement and preventive measures, along with the taking 33785377. 12. Arevalo-Rodriguez I, Buitrago-Garcia D, Simancas-Racines D, et al. of antipyretics. False-negative results of initial RT-PCR assays for COVID-19: A systematic Discussions with the referring doctor, the health mon- review. PLoS One. 2020; 15(12): e0242958, doi: 10.1371/journal. itoring office and the cruise manager were invaluable in pone.0242958, indexed in Pubmed: 33301459. managing each positive case, the risks of transmission and 13. Pisanic N, Randad P, Kruczynski K, et al. COVID-19 serology at population evacuations ashore. scale: SARS-CoV-2-specific antibody responses in saliva. J Clin Microbiol. 2020; 59(1), doi: 10.1101/2020.05.24.20112300. In summary, the cruise was able to be completed, with- 14. Nagura-Ikeda M, Imai K, Tabata S, et al. Clinical Evaluation of Self-Col- out any transmission on board among the tourists and with lected Saliva by Quantitative Reverse Transcription-PCR (RT-qPCR), a minimum of transmission among the crew members, Direct RT-qPCR, Reverse Transcription-Loop-Mediated Isothermal ensuring the tourist and economic activity of the islands, Amplification, and a Rapid Antigen Test To Diagnose COVID-19. J during the peak of the COVID-19 pandemic. Clin Microbiol. 2020; 58(9), doi: 10.1128/JCM.01438-20, indexed in Pubmed: 32636214. 15. Esteve C, Catherine FX, Chavanet P, et al. How should a positive PCR Conflict of interest: None declared test result for COVID-19 in an asymptomatic individual be interpreted and managed? Med Mal Infect. 2020; 50(8): 633–638, doi: 10.1016/j. REFERENCES medmal.2020.09.014, indexed in Pubmed: 33022291. 1. Kakimoto K, Kamiya H, Yamagishi T, et al. Initial Investigation of Trans- 16. Bahl P, Doolan C, de Silva C, et al. Airborne or droplet precautions for mission of COVID-19 Among Crew Members During Quarantine of health workers treating coronavirus disease 2019? J Infect Dis. 2020, a Cruise Ship — Yokohama, Japan, February 2020. MMWR Morb Mortal doi: 10.1093/infdis/jiaa189. Wkly Rep. 2020; 69(11): 312–313, doi: 10.15585/mmwr.mm6911e2, 17. Heinzerling A, Stuckey MJ, Scheuer T, et al. Transmission of COVID-19 indexed in Pubmed: 32191689. to Health Care Personnel During Exposures to a Hospitalized Patient — 2. Hung IFN, Cheng VCC, Li X, et al. SARS-CoV-2 shedding and serocon- Solano County, California, February 2020. MMWR Morb Mortal Wkly Rep. version among passengers quarantined after disembarking a cruise 2020; 69(15): 472–476, doi: 10.15585/mmwr.mm6915e5, indexed in Pubmed: 32298249. ship: a case series. Lancet Infect Dis. 2020; 20(9): 1051–1060, doi: 18. Morawska L, Tang JW, Bahnfleth W, et al. How can airborne transmission 10.1016/S1473-3099(20)30364-9, indexed in Pubmed: 32539986. of COVID-19 indoors be minimised? Environ Int. 2020; 142: 105832, 3. Tabata S, Imai K, Kawano S, et al. Clinical characteristics of COVID-19 doi: 10.1016/j.envint.2020.105832, indexed in Pubmed: 32521345. in 104 people with SARS-CoV-2 infection on the Diamond Princess 19. MacIntyre CR, Chughtai AA. A rapid systematic review of the efficacy of cruise ship: a retrospective analysis. Lancet Infect Dis. 2020; 20(9): face masks and respirators against coronaviruses and other respira- 1043–1050, doi: 10.1016/S1473-3099(20)30482-5, indexed in tory transmissible viruses for the community, healthcare workers and Pubmed: 32539988. sick patients. Int J Nurs Stud. 2020; 108: 103629, doi: 10.1016/j. 4. Lauer SA, Grantz KH, Bi Q, et al. The Incubation Period of Coronavirus ijnurstu.2020.103629, indexed in Pubmed: 32512240. Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: 20. Pradhan D, Biswasroy P, Kumar Naik P, et al. A review of current interven- Estimation and Application. Ann Intern Med. 2020; 172(9): 577–582, tions for COVID-19 prevention. Arch Med Res. 2020; 51(5): 363–374, doi: 10.7326/M20-0504, indexed in Pubmed: 32150748. doi: 10.1016/j.arcmed.2020.04.020, indexed in Pubmed: 32409144. 5. van Kampen JJA, van de Vijver DA, Fraaij PLA, et al. Duration and key 21. Bian T, Corral P, Wang Y, et al. Kava as a clinical nutrient: promises determinants of infectious virus shedding in hospitalized patients with and challenges. Nutrients. 2020; 12(10), doi: 10.3390/nu12103044, coronavirus disease-2019 (COVID-19). Nat Commun. 2021; 12(1): 267, indexed in Pubmed: 33027883. doi: 10.1038/s41467-020-20568-4, indexed in Pubmed: 33431879. 22. Bueckert M, Gupta R, Gupta A, et al. Infectivity of SARS-CoV-2 and 6. Foppiani A, Bertoli S, Battezzati A, et al. Data to guide the applica- other coronaviruses on dry surfaces: potential for indirect transmission. tion of the new WHO criteria for releasing COVID-19 patients from Materials (Basel). 2020; 13(22), doi: 10.3390/ma13225211, indexed isolation. Pharmacol Res. 2020; 160: 105063, doi: 10.1016/j. in Pubmed: 33218120. phrs.2020.105063, indexed in Pubmed: 32663611. 23. Carraturo F, Del Giudice C, Morelli M, et al. Persistence of SARS-CoV-2 7. WHO. Criteria for Releasing covid-19 Patients From Isolation. . https:// in the environment and COVID-19 transmission risk from environmental www.who.int/news-room/commentaries/ (2020). matrices and surfaces. Environ Pollut. 2020; 265(Pt B): 115010, doi: 8. Ooi EE, Low JG. Asymptomatic SARS-CoV-2 infection. Lancet Infect Dis. 10.1016/j.envpol.2020.115010, indexed in Pubmed: 32570023. 2020; 20(9): 996–998. 24. Kampf G, Todt D, Pfaender S, et al. Persistence of coronaviruses on 9. Chaimayo C, Kaewnaphan B, Tanlieng N, et al. Rapid SARS-CoV-2 inanimate surfaces and their inactivation with biocidal agents. J Hosp antigen detection assay in comparison with real-time RT-PCR assay for Infect. 2020; 104(3): 246–251, doi: 10.1016/j.jhin.2020.01.022, laboratory diagnosis of COVID-19 in Thailand. Virol J. 2020; 17(1): 177, indexed in Pubmed: 32035997. doi: 10.1186/s12985-020-01452-5, indexed in Pubmed: 33187528. 25. Tedesco LM, Ferrara P, Stromillo L, et al. Seafarers’ perceptions of job 10. Gambino CM, Lo Sasso B, Colomba C, et al. Comparison of a rapid demand: A cross-sectional study. Arch Environ Occup Health. 2018; immunochromatographic test with a chemiluminescence immunoassay 73(5): 278–283, doi: 10.1080/19338244.2017.1342590, indexed for detection of anti-SARS-CoV-2 IgM and IgG. Biochem Med (Zagreb). in Pubmed: 28622113.

162 www.intmarhealth.pl Int Marit Health 2021; 72, 3: 163–171 10.5603/IMH.2021.0032 www.intmarhealth.pl Copyright © 2021 PSMTTM ORIGINAL ARTICLE ISSN 1641-9251 eISSN 2081-3252 Evaluation of maritime accident reports of main search and rescue coordination centre between 2001 and 2012

Hüseyin Koçak1 , Kerim Hakan Altıntaş2

1Department of Emergency and Disaster Management, Çanakkale Onsekiz Mart University Faculty of Health Sciences, Çanakkale, Turkey 2Department of Public Health, Faculty of Medicine, Hacettepe University, Ankara, Turkey

ABSTRACT Background: The aim of the study was to evaluate the marine accident and incident reports between 2001 and 2012 by the Main Search and Rescue Coordination Centre (MSARCM). The method of the study was a descriptive-cross-sectional epidemiological study. Materials and methods: The data of the research were composed of MSARCM’s marine accident, incident and medical evacuation reports between 2001 and 2012. In the research, 1796 marine accident/incident reports were examined. The data were evaluated statistically by frequency distribution, univariate and bivariate regression analysis and multidimensional scaling analysis. Results: The highest number of cases in the study occurred in 2010 (n = 228, 12.7%). Considering the time of realisation of the cases, the highest number of cases occurred between 12:00 and 17:59 (n = 538, 30.0%). In the total of 1796 cases, there were 150 injured, 6046 rescued, 311 deaths, 202 missing and 73 patients. Considering the causes of accidents, the first three places were bad weather conditions (n = 287, 16.0%), human errors (n = 241, 13.4%) and machine malfunctions (n = 232, 12.9%). In the univariate and bivariate analysis of the data, it was seen that injuries in the Istanbul region were statistically more significant than those in the international region (8.5 fold, 95% confidence interval). Conclusions: The risk management activities on injuries and accidents need to be carried out more carefully particularly in the areas with a high occurrence of marine accidents/events and medical evacuations (such as strait traffic, ports, shipyards), in the hotspots for shipping accidents. (Int Marit Health 2021; 72, 3: 163–171) Key words: maritime accident, maritime ıncident, medical evacuation, search and rescue, Turkey

INTRODUCTION related to transportation are a major source of injury and There has been an increase in man-made disasters due death. The accidents in the transportation sector can be to developing technology and growing population every day. classified as the accidents in or on aviation vehicles, marine One of the reasons of such increase is the growing number vehicles, rail vehicles and road vehicles [2]. of accidents. An accident refers to an unplanned, unexpect- Seventy one per cent of the earth’s surface is covered ed event, which results in injury, damage or human/property with water. Ninety per cent of the World’s trade is carried losses. Intentional events are not considered as accidents by the sea [3, 4]. Despite the developments in the avi- [1]. Transportation accidents have an important place in ation sector, the maritime trade is preferable since it is human-induced disasters. According to the World Disasters more cost-effective particularly for long distances. Turkey Report 2003 published by the Red Cross, the disasters is a peninsular country surrounded on three sides by wa-

Dr. Hüseyin Koçak, Çanakkale Onsekiz Mart University, Faculty of Health Sciences, Department of Emergency Aid and Disaster Management, Terzioğlu Yerleşkesi Sağlık * Bilimleri Fakültesi, 17100 Çanakkale, Turkey, e-mail: [email protected] This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

www.intmarhealth.pl 163 Int Marit Health 2021; 72, 3: 163–171 ter with the Dardanelles and the Bosphorus strait having in 1999 [10]. The manual was prepared so as to ensure a strategic importance. In this regard, Turkey is a transit that there is standardised cooperation and coordination in country in maritime transportation and maritime trade. For regard to SAR services among the member states. these reasons, it is a country at risk in regard to marine ac- Air and sea SAR services involve the use of various cidents. A marine accident is defined as an event resulting facilities including sea planes, helicopters, submarines, in unexpected and unintentional deaths or injuries leading rescue boats and vessels [9].When a marine accident takes to full/partial loss of limbs; and resulting in one or more place, the priority is to coordinate the SAR services ef- of the following consequences: the loss of human life, the fectively, quickly and properly as well as to reach out the sinking or loss of a vessel, severe material damage in the patients/injured as soon as possible. All of the institutions vessel, the grounding of a vessel, environmental damage and organizations under the National SAR Plan must use due to a vessel or vessels in an incident in a vessel and/or the most proper rescue method within the shortest possible in relation to a vessel [5–7]. time in the operations where several institutions take part Numerous marine accidents/incidents have taken place in and give the utmost importance to coordination so as to in the World and in Turkey. Titanic, considered as “Unsink- rescue the victims [10, 11]. able Ship”, hit an iceberg and sank within 2 hours and The Main Search and Rescue Coordination Centre 40 minutes on April 15th 1912 in “New Foundland” [8]. (MSRCC), which was established to coordinate search and Only 710 out of 2,207 passengers in Titanic survived the rescue operations in Turkey, is responsible for the coordi- disaster while a total of 1,514 passengers could not. Most nation of the SAR operations necessary as a result of air of them died from hypothermia and in less than 15 minutes and marine accidents (Fig. 1) and provides services for because of the water temperature at –2°C. A tanker with 24 hours a day. Table 1 presents the main tasks of the a cargo capacity for 120,000 tons of crude oil, namely Tor- centre [12–14]. rey Canyon, was shipwrecked due to a navigation error on The marine accidents/events and medical evacuations March 18th 1967, causing a serious environmental disaster. in Turkey are coordinated and recorded by the MSRCC. The increase in the number and tonnage of the vessels Since the analysis of these records would have a critical endangers the community health; in particular, the increase importance in the prevention and reduction of accidents in the number of vessels carrying hazardous cargo and in as well as the rescue of lives, this study was conducted. the amount of hazardous cargo creates a serious danger in terms of the course of the ship, human life and environ- MATERIALS AND METHODS mental safety. International Maritime Organization (IMO) This descriptive study evaluated the marine acci- introduced new regulations and measures especially upon dents/events and medical evacuation reports between the major accidents [9]. In parallel with the developments in the dates of January 1st 2001 and December 31st 2012 in the maritime sector, there have been increased efforts to save MSRCC section of the official web-site of the Turkey Ministry human life and to enforce international measures in order to of Transport, Maritime Affairs and Communications. The re- minimise marine accidents and losses. The IMO is a private ports on electronic media were printed out and the data were organization of the United Nations (UN) responsible for en- transferred to the registration forms. The information on these suring safety for ships and preventing marine pollution [10]. registration forms were entered into the database created by The organization has established a global system providing means of SPSS 15.0 software and then evaluated statistically. the actions and operations to be performed for sea and The statistical evaluation was performed through frequency air vehicles when in need of help at anywhere in the world distribution, one-variable and bivariate Poisson regression, [11]. The purpose of the system is to provide effective air Multidimensional scaling method. The study was performed and sea search and rescue (SAR) services, to support the between the dates of October 2012 — March 2014. coherence of these services, and to ensure that the units The frequency analysis examined the following variables: in distress around the world receive assistance regardless the years, months and hours of the accidents, the types of of their nations and locations [11]. accidents, the causes of accidents, the locations of acci- Contemporary SAR systems help a number of people, dents, the number of the injured, the dead, the patients, who become lost, injured or trapped in different places. Gov- the missing people and the rescued people, the presence ernments provide SAR services in response to plane crash- of pollution, the units participating in the rescue operations, es, ship accidents, lost and trapped people or those in need the types of ships, the flags of ships, the loads of ships, of rescue through this system. In order to set standards for the types of loads, the methods of evacuation, the types the global system in the world, the IMO and the International of vehicles participating in the evacuation, the status of Civil Aviation Organization published the International Aero- the person/institution who informed about the event, the nautical and Maritime Search and Rescue Manual (IAMSAR) distribution of the internationally coordinated centres.

164 www.intmarhealth.pl Hüseyin Koçak, Kerim Hakan Altıntaş, Maritime accident reports analysis

Marine Search and Rescue Coordination Air Search and Rescue Coordination Centre Centre (Coast Guard Command) (Directorate General of Civil Aviation)

•General Staff •Ministry of Internal Affairs •Ministry of Internal Affairs •Chief of General Staff •Ministry of Health •Ministry of Environment and Urban Planning •Ministry of Energy and Natural Resources •Ministry of Health •Ministry of Transport, Maritime Affairs •Ministry of Youth and Sports and Communications •Directorate General of Forestry and Water •Ministry of Environment and Urban Planning Affairs, of State Airports Authority •Ministry of Youth and Sports •Directorate General of Turkish Aeronautical •Directorate General of State Meteorological Association Affairs •Directorate General of Coastal Safety

Ministry of Foreign Affaırs

Ministry of Internal Affaırs

Main Search and Rescue Coordinatıon Centre (MSRCC)

Ministry of Transport, Maritime Affairs and Communicatıons

Ministry of Finance

Figure 1. The institutions in coordination with the Main Search and Rescue Coordination Centre (MSRCC)

Table 1. The main tasks of Main Search and Rescue Coordination Centre (MSRCC)

1. To ensure the coordination of sea search and rescue operations at the highest level 2. To establish, maintain and operate the search and rescue facilities in accordance with international standards in Turkish sea search and rescue field 3. To carry out the task of preparing the national legislations on sea search and rescue operations in accordance with international legislations, to prepare and publish the necessary announcements 4. To get in touch with the Turkish flagged sea/air vehicles in distress all over the world and activate the sea search and rescue units in the region 5. To serve as the first point of contact in case of armed robbery, piracy and terrorist attacks which may take place in Turkish search rescue region and its jurisdiction area 6. To maintain coordination and cooperation for the operations with neighbouring countries inside/outside the search rescue region 7. To act to liaise with the Turkey Ministry of Foreign Affairs in the enforcement of bilateral agreements on search and rescue region

The variables in the study were examined in the one vari- Poisson regression revealed that most of the variables were able and bivariate Poisson regression analysis through NCSS in interaction with each other. The section of findings indicat- statistical package software. The lowest variable or the highest ed the ones which were significant and those which could be variable in the data sets in the one variable Poisson regres- explained. This resulted in the use of the analysis of non-metric sion analysis was considered as reference (R) and the study multidimensional scaling (NMDS), which is an interdependence then determined whether there was a potentially significant technique, rather than the analysis of multivariable Poisson decrease or increase in the other variables. The bivariate regression, which is a dependence technique.

www.intmarhealth.pl 165 Int Marit Health 2021; 72, 3: 163–171

14.00% 0.127 12.00% 0.115

10.00% 0.085 0.082 0.09 0.095 8.00% 0.072 0.087 0.065 6.00% 0.065 0.065

4.00% 0.052

2.00%

0.00% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Figure 2. The distribution of the marine accidents/events and medical evacuations according to years (Turkey Ministry of Transport, Maritime Affairs and Communications, the Directorate General of Maritime and Inland Waters Regulation, Main Search and Rescue Coordination Centre, Ankara, Turkey, 01.01.2001–31.12.2012)

The study employed a multivariate analysis technique, evacuations). Further, the distribution of the marine acci- namely NMDS, in order to find out the interdependencies dents/events/medical evacuations according to months, among many characteristics (variables) of the marine ac- the highest number of events happened in November by cidents/events and medical evacuations, which were the 10.0% (179 accidents/events/medical evacuations) while subject of this study. Then, the study identified the areas the lowest number of events took place in April by 6.5% where the characteristics (stimulants) of the units in the (116 accidents/events/medical evacuations). When the multidimensional scaling, which were the subject of this marine accidents/events/medical evacuations were anal- study, could be indicated by points in multidimensional ysed according to the hours that they occurred, the highest space, and the representation in the two-dimensional space number of events took place at 12.00–17.59 by 30.0% attempted to reveal the confidential nature of the data. (538 accidents/events/medical evacuations) whereas Since the data were classified or sorted, the chi square the lowest number of events occurred at 06.00–11.59 by distance measure was used. The multidimensional loca- 22.1% (397 accidents/events/medical evacuations). tions of the characteristics of the marine accidents/events The highest number of the marine accidents/events and and medical evacuations coordinated between 2001 and medical evacuations took place in the region of Istanbul 2012 were analysed through IBM-SPSS (Alscal) programme (795 accidents/events/medical evacuations, 44.3%) while and the results were interpreted. the lowest number of them occurred in the region of Trabzon The permission (dated November 8th 2012 and num- (26 accidents/events/medical evacuations, 1.4%) (Table 2). bered B.30.2HAC.05.07.00/826) was obtained from the In regard to the flags of the vessels in the marine ac- Non-Interventional Clinical Research Ethics Board of Hac- cidents/events and medical evacuations, Turkish flagged ettepe University. vessels ranked the first (1043 accidents/events/medical evacuations, 49.2%); Panamanian flagged vessels ranked RESULTS the second (124 accidents/events/medical evacuations, FREQUENCY DISTRIBUTION 5.8%) and Maltese flagged vessels ranked the third (112 ac- In accordance with the reports which were analysed cidents/events/medical evacuations, 5.3%). in this study, the percentage of the years when the most In terms of the types of the vessels in the marine accidents/events took place were respectively 12.7% in accidents/events and medical evacuations, the top 2010 (228 accidents/events/medical evacuations), 11.5% three vessels were respectively cargo ships (1058 acci- in 2008 (207 accidents/events/medical evacuations) and dents/events/medical evacuations, 49.9%), small boats 9.5% in 2009 (171 accidents/events/medical evacuations) (627 accidents/events/medical evacuations, 29,5%) and (Fig. 2). The distribution of the accidents/events/medical tanker ships (174 accidents/events/medical evacuations, evacuations in the study according to seasons indicated 8.2%). In regard to the capacity of vessels in this study that the highest number of events occurred in fall sea- on marine accidents/events and medical evacuations, son by 27.7% (497 accidents/events/medical evacua- 70.0% of the vessels (1486 ships) had a gross tonnage tions) whereas the lowest number of events took place in of 120,000 gross tons or below; 7.3% of them (154 ships) spring season by 22.2% (398 accidents/events/medical had a gross tonnage of 10,001–25,000 gross tons; 5.8% of

166 www.intmarhealth.pl Hüseyin Koçak, Kerim Hakan Altıntaş, Maritime accident reports analysis

Table 2. The distribution of the Marine Accidents/Events and As for notices of the marine accidents/events and med- Medical Evacuations According to Regions (Turkey Ministry of ical evacuations, 4.2% of them (76 accidents/events/med- Transport, Maritime Affairs and Communications, the Direc- ical evacuations) were made by shipmasters whereas 2.6% torate General of Maritime and Inland Waters Regulation, Main Search and Rescue Coordination Centre, Ankara, Turkey, of them (47 accidents/events/medical evacuations) were 01.01.2001–31.12.2012) made by telehealth centres. However, the sources of the notices of 85.7% of them (1539 accidents/events/medical Region Number Percentage evacuations) were unknown. İstanbul 795 44.3% The Regional Cooperation Centre in Greece (17 acci- Çanakkale 297 16.5% dents/events/medical evacuations) ranked the first among İzmir 297 16.5% the international centres coordinated in the marine accidents/events and medical evacuations. While 58.7% of Antalya 108 6.0% the marine accidents/events and medical evacuations Mersin 73 4.1% (1054 accidents/events/medical evacuations) were in- Samsun 72 4.0% tervened by the Coast Guard Command, 13.7% of them Trabzon 26 1.4% (246 accidents/events/medical evacuations) were ad- International 128 7.1% dressed by the Directorate General of Coastal Safety. A total of 150 people were injured in a period of 12 years Total 1796 100% as a result of the marine accidents/events and medical evacuations. 3.7% of the marine accidents/events/medical them (123 ships) had a gross tonnage of 25,001 gross tons evacuations involved injuries. The average number of the in- or above. The information on these marine accidents/events jured was 2.2 ± 0.6 (lower-upper limit = 1–19, median = 1.0). and medical evacuations indicated that only 0.7% of a total of A total of 73 people fell ill in a period of 12 years as 2,122 recorded vessels (14 ships) had a date of manufacture. a result of the marine accidents/events and medical evacu- It was revealed that the masters of 43.5% of 2,122 record- ations. 3.6% of the marine accidents/events involved ill per- ed vessels (923 ships) were present at the ships when the sons. The average number of ill people was 1.1 ± 0.4 (low- accidents/events/medical evacuations took place. 27.7% of er-upper limit = 1–5, median = 1.0). A total of 202 people these recorded vessels (588 ships) had an IMO number. This went missing in a period of 12 years as a result of the study on the marine accidents/events and medical evacua- marine accidents/events and medical evacuations. 4.7% tions found out that 58.7% of the vessels which were involved of the marine accidents/events involved missing people. in an accident/event/medical evacuation were carrying car- The average number of missing people was 2.4 ± 0.8 (low- go. In terms of the types of the cargos, the vessels carrying er-upper limit = 1–25, median = 1.0). A total of 312 people building materials (iron, sand, cement, etc.) ranked the first died in a period of 12 years as a result of the marine acci- by 10.9% (136 ships); those carrying passengers ranked the dents/events and medical evacuations. 7.1% of the marine second by 5.8% (73 ships); those carrying passengers and accidents/events/evacuations involved death. The average vehicles ranked the third by 5.2% (37 ships). number of the dead people was 2.1 ± 5.6 (lower-upper The most frequent types of the marine accidents/events limit = 1–67, median = 1.0). A total of 6042 persons were and medical evacuations were respectively grounding by rescued in a period of 12 years as a result of the marine 18.5% (333 accidents/events/medical evacuations); clash- accidents/events and medical evacuations. 20.9% of the es by 15.1% (272 accidents/events/medical evacuations) marine accidents/events/evacuations involved rescuing and overturning by 14.1% (254 accidents/events/med- people. The average number of the rescued people was ical evacuations). The rarest types of the marine acci- 16.1 ± 97.8 (lower-upper limit = 1–1636, median = 3.0). dents/events were the attacks by sea raiders by 0.6% Evacuations were ordered in 62.8% of the marine acci- (11 accidents/events/medical evacuations), contact dents/events. The most commonly used vehicle for the evac- with other vessels by 3.1% (56 accidents/events/medi- uations was boat by 22.7% (407 accidents/events/medical cal evacuations), and machine failure by 3.6% (65 acci- evacuations). The study concluded that marine vessels dents/events/medical evacuations), respectively. (boat, tugboat, ship, boat/tugboat) were the most preferred The top three reasons of the marine accidents/events among the vehicles used for the evacuations by 30.0% were respectively adverse weather conditions by 16.0% (538 accidents/events/medical evacuations). (287 accidents/events/medical evacuations), human errors There were state hospitals, university hospitals, private by 13.4% (241 accidents/events/medical evacuations), hospitals and foreign hospitals among the hospitals to which and machine errors by 12.9% (232 accidents/events/med- people were referred. The referrals were not focused on ical evacuations). a single hospital. The type of the hospitals to which most

www.intmarhealth.pl 167 Int Marit Health 2021; 72, 3: 163–171 of the referrals were made was state hospitals by 70.6% most important discriminators in the primary dimension (48 hospitals). were season and the time of incident. The type of vessel had a positive loading value close to 1. In a similar way, GRT, ONE-VARIABLE AND BIVARIATE POISSON captain, region and the cause of accident were positive. REGRESSION ANALYSIS That is, the type of vessel, GRT, captain, region and the The average number of the accidents/events which resulted cause of accident, respectively, were variables of secondary in injuries in the international region was significantly higher than importance in the primary dimension. that of the accidents/events which resulted in injuries in the The coordinates of the variables in the 2-dimensions region of Istanbul (8.5 times, 95% confidence limits 4.5–15.8). demonstrated that IMO number and crew had a positive It was observed that the number of the accidents/events loading value above 1 and were the most important dis- in the type of overturning, clashes, the attacks by sea raid- criminators in the secondary dimension. These variables ers, fire and explosion and in other types was significantly in the secondary dimension were of primary importance in higher than the number of the accidents/events in the the evaluation of marine accidents/events in a similar way. type of grounding which resulted in death (approximately Year groups had a positive loading value above 1; similarly, 27 times, 95% confidence limits 8.3–87.6; 4.2 times 95% season, the time of incident, the type of accident, the cause confidence limits 1.1–15.4; 11 times 95% confidence lim- of accident, region, GRT and the cases of disease were its 1.1–115.2; 7.8 times 95% confidence limits 2.2–27.9; positive, which indicating that these variables were of sec- 9.2 times 95% confidence limits 2.5–34.2 and 37 times ondary importance. The variable of Captain with the highest 95% confidence limits 11.4–120.3, respectively). negative value was insignificant in the secondary dimension. The study observed that the characteristics of the time MULTIDIMENSIONAL SCALING ANALYSIS of accident (year, season, the hour of incident), the type of The multidimensional scaling analysis (MSA) was con- accident, the unit involved in the operation and the cargo ducted in order to determine the positions of the dimensions status of vessel were centred on the primary dimension of the marine accidents/events in the study in the multi- (axis) in the 2-dimensional space. The results of accident dimensional space, to provide an overall structure of the (injuries, death, rescue, missing or disease, environmental marine accidents/events and, in the case that there may pollution) and certain characteristics of vessels (IMO num- be variations in the structure, to reveal the dimensions of ber, year of manufacture, crew) were at the other end of the the marine accidents/events that lead to such variations. primary dimension, which showed that the time and type of The characteristics of vessel (IMO number, the year of accident as well as the cargo status of vessel were important manufacture, crew, captain, cargo status, gross register in the marine accidents/events and have an impact on the tonnage [GRT] and vessel type), the place of accident, the consequences of accident (Fig. 3). time of accident (year group, season, time of the incident), the type of accident, the cause of accident and the results DISCUSSION of accident (the incidence of injury, death, rescue, loss or National and international coordination are of critical disease, the unit involved in the operation, environmental importance for quick, efficient and effective response to pollution) (20 variables) were analysed through the MSA and marine accidents. This study was performed through the the study accordingly reviewed the patterns of the marine marine accidents/events and medical evacuation reports accidents/events which have taken place for 12 years. published at the website of the Main Search and Rescue There was a poor fit in 1-dimensional solution, a slightly Coordination Centre (MSRCC) affiliated to the Turkish Minis- lower fit in 2-dimensional solution and a better fit in 3-dimen- try of Transport, Maritime Affairs and Communications. The sional solution. Given that the transition from 2-dimensional MSRCC is the centre responsible for coordinating search solution to 3-dimensional solution resulted in a slight de- and rescue operations at the highest level in case of any crease in the stress value less than 0.05, it was concluded accident related to marine or air vehicles in Turkey. that 2-dimensional solution would be the most appropriate The distribution of the marine accidents, events and solution for the study. The stress value in 2-dimensional medical evacuations coordinated by the MSRCC from had a slightly lower fit and explained the data by 93.1%. 2001–2012 (for 12 years) showed that there were dif- The coordinates of the variables in 2-dimensional in- ferences depending on years (Fig. 2). According to the dicated that the variables of season, time of the incident, 2012 Maritime Trade Statistics (marine vehicles, maritime the type of accident, cargo status, year groups and the transport and incentive statistics) published by the Direc- unit involved in the operation had positive loading values torate General of Merchant Marine in 2012, the number above 1. These variables were of primary importance in the of registered vehicles has increased from 2003 to 2011. It evaluation of marine accidents/events in a similar way. The was concluded that one of the most important factors re-

168 www.intmarhealth.pl Hüseyin Koçak, Kerim Hakan Altıntaş, Maritime accident reports analysis

Euclidean Distance Model

2 Crew

IMO No Year 1 The Cause Type of Accident of Accident Event time Sick Injuries Region GRT Ship Type Season 0 Environment Year of manufacture Pollution Death Operational Unit Lost –1 Salvation Dimension 2

Load Condition –2 Pilot

–3

–1,5 –1,0 –0,5 0,0 0,5 1,5 1,5 Dimension 1

Figure 3. Spatial view of the dimensions of the marine accidents/events and medical evacuations sulting in a yearly difference might have been the increase The distribution of the cases coordinated by the MSRCC in the number of marine vehicles. Moreover, there has been demonstrated that the highest percentage of the cases oc- a gradual increase in the number of vessels calling on the curred between the hours of 12.00 and 17.59 by 30.0% ports in Turkey and the amount of cargo transported over (538 accidents/events/medical evacuations). This finding was the years [15]. Accordingly, the number of vessels of other similar to the results of the study on the accidents of fishing countries, thus, the number of vessels passing through the vessels in England. The results of the study on the accidents in territorial waters of the country has increased as well [16]. England revealed that more accidents took place in afternoon These factors were considered to lead to the increase in and after midnight [18]. The factors such as fatigue and heavy the number of cases in the last 5 years. maritime traffic might have been the reasons that lead to the The distribution of the cases coordinated by the MS- emergence of more accidents at such hours. RCC according to seasons demonstrated that the highest The region where the marine accidents/events and med- percentage of the cases took place in the season of fall by ical evacuations were most commonly seen was the region 27.7% (497 accidents/events/medical evacuations). The of Istanbul (795 accidents/events/medical evacuations, results of a study on the accidents of fishing vessels in En- 44.3%) and the region where they were the least commonly gland between 1948 and 2008 indicated that the highest seen was the region of Trabzon (26 accidents/events/med- number of accidents occurred in the season of winter [17]. ical evacuations, 1.4%). The analysis on the vessels reg- The results of this study do not conform with the results of istered to Turkish International Vessel Registry and the the study on the accidents of fishing vessels. The reason National Vessel Registry showed that almost half of them might have been a number of factors such as the different were registered to Istanbul [15]. Among the most important maritime geography, different climatic characteristics of the reasons that the region of Istanbul was the region where study as well as different features of the vessels. marine accidents/events and medical evacuations were The distribution of the cases coordinated by the MSRCC most commonly seen, we may mention heavy maritime according to months indicated that the highest percentage traffic due to the Bosphorus, the presence of the largest of the cases took place in the month of November by 10.0% passenger and freight ports, and the busiest maritime trade (179 accidents/events/medical evacuations). These varia- routes in the region. tions might have resulted from the different climatic conditions The analysis on the flags of the vessels involved in over months (types of wind, extreme cold, extreme precipita- the marine accidents/events and medical evacuation) and the differences in the vehicular traffic in the sea. tions indicated that Turkish flagged vessels ranked the

www.intmarhealth.pl 169 Int Marit Health 2021; 72, 3: 163–171 first (1043 accidents/events/medical evacuations, is the one who leads the vessel, it is expected that the 49.2%); Panamanian flagged vessels ranked the sec- master should be among the people who made the notice. ond (124 accidents/events/medical evacuations, 5.8%) Furthermore, the notices of most of the medical evacuations and Maltese flagged vessels ranked the third (112 acci- were made by telehealth centres. Telehealth centres are the dents/events/medical evacuations, 5.3%). This finding was primary institutions to seek medical consultancy services reasonable given that most of the vessels in Turkish seas when injuries/diseases occur in a vessel. Moreover, these were Turkish flagged vessels. centres decide whether to transfer an injured/a patient to In terms of the types of vessels in the marine acci- the hospital via marine vehicles or not. For that reason, dents/events and medical evacuations, cargo vessels these two were expected to rank first and second. However, ranked the first place (1058 accidents/events/medical the lack of records on these data was remarkable since the evacuations, 49.9%); small boats ranked the second (627 ac- number of unknown notices was 1539 (85.7%). cidents/events/medical evacuations, 29.5%) and tankers Furthermore, the top three causes of the ma- ranked the third (174 accidents/events/medical evacua- rine accidents/events/medical evacuations were re- tions, 8.2%). Since 90% of the freight transportation in the spectively weather conditions by 16.0% (287 acci- world takes place by sea, the most commonly used type of dents/events/medical evacuations), human errors by vessels was cargo vessels. As a result, this type of vessels 13.4% (241 accidents/events/medical evacuations) and were involved in more marine accidents/events/medical machine errors by 12.9% (232 accidents/events/medical evacuations. In regard to the capacity of vessels in this evacuations). Weather conditions are one of the most critical study on marine accidents/events and medical evacuations, factors affecting the marine transportation. The conditions 70.0% of the vessels (1486 ships) had a gross tonnage of such as severe storms, fog, heavy snowfall, in particular, 120,000 gross tons or below; 7.3% of them (154 ships) had may dramatically disrupt the marine transportation. It is a gross tonnage of 10,001–25,000 gross tons; 5.8% of them the people who are in control of any kind of vehicle in (123 ships) had a gross tonnage of 25,001 gross tons or the maritime sector, like in many other sectors. For that above. The review on the sinking of the vessels with 100 GRT reason, the most important factor in a potential injury or or more around the world and the reasons of these incidents accident is the human factor. There are certain factors that between 2001 and 2012 in the Safety and Shipping Review have an impact on the human factor such as educational 2013 demonstrated that cargo ships ranked first by 41% background, psychological state, physical factors, work en- (n = 640) among the vessels, which was a finding similar vironment, equipment and the design of engine room [17]. to that of this study. Another study was conducted on the Although only 12.9% of the errors identified in the reports, accidents of Greek flagged vessels between 1993 and which were analysed in this study, involved a human error, 2006 in Greece and cargo vessels ranked first in regard the direct or indirect effect of the human error (such as to the types of vessels [19]. The 2007 study by Sanal [20], carelessness, lack of education, lack of maintenance and which was titled as “Vessels Casualties Occurred on Turkish repair) in regard to the causes of accidents/incidents was Territorial Waters Resulted from Machinery Failure and believed to be more reasonable. Analysis”, reflected that the type of vessels involved in A total of 150 people became injured as a result of the ma- accidents most was dry cargo ships by 31.2% [16]. A thesis rine accidents/events and medical evacuations in a process study in 2010 by Kızkapan [3] performed an analysis of of 12 years. 3.7% of the marine accidents/events/medical safety management in coastal areas and marine accidents evacuations resulted in injuries. Although the percentage between 2004 and 2008, and indicated that the type of seems to be low, certain types of accidents (such as grounding, vessels involved in accidents most in a total of 115 cases, machine error) did not affect the health of crew members and which were analysed in the study, was general cargo and passengers in any way. The analysis on the number of injuries dry bulk vessels by 54.8% [21]. In regard to the types of in relation to the marine accidents/events and medical evac- vessels, the 2012 data of the Turkish commercial fleet uations in the study according to regions indicated that the demonstrated that cargo vessels accounted for almost half highest number of injuries took place in international waters. of the vessels [15]. The reason that cargo vessels ranked A total of 6042 people were rescued from the marine first in the marine accidents/events/medical evacuations accidents/events and medical evacuations in a process of was that they were high in number. 12 years. A rescue operation was performed in 20.9% of As for the notices of the marine accidents/events and med- them. The effectiveness and speed of search and rescue ical evacuations, 4.2% of them (76 accidents/events/med- services are of vital importance in reducing the number of ical evacuations) were made by shipmasters whereas 2.6% injuries and deaths. A total of 312 people died as a result of them (47 accidents/events/medical evacuations) were of the marine accidents/events and medical evacuations in made by telehealth centres. Given that the master of a ship a process of 12 years. 7.1% of the marine accidents/events

170 www.intmarhealth.pl Hüseyin Koçak, Kerim Hakan Altıntaş, Maritime accident reports analysis resulted in death. Although the mortality of marine accidents the hotspots for shipping accidents. Additional emergency is significantly lower than that of traffic accidents, they are measures may be taken in the weather conditions and at to become a disaster since a marine accident results in the the hours when most accidents happen. The available data death or injury of a great number people. collection forms can be improved based on these insights In regard to the type of hospitals to which most of the refer- and more detailed research can be conducted given that rals of the patients/injured people were made within the study, the problematic areas have been already identified. state hospitals ranked the first place by 70.6% (48 hospitals). It is essential that the state hospitals located on the coast are Conflict of interest: None declared prepared to manage injuries and diseases that may emerge due to marine accidents. Due to the heavy maritime traffic REFERENCES across the hospitals in the area surrounding the Bosphorus 1. Özcebe H. Yaralanma Kontrol ve Korunma Programları ve Güvenli and the Dardanelles, in particular, a disaster and emergency Toplumlar. In: Ç. Güler, L. Akın (Eds.), Halk Sağlığı Temel Bilgiler Kitabı. 2nd ed. Hacattape, Ankara 2012: 1134–1145. planning for potential marine accidents is fundamental. 2. Björnstig U, Forsbeg R. Transportation Disasters. In: K.L. Koenig, Among the international centres in coordination in the C.H. Schultz (Eds.), Koenig and Schultz’s Disaster Medicine Comprehensive marine accidents/events and medical evacuations, Greece Principles and Practices Disaster Medicine Comprehensive Priciples and Rescue Coordination Centre ranked the first place (17 acci- Practices. Cambridge University Press, Cambridge 2010: 253–274. dents/events/medical evacuations, 12.3%). Greece ranks 3. Kızkapan T. Kıyı Alanlarında Gemi Emniyet Yönetimi ve Deniz Kazaları Analizi. Dokuz Eylül University 2010. first in the merchant fleets of the world. Greece, a neigh- 4. Walmsley S. Accident at Sea Report Summary 2013. Switzerland. 2013. bouring country of Turkey, has a maritime border to Turkey. 5. RG. Türk Arama Kurtarma Yönetmeliği 2001. That being said, there is a great cooperation between Turkey 6. RG. Ulusal Arama Kurtarma Planına İlişkin Tebliğ 2002. Türkiye: Resmi and Greece in regard to any potential maritime accident Gazete. 2002. that may take place and such cooperation will be essential 7. TBMM. Denizde Arama Kurtarma Uluslararası Sözleşmesi 1979. Türkiye. 8. Frey B, Savage D, Torgler B. Behavior under Extreme Conditions: in the future as well. The Titanic Disaster. Journal of Economic Perspectives. 2011; 25(1): The results of the multidimensional scale analysis re- 209–222, doi: 10.1257/jep.25.1.209. vealed that the time and type of an accident as well as cargo 9. Ece JN. İstanbul Boğazı’ndaki Deniz Kazalarının Seyir ve Çevre Güvenliği status had an impact on the consequences of the accident Açısından Analizi ve Zararsız Çevre Koşullarında Değerlendirilmesi. Gazi (injury, death, rescue, loss and disease) (Fig. 3). Üniversitesi. 2005. 10. Rescue N. A. for S. and. Fundamentals of Search and Rescue. Lon- dra-United Kingdom: Jones and Barlett Publishers. 2005. LIMITATIONS OF THE STUDY 11. IMO&ICAO. Uluslararası Havacılık ve Denizcilik Arama ve Kurtarma Kılavuzu The limitations of the study may include the lack of suf- (IAMSAR Manuel). Londra-United Kingdom: IMO ve ICAO. 1998. ficient variables related to health (such as cause of death, 12. AAKKM, Türkiye Cumhuriyeti Ulaştırma, D. ve H. B. B. A. A. K. K. M. No cause of injury, type of injury, interventions made during the Title. Retrieved May 12, 2013. http://www.denizcilik.gov.tr/tr__/aakm/ evacuation of vessel) in the forms analysed in the study, the peryapi.asp (2013). 13. Durmaz H. Türkiye’de Arama Kurtarma Sistemi, Teknolojileri ve AAKKM lack of the socio-demographic characteristics of the injured, Faaliyetleri. In II. Arama Kurtarma Sempozyumu. (n.d.). dead and missing people (such as age, gender, passen- 14. Müsteşarlığı D. Türk Ana Arama Kurtarma Koordinasyon Merkezi ger/personnel or staff in charge) and certain information Çalışmalar. 2011. unfilled by these people in the forms. The temporal infor- 15. UNCTAD U.N. on T. and D. Review of Maritime Transport 2013. Retrieved mation, which was not duly included in the forms and was April 8, 2014. unctad.org/en/PublicationsLibrary/rmt2013_en.pdf indeed of critical importance for the study, posed an obstacle (2013). 16. a D. ve H. B. D. T. G. M. Deniz Ticareti 2012 to the evaluation of search, rescue and medical evacuations DTGM T.C. Ulaştırm İstatis- tikleri Deniz Taşıtları, Denizyolu Taşıma, Teşvik ve Gemi Sanayi İstatis- according to time. The strength of the study was that this has tikleri. Ankara: Neyir Yayıncılık. 2013. been the first study to evaluate the search, rescue operations 17. Roberts S, Jaremin B, Marlow P, et al. Human and Fishing Vessel Losses and medical evacuations throughout Turkey. in Sea Accident in the UK Fishing from 1948 to 2008. Int Marit Health. 2010; 61(3): 143–153, indexed in Pubmed: 21154301. 18. Allianz Global Corporate & Specialty. World Losses in review: by Location, CONCLUSIONS Type and Cause. Munich, Germany. 2010. The study has provided valuable insights into the 19. Tzannatos E. Human Element and Accidents in Greek Shipping. marine accidents/events and medical evacuations which Journal of Navigation. 2009; 63(1): 119–127, doi: 10.1017/ took place in the activity area of MSRCC in Turkey. The risk s0373463309990312. 20. Sanal TH. Vessel Casualty Occurred on Turkish Territorial Waters Resulted management activities on injuries and accidents need to From Machinery Failure and Analysis. Ship Accidents Caused by Machine be carried out more carefully particularly in the areas with Failure and Analysis. Master Thesis, Gazi University, Ankara 2007. a high occurrence of marine accidents/events and medi- 21. Canca HS. Uluslararası Hukukta Türk Boğazları. Ankara: Seçkin cal evacuations (such as strait traffic, ports, shipyards), in Yayınevi. 2012.

www.intmarhealth.pl 171 Int Marit Health 2021; 72, 3: 172–178 10.5603/IMH.2021.0033 www.intmarhealth.pl Copyright © 2021 PSMTTM ORIGINAL ARTICLE ISSN 1641-9251 eISSN 2081-3252 Analysis of the implementation of the International Safety Management Code using motivation theory: the seafarer’s views

Tem Suzie-Solange Mbong, Despena Andrioti Bygvraa

Centre for Maritime Health and Society, Institute of Public Health, University of Southern Denmark, Esbjerg, Denmark

ABSTRACT Background: “Safety First!” as it is always said, safety is a primary concern in any human activity. Shipping, one of the most dangerous industries in the world demands the establishment and implementation of safety rules, regulations and standards. Before the International Safety Management (ISM) Code was adopted and came into effect, the maritime industry experienced catastrophic disasters which resulted in loss of life and property. The occurrence of huge marine casualties triggered maritime safety rules, regulations and standards at an international level. International maritime safety standards are meant to create uniformity in safety rules and regulations. Human errors are considered the most important reason for maritime accidents. The ISM Code has been established to clarify the responsibilities of safety on vessels and to mitigate the occurrence of human errors by creating a safety-oriented organizational culture. There is still a question of whether this culture is actively practised by shipping companies. Through the lens of Kanter’s theory of structural empowerment and Alderfer’s theory of employee motivation, this study sought to explore seafarers’ views and perceptions of the implementation of the ISM Code. Materials and methods: In-depth interviews were conducted with 6 participants (4 seafarers and 2 resource maritime industry persons). The interviews with seafarers took place on the 22nd of October, 2019. A semi-structured questionnaire was used to describe the views of the participants in relation to the implementation of the ISM Code on their ship in the following areas: communication, organizational commitment, management involvement, reporting system, and empowerment of employees Results and Conclusions: The participants pointed out that with the implementation of ISM Code the maritime personnel’s safety attitudes have improved. The employees enthusiastically participate in safety meetings and trainings. The organization on board is more open, so is the communication between officers and the crew. Working on board is nowadays teamwork instead of being autocratic. (Int Marit Health 2021; 72, 3: 172–178) Key words: International Safety Management (ISM) Code, seafarers, maritime industry (shipping), structural empowerment, employee motivation

INTRODUCTION shipowner or any person, such as the manager, who The International Safety Management (ISM) Code has assumed responsibility for operating the ship. The became mandatory in 1998 as a response to poor man- purpose of the ISM Code is to provide an international agement practices and major shipping accidents [1]. standard for the safety operation of ships and prevent The Code establishes safety-management objectives pollution. The ISM Code is a global regulatory framework and requires a safety management system (SMS) to be with the aim to upgrade the safety and quality levels in established by “the company”, which is defined as the the shipping industry.

* Dr. Despena Andrioti Bygvraa, University of Southern Denmark, Neils Bohrs Vej 9, 10, +45 Esbjerg, Denmark, e-mail: [email protected] This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

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For decades, the International Maritime Organization resolution A.741(18). The current 1993 resolution adopted (IMO) has had the responsibility to develop uniform measures was made mandatory and into force the 1st July 1998. and designs to improve the safety of international shipping and to prevent marine pollution from ships [2]. Several ac- MATERIALS AND METHODS cidents at sea accelerated the IMO’s decision to adopt in- THE MARITIME COMPANY ternational guidelines to ensure safety, to prevent human The maritime industry fulfils a critical role in the world injury or loss of life and to avoid damage to the environment economy as the primary carrier of international trade and and to property. driver of global supply chains. Commercial shipping trans- Safety is at the core of going to sea. Safety in shipping ports over 90% of the world trade in volume, and generates involves; vessels fit for their purpose, safety of all aboard significant revenue for States. Regulating the maritime a ship, safety of seafarers on flagged vessels, environmental industry is a challenging task. Due to the nature of the busi- safety of coastal waters, to name a few. With this at the ness, ships sail in high seas remote from their managers and forefront, the shipping industry implemented SMS to en- regulatory authorities. The ISM Code was introduced into the sure that commercial vessels are maintained and operate maritime industry to provide the basis on which ship owners safely to prevent maritime accidents and protect the marine are required to set up written policies and procedures and environment. A couple of accidents triggered the shipping document safety management systems for implementation industry to take another look into its safety systems. in their organizations [5]. A well-established SMS should The Belgian, Roll on/Roll off Passenger and Freight incorporate the following elements: Ferry “The Herald of Free Enterprise” capsized on the — safety and environmental policies; 6th of March 10987 in Zeebrugge. 150 passengers out of — procedures to ensure safe operation of ships and pro- the 459 who had originally boarded and 38 crew members tection of the environment; out of the 80 were killed. A formal investigation ordered — defined level of authority and lines of communication; by the Flag State (United Kingdom) of the vessel, was — procedures for reporting accidents and non-conformities; chaired by Hon. Mr. Justice Sheen. In his report, released — procedures to prepare for and respond to emergency in September 1987, Justice Sheen famously wrote, about situations; the management of the vessel: “(…) All concerned in man- — procedures for internal audit and management reviews. agement, from the members of the Board of Directors down to the junior superintendents, were guilty of fault THE SEAFARER in that all must be regarded as sharing responsibility for A seafarer is any person who is employed and works the failure of management. From top to bottom the body in any capacity on a ship covered by the Maritime Labour corporate was infected with the disease of sloppiness” Convention (MLC). The MLC, also known as the Seafarers’ Bill (Sheen, 1987). of Rights, protects seafarers’ rights by creating a comprehen- The ferry left the harbour with the bow doors open and as sive set of basic maritime labour principles and rights. As al- the ferry sped off, the bow wave grew and reached the free- ready mentioned, 90% of world trade is carried by ships. Sea- board. Water got into the car deck and within a few minutes, farers, therefore, ensure that the goods and commodities on the ferry capsized. The accident occurred due to omissions the ships reach their various destinations. Seafaring has long and negligence at all levels of the shipping organization been identified as a hazardous job with unique pressures preceding the accident. There were no explicit instructions and risks [6, 7]. It is well recognised that shipping safety for safety actions leading to unclear roles and responsibili- continues to be a major topic of interest in the maritime ties. This is an important role of senior management, but they community. Findings indicate that the critical factors of ISM were nonchalant towards upgrading safety of the ship [3]. Code implementation can be categorised in the crew-related The accident investigation committee concluded that, and the company-related dimensions. Also, the fulfilment of both ship and crew were not seaworthy. The shipping com- the intended purpose of the ISM Code consists of the factors pany took a risk with safety by hastily deploying the ship of safety management system efficiency and increased safe- on a new route [4]. ty, which were also found to be significantly associated with The IMO responded to this maritime accident and others, the crew-related dimension of ISM Code implementation [8]. by developing guidelines (adopted in 1989, IMO Assem- bly by resolution A.647(16)), concerning shipboard and MOTIVATION THEORY shore-based management to ensure the safe operation of Determining and understanding the factors that moti- ships. After some experience in the use of the guidelines, vate employees is an essential need, since the performance in 1993 IMO adopted the ISM Code for the safe operation of any organization depends on the availability of a satisfied of ships and for pollution prevention (the ISM Code) [1] and motivated workforce.

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Clayton Alderfer’s Motivation Management looking for employees who are resourceful and respond cre- theory (ERG theory) atively to the challenges of the job, empowerment becomes Maslow (1970) [9] proposed the hierarchy of human important at both individual and organizational levels. needs in five levels of basic needs as, physiological needs, safety needs, needs for love, affection and belonging, needs Kanter’s theory of structural empowerment for esteem, and needs for self-actualisation. Alderfer [10] Kanter [13] proposes that a leader’s effectiveness on expanded Maslow’s basic needs and refined them into exis- the job is influenced by the structural aspects of a work envi- tence needs, relatedness needs, and growth needs. Alderfer ronment that provides access to formal and informal power. proposed the ERG (Existence, Relatedness, Growth) theory A structurally empowered work environment offers access based on results of empirical studies to explain the rela- to information, support, resources, and opportunity to all tionship between satisfaction of needs and human desires. employees [12]. Empowerment is promoted in work envi- Existence needs. Existence needs include various forms ronments that provide employees with access to informa- of safety, physiological and material needs. Physiological tion, resources, support, and the opportunity to learn and needs refer to an individual’s pursuit of satisfaction at the develop [14]. Another study states that employees who are vitality level, such as leisure, exercise, food, shelter, clothing, empowered become more committed to the organization, rest, air, water, sleep etc. Safety needs on the other hand, fulfil demands effectively, and are more accountable for are the needs connected with the psychological fear of loss their work [15]. of job, property, natural calamities or hazards. A seafarer wants protection from such types of fear. Employees prefer EMPOWERING THE SEAFARER adequate safety or security in this regard i.e., protection Organizations that empower their employees are those from physical danger, security of job, pension for old age, which provide access to information (decisions, data, tech- insurance cover for life and so on. Employees, who are nology), support (feedback, guidance), resources (money, sufficiently motivated to perform, will be more engaged, supplies, time) and opportunities (mobility, growth, partici- productive and committed to their work. pation in committees) to get the work done [14]. Relatedness needs. Relatedness corresponds to social The ISM Code implementation offers an opportunity for needs, the need for meaningful interpersonal relations the shipping industry to move away from a culture biased in the work settings with superiors, peers, and subordi- towards blame, to one of shared sense of personal respon- nates. Managers should develop the ability to listen. For sibility for safety throughout the organization. The Code example, through positive communication, a ship captain states that it is the responsibility of ‘the Company’ to take can establish himself as approachable, open to new ideas over all duties imposed by the Code and incorporate SMS and respectful to other’s opinions. This will create an active into normal business operations. This involves assigning environment with co-workers and seafarers who listen to the designated person(s) (DPs), who will be a link between ideas and concerns of one another making implementation ship and shore and clarify levels of authority and lines of of new procedures easy and a focused motivated team. communication. The ISM Code has empowered the seafar- Growth needs. These needs are about continuous ers in the following ways: personal development in one’s job, career or profession. — Organizational commitment. The shipping company as Training and development policies are important for demon- required by the ISM Code has encouraged safe practices strating company’s interest in employees’ growth. This is in ship operations for a safe working environment for a motivational tool because employees see themselves their employees. The shipping company’s SMS assesses as being prepared for taking on more responsible posi- all risks on their ships, personnel and the environment tions. The company therefore benefits from providing train- and establishes necessary safeguards. Moreover, there ing and enhancing existing workplace skills leading to higher should be a policy in place for continuous safety im- productivity. provement skills of personnel, including preparing for emergencies related to both safety and environmental EMPOWERMENT THEORY protection. Employees feel empowered to work in an Empowerment is “a principal component of manageri- environment where their safety needs are met, and al and organizational effectiveness... [and] empowerment where they are armed with the necessary training to techniques play a crucial role in a group’s development and tackle any future incident or accident. maintenance” [11]. Employee empowerment, therefore, has — Management involvement. One of the requirements of been identified as an effective practice necessary to the the ISM Code for employee empowerment is that the effective functioning of any organization through the wise Company gives the necessary support, so the master’s usage of human resources [12]. As more organizations are duties are performed safely. The Company ensures the

174 www.intmarhealth.pl Tem Suzie-Solange Mbong, Despena Andrioti Bygvraa, The ISM Code and seafarers views

master has the appropriate training, conversant with the facilitator, the first researcher approached the seafarers Company’s SMS and qualified for this role. Management at the port and they gave their consents for the interview involvement in seafarers’ duties enables them to identify by signing consent forms. The interviews lasted at most the training needs of individual seafarer. The means of 15 minutes, and incentives (telephone cards) were given identifying theses needs could be through appraisal to those who wanted them. reports, records of previous training and performance The participants have been actively working in the mari- during drills and exercises. Through these involvements, time industry for the last 6 years. All respondents had the basic the Company ensures each ship is manned only by safety management training course and had come in contact qualified, certified and medically fit seafarers according one way or another, with the ISM Code implementation. In to international requirements. total 6 people (4 seafarers and 2 maritime industry resource — Communication. Another requirement of the ISM Code persons) participated in this study. Two of the seafarers served for the shipping industry is to define lines of commu- as officers, while the other two were non-officers. Five of the nication between shore and shipboard personnel. The participants were from Denmark and one from Spain. SMS operation on board the ship contains clear state- To explore the companies’ views, a request for participa- ments emphasising the master’s authority. The mas- tion went out to the Chief Executive Officers via the Univer- ter’s defined responsibility is to issue appropriate and sity of Southern Denmark institutional email address, delin- clear instructions to the understanding of the crew. eating the purpose of the study with 3 follow-up emails. Two This enables all personnel involved in the Company’s resource persons agreed to participate. SMS to have adequate understanding of codes and A qualitative, semi-structured individual interview guidelines. Also, seafarers receive relevant information with the respondents encouraged them to express them- on SMS in a working language(s) understood by them selves freely. An interview guide was used to keep the so they can effectively communicate when executing respondents focused and give room for their opinions their duties. and experiences [16]. The questionnaire consisted of — Employee empowerment. The ISM Code requires the questions gathering background from both employer and shipping industry to define levels of authority among employees, and analysing the main research themes; em- shore and shipboard personnel. The company has de- ployee empowerment, communication, reporting system, fined and documented the responsibility, authority and management involvement, motivation and their percep- interrelation of all personnel who manage, perform and tion of the ISM Code. verify work relating to and affecting safety and pollution Each respondent was asked similar questions to find prevention. Moveover, the company provides resources out possible irregularities in their answers. For example, and support for DPs to adequately perform their du- the Chief Executive Officers were asked how often they ties. Acting as a link between the company and those on communicate with the ships, how they communicate and board; his/her responsibility is monitoring the safety and if the employees talk about their risks and working condi- pollution, prevention aspects of the operation of the ship tions. The seafarers on the other hand were asked if how and ensuring that adequate resources and shore-based they communicate with their managers/senior officers, if support are applied as required. The Company has es- they could freely express their concerns and if they had any tablished measures to respond to hazards, emergencies concerns at the time of the interview. To evaluate empow- and accidents, whenever they arise. Other emergency erment, the respondents were asked if the DPs are aware response plans are; drills and exercises, carried out by of the ship’s safety requirements and if there were enough both on board and offshore personnel whose responsi- resources and skills to fulfil their duties. bilities are related to safety and pollution. — Reporting system. The SMS of the shipping companies RESULTS include procedures that ensure accidents and hazardous Using semi-structured one-on-one interviews with seafar- situations are reported to the Company. Investigations to ers, and phone interviews with resource persons, this study the hazards are carried out followed by an analysis with sought to describe the seafarers and resource persons’ the objective to improve safety and pollution prevention. views on the implementation of the ISM Code and its impact Measures are taken to prevent reoccurrence. on their work-life (Table 1).

METHODS COMMUNICATION A sample of convenience was interviewed in the port All the participants stressed that they take part in safety of Esbjerg, Denmark. The first researcher visited the local meetings and they have a good knowledge of the ISM Code seaman’s home at Esbjerg port. Together with the centre and safety methods. The resource persons confirmed that

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Table 1. Themes and sub themes of the interviews existence of a reporting system and thanks to a friendly environment in their ships, they are free to report any near Number Themes Sub themes of themes miss or accident anytime it occurs. 1 Communica- Relationship with superior and tion other crew men PERCEPTION OF THE ISM CODE Trust All participants appreciated the implementation of the Empathy ISM Code. Some were happy the code is in place to always 2 Organizatio- Educational and training remind them of safety. Others appreciated the existence of nal commit- opportunity the code because they now pay attention to safety practices ment and this has improved their safety behaviour whereas be- 3 Management Leader as source of information fore, they just wanted their jobs done as soon as possible. involvement 4 Reporting Lack of communication system Blame or no blame culture EMPLOYEE EMPOWERMENT When asked about empowerment, they all agreed that 5 Perception Helpful of the ISM Not helpful training was an important component to understand and Code perform their specific tasks. So, the felt empowered and 6 Employee Shared governance continue taking other courses to stay current. empower- Autonomy ment Accountability DISCUSSION ISM — International Safety Management This paper sought to describe seafarers and Chief Exec- utive Officers perceptions on the effectiveness of the ISM the personnel are not afraid to stand up and talk about safety Code. Findings showed that the ISM Code has been imple- issues. All the participants agreed that today, the discussion mented effectively in the shipping companies, where the with all parties is straight forward and has a great influence interviewees were employed as they haven’t experienced on how good the ship’s spirit and atmosphere are which in any accidents. The effectiveness in the ISM Code imple- turn have a direct effect on the personnel’s safety behaviour. mentation was complimented by the views of the shipping industry too. This is seen through visible positive attitude to- ORGANIZATIONAL COMMITMENT wards safety: promoting a safety culture, enough funding to- When asked how the management supports the person- wards safety activities, and management commitment [17]. nel in safety issues, the resource persons remarked that, According to all participants, the management of the ship- one of the most significant effects of the ISM Code has been ping companies have demonstrated their commitment that the company and its management have been assigned clearly in comparison with before the implementation of responsibilities for ensuring safety. Also, they must be able the ISM Code. to present an image of safety to the customers who are The management provides resources and funds for aware and have higher requirements on safety procedures. safety investments and safety trainings targeted at the Management attitude towards safety is constantly improv- crew. Every participant stressed that the top management ing accordingly. The employees also highlighted that the attitude have a lot more interest regarding safety. The interviews towards safety management in their company management revealed no opposite reflections. No participant said that are positive and they support the application of the system. the management are purely indifferent or negligent. In the light of the results of this research, it seems that the top MANAGEMENT INVOLVEMENT management are responsible and aware of safety. All respondents emphasised the involvement of manage- Employee participation was apparent. Each participant ment especially in providing resources for their safety. Most gave a positive and consistent opinion regarding the em- responded positively to their monthly safety meeting held ployee participation in meetings and on-board activities. For on board their ships with superior, on safety issues. Some example, seafarers are active and initiate suggestions about respondents agreed that the management provided them safety, they ask questions independently and seek advice with resources including accurate information and guide- from their superiors when necessary. They are encour- lines to carry out safety practices. aged to discuss safety issues and highlight problems and faults. Both seafarers and resource persons mentioned REPORTING SYSTEM the importance of their training courses and each shared When asked how the incidents have been reported and a positive opinion about how they actively participate in the analysed in their shipping companies, they pointed out the safety trainings. They emulate near misses when manage-

176 www.intmarhealth.pl Tem Suzie-Solange Mbong, Despena Andrioti Bygvraa, The ISM Code and seafarers views ment communicates relevant reports as case studies, and has been supported that the proposed factors are verified by they attend trainings to prevent incidents from reoccurring. interview informants. It is apparent from this research that Participants indicated that the implementation of the the successful implementation of the ISM Code depends ISM Code is beneficial and essential. The individual inter- on several key factors such as maritime safety awareness views were quite consensual about the issue. No respondent which should be resulted from the safety culture promul- presented any arguments against the usefulness of safety gated and fostered across all the relevant stakeholders management. Seafarers shared a common opinion that the and the shipping industry. The role of senior management responsibility the ISM Code imposes onto the company and both in maritime administration and shipping companies, management is one of the most significant benefits of the is especially important to nurture the safety culture, as ISM Code about taking care of safety. One of the advantag- well as providing support such as training for employees in es of the safety management system is that it clarifies the implementing the Code. Other factors which are essential roles and responsibilities on board, as they are defined in for the Code implementation are also confirmed such as the system. To them, the clarified roles and responsibilities training and development for shipping personnel, quali- provide several concrete benefits: they know who to contact ty management principles applied to safety management and they can rely on the fact that the company must take systems, rationalisation of documentation, and employee a stand on a matter; clarified roles and responsibilities facili- involvement and empowerment. tate better communication between the ships and the office. This study found that all participants are well informed The seafarer’s views were backed up by the resource about the ISM Code as it is encountered in their every- persons. They highlighted that the safety management day life. They also believed that with the Code in place, systems have unified the procedures on board, which has their SMS has prevented accidents from occurring. Partic- made the maritime personnel’s job much easier. To them, ipants’ attitudes towards safety have also improved both this makes it easier to orientate new employees and to on management level and among seafarers during the past transfer personnel from one ship to another as well. They all 15 years. This positive change in attitude can be seen in the shared the opinion that it is beneficial that the procedures management’s support, safety equipment and moral, for related to safety are documented and the needed instruc- safety and security issues. Seafarers reveal their changed tions are easily found. The users can rely on the fact that attitudes by following and complying with safety measures, they are following correct, current and accepted guidelines rules and regulation most of the time. Both the manage- provided by the documentation of the SMS. Participants ment and the personnel feel that safety is a part of their reported that, they do not have to learn new things by trial day-to-day work. And this is all due to the implementation and error. Moreover, most participants thought that the of the ISM Code. harmonised procedures and system documentation main- The implementation of the ISM Code is perceived mainly tain the continuity of good practices on board, as the crew as positive. The ISM Code has ensured; better organization members are changing. of operations, clarified roles and responsibilities of maritime personnel, and the systematic approach to safety LIMITATIONS OF THE STUDY management which lead to helping personnel to assimilate The sample was small, and the results cannot be gener- instructions and safe working methods. Seafarers also alised. However, they could be used as indicators towards considered that the introduction of the ISM Code forced successful improvement of safety culture in the maritime companies to actively engage and take responsibilities industry. concerning safety. Therefore, the ISM Code has fulfilled Also, several attempts to conduct interviews with mar- its original purpose. itime industry Chief Executive Officers were unsuccess- ful; therefore, the team chose to interview resource per- Conflict of interest: None declared sons. Chief Executive Officers may provide more in-depth views regarding the implementation of the ISM Code but the REFERENCES views of the resource persons are in any case compatible. 1. International Maritime Organization. ISM Code, International Safety Some future research directions are desired, e.g., con- Management code and guidelines on implementation of the ISM code. IMO Publishing, London 2010. ducting the same research in other countries or regions. 2. Rodriguez AJ. Campbell Hubbard M. International Safety Management (ISM) Code: A New Level of Uniformity. 73, Tulane Law Review 1999: 1585–1618. CONCLUSIONS 3. Department of Transport. The Merchant Shipping Act 1894, mv He- Through literature review, six factors were identified rald of Free Enterprise. Report court no. 8074, Formal Investigation, Department of Transport, HMSO, London 1987. and proposed as critical factors to be tested empirically. 4. Robinson A. The Scandinavian Star Incident: A Case Study. Fire Through analyses and discussions of empirical findings, it Engineers Journal. 1999; 59: 36–38.

www.intmarhealth.pl 177 Int Marit Health 2021; 72, 3: 172–178

5. Bhattacharya S. Impact of the ISM Code on the Management of 11. Conger J, Kanungo R. The empowerment process: integrating theory Occupational Health and Safety in the Maritime Industry. (Doctoral and practice. Academy of Management Review. 1988; 13(3): 471, dissertation). Cardiff University 2009. doi: 10.2307/258093. 6. Roberts SE. Hazardous occupations in Great Britain. Lancet. 2002; 12. Siegall M, Gardner S. Contextual factors of psychological em- 360(9332): 543–544, doi: 10.1016/S0140-6736(02)09708-8, powerment. Personnel Review. 2000; 29(6): 703–722, doi: indexed in Pubmed: 12241660. 10.1108/00483480010296474. 7. Home WE. Mortality of British merchant seamen. Lancet. 1934; 13. Kanter R. Men and women of the corporation. Basic Books, New 223(5777): 1081–1083, doi: 10.1016/s0140-6736(00)94094-7. York, 1977. 8. Karakasnaki M, Vlachopoulos P, Pantouvakis A, et al. ISM Code 14. Kanter RM. Men and women of the corporation. 2nd ed. Basic implementation: an investigation of safety issues in the shipping Books, New York 1993. industry. WMU Journal of Maritime Affairs. 2018; 17(3): 461–474, 15. Degner LF. Knowledge translation in palliative care: can theory help? Can doi: 10.1007/s13437-018-0153-4. J Nurs Res. 2005; 37(2): 105–113, indexed in Pubmed: 16092783. 9. Marlow A Motivation and Personality. Harper and Row, New York 16. Patton MQ. Qualitative research and evaluation methods. 3 ed. 1970. Thousand Oaks, Sage Publications 2002. 10. Alderfer C. An empirical test of a new theory of human needs. Orga- 17. Wiegmann DA, Zhang H, von Thaden T, Sharma G, Mitchell A. nizational Behavior and Human Performance. 1969; 4(2): 142–175, A synthesis of safety culture and safety climate research. University doi: 10.1016/0030-5073(69)90004-x. of Illinois, Aviation Research Lab, Savoy 2002.

178 www.intmarhealth.pl Int Marit Health 2021; 72, 3: 179–182 10.5603/IMH.2021.0034 www.intmarhealth.pl Copyright © 2021 PSMTTM REVIEW ARTICLE ISSN 1641-9251 eISSN 2081-3252 Procedural aspects of COVID-19 vaccinations for seafarers on ocean-going vessels

Clara C. Schlaich, Katharina Lucas, Sophia Sydow, Eike Beyer, Karl P. Faesecke

Hafenpraxis Dr. Schlaich and Dr. Beyer, Hamburg, Germany

ABSTRACT The increasing availability of safe and authorised coronavirus disease 2019 (COVID-19) vaccines for the first time provides the opportunity to vaccinate seafarers on board their ships while in port. Speedy vaccination of seafarers secures their health and serves to avoid the international propagation of COVID-19 virus variants via maritime traffic. As a port medical clinic, we will share our practical vaccination experience on board of merchant vessels in German/European ports with our esteemed coastal colleagues to stimulate their participation in this endeavour. You will have to adapt the procedure to your national particularities, otherwise please freely share the information with interested parties. Detailed guidance on COVID-19 vaccination in shipping and accompanying legal issues was published by the International Chamber of Shipping (www.ics-shipping.org). (Int Marit Health 2021; 72, 3: 179–182) Key words: procedural aspects, COVID-19, vaccinations for seafarers

INTRODUCTION recommendations of STIKO (the German Permanent Com- The increasing availability of safe and authorised coro- mission on Vaccination), these ICS guidelines provide a ba- navirus disease 2019 (COVID-19) vaccines for the first time sis for all parties for the joint execution of vaccinations on provides the opportunity to vaccinate seafarers on board board, in particular about issues of liability, data protection, their ships while in port. safety and the voluntary nature of vaccination. Speedy vaccination of seafarers secures their health and The responsible port health service, representing the serves to avoid the international propagation of COVID-19 vi- medical authority of the port, must be informed about the rus variants via maritime traffic. start of vaccination activities in the port area. As a port medical clinic, we will share our practical A list of contacts of the port health services in Germany vaccination experience on board of merchant vessels in can be found on the website of the Working Group of the German/European ports with our esteemed coastal col- Coastal States for Ships Hygiene: www.hamburg.de/hu/ leagues to stimulate their participation in this endeavour. /arbeitskreis-kuestenlaender [3]. You will have to adapt the procedure to your national particularities, otherwise please freely share the information RESPONSIBILITIES with interested parties. The vaccinators are responsible for: Detailed guidance on COVID-19 vaccination in shipping — commissioning of vaccines and paraphernalia; and accompanying legal issues was published by the Inter- — storage, vibration-free transport of the vaccine adhering national Chamber of Shipping (ICS): www.ics-shipping.org to the cold chain on board and the correct processing [1, 2]. of the vaccine; In addition to the well-known information provided by — if the responsible physicians direct other persons to the manufacturers on the application of vaccines and the transport the vaccine on board, it must be ensured

Dr. med. Clara C. Schlaich, MPH and Dr. med. Karl P. Faesecke, Hafenpraxis Dr. Schlaich and Dr. Beyer, Shanghaiallee 15-17, D-20457 Hamburg, Germany, * e-mail: [email protected]; [email protected]

This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

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that the vaccine is transported smoothly and stored in VACCINES accordance with the cold chain. It is preferred to charge All available COVID-19 vaccines in Germany can be ship chandler pharmacies with delivering the vaccine on applied for seafarers. board, as they are familiar with the specific features of Janssen© vaccine by Johnson & Johnson is especially ports and ships; suited for the use on seafarers; it needs to be applied only — provision of information sheets and medical history to once, it is easier to prepare on board and can be kept seafarers in advance; Robert-Koch-Institute (RKI) pro- protected against light at 2° to 8° for up to 3 months after vides updated fact sheets in different languages [4]; the removal from the freezer. International Chamber of Shipping has written a general In the European Union, the vaccine is authorised for per- statement on COVID-19 for shipping to be made avail- sons aged 18 and over; based on the current data, the Perma- able to seafarers in advance [5]; nent Commission on Vaccination at the Robert Koch Institute — establishing vaccination indication or contraindication (STIKO) recommends that Johnson & Johnson’s vaccine Jans- and individual information and counselling; sen® should normally be used for persons aged 60 and over. — one specific feature of seagoing vaccination is the assess- The use of this vaccine as a one-time vaccination below ment of heterologous vaccination schemes; seafarers this age limit is permitted based on medical information and have often received first vaccinations in other countries, individual risk acceptance by the vaccinee and makes sense sometimes with vaccines that are not authorised in the in view of the above-mentioned advantage for seafarers in European Union. The vaccinators must check on a case- active employment. by-case basis whether a follow-up vaccination is indicated; If another vaccine is used, it should be possible for — implementation of vaccination with the appropriate par- the shipping company to apply the second dose of the aphernalia; corresponding vaccine in the authorised time interval, if — follow-up and treatment of acute vaccine complications; necessary, by postponing the entry into service on board. — issuing a vaccination certificate; Follow-up vaccination is still possible even if the recom- — recording of vaccination information; mended time-lap is exceeded. — notification of the dataset under the vaccination order to the RKI. DATA PROTECTION The remaining responsibility for the procedure on board The seagoing population must be assured that vaccina- remains with the shipping companies, the port agent, if tion remains a voluntary action and the employer does not applicable, and the master: have any access to the medical data of crew members. The — prior registration of seamen willing to be vaccinated; medical history and consent sheets remain with the vacci- — providing name and address in CVS format (for the RKI); nating physicians (the retention period is 10 years). The — observance of data protection; general data protection rules apply to the collection and — advance information on previous vaccinations; processing of health data. Participation in vaccination man- — keeping a list of reserve applicants to avoid waste of vaccines; dates the notification of anonymized data by the responsible — distribution of information and consent sheets; physician to the RKI. — reminder to bring along vaccination certificate and ID card; EQUIPMENT — procedures regarding access to terminal/vessel for vac- To be made available on board by the shipping com- cinators; pany/master: — provision of support staff on board for follow-up of vac- — suitable vaccination area, e.g. ship’s hospital, office or cinated; mess-room; — provision of ship’s hospital/vaccination area and nearby — nearby waiting and observation area; follow-up space; — seating accommodation for all vaccinated for 15– — provision of refrigerator with documented temperature –30 min, at least one berth; control (2–8oC); — FFP2-/surgical masks for vaccinees; — compliance with infection prevention during vaccination — refrigerator with temperature control 2–8oC; (distance rules, mouth-nose-protection); — water/juice/soft drinks available. — allow a rest period of 15–30 min after vaccination before To be brought by the vaccinating physicians: return to work; — vaccines and paraphernalia; — rescue chain, securing the access of ambulance to the — personal protective equipment; terminal/ship; — batch sticker, vaccination stamp, health certificate (in — communicating the voluntariness of vaccination. lieu of Vacc. Certif.).

180 www.intmarhealth.pl Clara C. Schlaich et al., Procedural aspects of COVID-19 vaccinations for seafarers on ocean-going vessels

Table 1. Equipment for corona vaccinations on cargo ships

Present on Bring with doctor’s bag ships (3) Working mobile phone x Manual blood pressure meter X Stethoscope X Pulse-oximeter X Pupillary light X Tongue depressor X Intravenous fluid, e.g. 500 cc NaCl 0.9%, infusion set, X Preferably include in doctor’s bag in incl. i.v. cannula and fixed swabs addition to supply on board Infusion stands or other suspension device X Defibrillator X Medical oxygen incl. mask X Sharp waste disposal box X Emergency medication for anaphylaxis Preferably bring your own set of medication for readiness in case of emergency Epinephrine auto-injector or prefilled syringe X X 2 pcs Bronchodilator, e.g. salbutamol X X Antihistaminic tbl X X Antihistaminic amp X X Prednisolone tablets or fluid preparation X X Steroid i.v., e.g. 250 mg prednisolone X X

Clearance for passing through restricted port areas and — Safety jacket (reflective); access to the ship must be provided by the ship-owner, ship — Protective gloves; agent or master in advance. — Rescue vest as appropriate; — Mobile phone/hands-free system in the car; EMERGENCY MEDICAL KIT — Sufficient transportation bags for vaccines and emergen- Medical materials must be available for treatment of cy equipment (preferred rucksack to keep hands free); vaccine reactions, in particular allergic reactions, in accor- — Single-use gloves, FFP2 mask. dance with guidelines [6, 7]. Sometimes the ship’s pharmacy may be accessed in TIME ASSESSMENT part [8]. — Travelling from office to terminal: to be determined…; Before commencing vaccination, the vaccinating physi- — Individual voyage from terminal entrance to ship: cians must ensure that the necessary equipment on board is 30–60 min; operational, e.g. the semi-automatic defibrillator or medical — Establishment of the vaccination area, getting to know the oxygen. To this end, a prior visit to the ship’s hospital will take location, assessment of emergency equipment: 30 min; place, together with the nautical officer responsible for medical — Vaccination: 5 persons/hour, up to 10/h; care, applying the check-list below. The medication for the — Follow-up: 15–30 min/person. treatment of anaphylactic emergencies is brought on board in their emergency set by the vaccinating physicians (Table 1). Conflict of interest: None declared

PROTECTIVE EQUIPMENT FOR REFERENCES VACCINATORS 1. International Chamber of Shipping: © Coronavirus (COVID-19) — Depending on the terminal traffic situation: rotating Roadmap for Vaccination of International Seafarers Published by Marisec Publications Version 1.0 — May 2021. www.ics-shipping. warning light for the car; org (11.7.2021). — Safety shoes, at least closed footwear with non-slip sole; 2. International Chamber of Shipping: © Coronavirus (COVID-19) Legal, — Protective helmet, size adjustable; Liability and Insurance Issues arising from Vaccination of Seafarers

www.intmarhealth.pl 181 Int Marit Health 2021; 72, 3: 179–182

Published by Marisec Publications 38 St Mary Axe London EC3A uploads/2021/03/Coronavirus-COVID-19-Vaccination-for- 8BH Version 1. Seafarers-and-Shipping-Companies-A-Practical-Guide.pdf 3. Coastal States Working Group on Ships Hygiene. www.hamburg.de/ (11.7.2021). hu/arbeitskreis-kuestenlaender (11.7.2021). 6. Ring J, Beyer K, Biedermann T, et al. Guideline (S2k) on acute therapy 4. Robert-Koch Institute: Vaccination awareness sheets. https://www. and management of anaphylaxis: 2021 update. Allergo J Int. 2021; rki.de/DE/Content/Infekt/Impfen/Materialien/COVID-19-Aufk- 30(1): 1–25, doi: 10.1007/s40629-020-00158-y. laerungsbogen-Tab.html (11.7.2021). 7. ‌ www.cdc.gov/vaccines/covid-19/clinical-considerations/manag- 5. International Chamber of Shipping: © Coronavirus (COVID-19) ing-anaphylaxis.html (11.7.2021). Vaccination for Seafarers and Shipping Companies: A Prac- 8. Committee on Maritime Medical Equipment SDdBV. Changes in tical Guide Your Questions Answered — 2021. www.ics- medical equipment on German seagoing vessels. 18 June 2021. shipping.org (11.7.2021) www.ics-shipping.org/wp-content/ www.deutsche-flagge.de (11.7.2021).

182 www.intmarhealth.pl Int Marit Health 2021; 72, 3: 183–192 10.5603/IMH.2021.0035 www.intmarhealth.pl Copyright © 2021 PSMTTM REVIEW ARTICLE ISSN 1641-9251 eISSN 2081-3252 Mental health of Filipino seafarers and its implications for seafarers’ education

Sanley Salvacion Abila1 , Iris Lavalle Acejo2

1University of the Philippines Visayas, Iloilo City, Iloilo, Philippines 2Seafarers International Research Centre, Cardiff University, Cardiff, United Kingdom

ABSTRACT This narrative review examines current academic literature on the mental health of Filipino seafarers working internationally, including the mental health effects of coronavirus disease 2019 (COVID-19). Framed within a rights-based approach, it aims to identify and analyse emerging themes on Filipino seafarers’ mental health literature to understand what these studies potentially mean for the improvement of seafarers’ education on mental health. Based on a broad selection criteria, 28 eligible papers demonstrate collectively three key findings: firstly, there is paucity in published research on seafarers’ mental health; secondly, the majority of published studies are associated with a recent piracy crisis, where a significant number of mariners were attacked, taken as hostages, or killed; thirdly, three key areas emerged under which research on Filipino seafarers’ mental health can be organized: the medical repatriation of seafarers, system of care for the mental health of seafarers including the diagnostic standards used, and seafarers’ experiences and conceptions of mental health including the mental health effects of COVID-19. Though the bulk of the current understanding of the mental health problems is associated with piracy, several risk factors for which the quality of quantitative and qualitative evidence are patchy. The few sources of primary data to date lack focus on mental health needs which makes it difficult to grasp the extent of the problem. Developing policies and programmes for the promotion of mental health through mental health education among seafarers is important for a couple of reasons. Seafaring remains a dangerous and socially isolating occupation where work-related accidents are likely and will be potentially traumatic to mariners. Research on occupational stressors is increasingly providing evidence of their contributions to poor mental health outcomes among seafarers. Thus, mental health education of seafarers in the context of their work is important for proactive training and development. (Int Marit Health 2021; 72, 3: 183–192) Key words: mental health of Filipino seafarers, mental health education of seafarers, COVID-19 and mental health of seafarers

INTRODUCTION flagged ships. A Filipino nationality-specific study on Research on mental health (herein after MH) of mer- seafarers’ MH is scarce in spite of their established chant seafarers has recently gained increasing focus in presence in the maritime labour market sector since terms of particularly framing MH as part of seafarers’ the 1970’s. Studying this seafaring nationality offers well-being. To understand what these studies potentially a critical case in understanding seafarers’ MH because it mean for the improvement of seafarers’ education on can offer insights about how nation-states and the global MH, this paper reviews the academic literature on the maritime industry can be seen promoting seafarers’ MH MH of Filipino seafarers working aboard internationally through education.

Sanley Salvacion Abila, PhD, Assistant Professor, Division of Professional Education, Graduate and Continuing Education Building, University of the Philippines Visayas, * General Luna Street, Iloilo City 5000, Philippines, tel/fax: 00630333372929, e-mail: [email protected] This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

www.intmarhealth.pl 183 Int Marit Health 2021; 72, 3: 183–192

This paper is framed within a rights-based approach farers working internationally. To do this, six databases where human rights are viewed as rational and moral bases were searched (EBSCOhost, Google Scholar, Medline, and used in developing and implementing social interventions ProQuest which has 3 databases — Coronavirus research (e.g. education) aimed to produce public good (e.g. promot- database, ProQuest One Academic and Publicly Available ing good MH). This framing is attuned with World Health Or- Content Database) where studies from 2000 to 2020 were ganization’s (WHO) definition of MH as “a state of well-being considered. To augment academic publications, this paper in which the individual realises his or her own abilities, can also looked into the grey literature which includes research cope with the normal stresses of life, can work productively studies published outside the typical academic and com- and fruitfully, and is able to make a contribution to his or mercial publishing networks (Examples of these are industry her community” [1]. Though WHO’s definition is not without papers, reports of charities, government reports, seafarers’ criticisms [2], it remains influential as nation-states such as union reports, etc.) in order to examine what policies, stan- the Philippines adopt it in its MH law, the 2018 Philippine dards, strategies, interventions and the like were dedicated Mental Health Act [3]. In the MH law, the promotion of MH to protecting or promoting the MH of seafarers. of Filipinos is valued as part of their basic rights. In effect, Two independent reviewers searched for eligible ma- various organizations such as maritime schools and maritime terials with the following inclusion criteria: the date of employers are mandated by law to formulate MH policies publication, key search terms, the language (English) of and programmes for students and workers, respectively, as the manuscripts, and inclusion of Filipino seafarers in the part of both promoting and supporting the MH of Filipinos [3]. study sample. A 21-year period (i.e. 2000–2020) was used These legal developments are crucial as seafaring remains in order to cover the most recent research on the MH of one of the most attractive employment options for young Filipino seafarers. For the key search terms, the following Filipinos but remains as one of the most dangerous occu- were used: “Filipino seafarers and mental health”, “mental pations [4, 5] with growing evidence of poor MH outcomes well-being/welfare of Filipino seafarers”, “psychological among seafarers. health of Filipino seafarers”, “mental stress among Filipino Current research on seafarers’ MH revolves around two seafarers”, “psychological stress among Filipino seafarers”, related aspects [6, 7]. Firstly, research compare seafarers’ “depression among Filipino seafarers”, “suicide among MH with land-based workers, primarily comparing evidence Filipino seafarers”, “mental anxiety and Filipino seafarers”, on clinical psychological ill health such as depression, anx- “social isolation among Filipino seafarers”, and “maritime iety, and suicide rates [8]. Secondly, research tend to ex- piracy and Filipino seafarers”. Based on the various search amine risk factors (or occupational stressors) related to terms and other inclusion criteria, the two reviewers as- the working and living environment aboard vessels which sessed multiple studies as the initial hits were too many contribute to poor MH [9]. These include long-term separa- ranging from 55 to 13,400 but with a significant number tion from home, fatigue and work intensification [10, 11], of these deemed ineligible. Abstracts and titles of top hits multinational crewing, social isolation [12], ill-treatment, were assessed against the inclusion criteria, which even- poor life-work balance, job insecurity, criminalization of tually was narrowed down to 28 eligible materials where seafaring activities, working in constrained space, bullying, 17 are academic publications and 11 are either reports of piracy [13–15], lack of shore leave, short port stay, HIV/AIDS organizations or conference presentations. As a limitation [16] or in general terms psychosocial and psychophysical of this paper, the studies included in this paper were not stress [17–20]. based on a highly systematic criteria-based strategy but Merchant mariners are collectively a global workforce primarily for their thematic relevance based on the broad estimated at around 1,647,500 in 2015 where Filipino inclusion and exclusion criteria. seafarers constitute at least 20% of this global population [21]. In a report, the Philippines is the top supplier of ratings FINDINGS AND ANALYSIS and ranks second in supplying officers to the international This review found 28 eligible studies based on the broad labour market [21]. Financially, deployment of seafarers criteria set above (Table 1). In general terms, the findings translates to substantial remittances sent to the Philippines from these studies are: where in 2019 remittances amounted to US$6.53 billion, 1. There is paucity in academically published research on after sending US$6.13 billion in 2018 [22]. the MH of seafarers in spite of the established presence of Filipinos in the international seafaring labour market. NARRATIVE REVIEW AND 2. The majority of published materials began after the peak LIMITATIONS OF THE STUDY of maritime piracy crisis between 2009 to 2012, where For this narrative review, the focus is to construct a significant number of Filipino mariners were attacked, a discussion on the state of MH research on Filipino sea- taken as hostages, or killed in hostage situations.

184 www.intmarhealth.pl Table 1. Twenty eight eligible studies organized under three research themes [Source: Authors]

Author(s), Type of study Sample description (number of participants, Focus of study or relevant results/findings publication year nationality of seafarers)

THEME 1: MEDICAL REPATRIATION OF SEAFARERS Bell and Jensen, Case study of one cruise ship 25,039 disembarkation cases of multi-national crew Analysed 25,039 disembarkation cases, where Filipinos accounted for 2009 company, descriptive statistics members of one company where the majority came from 105 (0.71%) cases. Only 1 Filipino disembarked due to psychiatric case the Philippines, India and United Kingdom

Sanchez, 2013 Descriptive, conference report 4 cases of Filipino ratings with mental disorders (depres- Mental disorders due to depression can affect seafarers while working on board Sanley SalvacionAbila,IrisLavalleAcejo,Reviewofseafarers’mentalhealth sion) who disembarked on medical grounds Abaya et al., 2015 Retrospective analysis of Analysed medical records of Filipino seafarers using 10th Of 6,759 repatriated cases, only 1.8% (n = 118) of these were categorised as medical repatriation records, edition of International Statistical Classification of Diseases psychiatric or psychological disorders descriptive statistics and Related Health Problems (ICD-10) for repatriation claims Abaya et al., 2018 Retrospective analysis of Analysed repatriation documents of Filipino seafarers who 51,850 Filipinos have an overall mean length of stay until repatriation at 246.72 ± repatriation records have worked for more than 200 days on board from January± 48.3 days. Majority of illnesses as causes for repatriation comprise gastrointesti- 2014 to December 2016 nal and musculoskeletal issues with very few mental illnesses reported (less than 1%) www.intmarhealth.pl

THEME 2: SYSTEM OF MENTAL HEALTH CARE OF SEAFARERS OEF, 2010 Report, mixed methods 4,185 multi-national seafarers including Filipinos All 4,185 seafarers were attacked by Somali pirates, of which 1,090 were taken as hostages OEF, 2011 Report, mixed methods 3,863 multi-national crew including Filipinos Seafarers were attacked by Somali pirates, and 565 were taken as new hostages on top of the 645 remaining hostages taken in 2010. 205 of these hostages were Filipinos OEF, 2012 Report, mixed methods 1,817 multi-national crew including Filipinos Seafarers were attacked by pirates in West and East Africa; 187 Filipino seafarers were taken as hostages in West and East Africa OEF, 2013 Report, mixed methods 2,357 multi-national crew including Filipinos Seafarers were either attacked or taken as hostages by pirates from Africa; at least 21 Filipino seafarers were hostages OEF, 2014 Report, mixed methods 5,009 multi-national crew including Filipinos Seafarers were either attacked or taken as hostages by pirates from Africa and Asia; at least 1,524 Filipino seafarers were affected Abila and Tang, Qualitative study 12 Filipino seafarers and 3 wives of seafarers who Survivors were cared for and compensated for their physical injuries but not for 2014 were hostage survivors mental or psychological illnesses due to work-related trauma due to piracy because Philippine labour laws cover only physical illnesses OEF, 2015 Report, mixed methods 5,205 multi-national crew including Filipinos Seafarers were either attacked or taken as hostages by pirates from Africa and Asia Seyle, 2016 Mixed methods 465 seafarers from India, Philippines and Ukraine Seafarers are resilient; being held hostage leads to lasting effects; non-piracy traumatic experiences are fairly high in number and degree for seafarers in the course of their regular job; traumatic experiences can make seafarers stop Æ sailing; family members of seafarers held as hostages may suffer lasting distress 185 186 Table 1 cont. Twenty eight eligible studies organized under three research themes [Source: Authors]

Author(s), Type of study Sample description (number of participants, Focus of study or relevant results/findings publication year nationality of seafarers) Simon and Qualitative study 3 Filipino seafarers who experienced piracy Two broad themes based on narratives came out: themes related to piracy expe- Fernandez, 2016 rience (e.g. fear and hopelessness, prayer as coping mechanism, importance of family, etc.); and themes related to seafarer schemata (e.g. seafarer’s understanding of piracy, seafarer’s fortitude etc.) OEF, 2016 Report, mixed methods Multi-national seafarers including approximately 1,871 Seafarers have either been subjected to pirate attacks, or armed robberies Filipinos including being taken hostage Seafarers have either been subjected to pirate attacks, or armed robberies OEF, 2017 Report, mixed methods Multi-national crew including approximately 1,129 Filipinos including being taken hostage OEF, 2018 Report, mixed methods Multi-national seafarers crew including approximately Seafarers have either been subjected to pirate attacks, or armed robberies 742 Filipinos including being taken hostage Fernandez, Seyle Semi-structured, quantitative 135 Filipino seafarers Depression is conceptualised and expressed differently by Filipino seafarers

and Simon, 2018 interview compared to Westerners Int MaritHealth2021;72,3:183–192 Seyle, Fernandez, Statistical using hierarchical 462 seafarers from India, Philippines and Ukraine Short and long-term impacts of piracy to seafarers and their families include Dmitrich, and linear modelling PTSD, depression, and loss of occupation www.intmarhealth.pl Bahri, 2018

THEME 3: SEAFARERS’ EXPERIENCES AND/OR CONCEPTIONS OF MH OR MH ISSUES INCLUDING MH RESEARCH DURING COVID-19 PANDEMIC ITF, 2015* Report, mixed methods 615 multiple nationalities including 124 Filipinos Seafarers’ concerns are focused on HIV/AIDS prevention, sexually transmitted infections, stigma and discrimination related to HIV/AIDS, alcohol abuse, weight control (i.e. obesity-related), depression and other mental health issues (e.g. witnessing suicide of crewmates) Panganiban and Descriptive research 205 Filipino seafarers Four broad areas that contribute to stress and fatigue of seafarers are physical, Garcia, 2017 psychological, emotional and environmental McVeigh and Mac- Qualitative research 32 Filipino seafarers (all ratings) 11 domains related to perceptions of stress, resilience and well-being: workload; Lachland, 2019 safety; social; support; salary; food; shore leave and signing off and on; nationality and culture; management; inequality; optimization Jensen and Mixed methods 323 multi-nationalities including Filipinos Experiences of injury or death on board led to serious psychological stress among Oldenburg, 2019 crewmembers. These experiences are particularly distressing to Filipinos with their strong sociocentric bonds and religious values. Priestly support is often needed to help Filipino seafarers cope with serious psychological stress Lefkowitz, Slade Descriptive statistics 278 seafarer claims from various nationalities of which The crude mental illness rate was 3.9 per 100,000 person-years, using data and Redlich, 97 were from claims from the Philippines representing 15% of global seafarers, which is probably an underestimate of the 2019 true burden of mental illness at sea Lefkowitz and Two pre-validated mental 1,572 completed questionnaires from various seafaring 25% of surveyed seafarers had scores suggesting depression, 17% demonstra- Slade, 2019 health screening survey nationalities including 621 Filipinos and from Pacific regionted anxiety, 20% had suicidal ideation Æ instruments Table 1 cont. Twenty eight eligible studies organized under three research themes [Source: Authors]

Author(s), Type of study Sample description (number of participants, Focus of study or relevant results/findings publication year nationality of seafarers) Pauksztat, Grech, Online survey 671 multi-national seafarers including 215 Filipinos Effects of COVID-19 on seafarers’ mental health are presented. Of the 671- re Kitada and spondents, 15.4% report being depressed almost every day, 21.9% claims being Jensen, 2020 anxious almost daily and 73.3% say they are mentally exhausted Slišković, 2020 Qualitative, online in-depth 752 multi-national seafarers including 60 Filipinos Of the 752 respondents, majority of the respondents report some negative interviews effects of the COVID-19 pandemic related to their physical, social and economic well-being. These negative effects have repercussions on health, work efficiency,

safety on-board and financial well-being of seafarers especially those who have Sanley SalvacionAbila,IrisLavalleAcejo,Reviewofseafarers’mentalhealth not worked for an extended period Stokes and Paper presentation, online Multi-nationalities including Filipinos but covered both Due to the COVID-19 pandemic, crew change developed into a crisis level -situ Arslan, 2020 survey land-based and sea-based personnel in the maritime sectoration where seafarers have extended contracts whilst those who were on vaca- tion have difficulties going back to sea to work. For seafarers on extended work contracts, they feel exhausted and anxious *The paper of Altaf Chowdhury et al., 2016 is based on the same ITF report. COVID-19 — coronavirus disease 2019; HIV/AIDS — Human Immunodeficiency Virus infection/Acquired Immunodeficiency Syndrome; ITF — International Transport Federation; MH — mental health; OEF — One Earth Future;

www.intmarhealth.pl PTSD — post-traumatic stress disorder as psychiatricdisorders(i.e.anxiety,depression,psycho reasons. Ofthesecases,1.8%(n=118)werecategorised 2014 therewere6,759repatriatedcasesbasedonmedical et al.’s study [24], between January 2010 and December of Filipinosremainssurprisinglyunderstudied[24].InAbaya of aseafareronmedicalgrounds[23].Medicalrepatriation including medical repatriation, which is the disembarkation repatriation ofseafarersistheresponsibilityemployers call ofavesseltobeboarded.UnderPhilippinelaw,the of theseafarerfromhis/herhomeaddresstoport ation of seafarers.Repatriationseafarersisthetransport 3. farers especiallythosetaken as hostagessuffermuch 2019 [28–36].Itisalsoreported thatthefamiliesofsea including beingtakenashostages bypiratesfrom2009to been subjectedtopirateattacks and/orarmedrobberies piracy, whereapproximatelymore than6,000Filipinoshave ports from2010to2018focusing on thestateofmaritime situations. The foundation produced a series of annual re taken ashostagesandanumberwerekilledinhostage a significantnumberofseafarersincludingFilipinoswere time piracycrisisparticularlyfrom2009to2012,where and similarstudiescameoutattheheightofmari Future Foundation,anon-governmentalorganization.These puts relatedtothemaritimepiracyresearchofOneEarth used. Mostofthesestudiesunderthisthemewereout health careofseafarers,includingdiagnosticstandards mental ill-health[27]. 2016. Theyfoundlessthan1%wererepatriateddueto than 200daysonboardfromJanuary2014toDecember documents of51,850Filipinoswhohaveworkedformore psychiatric case[26].Lastly,1studyanalysedrepatriation for lessthan1%ofthesecases(i.e.105)butonlyone kation duetovariousmedicalreasons,Filipinosaccounted Jensen’s [26]workwhereofthe25,039 cases ofdisembar low reportingofmentalillnessescanbeseeninBelland were reportedina2013MHconference[25].Thesamevery of disembarkationFilipinoratingswithmentalillnesses sis/schizophrenia orbipolardisorder)[24].While4cases MENTAL HEALTH OFFILIPINOMARINERS The first thematic finding focuseson the medicalrepatri discussed below. 2019 (COVID-19) on seafarers’MH. These themesare on-going pandemic caused by the coronavirus disease of MHincludingstudiesexaminingtheeffects standards, and seafarers’ experiences and conceptions of care for the MH of seafarers including diagnostic are organized: medical repatriation of seafarers, system major areas under which research on seafarers’ MH Of thematerialsconsidered,threethemesillustrate The second theme centres on the system of mental KEY THEMESONRESEARCH ONTHE 187 ------Int Marit Health 2021; 72, 3: 183–192 as the seafarers, including being psychologically impacted and Garcia [41], McVeigh and MacLachland [42], Jensen by the captivity of seafarers [13]. In the last decade, the and Oldenburg [43], Simon and Fernandez [44], Lefkowitz maritime industry was pushed to act because of economic and Slade [45] and Lefkowitz et al. [46]. impact and human suffering caused by piracy crimes could Using the broader concept of seafarers’ well-being, not be ignored. In effect, in terms of research this crisis led ITF’s [40] survey showed that among seafarers, Filipinos to an acute focus on the psychological impacts of piracy included, HIV/AIDS remains a pressing concern together on seafarers. with other MH concerns (e.g. depression, alcohol use) and In Abila and Tang [37], the authors presented qualita- related health concerns such as nutrition and obesity. The tive evidence on the physical and psychological abuses work of Altaf Chowdhury et al. [16] is based on the same ITF that Filipino seafarers experienced as hostages of pirates, Report [40] thus these two have similar key MH findings. and the potential psychological effects of these abuses. In In Panganiban and Garcia [41], 205 Filipinos were sur- Fernandez et al. [38], the authors provided limited evidence veyed on factors that contribute to stress and fatigue. In this that depression is conceptualised and expressed differently study, four broad areas are presented to contribute to stress by Filipino seafarers compared to Westerners. In their study and fatigue of seafarers, which are the physical, psycholog- the sample of seafarers’ conceptualisation of depression ical, emotional and environmental aspects of seafaring. has certain distinctions from a Western sample. The au- In the study of McVeigh and MacLachland [42], the thors applied the United States’ Centre for Epidemiological authors examined Filipino ratings’ perceptions and expe- Studies – Depression (CES-D) scale to Filipino seafarers in riences of stress, resilience and well-being in relation to order to identify the appropriate factor structure of CES-D 11 domains (i.e. workload, safety, social, support, salary, for 135 seafarers. CES-D scale was developed in the United shore leave, signing off and on, nationality and culture, man- States and it uses a four-factor structure [39]. The authors agement, inequality, and optimization). Stress is reported to found that a three-factor structure is appropriate for the be a very common and day-to-day experience of seafarers surveyed population instead of the four-factor structure that is known to contribute to poor MH. This finding is not used in other studies. The seafarers’ factor structure ap- novel but echoes a commonly held view on seafarers’ health pears to collapse depressive affect and somatic factors research where stress is considered not only a perennial found in other studies, while including a specific factor of problem but a day-to-day reality. social-focused symptoms of depression [38]. In other words, Jensen and Oldenburg [43] examined serious psycho- when compared to the established factor structure of CES-D logical stress among crewmembers of different nationalities the sample of Filipino seafarers’ conceptualisation of de- due to experiences of serious injuries or death of crewmates pression has certain distinctions from a Western sample. on board. The study argues that the experiences of serious Fernandez et al. [38] argued that this conceptualization injuries or death of crewmates are particularly distressing of depression has implications for the clinical diagnosis of to the Filipino crew with their strong sociocentric bonds and depression and depressive symptoms among Filipinos. They religious (i.e. Christian) values. Due to the dominance of argued that the communication of physical distress, particu- Roman Catholicism in the Philippines, chaplain or priestly larly when Filipinos do not differentiate between emotions or support is often needed to help Filipino seafarers cope with feelings and bodily discomfort might imply that these expres- serious psychological stresses [47]. sions may have significance when assessing their mental The work of Simon and Fernandez [44] explored mean- or psychological health. As noteworthy, the authors pointed ings of experiencing piracy based on the accounts of 3 Fil- out that among the respondents feeling disconnected from ipino seafarers. This qualitative phenomenological paper others is an important expression of their conceptualisation found out that seafarers ascribed 4 clusters of meanings of depression [38]. It appears that depression is viewed as to their piracy experiences, which are fear and hopeless- interpersonal because their study has shown that Filipinos ness, holding on to protocol, prayer as an automatic coping believe that the interpersonal integrates physical with psy- response, and the importance of the family, where the chological well-being where one’s self-conception includes thematic finding of fear and hopelessness appears to be the other. In effect, it is suggested that clinical diagnostics most salient among the participants [44]. of depression of Filipinos should afford the time and space In Lefkowitz and Slade [45], 1,572 seafarers were sur- for the examination of the client’s interpersonal context. veyed from various seafaring nationalities including 621 Fil- The third theme focuses on the experiences and concep- ipinos. Of these, 25% had scores suggesting depression, tions of Filipino mariners of their MH including the relation- 17% demonstrated anxiety, and 20% had suicidal ideation. ship of MH to their well-being. Research which falls under The work of Lefkowitz et al. [46] analysed 278 seafarer this theme are the report of the International Transport Fed- claims from various nationalities including 97 Filipinos. Us- eration (ITF) [40], Altaf Chowdhury et al. [16], Panganiban ing data representing 15% of global seafarers, a crude

188 www.intmarhealth.pl Sanley Salvacion Abila, Iris Lavalle Acejo, Review of seafarers’ mental health mental illness rate was calculated at 3.9 per 100,000 per- research limits the current understanding of the extent of son-years, which is probably an underestimate of the true MH problems for Filipino seafarers because of the practical burden of mental illness at sea. problems in conducting extensive MH research aboard ves- Lastly, a significant number of seafarers including Fil- sels. Nevertheless, the existing body of MH research taken ipinos are already facing negative consequences to their collectively as well as the enactment of the Philippine MH MH due to the on-going pandemic. These negative effects law are providing an urgency to advocate for the inclusion include coping with extended stay on board ships due to of MH in the education of Filipino seafarers and among difficulties in crew change owing to national travel restric- key stakeholders in the maritime sector, particularly the tions and having very few opportunities for shore leave government, employers, healthcare professionals, chap- when in ports. Four studies demonstrate various effects lains, and families of seafarers. Seafarers and aspiring of COVID-19 on seafarers’ MH including anxiety, mental seafarers must be provided with evidence-based data on exhaustion even depression due to extended contracts seafarers’ MH to promote, protect and support relevant MH working aboard vessels [48–51]. Of the 671 respondents in educational initiatives. the study of Pauksztat et al. [48], 32% are Filipinos. Among the respondents, 15.4% expressed being depressed almost DISCUSSION AND CONCLUSIONS daily, 21.9% claimed being anxious almost daily and 73.3% Despite the emerging evidence highlighted above, the said they are mentally exhausted [48]. In the work of Sliškov- scant research is a major problem in itself. The bulk of ić [49], 7.7% of the 752 respondents are Filipinos. Majority the current understanding of the MH problems of Filipino of the respondents report some negative effects of the seafarers relates to distress arising from piracy attack. Yet, pandemic related to their physical, social and economic MH problems have several facets (i.e. risk factors on board) well-being. These negative effects have repercussions on for which the quality of evidence is patchy both in terms health, work efficiency, safety on-board and financial well-be- of methodology and treatment design. The few sources ing of seafarers especially those who have not worked for of primary data on Filipino seafarers to date lack focus on an extended period [49]. mental health needs which makes it difficult to grasp the In summary, the available evidence describing Filipino extent of the problem. The situation regarding seafarers’ seafarers’ MH was presented in relation to three issues: disclosure of MH as well as disclosures of ship operators or mental illnesses as bases of seafarers’ repatriation, system companies suffers from inconsistent reporting and a lack of care for seafarers’ MH, and experiences or conceptions of a mandatory centralised database offers little help in of seafarers of MH. However, each of these areas were understanding repatriation and suicide rates. based on studies which offered very limited evidence, and The qualitative work alongside quantitative methods thus, it is very hard to come up with robust generalisations under the system of MH care highlighted areas crucial for or a broad picture of the MH of Filipino seafarers. For exam- understanding MH needs. However, the qualitative studies ple, Abaya et al.’s [24] medical repatriation data of Filipino are very few but some of these demonstrate that cultural seafarers based on aggregate level data of Manila-based conceptualisation of MH (e.g. depression) has implications manning agencies makes it difficult to gauge whether the for the clinical diagnosis of MH problems [38]. Hence, qual- pattern widely represents the norm. The publicly available itative approaches such as phenomenological research on list of manning agencies is incomplete in terms of several MH [44] are full of potentials in better understanding MH indicators such as organizational size and number of ships of seafarers because they are often times grounded on the or seafarers it handles for a certain reference year. As the subjective and cultural experiences and views of seafarers. available data from various maritime bodies and adminis- The evidence presented reflects a mosaic of necessary trations are not well organized, it has become difficult to interventions from different organizations. The lack of data, construct even the crudest measure of repatriation. however, on how work levels in terms of task, individuals, A couple of notable gaps in the existing literature per- team and organizational culture and its complex interaction tains to the lack of systematic recording and reporting with MH needs make it difficult to identify how these link of suicide cases for which the repatriation data cannot to MH distress. Unmet data needs at various levels: firms, provide a clear insight as a proxy indicator, and detailed maritime authorities and other agencies can provide the discussions of MH concerns of women seafarers (e.g. sexual necessary direction for both qualitative and quantitative harassment and MH). The disclosures of severe MH-related inquiries on seafarers’ MH conception, among others. The problems such as suicide or sexual harassment are stigma- kind of social support and adaptive coping mechanisms for tising experiences for seafarers who become vulnerable seafarers can highlight the quality of care required includ- to unfair labour practices. An implicit assumption of the ing how it can be best established and sustained as well shipboard environment as the natural setting to conduct MH as in what form of health services. The lack of foresight in

www.intmarhealth.pl 189 Int Marit Health 2021; 72, 3: 183–192 planning and policies aimed at primary prevention of MH A particular gap in MH research on Filipino seafarers for hamper appropriate interventions of emerging concerns. future researchers to consider is the need of a culture-based Developing policies and programmes for the MH educa- conceptualisation of mental illnesses. It can be recalled that tion of seafarers and other key maritime stakeholders are, researchers suggested an appropriate culture-based psycho- therefore, crucial for two broad reasons. Firstly, seafaring re- logical diagnostics and interventions for Filipino seafarers mains a dangerous and socially isolating occupation where [38]. For health care providers, the potential changes in psy- work-related accidents will likely continue and will be po- chological diagnostics of Filipino seafarers suggested here tentially traumatic to crewmembers. Secondly, research on must be incorporated in their clinical education and training occupational stressors of seafaring is increasingly providing as health care professionals and port chaplains are often evidence of their contributions to poor MH outcomes. Given times the first responders to traumatised seafarers. Lastly, this scenario, governments like in the Philippines and key future research should prioritise collecting robust data on maritime stakeholders appear to be duty bound to protect suicide among Filipino seafarers because its absence makes and support MH initiatives especially in educating seafarers. it very conspicuous and without it a broad and clear picture Ideally, maritime students and seafarers will be educat- of Filipino seafarers’ mental health is incomplete. ed in the basics of MH in the context of their work, so that they can be trained to manage not only their MH but their Conflict of interest: None declared health in general. The biomedical model of MH suggests that psychological problems are diseases of the brain [52]. This REFERENCES model has dominated the diagnosis and treatment of MH 1. World Health Organization. Promoting mental health: concepts, because it is the model which is the basis of mainstream emerging evidence, practice: a report of the World Health Orga- nization, Department of Mental Health and Substance Abuse in practice of the mental healthcare of seafarers. Developing collaboration with the Victorian Health Promotion Foundation and MH educational policies and programmes based on this the University of Melbourne. World Health Organization. 2005. model, which the literature refers to as psychoeducation 2. Galderisi S, Heinz A, Kastrup M, et al. Toward a new definition is arguably necessary for seafarers and their families not of mental health. World Psychiatry. 2015; 14(2): 231–233, doi: only after surviving traumatic episodes but also in daily life 10.1002/wps.20231, indexed in Pubmed: 26043341. routines. Psychoeducation means providing seafarers with 3. Republic Act 11036 or the Mental Health Act of the Philippines of 2018. Congress of the Republic of the Philippines. - basic information on probable impact of traumatic experi 4. Roberts SE, Nielsen D, Kotłowski A, et al. Fatal accidents and ences, coping strategies and other fundamental techniques injuries among merchant seafarers worldwide. Occup Med (Lond). that aid recovery from trauma. It involves identifying the 2014; 64(4): 259–266, doi: 10.1093/occmed/kqu017, indexed types of symptoms which may require additional support to in Pubmed: 24671028. every survivor of traumatic experiences along with targeted 5. Walters D, Bailey N. Lives in peril: Profit or safety in the global maritime industry? Springer, Hampshire, UK 2013. support and interventions designed to help seafarers with 6. Iversen RTB. The mental health of seafarers. Int Marit Health. 2012; more specific distress. 63(2): 78–89, indexed in Pubmed: 22972547. The biopsychosocial model of MH is a healthcare model 7. Sampson H, Ellis N. Seafarers’ mental health and wellbeing. IOSH 2019. where clinicians or caregivers offer a holistic approach to 8. Mellbye A, Carter T. Seafarers’ depression and suicide. Int Marit care where the biological, psychological and socio-cultural Health. 2017; 68(2): 108–114, doi: 10.5603/IMH.2017.0020, dimensions of mental illnesses are addressed simultane- indexed in Pubmed: 28660614. 9. Slišković A, Penezić Z. Occupational stressors, risks and health in ously by professional healthcare workers [53]. This model the seafaring population. Rev Psychology. 2016; 22(1-2): 29–39, attempts to bring the subjective experiences of illness of the doi: 10.21465/rp0022.0004. clients into clinical practice hence this model gives voice and 10. Dohrmann SB, Leppin A. Determinants of seafarers’ fatigue: power to the client and not just to the professionals [53]. a systematic review and quality assessment. Int Arch Occup Environ A biopsychosocial model is advocated by port chaplains Health. 2017; 90(1): 13–37, doi: 10.1007/s00420-016-1174-y, indexed in Pubmed: 27804037. because they argue that seafarers come from different 11. Hystad SW, Eid J. Sleep and fatigue among seafarers: the role cultures and religions where their concepts of relief from of environmental stressors, duration at sea and psychological distress, for example, can at times be influenced by their capital. Saf Health Work. 2016; 7(4): 363–371, doi: 10.1016/j. religions [47]. Thus, aside from the dominant biomedical shaw.2016.05.006, indexed in Pubmed: 27924241. model of MH, other models such as the biopsychosocial 12. Sampson H, Thomas M. The social isolation of seafarers: causes, model should also be part of the education of seafarers. To effects, and remedies. Int Marit Health. 2003; 54(1-4): 58–67, indexed in Pubmed: 14974778. recap, an MH education programme for seafarers should be 13. Seyle D, Fernandez K, Dimitrevich A, et al. The long-term impact informed by basic and different models of mental health- of maritime piracy on seafarers’ behavioral health and work care, which seafarers can actually use during their seafaring decisions. Marine Policy. 2018; 87: 23–28, doi: 10.1016/j.mar- careers. pol.2017.10.009.

190 www.intmarhealth.pl Sanley Salvacion Abila, Iris Lavalle Acejo, Review of seafarers’ mental health

14. Seyle DC, Bahri C, Brandt K. After the release: The long-term beha- 31. Oceans Beyond Piracy. The State of Maritime Piracy 2013. One Earth vioral impact of piracy on seafarers and families. One Earth Future Future Foundation, Broomfield, CO, USA; 2014. http://oceansbey- Foundation, Broomfield, CO 2016. ondpiracy.org/sites/default/files/attachments/SoP2013-Digital_0. 15. Ziello AR, Degli Angioli R, Fasanaro AM, et al. Psychological consequ- pdf (Last accessed 11 January 2021). ences in victims of maritime piracy: the Italian experience. Int Marit 32. Oceans Beyond Piracy. The State of Maritime Piracy 2014: Health. 2013; 64(3): 136–141, indexed in Pubmed: 24072540. Assessing the Economic and Human Cost. One Earth Future 16. Altaf Chowdhury SA, Smith J, Trowsdale S, et al. HIV/AIDS, health and Foundation, Broomfield, CO, USA; 2015. DOI: 10.18289/ wellbeing study among International Transport Workers’ Federation OBP.2015.001. http://oceansbeyondpiracy.org/sites/default/ (ITF) seafarer affiliates. Int Marit Health. 2016; 67(1): 42–50, doi: files/attachments/StateofMaritimePiracy2014.pdf (Last acces- 10.5603/IMH.2016.0009, indexed in Pubmed: 27029929. sed 11 January 2021). 17. Carter T. Working at sea and psychosocial health problems Report of 33. One Earth Future Foundation. The State of Maritime Piracy 2015: an International Maritime Health Association Workshop. Travel Med Assessing the Economic and Human Cost. One Earth Future Foun- Infect Dis. 2005; 3(2): 61–65, doi: 10.1016/j.tmaid.2004.09.005, dation, Broomfield, CO, USA; 2016. http://oceansbeyondpiracy. indexed in Pubmed: 17292007. org/sites/default/files/State_of_Maritime_Piracy_2015.pdf (Last 18. Oldenburg M, Jensen HJ. Stress and strain among merchant accessed 11 January 2021). seafarers differs across the three voyage episodes of port 34. One Earth Future Foundation. The State of Maritime Piracy 2016. stay, river passage and sea passage. PLoS One. 2019; 14(6): One Earth Future Foundation, Broomfield, CO, USA; 2017. http:// e0217904, doi: 10.1371/journal.pone.0217904, indexed in oceansbeyondpiracy.org/sites/default/files/one_earth_future_sta- Pubmed: 31163071. te_of_piracy_report_2017.pdf (Last accessed 11 January 2021). 19. Carotenuto A, Fasanaro AM, Molino I, et al. The Psychological 35. One Earth Future Foundation. The State of Maritime Piracy 2018. General Well-Being Index (PGWBI) for assessing stress of seafarers One Earth Future Foundation, Broomfield, CO, USA; 2018. https:// on board merchant ships. Int Marit Health. 2013; 64(4): 215–220, www.stableseas.org/sites/default/files/stateofpiracy2018_0.pdf doi: 10.5603/imh.2013.0007, indexed in Pubmed: 24408143. (Last accessed 11 January 2021). 20. Carotenuto A, Molino I, Fasanaro AM, et al. Psychological stress in 36. One Earth Future Foundation. The State of Maritime Piracy 2019. seafarers: a review. Int Marit Health. 2012; 63(4): 188–194, indexed One Earth Future Foundation, Broomfield, CO, USA; 2020. https:// in Pubmed: 24595974. www.stableseas.org/sites/default/files/stateofpiracy2019.pdf (Last 21. Baltic and International Maritime Council (BIMCO) and International accessed 11 January 2021). Chamber of Shipping (ICS). The Global Demand and Supply of Seafa- 37. Abila S, Tang L. Trauma, post-trauma, and support in the ship- rers in 2015. The Baltic and International Maritime Council (BIMCO) ping industry: The experience of Filipino seafarers after pirate and International Chamber of Shipping (ICS), 2015. attacks. Marine Policy. 2014; 46: 132–136, doi: 10.1016/j. 22. Bangko Sentral ng Pilipinas. Overseas Filipinos’ Cash Remittances. 2019. marpol.2014.01.012. 23. Philippine Overseas Employment Administration (POEA). Memoran- 38. Fernandez K, Seyle D, Simon E. The conceptualization of depression dum Circular No. 14, Series of 2018. Guidelines in the Repatriation among Filipino seafarers. J Pacific Rim Psychology. 2018; 12: e23, of Overseas Filipino Workers (OFWs) and Seafarers. doi: 10.1017/prp.2018.12. 24. Abaya AR, Roldan S, Ongchangco JC, et al. Repatriation rates in 39. Radloff LS. The CES-D scale: A self-report depression scale for re- Filipino seafarers: a five-year study of 6,759 cases. Int Marit Health. search in the general population. App Psych Measurement. 1977; 2015; 66(4): 189–195, doi: 10.5603/IMH.2015.0038, indexed in 1(3): 385–401, doi: 10.1177/014662167700100306. Pubmed: 26726888. 40. Maritime IT. A Broader Vision of Seafarer Wellbeing: Survey of ITF 25. Sanchez M. Emerging Mental cases. In: Jeżewska M, Iversen RT, Maritime Affiliates on HIV/Aids, Health and Wellbeing. ITF House, Leszczyńska I. MENHOB — Mental Health on Board. In 12th Interna- London 2015. tional Symposium on Maritime Health; 2013 Jun 6. Brest, France. 41. Panganiban AU, Garcia OB. Contributory to stress and fatigue of Int Marit Health. 2013; 64(3): 168–174. Filipino seafarers. Asia Pac J Marit Educ. 2017; 3(1): 1–14. 26. Bell SS, Jensen OC. An analysis of the diagnoses resulting in re- 42. McVeigh J, MacLachlan M. A silver wave? Filipino shipmates’ expe- patriation of seafarers of different nationalities working on board rience of merchant seafaring. Marine Policy. 2019; 99: 283–297, cruise ships, to inform pre-embarkation medical examination. Med doi: 10.1016/j.marpol.2018.10.012. Marit. 2009; 9(1): 32–43. 43. Jensen HJ, Oldenburg M. Potentially traumatic experiences of se- 27. Abaya A, Rivera J, Roldan S, et al. Does long-term length of stay on afarers. J Occup Med Toxicol. 2019; 14: 17, doi: 10.1186/s12995- board affect the repatriation rates of seafarers? Int Marit Health. 019-0238-9, indexed in Pubmed: 31164911. 2018; 69(3): 157–162, doi: 10.5603/imh.2018.0025. 44. Simon E, Fernandez K. The phenomenology of maritime piracy 28. Hurlburt K. The Human Cost of Somali Piracy. One Earth Future experiences of filipino seafarers. Psychological Studies. 2015; 61(1): Foundation, Broomfield, CO, USA; 2011. http://oceansbeyondpira- 40–47, doi: 10.1007/s12646-015-0348-0. cy.org/sites/default/files/human_cost_of_somali_piracy.pdf (Last 45. Lefkowitz R, Slade MD. Seafarer mental health study. ITF House, accessed 11 January 2021). London 2019. 29. One Earth Future. The Human Cost of Somali Piracy 2011. One Earth 46. Lefkowitz RY, Slade MD, Redlich CA. Rates and occupational charac- Future Foundation, Broomfield, CO, USA; 2012. http://oceansbey- teristics of international seafarers with mental illness. Occup Med ondpiracy.org/sites/default/files/economic_cost_of_piracy_2011. (Lond). 2019; 69(4): 279–282, doi: 10.1093/occmed/kqz069, pdf (Last accessed 11 January 2021). indexed in Pubmed: 31094424. 30. Hurlburt K. The Human Cost of Somali Piracy 2012. One Earth 47. Palmer T, Murray E. “Christ offered salvation, and not an easy life”: Future Foundation, Broomfield, CO, USA; 2013. doi: 10.18289/ How do port chaplains make sense of providing welfare for seafa- OBP.2013.001. https://oefresearch.org/sites/default/files/docu- rers? An idiographic, phenomenological approach analysis. Int Marit ments/publications/hcop2012forweb_6.pdf (Last accessed 11 Health. 2016; 67(2): 117–124, doi: 10.5603/IMH.2016.0022, January 2021). indexed in Pubmed: 27364178.

www.intmarhealth.pl 191 Int Marit Health 2021; 72, 3: 183–192

48. Pauksztat B, Grech M, Kitada M, et al. Seafarers’ experiences 51. Hebbar AA, Mukesh N. COVID-19 and seafarers’ rights to shore leave, during the COVID-19 pandemic: Report. 2020, doi: 10.21677/ repatriation and medical assistance: a pilot study. Int Marit Health. wmu20201213. 2020; 71(4): 217–228, doi: 10.5603/IMH.2020.0040, indexed in 49. Slišković A. Seafarers’ well-being in the context of the COVID-19 Pubmed: 33394486. pandemic: A qualitative study. Work. 2020; 67(4): 799–809, doi: 52. Deacon BJ, McKay D. The biomedical model of psychological pro- 10.3233/WOR-203333, indexed in Pubmed: 33325430. blems: A call for critical dialogue. Lancet. 2015; 16: 2–3. 50. Stokes J, Arslan, V. (2020) Maritime Welfare Survey. Paper 53. Borrell-Carrió F, Suchman AL, Epstein RM. The biopsychosocial presented at World Maritime University’s webinar entitled model 25 years later: principles, practice, and scientific inquiry. Ann “Understanding the Effects of COVID19 on Seafarers” on 25 Fam Med. 2004; 2(6): 576–582, doi: 10.1370/afm.245, indexed November 2020. in Pubmed: 15576544.

192 www.intmarhealth.pl Int Marit Health 2021; 72, 3: 193–194 10.5603/IMH.2021.0036 www.intmarhealth.pl Copyright © 2021 PSMTTM SHORT COMMUNICATION ISSN 1641-9251 eISSN 2081-3252 Face-to-face versus distance learning in a seaside area: the teacher’s point of view

Antonella Centonze1, Rosa Anfosso2, Roberta Pujia3, Stefania Zampogna4, Domenico Sinopoli5, Ilaria Prosperi Porta6, Emanuele Baldassarre7

1Department of Paediatric Surgery, Pugliese-Ciaccio Hospital, Catanzaro, Italy 2Department of Health Promotion ASP, Catanzaro, Italy 3Department of Medical Sciences, University of Catanzaro “Magna Grecia”, Italy 4Department of Paediatric, Pugliese-Ciaccio Hospital, Catanzaro, Italy 5Department of Oncology, Pugliese-Ciaccio Hospital, Catanzaro, Italy 6Department of Emergency Medicine, ASL Valle d’Aosta, Italy 7Department of Andrology and Paediatric Urology, ASL Valle d’Aosta, Italy

ABSTRACT The total or partial replacement of face-to-face teaching with distance teaching brings a number of problems for teachers, children and families. Recently, in our province in Southern Italy, in a seaside area, we conducted a survey to assess the experiences of high school teachers faced with distance learning during the COVID-19 pandemic, with the purpose of examining the real impact of these dramatic changes, both from social and health perspectives. From the preliminary aspects of this survey it emerges that it is difficult to univocally consider the effectiveness of distance learning in such a complex territory, especially in a seaside area. This experience will serve us to reflect in the future on a school tailored to the individual student by a permanent integration of face-to-face forms with distance learning. (Int Marit Health 2021; 72, 3: 193–194) Key words: COVID-19, distance learning, survey, seaside area

Recently we read some recently published articles about ences of high school teachers faced with distance learn- the effects of the pandemic on the school population, such ing during the coronavirus disease 2019 (COVID-19) as education loss, increasing mental health disorders, pandemic, with the purpose of examining the real impact lack of physical activity, possibly developing negative be- of these dramatic changes, both from social and health haviours up to violence and abuse [1]. The total or partial perspectives. A questionnaire containing 18 questions, replacement of face-to-face teaching with distance teaching closed-ended and multiple-choice, were administered to brings a number of problems for teachers, children and the teachers of 4 high schools of Catanzaro city (I) and families. From worldwide experience, the main reported province, for a total of 167 persons. 54% of teachers be- problems are: the lack of teacher’s authority, the socio- longed to a humanistic/linguistic area, 27% scientific and economic gap of children who are economically deprived technological, 8% historical-social-religious, 11% mixed. and with difficulties in accessing online education, like the Almost all of the teachers (98%) activated the distance availability of a computer suitable for education, internet learning using video and audio lessons, giving homework, access, difficulties in concentrating in the crowded home questionnaires and online tests. 75% of the teachers used environment [2, 3]. films and documentaries. The distance learning dialogue Recently, in our province in Southern Italy, in a sea- with students is judged good by 47%, teachers, sufficient side area, we conducted a survey to explore the experi- by 40%, insufficient/medium by 8% and excellent by only

Emanuele Baldassarre, MD, Umberto Parini Hospital, Department of Andrology and Paediatric Urology, Viale Ginevra 3 11100 Aosta, Italy, tel: +390165543272, * e-mail: [email protected] This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

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5% of teachers. The scholastic commitment of the children one. Another very important aspect for distance learning is was judged excellent by 4%, good by 45%, sufficient by represented by the geographical characteristics of the ter- 49% and totally insufficient by 6% of the teachers. 44% of ritory. In our area there is a lot of unevenness as it passes teachers did not prepare specific activities or materials for from mountainous areas that are difficult to access to port students with special educational needs. The main highlight- and marine areas. ed problems in the teacher-student relationship were the Our region has some peculiarities compared to the Ital- difficulty of communication (30%), difficulty in interaction ian territory and the presence of distance learning requires with the individual student and with the class group (30%). a considerable investment of public funds. Unlike many A consequent lack of interest and motivation was reported regions of a more industrial nature in Central and Northern in 28% of interviewed teachers. The commonest reported Italy, the territory completely interfaces with the social fabric technical difficulties were the slow or insufficient internet typical of port cities and mass summer tourism. The invest- connection (39%), lack of scholastic guidelines and clear ment of public funds for the school system should protect references (11%), and for a small percentage difficulty in above all the most disadvantaged areas, characterized by using the tools and lack of a computer or tablet (4%). In migratory phenomena. conclusion, 54% of teachers affirmed to have totally revised This experience will serve us to reflect in the future on the teaching methods, while 19% have tried to adapt them. a school tailored to the individual student by a permanent In light of the raw data emerging from this interview, it integration of face-to-face forms with distance learning. appears a great effort has been made by the teachers to adapt themselves to the situation in a short time. Beyond Conflict of interest: None declared the technical aspects, such as the lack of homogeneity in the territory of the internet connection and the specific REFERENCES skills, the more relevant aspect is the difficulty in building 1. Hacımustafaoğlu M. COVID-19 and re-opening of schools: Opinions a tailored approach for the single realities within a school, or with scientific evidence. Turk Pediatri Ars. 2020; 55(4): 337–344, doi: 10.14744/TurkPediatriArs.2020.90018, indexed in Pubmed: even for the single students within a single class. However, 33414650. it remains utopian to create common guidelines worldwide. 2. Fantini MP, Reno C, Biserni GB, et al. COVID-19 and the re-opening Within a single region or nation, as in our case, there is an of schools: a policy maker’s dilemma. Ital J Pediatr. 2020; 46(1): extreme differentiation and different degrees of experience 79, doi: 10.1186/s13052-020-00844-1, indexed in Pubmed: and resilience of the student population. In developed west- 32517815. ern states, countries with a low population density such as 3. Lakha F, King A, Swinkels K, et al. Are schools drivers of COVID-19 infections-an analysis of outbreaks in Colorado, USA in 2020. J Public the United States or Australia have a greater confidence in Health (Oxf). 2021 [Epub ahead of print], doi: 10.1093/pubmed/ distance learning than European realities such as the Italian fdab213, indexed in Pubmed: 34179987.

194 www.intmarhealth.pl Int Marit Health 2021; 72, 3: 195–198 10.5603/IMH.2021.0037 www.intmarhealth.pl Copyright © 2021 PSMTTM ORIGINAL ARTICLE ISSN 1641-9251 eISSN 2081-3252 The relationship between work environment and occupational accidents among fishermen in Indonesian coastal areas

Putri Ayuni Alayyannur, Shintia Yunita Arini

Department of Occupational Safety and Health, Faculty of Public Health, Universitas Airlangga, C Campus, Mulyorejo, Surabaya, East Java, Indonesia

ABSTRACT Background: Two-thirds of Indonesia’s territory is water, creating much of the coastal area. Unfortunately, there is no data regarding the exact number and demographics of the population in coastal areas who work as fishermen. Residents who work as fishermen are at risk of work accidents. The increasingly uncertain number of fishermen makes it more difficult to analyse work accidents around the coastal areas. This study is an observational study and cross-sectional study. It aims to analyse the relationship between work environment and occupational accidents among fishermen in coastal areas. Materials and methods: It was conducted using a quantitative approach. This study was located in the coastal areas in Sidoarjo, Tarakan, and Bangkalan. Sampling was conducted using snowball technique which obtained 56 respondents. Variables in this study included work climate, noise, lighting, and occupational accidents with data analysis using the Spearman’s rank test. Results: The results showed that work environment which included work climate, noise, and lighting had no relationship with occupational accidents among fishermen since p-value > 0.05. Conclusions: This study concludes that work climate, noise and lighting have no significant relationship with occupational accidents. (Int Marit Health 2021; 72, 3: 195–198) Key words: work environment, occupational accidents, fishermen

INTRODUCTION Sepulu, Socah, Tanah Merah, Tanjungbumi, and Tragah Two-thirds of Indonesia’s territory is water, creating sub-districts. There are 10 of the 18 sub-districts border- much of the coastal area. There is no data regarding ing the sea and have an altitude of 2–100 m above sea the exact number and demographics of the population level. Sidoarjo area borders Madura Strait in the east. in coastal areas who work as fishermen. It is difficult to In general, the coastal area of Sidoarjo has many rivers collect data on the number of fishermen because they are that flow out into the Java Sea. Tarakan City is one of the sometimes ashamed with their job status as fishermen. areas in the northern part of East Kalimantan Province. Three of the coastal areas in Indonesia are the coasts of It has a total area of 657.33 km2 consisting of 38.2% of Madura, Sidoarjo and Tarakan. land and 61.8% or 406.53 km of oceans. This shows that Furthermore, Bangkalan Regency is located on the most of this area is water or coastal areas. island of Madura which consists of 18 sub-districts: Aros- In fact, occupational accidents in one industry have baya, Bangkalan, Blega, Burneh, Galis, Geger, Kamal, caused considerable losses to business owner. The disad- Klampis, Kokop, Konang, Kwanyar, Labang, Modung, vantage is of course even greater if the business owner has

Dr. Putri Ayuni Alayyannur, Department of Occupational Safety and Health, Faculty of Public Health, Universitas Airlangga, C Campus, Mulyorejo, Surabaya, East Java, * Indonesia, e-mail: [email protected]

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several industries. Thus, aspects of Occupational Safety and 1. Ever had an accident at work. Health (K3) in informal industry need to be encouraged. a. Yes b. No Occupational accidents and diseases can be minimised by the presence of K3 among informal sector workers, 2. Have had an accident while traveling to or from work. including fishermen. The more it is underestimated, the a. Yes b. No more fishermen experience occupational accidents. This is 3. When did the accident occur? ...... exacerbated by the large number of work accidents in in- 4. In the last 6 months, how many times have you had an formal sector that have not been recorded and recognised. accident at work?...... This study aims to analyse the relationship between 5. Mention the type of work accident! work environment and occupational accidents among fish- a...... date...... ermen in coastal areas. Work environment in this study is b...... date...... the fishermen’s perception of work climate, noise, lighting 6. Do you feel disturbed by the working climate conditions in while working. your workplace? a. Yes b. Not MATERIALS AND METHODS 7. Are you bothered by noise conditions in your workplace? This study is a quantitative research with observational a. Yes b. Not research type. It is a cross-sectional study, which was located in the coastal area of Sidoarjo Regency, Tarakan City, 9. Are you bothered by the lighting conditions in your work environment? and Bangkalan Regency. Population in this study were all fishermen in coastal a. Yes b. Not areas in Sidoarjo, Tarakan City, and Bangkalan Regency. By Figure 1. Questionnaire using snowball sampling technique, 56 respondents were obtained. This study has obtained Ethical Clearance No. 84/EA/KEPK/2020 from Health Research Ethics Commit- Table 1. Frequency distribution of work climate in the coastal tee, Faculty of Public Health, UNAIR. areas of Sidoarjo, Madura, and Tarakan in 2020 We conducted interviews with a questionnaire guide that Category Frequency Percentage (%) had been made based on Figure 1; this was because not all Work climate fishermen who were respondents in this study could read Disturbed 52 92.9 and write. Interviews were conducted by one person who had been trained by researchers so as to minimise bias. We Undisturbed 4 7.1 tested the validity and reliability before this research was Total 56 100.0 conducted on 15 respondents. The results showed that all Noise questionnaires were valid and reliable. Disturbed 49 87.5 Variables in this study included work climate, noise, Undisturbed 7 12.5 lighting, and occupational accidents. The data obtained Total 56 100.0 were then analysed. Data analysis was performed using data processing software. Significance test between the Lighting two variables was carried out using the Spearman’s rank Disturbed 54 96.4 test. This was conducted to determine degree of closeness Undisturbed 2 3.6 of the relationship between questionnaire results for one Total 56 100.0 variable and questionnaire results for other variables. There is no relationship between one variable and another if the level of significance (p value > 0.05). it can be seen that the majority of respondents (87.5%) stated that they were disturbed by noise in their work RESULTS environment in the coastal areas of Sidoarjo, Madura, Work climate in this study was divided into two catego- and Tarakan. ries: disturbed and undisturbed. Table 1 shows that most Additionally, lighting in this study was divided into respondents (92.9%) felt disturbed by work climate in their two categories: disturbed and undisturbed. Based on work environment in the coastal areas of Sidoarjo, Madura, Table 1, it can be concluded that most of the respondents and Tarakan. (96.4%) stated that they were disturbed by lighting in work More importantly, noise in this study was divided into two environment in the coastal areas of Sidoarjo, Madura, categories: disturbed and undisturbed. Based on Table 1, and Tarakan.

196 www.intmarhealth.pl Putri Ayuni Alayyannur, Shintia Yunita Arini, The relationship between work environment and occupational accidents among fishermen

Table 2. Analysis of the relationship between work environ- by work climate in the workplace. However, there was only ment factors and occupational accidents among fishermen in a minority of fishermen who had experienced occupational the coastal areas of Sidoarjo, Madura, and Tarakan in 2020 accidents both at work and on their way. Based on the anal- Occupational Conclusion ysis of the relationship, there was no relationship between accidents work climate and occupational accidents. Work climate Several studies have shown that work climate, espe- Correlation coefficient –0.132 Not significant cially hot weather, has a positive but inappropriate rela- Sig. (2-tailed) 0.334 tionship with occupational accidents. This is because the possible mechanism is that hot weather can cause fatigue, Noise decreased psychomotor abilities, loss of concentration, Correlation coefficient –0.239 Not significant and decreased alertness that can lead to occupational Sig. (2-tailed) 0.076 accidents [1]. It is in line with a research conducted at Lighting a construction company which shows a relationship be- Correlation coefficient 0.122 Not significant tween work environment temperature and work stress [2]. Sig. (2-tailed) 0.372 Moreover, a research conducted on workers in ship repair in a company shows that work climate affects the occurrence of work fatigue [3]. Therefore, although most fishermen in the coastal areas of Sidoarjo, Madura, and Tarakan claimed that they were disturbed by work climate, there was actually no relationship between work climate and occupational accidents since there were mechanisms having a greater role in occupational accidents.

THE RELATIONSHIP BETWEEN NOISE AND OCCUPATIONAL ACCIDENTS The majority of fishermen in the coastal areas of Sido- arjo, Madura and Tarakan claimed that they were disturbed by noise at work, but there was only a minority of fishermen who had experienced occupational accidents both at work and on their way. Thus, there was no relationship between noise and occupational accidents. Results of a research conducted on workers in spinning companies show that noise has a strong relationship with work stress [4]. It is supported by a research conducted on workers in body frame in a company which shows a relationship between noise and work stress [5]. In addition, Figure 2. The boats on shore located for the daylight noise also has a significant relationship with worker fatigue in machine-building companies [6]. Based on these studies, Environmental factors in this study consisted of work it can be seen that noise has a relationship with work stress climate, noise, and lighting. Based on the Spearman’s rank and fatigue. However, the noise stated to be disturbing by test in Table 2, it was shown that those three environmental fishermen in the coastal areas of Sidoarjo, Madura, and factors had no relationship with occupational accidents since Tarakan had no significant relationship with work acci- the overall p-value is greater than 0.05. Based on Figure 2, dents. This is probably due to other mechanisms caused by the lighting for fishermen are coming from the sun (daylight) noise that can affect occupational accidents, so that noise and moon (night). Thus, work environment factors in this does not directly affect work accidents. Therefore, it is very study had no relationship with occupational accidents. important to control noise in the workplace.

DISCUSSION THE RELATIONSHIP BETWEEN LIGHTING THE RELATIONSHIP BETWEEN WORK CLIMATE AND OCCUPATIONAL ACCIDENTS AND OCCUPATIONAL ACCIDENTS The majority of fishermen in the coastal areas of Sidoar- The majority of fishermen in the coastal areas of Sido- jo, Madura and Tarakan claimed that they were disturbed by arjo, Madura and Tarakan claimed that they were disturbed lighting in the workplace. However, there was only a minority

www.intmarhealth.pl 197 Int Marit Health 2021; 72, 3: 195–198 of fishermen who had experienced occupational accidents lighting have no significant relationship to occupational both at work and on their way. Based on the analysis of the accidents since p value > 0.5. relationship, there was no relationship between lighting and occupational accidents. Conflict of interest: None declared Unsuitable lighting can interfere with visual comfort and are an indirect cause of occupational accidents [7]. REFERENCES Results of a research conducted on informal workers in 1. Varghese B, Hansen A, Bi P, et al. Are workers at risk of occupational market indicate that lighting has a significant relationship injuries due to heat exposure? A comprehensive literature review. Safety Science. 2018; 110: 380–392, doi: 10.1016/j.ssci.2018.04.027. with the incidence of knife cuts [8]. However, this is contrary 2. Lukas L, Suoth L, Wowor R. Hubungan antara Suhu Lingkungan Kerja to results of this study on fishermen in the coastal areas of dan Jam Kerja dengan Stres Kerja di PT Adhi Karya (Persero) Tbk Unit Ma- Sidoarjo, Madura, and Tarakan, which found that lighting nado Proyek Universitas Sam Ratulangi. Jurnal Kesmas. 2018; 7(4): 1–9. in the workplace had no relationship with occupational ac- 3. Suryaningtyas Y, Widajati N. Iklim Kerja Dan Status Gizi Dengan Kele- cidents. It is in line with a research conducted on musical lahan Kerja Pada Pekerja Di Ballast Tank Bagian Reparasi Kapal Pt. instrument craftsmen in a village which shows that there X Surabaya. Jurnal Manajemen Kesehatan Yayasan RS.Dr. Soetomo. 2017; 3(2): 225, doi: 10.29241/jmk.v3i1.83. is no significant relationship between lighting and occupa- 4. Budiawan W, Ulfa E, Andarani P. Analisis Hubungan Kebisingan Mesin tional accidents [9]. dengan Stres Kerja (Studi KAsus: Mesin Two for One Twister (TFO) PT Lighting in the fishermen’s workplace does not show XYZ). Jurnal Presipitasi. 2016; 13(1): 1–7. a significant relationship with occupational accidents 5. Amir J, Wahyuni I, Ekawati C. Hubungan Kebisingan, Kelelahan Kerja, since there may be other factors that have a significant dan Beban Kerja Mental terhadap Stres Kerja pada Pekerja Bagian Body Rangka PT X. Jurnal Kesehatan Masyarakat. 2019; 7(1): 345–350. relationship. However, it is still necessary to improve 6. Suryaatmaja A, Pridianata VE. Hubungan antara Masa Kerja, Beban the quality of lighting considering that the majority of Kerja, Intensitas Kebisingan dengan Kelelahan Kerja di PT Nobelindo fishermen felt disturbed with bad lighting while working. Sidoarjo. Journal of Health Science and Prevention. 2020; 4(1): 14–22, Suitable lighting can support fishermen’s productivity at doi: 10.29080/jhsp.v4i1.257. work [10]. 7. Sawicki D, Wolska A. Objective assessment of glare at outdoor workpla- ces. Building and Environment. 2019; 149: 537–545, doi: 10.1016/j. buildenv.2018.12.049. WEAKNESSES AND STRENGTHS OF RESEARCH 8. Suwignyo S, Dhina D, Rahayu S. Hubungan Faktor Penyebab Kece- The weakness in this study is the data collection tech- lakaan Kerja dengan Kejadian Tersayat pada Pembersih Bawang di nique used so that the number of respondents obtained is Pasar Segiri dan Pasar Kedondong Samarinda. KESMAS UWIGAMA: only small. It is necessary to expand the criteria in taking Jurnal Kesehatan Masyarakat. 2019; 4(2): 79, doi: 10.24903/ kujkm.v4i2.466. research respondents so that the number can be greater. 9. Juliana, Purna I, Aryana I. Faktor-Faktor yang Berhubungan dengan The advantage of this research is the provision of research Kecelakaan Kerja pada Pengrajin Gong di Dusun Tihingan, Ka- enumerators so that fishermen who cannot read and write bupaten Klungkung Tahun 2018. Jurnal Kesehatan Lingkungan. can still be involved in this research. 2018; 8(2): 82–91. 10. Hoffman G, Guvler V, Griesmacher A, et al. Effects of variable lighting intensities and colour temperatures on sulphatoxymelatonin and sub- CONCLUSIONS jective mood in an experimental office workplace. Appl Ergon. 2008; Based on the results of the Spearman’s rank test, work 39(6): 719–728, doi: 10.1016/j.apergo.2007.11.005, indexed in environment factors including work climate, noise, and Pubmed: 18164275.

198 www.intmarhealth.pl Int Marit Health 2021; 72, 3: 199–205 10.5603/IMH.2021.0038 www.intmarhealth.pl Copyright © 2021 PSMTTM REVIEW ARTICLE ISSN 1641-9251 eISSN 2081-3252 Occupational noise exposure and health impacts among fish harvesters: a systematic review

Om Prakash Yadav1 , Atanu Sarkar1 , Desai Shan1 , Arifur Rahman1 , Lorenzo Moro2, 3

1Division of Community Health and Humanities, Faculty of Medicine, Memorial University, St. John’s NL A1B 3V6, Canada 2Department of Ocean and Naval Architectural Engineering, Memorial University of Newfoundland, St. John’s NL A1B 3X5, Canada 3SafetyNet Centre for Occupational Health and Safety Research, Memorial University of Newfoundland, St. John’s NL A1B 5S7, Canada

ABSTRACT Background: Occupational noise exposure has been identified as a significant risk factor for fish harvesters. Chro- nic noise exposure causes hearing and other health problems and undermines the quality of life and well-being. This review paper aims to highlight noise-related auditory and non-auditory health effects among fish harvesters. Materials and methods: A systematic literature search approach was adopted using the following databases: PubMed, Embase, SCOPUS, Web of Science, Google Scholar, and by exploring grey literature. The literature search was conducted in 2020 (between October 15 and November 30). Relevant articles were explored by reviewing title, keywords, and abstract based on the inclusion and exclusion criteria. The full-text critical review of selected papers was made and finalized the most relevant studies. Results: Initial 1,281 records were identified, exploring various databases and additional sources using relevant keywords. Duplicate articles were removed and retrieved 746 articles. After that, a screening of 746 research papers was done based on the selection criteria and finalised 28 articles for full-text review. Finally, articles were filtered based on the study’s aim and extracted 17 papers for the final review. Conclusions: Noise-induced hearing loss was considered a significant health risk to fish harvesters across the studies, affecting physical and emotional well-being. The prevalence of hearing loss was observed from 6% to 80%. Other health problems, such as headache, dizziness, annoyance, stress, fatigue, elevated blood pressure, sleep disturbances, and impaired cognitive performance, were also reported. Further research is needed to validate the non-auditory health effects among fish harvesters. (Int Marit Health 2021; 72, 3: 199–205) Key words: occupational noise exposure, hearing loss, noise-induced hearing loss, tinnitus, sound pressure level, fish harvesters

INTRODUCTION are powered by the motorised engine, and 98% are smaller The fishing industry employs millions of people and than 24 m in length overall [2]. plays a significant role in economic growth and development The fishing sector involves high risk and frequent oc- worldwide [1]. Around 60 million people are engaged in the cupational-related accidents [3–5]. Fish harvesters face fisheries and aquaculture sectors, and more than half are adverse working conditions that affect their health and in fishing [2]. The global fishing fleet covers approximately well-being. Fishing workers are at increased risk of exposure 5 million vessels, including small non-motorised to large to infectious agents, chemicals and toxins, physical and industrial vessels. About two-thirds of total fishing vessels psychological hazards [5–8].

Dr. Om Prakash Yadav, Division of Community Health and Humanities, Faculty of Medicine, Memorial University, St. John’s NL A1B 3V6, Canada, 41 Allandale Road, * St. John’s, Newfoundland and Labrador, A1B2Z8 Canada, tel/fax: +1 (709)770-6592, e-mail: [email protected]

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Noise has been identified as a significant physical ELIGIBILITY CRITERIA hazard to fish harvesters [9–11]. On-board noise control Eligibility criteria were established before the literature regulations at small fishing vessels are inconsistent, frag- search following the Population, Intervention (Exposure), Com- mented, and often voluntary. The International Labour parator, Outcome, and the Study design (PICOS) framework: Organization, International Maritime Organization, and — Population: Fish harvesters aged 16 years or older with Food and Agriculture Organization of the United Nations occupational exposure to noise; have not specified any noise limits for fishing vessels; — Intervention/exposure: Occupational exposure of noise; however, some practical guidelines are described for fish — Comparator: Fish harvesters not exposed to noise; owners/operators and crew members [3]. Organizations — Outcomes: Adverse auditory and non-auditory health ef- in the United States (National Institute of Occupational fects; Safety and Health [NIOSH], Occupational Safety and Health — Study design: Any quantitative or qualitative studies, e.g., Administration, United States Coast Guard) recommend cross-sectional, reviews, cohort/observational, qualita- 8 hours noise exposure limits for commercial fishing boats: tive studies except case studies/case series, editorial, 90, 85, and 90 decibel (dB), respectively [12–14]. When news articles, conference abstracts, or book reviews. the sound level exceeds 85 dB, it is considered harmful to human health, and the impact gets further worsened de- LITERATURE SEARCH pending on the duration, systematic exposure, frequency, The search strategy was developed by O.P. and A.R. intensity, and existing risk factors in the exposed popula- and peer-reviewed by other writers using the PRESS check- tion such as gender, ethnicity, individual susceptibility, and list [18]. Database searches were conducted in PubMed the presence of other physical, chemical, and biological (MEDLINE), Embase SCOPUS, Web of Science, and Google agents [15]. Scholar during October 15 to November 30, 2020, and Reviews describing occupational noise exposure and its included human studies published in the English language. adverse health impacts among fish harvesters are scarce. A secondary search was also carried out, exploring the “In- As per the literature search, no systematic review was con- ternational Maritime Health” journal and the reference list of ducted to highlight both auditory and non-auditory health selected articles. (Full search strategy in the Supplementary effects of noise among fish harvesters. Collective informa- file: Suppl. Table S1 and Suppl. S2, see journal website). tion regarding this issue is highly desirable to researchers, stakeholders, policymakers, private and public organiza- STUDY SELECTION, DATA EXTRACTION, tions working in this field to improve the occupational health QUALITY ASSESSMENT and safety regulations and awareness in reducing the risk The PICOS criteria were used to assess the eligibility of of noise exposure in fish harvesters. the studies. Standardised screening questionnaires were This review paper provides an overview of noise ex- developed before the title/abstract (level 1) and full-text (lev- posure and its auditory and non-auditory health impacts el 2) screening. Prior to screening both level 1 and level 2, among fish harvesters. Considering the significance of pilot-testing was carried out with the review team (O.P., noise-related health impacts in the fishing population, we A.R., A.S., D.S., and L.M.) to refine the screening ques- proposed the following research question: What are the oc- tionnaires and ensure consistency. A full screening of an cupational noise-induced auditory and non-auditory health article proceeded if at least 70% agreement was received effects among fish harvesters worldwide? A systematic among reviewers. review was conducted to fill this existing knowledge gap Pairs of reviewers screened the articles independently through collecting, compiling, and describing the published for titles and abstracts and full-text articles. Any disagree- evidence to highlight occupational noise exposure and re- ment between the pairs of reviewers was resolved by the lated auditory and non-auditory health problems among fifth reviewer (L.M.). A standardised form related to the fish harvesters. study design (e.g., sample size, study setting), participant characteristics (e.g., age, sex, type of health effects, du- MATERIALS AND METHODS ration of illness), exposure (e.g., form and duration of PROTOCOL noise exposure), and outcomes (e.g., auditory effects, A protocol and work plan had been developed prior to other health effects) was developed for data abstraction, the review using the guidance provided in the Preferred which was pilot tested by reviewers. The same process of Reporting Items for Systematic Reviews and Meta-Analy- levels 1 and 2 reviewing was used for the data abstrac- sis for the Protocols (PRISMA-P) [16]. For the systematic tion form. The Newcastle Ottawa Scale (NOS) was used review, PRISMA statement was used to guide the reporting to evaluate the quality of the studies [19]. Each variable of results [17]. on the NOS (study sample, methods used, comparability

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Records identified through Additional records identified databases (PubMed, Scopus, through other sources (Journal EMBASE, Web of Science, of International Maritime and Google Scholar) Health, reference tracing of searching (n = 1278) selected papers, of (n = 3) Identification

Records after duplicates removed (n = 746)

Records excluded (n = 718); Records screened — Due to irrelevant topics (n = 685) (n = 746) — Not related to fish harvesters (n = 28)

Screening — Articles not in English (n = 5)

Full-text articles excluded with reasons Full-text articles assessed (n = 11); for eligibility — Not recorded health effect (n = 8) (n = 28) — Health impact only mentioned in the literature (n = 3) Eligibility

Studies included in qualitative synthesis (n = 17)

Studies included in

Included quantitative synthesis (systematic review) (n = 17)

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analysis for the Protocols (PRISMA-P) 2009 flow diagram pre- senting screening of articles of groups, and exposures and outcomes of interest) was sidered potentially relevant documents for further review. given a score from 0 to 10, with ‘10’ and ‘0’ indicating the After the level 2 screening, 17 publications were included highest and lowest quality, respectively (Suppl. Table S3, for data synthesis (Fig. 1). Population characteristics, pub- see journal website). The reviewers also conducted a pi- lication year, methods, and major outcomes of various lot-test of the quality appraisal tool prior to completing studies selected for the review are summarised in Tables the appraisal. 1 to 3. The majority of study designs were cross-sectional (n = 14; 82.35%) [20–22, 24–28, 30–32, 34–36], followed DATA SYNTHESIS OF THE INCLUDED STUDIES by reviews (n = 2; 11.76%) [23, 29] and interventional (n = 1; Data were synthesized descriptively and presented in 5.88%) [33]. The included studies were published from tables to provide a summary of the available evidence. The 2008 to 2020, and the majority of those were conducted review team considered a meta-analysis; however, due to in the United States (n = 5) [21, 23, 33–35]. The remaining a lack of detailed outcome information (e.g., effect esti- were from Brazil (n = 4), Denmark (n = 2), Indonesia (n = 2), mates not provided) and a high degree of heterogeneity in and one each from India, Italy, Spain, New Zealand [20, 22, outcomes, quantitative synthesis was not possible. 24–32, 36]. Sample sizes ranged from 13 to 3702 participants [27, 30]. RESULTS DESCRIPTION OF RELEVANT ARTICLES QUALITY APPRAISAL RESULTS The initial literature search resulted in 1281 articles. Af- The quality of the studies ranged from satisfacto- ter removing 532 duplicates, 746 titles and abstracts were ry to good studies because of several methodological included for the level 1 screening. Of these, 28 were con- limitations. The quality of some studies [22, 24, 27,

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Table 1. Studies describing noise exposure levels and auditory health impacts among fish harvesters

Co- Year Demographic Methods Outcome untry information [Refe- (N, gender, rence] age) Brazil 2009 141, male, SPLs, audiometric • SPLs recorded 38–58 dB (A) and 90–108 Leq dB (A) in vessels with and [20] 18–77 years test, questionnaire without an engine, respectively survey • Hearing impairment (82–90%) and sensorineural hearing loss (26%) in engine room personnel United 2016 227, male SPLs, audiometric • Noise level (94.8 to 105 dB (A)) in engine room States (191), testing, compre- • NIHL was associated with length of employment (not with age) [21] female (31), hensive survey • Hearing impairment was associated with age (not with length of fishing) ≥ 21 years Indo- 2017 186, male SPLs, hearing • Noise level exceeded the threshold recommended limit (> 85 dB) nesia function test, qu- in around two-third of participants [22] estionnaire survey • Hearing loss (60.2%) including regular • > 90% participants did not use earplugs use of earplugs • Significant relationship between earplug use and the degree of hearing loss United 2018 52 ma- Assessment of • Noise exposure ranged from 56 to 114 dBA States nuscripts occupational health • Noise exposure was considered a global risk irrespective of vessel size [23] risk factors Indo- 2019 40, male, SPLs, audiometric • Mean noise intensity (101.7 ± 2.342 dB) nesia ≥ 21 years testing • Prevalence of hearing loss in 97.50% ears [24] • Positive relationship of hearing loss with age, working period, and noise intensity Italy 2019 108, male, 49 Self-reported health • Highest SPL (106 and 109 dBA) observed in engine compartment [25] years (average) conditions and as- • Lowest SPL (70.5 and 78.8 dBA) was recorded in the sleeping berth sessment of noise • Low-frequency sounds can cause acoustic damage exposure levels Brazil 2020 466, male, SPLs, question- • SPLs > 80 dBA [26] 18–67 years naire survey and • Tinnitus (49%) audiological as- • NIHL (79%) observed in engine-room keepers sessment • NIHL risk increases with the length of employment NIHL — noise-induced hearing loss; SPL — sound pressure level

30–32, 34] was limited due to selective or non-repre- DISCUSSION sentatively samples, a reliance on self-reported data, NOISE EXPOSURE LEVEL AND AUDITORY HEALTH and diagnosis of health outcomes (Suppl. Table S3, see Sound pressure level (SPL) was measured at different journal website). parts of the fish vessels using various tools, including the data acquisition system and noise dosimeter. Noise expo- NOISE-RELATED AUDITORY AND NON-AUDITORY sure levels ranged from 56 to 114 dB, and the highest noise HEALTH IMPACTS level was recorded in engine rooms [20–26]. The noise level Table 1 depicts the studies describing noise exposure was detected higher than NIOSH’s recommended guidelines levels and auditory health impacts among fish harvest- in most studies [20–23, 26, 28]. SPL was recorded high ers. The studies mentioned the noise exposure levels in vessels with hydraulic fishing gears, electrical power at various fish vessels’ compartments and measured generators, and an engine [3, 11, 20]. Noise exposure was the impact of noise on fish harvesters’ hearing ability associated with the load on boat engines irrespective of [20–26]. Table 2 reflects the studies highlighting the vessels’ size, and engine-related hearing loss was found potential impact of noise on auditory health through a significant risk among fish harvesters [23]. clinical examination, self-reported questionnaires, and Noise-induced hearing loss (NIHL) is one of the most literature reviews [27–35]. Table 3 shows the noise-re- significant health problems observed in fish harvesters and lated non-auditory health impacts among fish harvesters, associated with employment length [21, 24, 26]. However, including physical and psychological disorders [22, 23, Levin et al. [21] reported that hearing impairment was 25, 30–32, 36]. associated with fish harvesters’ age. The prevalence of

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Table 2. Studies describing noise related auditory health impacts among fish harvesters

Country Year Demographic information Methods Outcome [Reference] (N, gender, age) Denmark [27] 2008 3702, male Assessment of SHCRs • Increased risk rates of NIHL in engine room personnel • Duration and length of employment were not associated with the NIHL Spain [28] 2008 247, male, Self-reported medical • Hearing problems found in 6% of the 40.3 ± 11.5 years conditions and lifestyle participants Denmark [29] 2014 Literature review Hospital records • SHCR for NIHL, tinnitus, conductive, and sensorineural hearing loss was 142 (118–171) • Increased rate of hospitalisation rate for hearing impairment Brazil [30] 2014 13, male, 33–62 years Assessment of otoneurologic • Hearing loss (76.9%) and tinnitus (61.7%) signs and symptoms, vesti- • Positive cases in vestibular examination bular examination (around 39%) India [31] 2015 63, male, 30–50 years Otorhinolaryngoogic assess- • Hearing loss 28.57% ment, audiometry test • Tinnitus 19.04% Brazil [42] 2015 30, male, 33–67 years Assessment of otoneurologic • Tinnitus (66.7%) signs and symptoms, vesti- • Hearing loss (53.3%) bular examination • Positive cases in vestibular examination (around 43%) United States 2016 217 and 206, male, Assessment of NIHL related • NIHL related behavioural beliefs, norma- [33] ≥ 21 years attitude and belief tive beliefs, and control beliefs changed significantly United States 2018 Pre-season survey: 60, male Self-reported hearing loss, • Self-reported hearing loss (50%) [34] (56), female (4), 19–73 years audiometric testing • Physical examination hearing loss (80%) Mid-season survey: 38, male (35), female (3), 19–73 years United States 2018 17,299, male (12,455), Audiometric data analysed • Hearing loss (19.47%) [35] female (4844), 18–75 years from the existing records NIHL — noise-induced hearing loss; SHCR — standard hospital contact ratio hearing loss ranged from 6% to 80% [28, 34], and engine earplugs, and out of them, around 65% had hearing loss room personnel affected the most [20, 21, 25–27]. Noise [22]. Fish harvesters usually skip HPDs, sometimes more exposure can also result in Sensorineural Hearing Loss than an hour during a shift, and while using HPDs, earmuffs (SNHL) and Conductive Hearing Loss (CHL). The prevalence were used longer than earplugs [23]. of SNHL was observed at 26% in engine room workers [26]. Standard hospital contact ratio (SHCR) for NIHL was found IMPACT OF NOISE EXPOSURE ON NON-AUDITORY 119 (95% confidence interval [CI] 85–162) and another HEALTH study highlighted SHCR for NIHL, tinnitus, CHL, and SNHL Extra-auditory health effects, including physiological and was 142 (95% CI 118–171) [27, 29]. Tinnitus, an early sign psychological disorders, are observed in various studies [22, of NIHL, with a prevalence of 19% to 67%, was recorded 23, 25, 30–32, 36]. Noise exposure could cause adverse as one of the most common otoneurological symptoms, health effects such as increased blood pressure, decrease followed by otalgia [26, 30–32]. performance, sleep disturbances, annoyance, and stress Attitudes/beliefs among fish harvesters may influence [23]. Low-frequency sounds can cause cardiovascular, gas- behaviours responsible for fatal and nonfatal injuries. An tric, and sleeping disorders [25]. interventional study reported a significant change in at- With a prevalence of 8%, sleep disturbance is consid- titude/belief response for noise exposure among shrimp ered the most deleterious non-auditory health effect [30, harvesters [33]. Attitude towards the use of Hearing Pro- 31]. Split sleep was observed comparing the last three tection Devices (HPDs) was found inconsistent. Despite days of sleep at home and first three days of sleep at sea. the awareness of hearing risk, none of the fishermen used Sleepiness ratings were recorded high after sleep at sea, HPDs [20]. More than 90% of fish harvesters were not using and it reduces sleep quality [36].

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Table 3. Studies describing noise related non-auditory health impacts among fish harvesters

Country Year Demographic Methods Outcome [Reference] information (N, gender, age) New Zealand [36] 2008 17, male Assessment of otoneurologic signs • Split sleep and symptoms, vestibular exami- • High sleepiness ratings nation • Reduced sleep quality Brazil [30] 2014 13, male, Assessment of otoneurologic signs • Dizziness and headache (46.1%) 33–62 years and symptoms, vestibular exami- • Fatigue (46.1%) nation • Depression (23%) • Anxiety (15.3%) • Insomnia (7.7%) • Agitation during sleep (7.7%) Brazil [32] 2015 30, male, Assessment of otoneurologic signs • Dizziness (63.3%) 33–67 years and symptoms, vestibular exami- • Fatigue (36.7%) nation • Anxiety (23.3%) • Depression (16.7%) India [31] 2015 63, male, Assessment of otorhinolaryngologic • Headache (38.09%) 30–50 years signs and symptoms, audiometry • Sleep disturbances (7.9%) testing • Noise exposure acts as a stressor Italy [25] 2017 108, male, Self-reported health conditions • Low-frequency sounds can cause cardio- 49 years vascular, gastric, and sleeping disorders United States [23] 2018 52 manuscripts Assessment of occupational related • Physical and psychological disorders can health risks occur

Dizziness and headaches with a prevalence ranged sonnel affected compare to other crew members. NIHL was 40–70% were also common conditions trigger due to noise considered a significant health risk to fish harvesters across exposure. Other adverse health effects such as fatigue the studies, affecting physical and emotional well-being. (37–46%), depression (16–23.0%), anxiety (23–15%), in- Various methods of controlling on-board noise expo- somnia, and agitation during sleep (8%) were also observed sure are recommended, including use of HPDs, regular among fish harvesters [30–32]. Non-auditory health effects large scale auditory screening, modifications in the vessels may be associated with many factors, and difficult to differ- design, adopting new technologies, implementing health entiate the specific risk factor responsible for the condition. promotional programmes, advocating culturally appropriate training programmes, promoting research activities, and STRENGTHS AND LIMITATIONS translating research findings into common practice. Other A systematic literature search criteria [16–18] with rele- areas for future research could be evaluating knowledge, vant databases used to explore the available evidence and awareness, behaviour, and practices towards noise sources, minimise the evidence selection and publication bias. We noise-induced health problems, and preventive approaches. considered the published research, and there may be several other unpublished projects that have not been included Conflict of interest: None declared in this review. It is challenging to prove a direct relationship between noise and associated non-auditory health condi- REFERENCES tions due to limited evidence. 1. Danger at sea — working in the fishing sector. International Labour Organization. 2004. https://www.ilo.org/global/about-the-ilo/ mission-and-objectives/features/WCMS_075579/lang--en/index. CONCLUSIONS AND FUTURE htm (cited 2020 Dec 12). RESEARCH DIRECTIONS 2. The state of world fisheries and aquaculture 2020. Food and Agri- culture Organization of the United Nations. 2020. http://www.fao. The present systematic review covered the published org/documents/card/en/c/ca9229en (cited 2020 Dec 12). literature on occupational noise exposure and its adverse 3. Burella G, Moro L, Colbourne B. Noise sources and hazardous noise health impacts among fish harvesters. In most studies, the levels on fishing vessels: The case of Newfoundland and Labrador’s noise level was recorded higher than the recommended fleet. Ocean Engineering. 2019; 173: 116–130, doi: 10.1016/j. oceaneng.2018.12.062. limits suggested by various agencies and organizations. The 4. Antão P, Almeida T, Jacinto C, et al. Causes of occupational accidents most common available evidence is hearing loss, which in the fishing sector in Portugal. Safety Science. 2008; 46(6): ranged from 19.47% to 60.2%. Mostly engine room per- 885–899, doi: 10.1016/j.ssci.2007.11.007.

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5. Insurance and safety at sea. Food and Agriculture Organization of J Occup Environ Med. 2016; 58(3): 306–313, doi: 10.1097/ the United Nations. http://www.fao.org/fishery/topic/16617/en JOM.0000000000000642, indexed in Pubmed: 26949882. (cited 2020 Dec 19). 22. Sholihah Q, Han AS. Relationship of Noise and the Use of Ear Plugs 6. Hazard prevention and control in the work environment: Prevention with Hearing Disorders on Fishermen. Asian J Sci Res. 2017; 10(2): and Control Exchange (PACE): A document for decision-makers. 104–109, doi: 10.3923/ajsr.2017.104.109. World Health Organization. 1995. https://apps.who.int/iris/han- 23. Myers M, Durborow R, Kane A. Gulf of Mexico Seafood Harvesters, dle/10665/60994 (cited 2020 Dec 19). Part 2: Occupational Health-Related Risk Factors. Safety. 2018; 7. OSH Answers Fact Sheets. Canadian Centre for Occupational Health 4(3): 27, doi: 10.3390/safety4030027. & Safety. 2018. https://www.ccohs.ca/oshanswers/occup_workpla- 24. Anwar M, Savitri E, Dyah T. Audiometric Profile of Fishermen ce/commercial_fishing.html (cited 2020 Dec 19). Using Motor Boat in Barombong Village, Makassar. Indian 8. Divincenzo K. The possible injury related dangers for fishing workers. J Public Health Res Dev. 2019; 10(10): 1530, doi: 10.5958/0976- Work-fit. 2020 Apr 11. https://www.work-fit.com/blog/the-possi- 5506.2019.03055.9. ble-injury-related-dangers-for-fishing-workers (cited 2020 Dec 19). 25. Mansi F, Cannone E, Caputi A, et al. Occupational exposure on 9. Burella G, Moro L. A comparative study of the methods to assess board fishing vessels: risk assessments of biomechanical overload, occupational noise exposures of fish harvesters. Saf Health Work. noise and vibrations among worker on fishing vessels in southern 2021; 12(2): 230–237, doi: 10.1016/j.shaw.2020.10.005, indexed italy. Environments. 2019; 6(12): 127, doi: 10.3390/environ- in Pubmed: 34178401. ments6120127. 10. Coady C, Feltham-Scott DA, Fewer C, et al. Building a safer tomor- 26. Albizu EJ, de Oliveira Gonçalves CG, de Lacerda AB, et al. Noise row. Workplace Health, Safety and Compensation Commission of exposure and effects on hearing in Brazilian fishermen. Work. Newfoundland and Labrador (WorkplaceNL). 2015. https://www. 2020; 65(4): 881–889, doi: 10.3233/WOR-203139, indexed in gov.nl.ca/education/files/k12_curriculum_guides_skilledtrades_ Pubmed: 32310217. building_a_safer_tomorrow_ohs-3203.pdf (cited 2020 Dec 19). 27. Kaerlev L, Jensen A, Nielsen PS, et al. Hospital contacts for no- 11. Giorgio B. Long- and short-term solutions for mitigating hazardo- ise-related hearing loss among Danish seafarers and fishermen: us noise exposure and noise levels on board vessels from the a population-based cohort study. Noise Health. 2008; 10(39): 41–45, small-scale fishing fleet of Newfoundland and Labrador. Memorial doi: 10.4103/1463-1741.40822, indexed in Pubmed: 18580037. University Research Repository. 2020. https://research.library.mun. 28. Novalbos J, Nogueroles P, Soriguer M, et al. Occupational health in ca/14431/ (cited 2020 Dec 19). the Andalusian Fisheries Sector. Occup Med (Lond). 2008; 58(2): 12. Occupational noise exposure. The National Institute for Occupational 141–143, doi: 10.1093/occmed/kqm156, indexed in Pubmed: Safety and Health (NIOSH). 2014 June 06. https://www.cdc.gov/ 18245787. niosh/docs/98-126/default.html (cited 2020 Dec 20). 29. Poulsen TR, Burr H, Hansen HL, et al. Health of Danish seafarers 13. Occupational Noise Exposure. United States Department of Labor. and fishermen 1970-2010: What have register-based studies https://www.osha.gov/noise (cited 2020 Dec 29). found? Scand J Public Health. 2014; 42(6): 534–545, doi: 14. Navigation and vessel inspection circular no. 10-82, change 2. U.S. 10.1177/1403494814534538, indexed in Pubmed: 24876236. Department of Transport. 1989 Sep 18. https://www.dco.uscg.mil/ 30. Zeigelboim BS, da Silva TP, Carvalho H, et al. Otoneurologic findings Portals/9/DCO%20Documents/5p/5ps/NVIC/1982/n10-82ch2. in a fishermen population of the state of Santa Catarina: preliminary pdf (cited 2020 Dec 29). study. Int Arch Otorhinolaryngol. 2014; 18(1): 6–10, doi: 10.1055/s- 15. Domingo-Pueyo A, Sanz-Valero J, Wanden-Berghe C. Disorders 0033-1358584, indexed in Pubmed: 25992055. induced by direct occupational exposure to noise: Systematic 31. Arumugam L, George T, Vineeth Abraham A, et al. Evaluation of review. Noise Health. 2016; 18(84): 229–239, doi: 10.4103/1463- noise induced hearing loss in fishermen who work in motor boats 1741.192479, indexed in Pubmed: 27762251. in karaikal. J Evol Med Dent Sci. 2015; 4(73): 12645–12650, doi: 16. Moher D, Shamseer L, Clarke M, et al. PRISMA-P Group. Pre- 10.14260/jemds/2015/1823. ferred reporting items for systematic review and meta-analysis 32. Zeigelboim BS, Santos da Carvalho HA, Gonçalves CG, et al. Otoneuro- protocols (PRISMA-P) 2015 statement. Syst Rev. 2015; 4: 1, doi: logical symptoms in Brazilian fishermen exposed over a long period to 10.1186/2046-4053-4-1, indexed in Pubmed: 25554246. carbon monoxide and noise. Noise Health. 2015; 17(78): 300–307, 17. Moher D, Liberati A, Tetzlaff J, et al. PRISMA Group. Preferred repor- doi: 10.4103/1463-1741.165053, indexed in Pubmed: 26356372. ting items for systematic reviews and meta-analyses: the PRISMA 33. Levin JL, Gilmore K, Shepherd S, et al. Factors influencing statement. PLoS Med. 2009; 6(7): e1000097, doi: 10.1371/journal. safety among a group of commercial fishermen along the pmed.1000097, indexed in Pubmed: 19621072. Texas Gulf Coast. J Agromedicine. 2010; 15(4): 363–374, 18. McGowan J, Sampson M, Salzwedel DM, et al. PRESS Peer Review doi: 10.1080/1059924X.2010.509701, indexed in Pubmed: of Electronic Search Strategies: 2015 Guideline Statement. J Clin 20954032. Epidemiol. 2016; 75: 40–46, doi: 10.1016/j.jclinepi.2016.01.021, 34. Eckert C, Baker T, Cherry D. Chronic health risks in commercial indexed in Pubmed: 27005575. fishermen: a cross-sectional analysis from a small rural fishing 19. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale village in Alaska. J Agromedicine. 2018; 23(2): 176–185, doi: (NOS) for assessing the quality of nonrandomised studies in meta- 10.1080/1059924X.2018.1425172, indexed in Pubmed: 29648956. -analyses. The Ottawa Hospital Research Institute. http://www.ohri. 35. Masterson EA, Themann CL, Calvert GM. Prevalence of hearing ca/programs/clinical_epidemiology/oxford.asp (cited 2020 Dec 29). loss among noise-exposed workers within the agriculture, forestry, 20. Paini MC, Morata TC, Corteletti LJ, et al. Audiological findings among fishing, and hunting sector, 2003-2012. Am J Ind Med. 2018; 61(1): workers from Brazilian small-scale fisheries. Ear Hear. 2009; 30(1): 42–50, doi: 10.1002/ajim.22792, indexed in Pubmed: 29152771. 8–15, doi: 10.1097/AUD.0b013e31818fba17, indexed in Pubmed: 36. Gander P, van den Berg M, Signal L. Sleep and sleepiness of 19050644. fishermen on rotating schedules. Chronobiol Int. 2008; 25(2): 21. Levin JL, Curry WF, Shepherd S, et al. Hearing Loss and Noise 389–398, doi: 10.1080/07420520802106728, indexed in Pub- Exposure Among Commercial Fishermen in the Gulf Coast. med: 18533331.

www.intmarhealth.pl 205 Int Marit Health 2021; 72, 3: 206–216 10.5603/IMH.2021.0039 www.intmarhealth.pl Copyright © 2021 PSMTTM REVIEW ARTICLE ISSN 1641-9251 eISSN 2081-3252 Fumigation on bulk cargo ships: a chemical threat to seafarers

Rune Djurhuus

Department of Occupational Medicine, Norwegian Centre for Maritime and Diving Medicine, Haukeland University Hospital, Bergen, Norway

ABSTRACT Fumigation is a process that is carried out to prevent deterioration of goods by pests and spread of unwanted organisms for example during long-distance carriage by sea. Several intoxications due to use of pesticides on bulk cargo ships have been indicated, but for some of these incidents the documentation are questionable. The objective of the present study was therefore to examine the extent of the problem by collecting available information of incidents or intoxications due to use of pesticides on bulk cargo ships. Information sources such as PubMed, Google Scholar, Gard (marine insurance company), Marine Accident Investigation Branch, United Kingdom, and Professional Mariner (a magazine) were searched using similar search phrases. The results indicate that the present practice of fumigation with pesticides of cargo holds on bulk ships represents a serious health risk to both seafarers and port workers. A thorough search for information in both scientific and non-scientific sources revealed a number of intoxications including several fatalities. According to the available documentation, phosphine seems to be used more or less exclusively as fumigant on bulk cargo ships today. Phosphine has a high acute toxicity, and recent findings suggest long-term effects. Several of the reported incidents point to lack of knowledge and neglecting of recommended procedures as key elements in this respect. The problem is likely underestimated due to lack of available documentation of several incidents. Preventive actions should be implemented that focus on documentation of incidents, increase knowledge of pesticide health hazard and implementation of safety procedures that are mandatory to perform when fumigated cargo is to be handled on bulk ships. (Int Marit Health 2021; 72, 3: 206–216) Key words: intoxication, phosphine, pesticide, seaman, chemical hazard, fumigated cargo

INTRODUCTION on board if fumigated cargo leak gaseous pesticides while Fumigation is a process that is carried out to prevent at sea. In addition, residual pesticides may still be present deterioration of goods by pests and spread of unwanted on arrival at the destination, representing a potential health organisms for example during long-distance carriage by hazard to dock workers unloading the cargo, ships’ crew, sea. Accordingly many freight container units and bulk cargo custom officers, and workers at warehouses receiving fu- holds on ships are treated with different chemical pesticides migated freight containers. termed fumigants. They are termed so because the pesti- Recently, our Department of Occupational Medicine cides are gaseous (usually applied as a “fume”) and easily completed a comprehensive report regarding health risks penetrate the cargo, but they may also escape the cargo of fumigated freight containers, commissioned by the Euro- holds or containers if these are not properly sealed. Unfor- pean Agency for Safety and Health at Work (EU-OSHA) [1]. tunately, these chemicals are also highly toxic to humans, The report concluded that the fumigation problem seems and therefore represent a potential health risk to the crew to be underestimated, probably due to lack of documen-

Rune Djurhuus, PhD, Department of Occupational Medicine, Norwegian Centre for Maritime and Diving Medicine, Haukeland University Hospital, NO-5021 Bergen, Norway, * e-mail: [email protected]

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Table 1. Overview of major pesticides used for fumigation of freight containers. All the compounds listed have significant toxic potential, including both acute and long-term effects

Pesticide CAS-no. Mol. weight Physical state OEL IDLH Group bp [ºC]* [ppm]** [ppm]§ IARC† Methyl bromide (MeBr) 74–83–9 94.94 g; 3.5 5 (1#) 250 3

Phosphine (PH3) 7803–51–2 34 g; –87.7 0.1 50 nc Formaldehyde 50–00–0 30.03 g; –19.5 0.3 20 1 Chloropicrin 76–06–2 164.38 liq; 112 0.1 2 nc 1,2-Dichloroethane 107–06–2 98.96 liq; 83–84 1 nv 2B Ethylene oxide 75–21–8 44.05 g/liq; 10.7 1 800 1 *Physical state at room temperature; bp — boiling point; g — gas; liq — liquid **OEL — Occupational exposure limit (time-weighted average for 8 h exposure), in Finland [42], Sweden [43], Denmark [44] #OEL in Germany [45] §IDLH — Immediate Dangerous to Life or Health, National Institute for Occupational Safety and Health [46], USA; nv — no value †Carcinogenicity classification by International Agency for Research on Cancer [47]. 1: Carcinogenic to humans; 2A: Probably carcinogenic to humans; 2B: Possibly carcinogenic to humans; 3: Not classifiable as to its carcinogenicity to humans; 4: Probably not carcinogenic to humans; nc — no classification by IARC CAS-no — Chemical Abstracts Service Registry Number tation of incidents. Moreover, lack of appropriate labelling actions are required. Our previous investigation [1] had and safe procedures for unloading containers based upon also indicated that intoxications on bulk ships involved appropriate risk assessments seemed to be major elements more severe effects and with some more documentation of the problem. than incidents with freight containers. Nevertheless, the The present review is complementary to this report, impression was that the documentation was insufficient addressing the potential health hazard of the fumigation and the problem probably underestimated. process related to sea transport of bulk cargo. The objective of the present study was therefore to reveal the extent of the problem by collecting available informa- FUMIGATION AND HEALTH HAZARDS tion of intoxications due to use of pesticides on bulk cargo ON BULK SHIPS ships. Both scientific and non-scientific sources were used. Fumigation of cargo transported in bulk on cargo vessels represents a considerable health hazard to the ships’ crew, METHODS and has led to a number of intoxications including fatali- PUBMED SEARCH ties. In contrast to fumigation of containers where several A literature search was conducted using PubMed in different pesticides may be used as shown in Table 1 [1], October 2020 with subsequent weekly updating. The search fumigation on bulk cargo ships today seems to be almost ex- was limited to the title/abstract field since search in all clusively carried out using phosphine (PH3) as the fumigant. fields returned a large number of non-relevant hits that However, the history of treating ships’ cargo with pesticides contained the search words in e.g. the reference list or in is approximately 100 years old, starting with hydrogen cya- affiliations of authors. nide (HCN) as the fumigant [2]. At this time, performing the The following search string in the title/abstract field fumigation without sufficient skills and competence resulted was used without any time limits: (fumigant OR fumigants in a number of intoxications and several deaths [3]. Later, OR fumigation OR fumigated OR fumigating OR pesticide methyl bromide (MeBr) was used as the preferred pesticide OR pesticides OR toxic OR intoxication OR intoxications OR for several stored food commodities in warehouses, grain si- intoxicated OR intoxicating OR poison OR poisoned OR poi- los, flourmills, ships’ holds, etc. [4]. According to Brodniewicz soning OR poisonous OR “methyl bromide” OR phosphine [5], the compound was frequently used for fumigation of OR formaldehyde OR chloropicrin OR 1,2-dichloroethane agricultural food products in many ports of the Far East. OR “ethylene oxide”) AND (ship OR ships OR freighter OR seafarer OR seafarers OR seaman OR seamen OR maritime). DOCUMENTATION OF INCIDENTS The search returned 411 references, and the oldest ON BULK CARGO SHIPS one was from 1893. The papers were examined by title Documentation of intoxications is an important issue and abstract. Only articles that concerned fumigation by since without adequate documentation it is difficult to con- pesticides on bulk cargo ships and related intoxications vince both authorities and industry (logistic companies, on humans were included, excluding papers concerning ship-owners, etc.) of the real hazard and that mitigating fumigation of freight containers only.

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Five possibly relevant papers based upon title were documents referred to an incident on a bulk vessel, and without abstract and inaccessible due to language (two a comprehensive report of that incident was subsequently Italian, two Russian and one of undetermined language retrieved [7]. according to PubMed), but since they were from 1968 or An example of seemingly relevant, but still not useful older they probably would have minor impact on the per- information was the Annual Report of the American Asso- ception of today’s situation. That left 9 relevant papers of ciation of Poison Control Centres’ National Poison Data the 411 hits. Weekly updating of the search has so far not System [8]. It contained a table describing all exposures retrieved any additional relevant records. by nonpharmaceuticals that included incidents with fu- Updated information regarding phosphine toxicity in migants like phosphine and methyl bromide, but without general was collected in March 2020, using the following any information of the circumstances of the incidents, search string in the title/abstract field without time limits: i.e. if it happened during fumigation of a house, a garden, phosphine AND (toxic OR toxicity OR toxicology OR poison warehouse, container or a bulk ship. The information is OR poisoning OR poisoned OR poisonous OR intoxication therefore of little value in the present context. A personal OR intoxicated). communication with the Norwegian Poison Information The search returned 364 references, 88 of these were Centre revealed that they would not release information from the period 2017–2020. Twenty of 364 were review regarding intoxications due to fumigation except gross articles. Only recent reviews and articles containing general numbers of persons intoxicated by a given chemical in toxicological information on phosphine were considered a defined period of time, no information of the circum- relevant in this respect. stances, age, gender, etc., primarily due to protection of personal privacy. It is likely that similar restrictions apply GOOGLE SCHOLAR SEARCH to other national poison centres. The exception is if the In contrast to PubMed, Google Scholar has several lim- poison centres themselves publish papers that describe itations with respect to literature search. It contains only two a number of incidents related to an actual problem. A re- options with respect to search field, and that is either in Title cent example of the latter is the paper from the Belgian only or in the full text document. Search in title only may be Poison Centre that described 18 incidents reported to the too narrow, but search in the full text document will include Centre. Most of the incidents were related to work with hits from reference list even if the document itself does not fumigated containers, only a few were related to fumigated contain any of the words in the search string. Moreover, bulk cargo ships, and the information presented for each there is a limit of 256 characters in the search field, trun- case was limited [9]. cation does not function, no more than 1000 results can be displayed, the sequence of search phrases influences the OTHER INFORMATION SOURCES result, and the results are not completely reproducible. For Gard — marine insurance company. Search using the a comprehensive evaluation of Google Scholar as a search same search words as for the PubMed search returned only engine for literature, see [6]. one relevant hit: “Fumigation of cargo on board ships: the Due to these limitations the Google Scholar search invisible killer”, an article in the company’s own newsletter, was conducted (February 2021) using the following search Gard News, containing several examples of intoxications by phrase in full text documents in English or German language fumigants on bulk ships. and initially without any time limit: (fumigation OR fumigat- Marine Accident Investigation Branch (MAIB). A unit ed) (intoxication OR intoxicated OR poison OR poisoning within the United Kingdom (UK) Department of Trans- OR poisonous) (ship OR freighter OR seafarer OR seaman port that investigates marine accidents involving UK-ves- OR maritime). sels. MAIB issues reports and safety flyers based on The initial search returned 5420 hits. Since the most the incidents. The documents found on MAIB consist of acknowledged documents assumingly had been collected “Current investigations” and “MAIB reports”. The former from the PubMed search, and additional documents older contained only 31 publications and was easily screened. than 10 years now would have more historic impact than MAIB reports contained 971 reports, and excluding the reflecting today’s situation, the search was then limited reports comprising fishing vessels and recreational crafts from 2010 to present. That returned 1634 hits, but due left 648 reports. Using similar words as in the PubMed to the limit described above the records were screened for search returned two relevant hits that described incidents one year at a time. on two different vessels. Only two of the documents contained information that Professional Mariner. A magazine owned by Navigator was not identified by the PubMed search and thus rele- Publishing LLC focusing on training and licensing, maritime vant for the fumigation on bulk cargo ships. One of the casualties, technology, engineering and regulatory issues

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Google Professional PubMed Gard MAIB Scholar Mariner N = 411 N = 77 N = 5 N = 1634 N = 58

N = 2185 records screened by title/abstract 2040 records excluded: 15 duplicates 2010 not relevant 15 records not English, German or Scandinavian language

Google Professional Gard MAIB PubMed Scholar Mariner N = 65 N = 5 N = 9 N = 9 N = 57

N = 145 records screened by title/full text 129 records excluded due to lack of relevance/eligibility

Google Professional PubMed Gard MAIB Scholar Mariner N = 9 N = 1 N = 2 N = 3 N = 1

N = 15 articles/reports 1 additional report found in reference list in one article

N = 16 articles/reports included in final review

Figure 1. Flow chart of the literature review. Records were initially identified through search in relevant databases and information sources using similar search phrases without time limits. The Google Scholar search excluded records that were not in English or Ger- man language and was limited to the period after 2009 (for details see Methods). The Marine Accident Investigation Branch (MAIB) search included all current investigations and all published investigation reports and safety bulletins excluding those on fishing vessels and recreational crafts related to commercial maritime vessels of all types in the METHYL BROMIDE AND PHASING OUT United States (US) and Canada since 1993. Using the sim- AS AN OZONE-DEPLETING AGENT ilar search words as for the PubMed search returned two Workers may be exposed to MeBr by inhalation or by relevant hits, both describing the same incident on a bulk the dermal route. It affects primarily the respiratory system ship in 2010. and central nervous system (CNS), but also gastrointestinal All relevant papers, reports or documents were used symptoms have been reported. MeBr has not been shown to for summarising and listing of reported intoxications due to be carcinogenic to humans [10], but other long-term effects fumigation on bulk cargo ships. A flow chart summarising seem to be frequent. MeBr may cause chronic effects like the literature review is shown in Figure 1. speech impairment, lack of coordination, visual impairment and loss of memory. More details on MeBr toxicology are RESULTS AND DISCUSSION available elsewhere (Alexeeff and Kilgore, 1983; de Souza The results from the literature review identified only et al., 2013; Bulathsinghala and Shaw, 2014).

MeBr and PH3 as the cause of documented intoxications In 1987, United Nations arranged the meeting that on bulk cargo ships. Moreover, for the last 40–50 years resulted in the Montreal Protocol on substances that de-

PH3 seems to be the prevailing compound in use, at least plete the ozone layer [11]. At the beginning, the protocol based upon the documented incidents. Accordingly, the comprised rather few substances to be controlled. Methyl present review will reflect these results and focus on those bromide was added to the list in 1992, and later amend- two with a brief description of MeBr and a more compre- ments increased the number of controlled substances hensive presentation of PH3 toxicology. substantially. The resolution on MeBr in 1992 stated that

www.intmarhealth.pl 209 Int Marit Health 2021; 72, 3: 206–216 one should make every effort to reduce emissions of and no mortality up to 59.2 ppm (the highest concentration to recover, recycle and reclaim MeBr, without specifying tested), while 4 hours exposure showed no mortality at explicit numbers. However, an exemption was agreed to 26.5 ppm and 100% mortality at 33.4 ppm, suggesting regarding its use for quarantine and preshipment applica- a LC50 between these two values [14]. Rats exposed to tions (QPS). At the time of the original banning of MeBr, the 5 ppm PH3 for 6 hours a day for 13 days showed no signif- use for QPS-purposes was small compared to other uses, icant adverse effects, while 7 ppm was fatal to pregnant while today other uses of MeBr have declined dramatically. rats after 3–10 days of exposure [15]. Similar results In 2017, the consumption of MeBr for QPS-use was reported were found in a study on mice and rats: No mortality was to 9960 tons, which comprised 97.5% of the total global found after exposure to 5 ppm PH3 for 6 hours a day use of MeBr, implying that non-QPS use in 2017 was not for 2 weeks, while inhalation of 10 ppm for 4 days was more than approximately 245 tons. The reported figures lethal [16]. These studies indicated a threshold for toxic also show that the use of MeBr for QPS use has been rather effects around 5–7 ppm and a median lethal dose of stable for many years [12]. approximately C × T = 180 ppm-hours. Furthermore, the The exemption of MeBr for QPS-use in the Montreal studies indicated that the primary hazard of phosphine Protocol urges all parties to seek for alternatives, but so exposure was lethality [15, 16]. A follow-up study with rats far, this seems to have had little effect on the QPS-use. inhaling 0.3–3 ppm PH3 for 6 hours/day, 5 days a week However, with respect to pest control on bulk cargo carried for 2 years showed no carcinogenic or other clinical ef- by sea, it seems that MeBr is of little use, at least in Europe- fects, supporting a threshold effect for PH3-toxicity [17]. an waters. Few, if any, documented intoxications by MeBr A recent study confirmed the steep dose-response curve the last 30–40 years have been found in public available when rats were exposed to 500–1000 ppm PH3 for sources, but this may be different in other parts of the world, 20–40 min. No adverse effects were observed after expo- since Asian countries accounted for approximately 55% of sure to 10,000 ppm-min, while exposure to 33,000 ppm- the global QPS consumption in 2017 [12]. It may also be min resulted in 100% lethality [18]. a consequence of lack of reporting such incidents. Incidents involving humans often lack precise exposure For those incidents/intoxications that have been re- data (e.g. time and concentration) and are difficult to use in ported the last 40 years, it seems that pest control on bulk estimation of human health risks associated with PH3-expo- cargo ships today is almost exclusively by use of PH3 as sure. Accordingly, governmental recommendations like the fumigant. There are several reasons for this; not at least US Acute Exposure Guideline Levels for Selected Airborne the availability of the substance and the ease of application Chemicals (AEGLs) mainly rely on animal data [19]. Species as outlined below. variations seem to be minimal, since dose-response data on lethality obtained from rats, rabbits, guinea pigs and PHOSPHINE cats followed the same curve when exposure concentration Phosphine holds a unique position among the fumigant was plotted against exposure time. They also indicated pesticides since it is the only one that is usually not applied a threshold value of 3–5 ppm, below which no adverse in gaseous form (fume), but is administered in the form of effects seemed to occur [13]. a metal phosphide like aluminium phosphide (AlP), magne- Typical symptoms of PH3-intoxication in humans are sium phosphide (Mg3P2) or zinc phosphide (Zn3P2). These respiratory effects with pulmonary oedema, cardiac failure phosphides are solid materials that react with water vapour and hepatic failure [20, 21]. Most incidents with fatalities (moisture) in the air (equations I–II) and liberate phosphine describe pulmonary and circulatory failure and ultimately gas, PH3, which is the active pesticide. Moreover, the fu- cardiac arrest. Cardiotoxicity was described in a case re- migation is often carried out as an in-transit process, i.e. port of three stowaways in a railcar loaded with rice and during the voyage at sea and may consequently represent fumigated with phosphine. One was found dead; the two a potential health hazard to the entire crew. others were brought to intensive care unit at the hospital. One died 12 hours later, and premortem echocardiogram I. AlP + 3 H O → Al(OH) + PH (s) 2 3 3 (g) revealed an ejection fraction of only 10%. The third subject II. Mg P + 6 H O → 3 Mg(OH) + 2 PH 3 2 (s) 2 2 3 (g) showed an ejection fraction of 15%, with improvements to Zn P reacts similar as Mg P 3 2 3 2 40% 3 days later. He recovered and was discharged from In pure form, phosphine is a colourless and odourless hospital on day 8 after the incident [22]. gas. However, impurities from the production process often The precise mechanism of phosphine toxicity is still not add a characteristic odour of garlic or decaying fish [13]. elucidated. Early studies using both animal and human data

PH3 is highly toxic, and animal experiments indicate a steep indicated that inhibition of mitochondrial respiration was dose-response curve. Mice inhaling PH3 for 1 hour showed a common critical effect. Moreover, several in vitro studies

210 www.intmarhealth.pl Rune Djurhuus, Fumigation on bulk cargo ships: a chemical threat to seafarers indicated that complex IV of the electron transport chain Few studies regarding long-term effects are available. (ETC) was the molecular target, i.e. cytochrome c oxidase As cited above, one of the few long-term animal studies that [23]. Neurological effects have also been reported, sug- have been conducted showed no effects after inhalation of gesting that PH3 increases neurotransmission by inhibiting 0.3–3.0 ppm PH3 for 2 years [17]. However, some human acetylcholine esterase (AChE) [24]. A study on fumigators data describe both persistent neurological and respiratory in USA using PH3 indicated that they had a decrease in effects. Two cases of phosphine-exposure for 30–60 min plasma choline esterase (ChE) of at least 20% [25]. How- indicated long-term effects in addition to acute intoxica- ever, a similar study from Australia on 31 fumigators using tions. One of them showed signs of obstructive airway dis-

PH3 and with an average personal exposure at 1 ppm for ease 3 months later, while the other was diagnosed with 2 hours (determined for 3 of them) found no effect on ChE, peripheral neuropathy 8 months after the incident [30]. and no other toxic effects [26]. A recent study on rats exposed to 500–1000 ppm

Many of the studies on acute effects of phosphine in PH3 (g) for 10–40 min demonstrated increased respiration humans are limited to accidental or intentional ingestion and pulmonary damage, mitochondrial compromise and (suicide) of high doses of metal phosphides like aluminium myofibril degeneration of left ventricular tissue. Notably, the phosphide (AlP). Although a widespread assumption is that results showed cardiac-specific alterations in gene expres- the toxicity of the metal phosphides proceeds via the internal sion indicating inflammation and metabolic aberrations in liberation of phosphine gas in the body, the toxicological the heart that might result in long-term effects [18]. Adding mechanism may not be the same for ingestion of a metal to this, a recent paper reported that 13 of 15 crewmembers phosphide as for the absorption of gaseous PH3 through the surviving an accidental exposure to PH3 on a bulk cargo ship lungs. In particular, there have been suggestions that the had clinical symptoms 3 months after the incident [31]. In metal itself may have a considerable effect on ChE and may particular, one crewmember showed subclinical left ven- be one explanation for the difference that has been observed tricular dysfunction 4 months after the same incident [32]. on ChE after in vitro exposure to PH3 gas compared to effects These reports suggest that PH3-exposure may have in vivo after ingestion of AlP. In addition, some data indicate persistent adverse effects on both the respiratory, cardiac that PH3 only partly inhibits cytochrome c oxidase in vivo [24]. and central nervous systems. Several animal studies have indicated that the major hazard from PH3 exposure is lethality, with no long-term INTOXICATIONS BY PESTICIDES effects [16, 17, 27]. The view of mainly acute effects was ON BULK CARGO SHIPS supported by case reports describing recovery of subjects As indicated above, treating of ships’ cargo with pesti- from acute intoxications without observable long-term ef- cides started almost 100 years ago. The first intoxication fects. The fact that breakdown products of PH3 are stable due to fumigation on a bulk cargo ship that is well described phosphorous oxides that enter normal cellular metabolism in a scientific paper occurred at the port of Haiphong in as phosphate [20], and that inhibition of energy metabolism Vietnam in 1958. A Polish bulk ship was loaded with rice may be reversible, also point to acute toxicity as the major and had the cargo fumigated with MeBr. The crew stayed on effect of PH3-poisoning [23]. A few epidemiological studies board throughout the fumigation process, and shortly before of workers exposed to PH3 gas had also indicated lack of leaving the port 10 crewmembers got ill, one of them died adverse health effects at concentrations up to 7 ppm (re- soon after. Medical examinations confirmed that the cause viewed by [23]), an observation in line with the threshold was poisoning by MeBr. The incident was not made public observed in animal studies [15, 16, 18]. until 1967 when Brodniewicz [5], a former head of the De- In 1978, an intoxication by phosphine occurred on a bulk partment of Disinfection at the State Institute of Hygiene in cargo ship that affected 29 crewmembers in addition to the Warsaw, Poland, published a paper that in detail described captain’s wife and 2 children. Sadly, one of the children died, the incident. However, since then no reports neither in the but the others recovered completely. All clinical symptoms scientific literature nor in the grey literature has been found and laboratory findings were normalised a week after the describing incidents on bulk cargo ships involving MeBr. incident, although the authors noted, “little is known, how- In this respect, it seems that PH3 has replaced MeBr as ever, about possible long-term effects of sustained low-dose fumigant, and today PH3 seems to be almost exclusively phosphine exposure” [28]. A more recent case report further used for pest control on bulk cargo ships as indicated above. adds to the view of only acute effects of phosphine: 6 family One of the first intoxications by PH3 on a bulk ship was members (2 adults and 4 children) in a home where AlP was reported in 1962, but this was not due to fumigation. It was used to kill voles in their yard were exposed to the PH3 gas; a ship loading barrels with ferrosilicon in Bremen, Germany. 2 of the children died, but the other 4 recovered without One of the barrels was damaged during the loading such any long-term symptoms reported [29]. that the content leaked out on the floor of the cargo hold.

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Due to rainfall during the operation, the floor was wet, and since the ferrosilicon had a minor content of metal phosphide (e.g. Ca3P2), it released PH3 gas after contact with the water. None of the crewmembers was informed of the possible hazard from the cargo, and unfortunately, some of the crew’s cabins were located right on top of the hold, and PH3-gas leaked into the cabins. Three seafarers were intoxicated, two of them with fatal outcome [33]. Since then a number of incidents arising from fumigation with phosphine have been reported, including several fatalities. One of the first detailed descriptions occurred on a bulk cargo ship in 1978 and affected 29 crewmembers in addition to the captain’s wife and two children including one fatality. The cargo had been fumigated using AlP-tablets that were spread on top of the grain load just before leaving the port [28]. This is the typical procedure for use of this fumigant and it illustrates one of the main reasons for using

PH3 as pesticide: its ease of application. Usually a metal phosphide (AlP, Mg2P3, Zn2P3) in the form of tablets, pellets, granulates or powder is packed in small sachets or textile hoses/socks. These are just buried in the cargo (e.g. in grain) or left on the top of the cargo (or in some cases without any packaging) as shown on Figure 2. The reaction with moisture in the air starts almost immediately releasing PH3, and then the holds are sealed. Since PH3 is slightly heavier than air, it sinks to the bottom of the hold penetrating the grain and Figure 2. Example of fumigation by aluminium phosphide on kills the pests throughout the cargo. The fumigators carrying board a bulk ship. Top panel: A typical fabric retainer or “sock” out this process usually wear proper protection equipment containing solid aluminium phosphide (AlP). Bottom panel: Distri- like gas masks or self-contained breathing apparatus (SCBA). bution of aluminium phosphide in “socks” (indicated by black The fumigation process is usually carried out in port, but after arrows) on top of a grain cargo on a bulk ship. The photographs the fumigators have left the ship, the ship often sails. If the are from the bulk ship Arklow Meadow at port of Warrenpoint, Northern Ireland, December 2012 and are reproduced with moisture content in the cargo holds’ air is sufficient, the reac- permission from Marine Accident Investigation Branch (MAIB), tion will be completed during the sea voyage, and the holds Southampton, United Kingdom may be ventilated to let out the remaining gas while still at sea. In some cases, however, the moisture content is limited, and the reaction will cease before completion, leaving solid soning. His cabin was located straight above the cargo hold, residues of metal phosphide. When the holds are opened at and inspection after the incident revealed pinholes into the the destination, fresh air with moisture will enter the holds cabin from the cargo hold [35]. Similar conditions led to the and the reaction will restart releasing PH3 gas. An example death of a seafarer on board a bulk cargo ship in 2008, of this was seen when the bulk ship Arklow Meadow arrived while four others recovered from adverse symptoms [36]. in the port of Warrenpoint in Northern Ireland in December A rather comprehensive review of several intoxications 2012. Both crewmembers and port workers were affected, was found as a non-scientific article from the insurance but due to rapid evacuation of both the ship and unloading company Gard [37]. The article described seven different area, serious health effects were avoided [34]. incidents in the period from 1997–2010, occurring in Euro- Performing the fumigation process while the ship is at pean, American and African waters. All incidents were due sea (in-transit fumigation) represents a serious health hazard to fumigation with PH3, and in most cases by using solid AlP to the entire crew. As indicated above, several of the ships tablets, usually placed on top of the cargo. A typical scenario involved are not technically suited for this process. Tiny holes was that fumigators entered the ship in port, distributed AlP in the fumigated holds may lead to escape of PH3-gas into tablets on top of the cargo or partially buried in the cargo, other parts of the ship, e.g. living quarters. Indeed, there are closed and sealed the hatches of the holds and left the several examples of that, for example the incident on MV ship. Shortly after the ship sailed, and after a few days at

Monika in 2007 where a young seafarer died due to PH3-poi- sea some crewmembers started to show signs of poisoning.

212 www.intmarhealth.pl Rune Djurhuus, Fumigation on bulk cargo ships: a chemical threat to seafarers

Table 2. Reported pesticide intoxications on bulk ships

Vessel, location, cargo Year Pesticide No. affected Reference All Deaths MS Marian Buczek, Haiphong, Vietnam, rice 1958 MeBr 10 1 [5]

MV Thermopylai, Canada-USA, grain 1978 PH3 31 1 [28] Danish vessels 1988–1996 un* 4 3** [48]

PH3 2 1**

Geared bulker, Brazil, soy bean meal 1997 PH3 5 0 [37]

Bulk carrier, West Coast, USA, soy bean meal 2000 PH3 12 0 [37]

Bulk cargo vessel, Panama, timber 2006 PH3 2 # 0 [37]

MV Monika, North Sea, wheat 2007 PH3 1 1 [35]

Bulk cargo vessel, Bretagne, France, peas 2008 PH3 5 1 [36]

Cargo vessel, Lagos, Nigeria, cocoa beans 2009 PH3 6** 1** [37]

General cargo ship, Antwerp, Belgium, wheat 2010 PH3 2 1 [37]

MV Herman Schoening, Lake Erie, Canada/USA, grain 2010 PH3 16 0 [37], [49]

MV Arklow Meadow, Warrenpoint, Northern Ireland, maize 2012 PH3 13 § 0 [34]

MV Nefryt, Gulf of Guinea, Ivory Coast, shea nuts 2015 PH3 17 2 [7]

Six bulk cargo vessels, Ukraine 2006–2016 PH3 66 9 [39]

Bulk cargo ship, Antwerp, Belgium 2014 PH3 1 † 0 [9]

MV Nazmehr, Caspian Sea, grain 2018 PH3 15 3 [38]

*Unidentified pesticide; **Stowaways; #Fumigators; §8 crew, 1 stevedore and 4 port workers; †Port worker; PH3 — phosphine; MeBr — methyl bromide

For some of the incidents the PH3-gas escaped through when they closed the hatches. Approximately 1 day later the tiny holes or leakages from the cargo holds and into the crew started to complain of stomach pains and vomiting, and accommodation area, while in some cases the gas was the conditions soon became worse. In the end, all 17 crew- distributed by a defect ventilation system. In total for all the members were intoxicated, and eventually two of them died. 7 incidents, 43 individuals were affected including 3 fatal- Moreover, long-term effects were indicated as 13 of the ities. The report points to several factors that contributed 15 surviving crewmembers still showed clinical symptoms to the intoxications including lack of following International 3 months later, and one showed cardiovascular effects even Maritime Organization (IMO)-recommendations when per- 4 months after the incident as indicated above [31, 32]. forming the fumigation, lack of knowledge of crewmembers The most recent documented incident occurred on an regarding the hazard of the fumigant, no use of monitor- Iranian bulk ship transporting grain on the Caspian Sea in ing equipment and lack of knowledge of poisoning symp- October 2018. Fumigation was performed using AlP tablets toms. Furthermore, some vessels seemed unsuitable for just before the vessel left port in Kazakhstan, and while the cargo fumigation due to lack of properly sealed boundaries ship was at sea 15 crew members were severely intoxicated between cargo holds and crew quarters. by phosphine, three of them with fatal outcome. According Another severe incident occurred in September 2015 at to the author, failure of safety requirements, decrepitude the port of Abidjan, Ivory Coast. In contrast to many other in- of the vessel and leakage from the cargo holds were the cidents this one has been thoroughly described by the State main reasons for the accident [38]. Marine Accident Investigation Commission of Poland [7]. As reported from the incident with Arklow Meadow above, A Polish ship had been loading shea nuts, and just before dockworkers may also be at risk during unloading of the car- leaving port 2 persons came on board to fumigate the cargo. go. A recent paper reported intoxication of a dockworker at They distributed AlP tablets on top of the cargo, and then the the port of Antwerp, Belgium, during unloading of a cargo ship hatches of the holds were closed. During the distribution of that had been fumigated with PH3 [9]. Still, the majority of the the AlP tablet a sharp, unidentified odour was noted, but reported intoxications involve seafarers only. An overview of the chief officer did not receive any information or warning the incidents found from the information search is presented leaflets about the possible effects of the fumigant. The chief in Table 2. Of the at least 21 incidents shown in the Table 2, officer then advised the crew not to inhale any smelling gas only two of these clearly indicate intoxication of port workers.

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It should be emphasised that a number of the incidents Technical conditions of the vessels seem also to play an presented in Table 2 are not reported in the scientific liter- important part, for example with leakages from the ships’ ature, are of variable quality with respect to details of the holds to the accommodation area [35, 37–39]. In addition, incidents, long-term follow-up of the victims, etc., and are not misinterpretations of symptoms as seasickness or food easily available. This leads to the speculation that a num- intoxications have also been involved in cases with fatal ber of additional incidents are not properly reported and outcome [35, 39]. documented. Appropriate documentation is a prerequisite for a realistic perception of the hazard. Nevertheless, the CONCLUSIONS incidents listed in Table 2 and the available information on The present practice of fumigation with pesticides of

PH3-toxicity in general underpin the need for serious efforts cargo holds on bulk ships represents a serious health hazard to address the problem and increase the safety of both the to seafarers and port workers. Search for information in both seafarers and port workers. scientific and non-scientific sources revealed a number of Details from the reported intoxications strongly indicate intoxications including several fatalities. Several of the in- that there is a lack of knowledge of the hazard of the fumi- cident reports point to lack of knowledge and neglecting of gation, both by the fumigators and not at least by the crew- recommended procedures as key elements in this respect. members on board the fumigated ships. This is emphasised in The problem is likely underestimated due to lack of available a recent report that also points to misinterpretation of symp- documentation. Preventive actions should include docu- toms as food intoxications due to lack of qualified medical mentation of incidents, increased knowledge of pesticide knowledge. For several incidents the result was inadequate health hazard and implementation of safety procedures medical care with severe outcomes including fatalities [39]. that are mandatory to perform when fumigated cargo is In addition, the report notes that in most cases the ships transported on bulk ships. were old and not technically prepared for the transport of fumigated cargoes and often lacked methods and equipment RECOMMENDATIONS for monitoring possible leaks of poisonous gas from the holds. Preventive actions are required to reduce the health risk Compared to the health hazards of fumigated freight to the seafarers. Knowledge is a key point in this respect. containers as documented in our recent EU-OSHA-report [1], All crewmembers must acknowledge the hazard from the the problem with fumigated cargo on bulk ships seems to fumigant and be thoroughly drilled of what precautions to include more severe intoxications, a considerable number implement. There should be written instructions in a lan- of fatalities and more documentation of the incidents. Nev- guage that all crewmembers can read on how to act when ertheless, the documentation of intoxications due to fumi- on board a fumigated ship. gation on bulk cargo ships is still limited, and the extent of Preferentially, the fumigation should be carried out in the problem is probably underestimated. Improved docu- port by professional fumigators while the ship’s crew is mentation and publication of incidents is required to get evacuated, and the ship should not sail until the fumiga- sufficient attention to the problem. tion process have been completed, the holds have been ventilated and residual fumigant concentration has been REGULATIONS IMO documented to be below recognised safe levels using ade- The IMO has issued detailed recommendations with quate measuring equipment. respect to fumigation, including in-transit fumigation that Measuring equipment for PH3 (or other actual fumi- often is carried out using phosphine [40]. Compliance with gant) should be available throughout the sea voyage, and these recommendations would reduce the health hazard a number of crewmembers should be trained in using it. considerably. The impression from the cases reported PH3-concentration in the ambient air of living quarters, above, however, is that in many cases these instructions mess room, etc. should be monitored routinely throughout are at least partly neglected. An illustrating example is the the sea voyage. Personal protective equipment including case of fumigation on board MV Nefryt that led to the loss gas masks and/or SCBA should be available and the crew of two lives. The following investigation revealed that human should be trained in using them. factors were the main reason for the intoxication, and lack of As indicated above, documentation of incidents is ex- compliance with requirements in ship-owner’s by-laws and tremely important, as future mitigating actions will rely on international requirements on ship cargo fumigation were a realistic perception of the problem. Accordingly, there major factors in this respect [7]. Similar marine casualties should be a system for reporting incidents and make it also seem to be caused by human factors including lack public available to both seafarers and professionals en- of knowledge and ignoring established procedures and gaged in occupational safety, preferably in scientific, ref- recommendations [39, 41]. eree-based journals.

214 www.intmarhealth.pl Rune Djurhuus, Fumigation on bulk cargo ships: a chemical threat to seafarers

ACKNOWLEDGEMENTS 15. Newton P, Schroeder R, Sullivan J, et al. Inhalation toxicity of phos- The author wishes to thank the Marine Accident Inves- phine in the rat: acute, subchronic, and developmental. Inhal Toxicol. tigation Branch (MAIB), Southampton, United Kingdom, for 2008; 5(2): 223–239, doi: 10.3109/08958379309034503. 16. Morgan DL, Moorman MP, Elwell MR, et al. Inhalation toxicity of kindly providing photographs illustrating fumigant adminis- phosphine for Fischer 344 rats and B6C3F1 mice. Inhal Toxicol. tration on bulk cargo ships. 1995; 7(2): 225–238, doi: 10.3109/08958379509029095. 17. Newton PE, Hilaski RJ, Banas DA, et al. A 2-year inhalation study Conflict of interest: None declared of phosphine in rats. Inhal Toxicol. 1999; 11(8): 693–708, doi: 10.1080/089583799196817, indexed in Pubmed: 10477443. 18. Wong B, Lewandowski R, Tressler J, et al. The physiology and REFERENCES toxicology of acute inhalation phosphine poisoning in con- 1. Bråtveit M, Djurhuus R, Kirkeleit J, et al. Human health risks and scious male rats. Inhal Toxicol. 2017; 29(11): 494–505, doi: prevention practises during handling of fumigated containers in 10.1080/08958378.2017.1406564, indexed in Pubmed: ports. European Agency for Safety and Health at Work (EU-OSHA). 29251003. 2018. https://osha.europa.eu/en/publications/handling-fumigat- 19. Bast C, Falke E. Phosphine and eight metal phosphides. Acute Ex- ed-containers-ports-health-risks-and-prevention-practices/view. posure Guideline Levels for Selected Chemicals. National Academy 2. Liston WG, Goré SN. The fumigation of ships with Liston’s cyanide Press, Washington DC, USA. 2008. http://nap.edu/12018. fumigator. J Hyg (Lond). 1923; 21(3): 199–219, doi: 10.1017/ 20. Nath NS, Bhattacharya I, Tuck AG, et al. Mechanisms of phosphine tox- s0022172400031430, indexed in Pubmed: 20474773. icity. J Toxicol. 2011; 2011: 494168, doi: 10.1155/2011/494168, 3. Bilderbeck CL. A practical note on the cyanide fumigation of ships. Ind indexed in Pubmed: 21776261. Med Gaz. 1932; 67(4): 200–207, indexed in Pubmed: 29010893. 21. Sciuto AM, Wong BJ, Martens ME, et al. Phosphine toxicity: a story 4. Alexeeff GV, Kilgore WW. Methyl bromide. Residue Rev. 1983; 88: of disrupted mitochondrial metabolism. Ann N Y Acad Sci. 2016; 101–153, doi: 10.1007/978-1-4612-5569-7_3, indexed in 1374(1): 41–51, doi: 10.1111/nyas.13081, indexed in Pubmed: Pubmed: 6348905. 27219283. 5. Brodniewicz A. Poisoning of seamen with methyl bromide due to 22. Vohra RB, Schwarz KA, Williams SR, et al. Phosphine toxicity with fumigation of a Polish cargo ship in Haiphong (Vietnam). Arh Hig echocardiographic signs in railcar stowaways. Abstracts of the 2006 Rada Toksikol. 1967; 18(1): 19–24, indexed in Pubmed: 6043110. North American Congress of Clinical Toxicology Annual Meeting, Clin 6. Boeker M, Vach W, Motschall E. Google Scholar as replacement for Toxicol. 2006; 44: 719-720. systematic literature searches: good relative recall and precision 23. Pepelko B, Seckar J, Harp PR, et al. Worker exposure standard are not enough. BMC Med Res Methodol. 2013; 13: 131, doi: for phosphine gas. Risk Anal. 2004; 24(5): 1201–1213, doi: 10.1186/1471-2288-13-131, indexed in Pubmed: 24160679. 10.1111/j.0272-4332.2004.00519.x, indexed in Pubmed: 7. SMAIC. Very serious marine casuality - MV Nefryt. State Marine 15563288. Accident Investigation Commission, Warsaw, Poland. 2016. https:// 24. Proudfoot AT. Aluminium and zinc phosphide poisoning. Clin Toxicol pkbwm.gov.pl/wp-content/uploads/images/uchwaly_raporty/ (Phila). 2009; 47(2): 89–100, doi: 10.1080/15563650802520675, raporty/Final_report_Nefryt_WIM_47_15.pdf. indexed in Pubmed: 19280425. 8. Gummin DD, Mowry JB, Spyker DA, et al. 2018 Annual Report of the 25. Potter WT, Garry VF, Kelly JT, et al. Radiometric assay of red cell American Association of Poison Control Centers’ National Poison and plasma cholinesterase in pesticide appliers from Minnesota. Data System (NPDS): 36th Annual Report. Clin Toxicol (Phila). 2019; Toxicol Appl Pharmacol. 1993; 119(1): 150–155, doi: 10.1006/ 57(12): 1220–1413, doi: 10.1080/15563650.2019.1677022, taap.1993.1054. indexed in Pubmed: 31752545. 26. Barbosa A, Bonin AM. Evaluation of phosphine genotoxicity at occu- 9. Van de Sijpe P, Lucas D, Canals ML, et al. Acute occupational phos- pational levels of exposure in New South Wales, Australia. Occup En- phine intoxications in the maritime shipping sector: Belgian and viron Med. 1994; 51(10): 700–705, doi: 10.1136/oem.51.10.700, French reported cases. Int Marit Health. 2020; 71(3): 151–159, indexed in Pubmed: 8000496. doi: 10.5603/IMH.2020.0028, indexed in Pubmed: 33001425. 27. Schaefer GJ, Newton PE, Gruebbel MM, et al. Acute and subacute 10. IARC. Methyl bromide. Monographs on the Identification of Car- inhalation neurotoxicity of phosphine in the rat. Inhal Toxicol. 1998; cinogenic Hazards to Humans. International Agency for Research 10: 293–320. on Cancer, World Health Organisation, Lyon, France. 1999. http:// 28. Wilson R, Lovejoy FH, Jaeger RJ, et al. Acute phosphine poisoning monographs.iarc.fr. aboard a grain freighter. Epidemiologic, clinical, and pathological 11. UNEP. Handbook for the Montreal Protocol on Substances that findings. JAMA. 1980; 244(2): 148–150, indexed in Pubmed: Deplete the Ozone Layer. United Nations Environment Programme, 7382074. Nairobi, Kenya. 2019. https://ozone.unep.org/sites/default/files/ 29. Lemoine TJ, Schoolman K, Jackman G, et al. Unintentional fatal Handbooks/MP_Handbook_2019.pdf. phosphine gas poisoning of a family. Pediatr Emerg Care. 2011; 12. MBTOC. Report of the Methyl Bromide Technical Options Commit- 27(9): 869–871, doi: 10.1097/PEC.0b013e3182348e40, indexed tee. 2018 Assessment. United Nations Environmental Programme, in Pubmed: 21926889. Nairobi, Kenya. 2019. https://ozone.unep.org/sites/default/ 30. Brautbar N, Howard J. Phosphine toxicity: report of two cases files/2019-04/MBTOC-assessment-report-2018_1.pdf (2018). and review of the literature. Toxicol Ind Health. 2002; 18(2): 13. Lyubimov AV, Garry VF. Phoshine. In: Krieger R, ed. Hayes’ Handbook 71–75, doi: 10.1191/0748233702th133oa, indexed in Pubmed: of Pesticide Toxicology. 3 ed. Academic Press, London, UK 2010: 12868795. 2259–2266. 31. Waszkowska M, Walusiak-Skorupa J, Merecz-Kot D, et al. [Late 14. Omae K, Ishizuka C, Nakashima H, et al. Acute and subacute inha- effects of mass acute phosphine poisoning. Case report]. Med Pr.

lation toxicity of highly purified phosphine (PH3) in male ICR mice. 2018; 69(3): 337–344, doi: 10.13075/mp.5893.00648, indexed J Occup Health. 1996; 38(1): 36–42, doi: 10.1539/joh.38.36. in Pubmed: 29565044.

www.intmarhealth.pl 215 Int Marit Health 2021; 72, 3: 206–216

32. Szymczyk E, Wiszniewska M, Walusiak-Skorupa J, et al. Subclinical 42. MSAH. HTP-VÄRDEN 2020. Koncentrationer som befunnits skadliga chronic left ventricular systolic dysfunction resulting from phosphine (Occupational exposure limits, in Swedish). Ministry of Social Affairs poisoning. Occup Med (Lond). 2017; 67(3): 233–235, doi: 10.1093/ and Health in Finland, Helsinki, Finland. 2020. https://julkaisut. occmed/kqx005, indexed in Pubmed: 28339702. valtioneuvosto.fi/handle/10024/162458 (Accessed November 33. Ziemer U. [Fatal hydrogen phosphide poisoning on a freighter]. Zentr- 26, 2020). albl Arbeitsmed. 1963; 13: 38–39, indexed in Pubmed: 14003625. 43. SWEA. Hygieniska gränsvärden (Occupational exposure limits, in 34. MAIB. Report on the investigation into the release of phosphine Swedish). Swedish Work Environment Authority, Stockholm, Swe- gas during cargo discharge on board Arklow Meadow, Warren- den. 2018. https://www.av.se/globalassets/filer/publikationer/ point, Northern Ireland on 5 December 2012. Marine Accident foreskrifter/hygieniska-gransvarden-afs-2018-1.pdf (Accessed Investigation Branch, Southampton, UK. 2013. https://www.gov. November 26, 2020). uk/maib-reports/release-of-phosphine-gas-during-discharge-of- 44. DWEA. Grænseværdier for luftforureninger m.v. (Limit Values for Air fumigated-maize-cargo-from-general-cargo-vessel-arklow-meadow- Contaminants, in Danish). Danish Working Environment Authority, at-warrenpoint-northern-ireland. Copenhagen, Denmark. 2020. https://at.dk/regler/bekendtgoer- 35. MAIB. Phosphine poisoning on general cargo vessel Monika with elser/graensevaerdier-stoffer-materialer-698/bilag-2/ (Accessed loss of 1 life. Marine Accident Investigation Branch, Southampton, November 26, 2020). UK. 2008. https://www.gov.uk/maib-reports/phosphine-poisoning- 45. BAUA. TRGS 900 Technical Rules for Hazardous Substances (in on-general-cargo-vessel-monika-with-loss-of-1-life. German). Bundesanstalt für Arbeitsschutz und Arbeitsmedizin., 36. Loddé B, Lucas D, Letort JM, et al. Acute phosphine poisoning on Dortmund, Germany. 2020. https://www.baua.de/DE/Angebote/ board a bulk carrier: analysis of factors leading to a fatal case. Rechtstexte-und-Technische-Regeln/Regelwerk/TRGS/pdf/TRGS- J Occup Med Toxicol. 2015; 10: 10, doi: 10.1186/s12995-015- 900.pdf?__blob=publicationFile (Accessed November 26, 2020). 0050-0, indexed in Pubmed: 25763098. 46. NIOSH. Immediately Dangerous To Life or Health (IDLH) Values. Na- 37. Gard. Fumigation of cargo on board ships: the invisible killer. Gard tional Institute for Occupational Safety and Health, Centers for Disease News 204, Gard AS. 2011. http://www.gard.no/web/updates/con- Control and Prevention, Washington DC, USA. 2019. https://www. tent/20650371/fumigation-of-cargo-on-board-ships-the-invisible-killer. cdc.gov/niosh/idlh/intridl4.html (Accessed November 26, 2020). 38. Afandiyev I. Mass phosphine poisoning on board a cargo ship. Clin 47. IARC. Monographs on the identification of carcinogenic hazards Toxicol (Phila). 2020; 58(6): 520. to humans. International Agency for Research on Cancer, World 39. Belobrov E, Torskiy V, Rangayeva G. Analysis of accidents during Health Organisation, Lyon, France. 2020. http://monographs.iarc.fr maritime transportation of cargo fumigated with phosphine: Causes, (Accessed November 26, 2020). consequences, prevention. In: Weintrit A, Neumann T, eds. Advances 48. Hansen HL, Pedersen G. Poisoning at sea: injuries caused by in marine navigation and safety of sea transportation. CRC Press, chemicals aboard Danish merchant ships 1988-1996. J Toxicol Taylor & Francis Group, London, UK 2019: 99–104. Clin Toxicol. 2001; 39(1): 21–26, doi: 10.1081/clt-100102875, 40. IMO. Recommendations on the safe use of pesticides in ships indexed in Pubmed: 11327222. applicable to the fumigation of cargo holds. MSC.1/Circ.1264, 49. Drouin M. Fumigation gas sickens 16 crewmembers aboard dry bulk International Maritime Organization, London, UK. 2008. ship near Welland Canal. Professional Mariner. Navigator Publishing 41. Kalbarczyk-Jedynak A, Stochla D, Kostecka E. Safety on-board a ship LLC, Portland, Maine, USA. 2011. http://www.professionalmariner. vs knowledge of the chemical processes discussed at the level of com/April-2011/Fumigation-gas-sickens-16-crewmembers-aboard- high school. Gen Prof Educat. 2018; 3: 39–44. dry-bulk-ship-near-Welland-Canal/.

216 www.intmarhealth.pl Int Marit Health 2021; 72, 3: 217–222 10.5603/IMH.2021.0040 www.intmarhealth.pl Copyright © 2021 PSMTTM ORIGINAL ARTICLE ISSN 1641-9251 eISSN 2081-3252 Comparison of insulation provided by dry or wetsuits among recreational divers during cold water immersion (< 5°C)

Pierre Lafère1, 2, 3, 4 , François Guerrero1, 4 , Peter Germonpré1, 3, 5, Costantino Balestra1, 3, 6, 7, 8

1DAN Europe Research Division 2Department of Anaesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium 3Environmental, Occupational, Ageing (Integrative) Physiology Laboratory, Haute Ecole Bruxelles-Brabant (HE2B), Brussels, Belgium 4Optimisation des Régulations Physiologiques (ORPHY), EA 4324, Université de Bretagne Occidentale, Brest, France 5Centre for Hyperbaric Oxygen Therapy, Military Hospital «Queen Astrid», Brussels, Belgium 6Anatomical Research and Clinical Studies (ARCS), Vrije Universiteit Brussel (V.U.B.), Brussels, Belgium 7Anatomical Research Training and Education (ARTE), Vrije Universiteit Brussel (V.U.B.), Brussels, Belgium 8Motor Sciences, Université Libre De Bruxelles (U.L.B.), Brussels, Belgium

ABSTRACT Background: Divers thermal status influences susceptibility to decompression sickness hence the need for proper insulation during immersion in cold water. However, there is a lack of data on thermal protection provided by diving suits, hence this study. Materials and methods: Two different groups of divers wearing either a wetsuit (n = 15) or a dry suit (n = 15) volunteered for this study. Anthropometric data and dive experience were recorded; skin temperatures at the cervical-supraclavicular (C-SC) area and hands were assessed through high-resolution thermal infrared imaging taken pre- and post-dive. Results: As far as anthropometrics, pre-dive C-SC temperatures (37.0 ± 0.4°C), depth (dry: 43 ± 4.6 mfw vs. wet: 40.3 ± 4.0 mfw) and water temperature exposure (4.3°C) are concerned, both groups were comparable. Total dive time was slightly longer for dry suit divers (39.6 ± 4.0 min vs. 36.5 ± 4.1 min, p = 0.049). Post-dive, C-SC temperature was increased in dry suit divers by 0.6 ± 0.6°C, and significantly decreased in wetsuit divers by 0.8 ± 0.6°C. The difference between groups was highly significant (dry: 37.5 ± 0.7°C vs. wet: 36.2 ± 0.7°C, p = 0.004). Hand’s temperature decreased significantly in both groups (dry: 30.3 ± ± 1.2°C vs. wet: 29.8 ± 0.8°C, p = 0.33). Difference between groups was not significant. Conclusions: Medium-duration immersion in cold water (< 5°C), of healthy and fully protected subjects was well tolerated. It was demonstrated that proper insulation based on a three-layer strategy allows maintaining or even slightly improve thermal balance. However, from an operational point of view, skin extremities are not preserved. (Int Marit Health 2021; 72, 3: 217–222) Key words: diving, cold water immersion, body insulation, wetsuits, dry suit, thermal imaging

INTRODUCTION data are available on the thermoregulatory responses of Although several studies have reported that moderate fully protected divers exposed to cold water for prolonged exercise in cold-water immersion, such as diving, facilitates time. Since divers need to avoid the “dive warm-decompress overall heat loss because of increased convective heat cool” pattern know to increase decompression risk substan- transfer from the body core to the skin [1, 2], only scarce tially [3, 4], this might be considered a dangerous gap of

* Pierre Lafère, PhD, Department of Anaesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium, e-mail: [email protected] This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

www.intmarhealth.pl 217 Int Marit Health 2021; 72, 3: 217–222 knowledge. Indeed, recent studies point out an increased (abdomen – neck) – 70.041 × log10 (height) + 30.30] incidence of decompression sickness among finnish tech- [12, 13]. Once recruited, participants were instructed to nical divers, whom performed long dives in areas where avoid alcohol beverages, smoking, caffeine, large meals, water temperature at the diving depths is 4–10°C even in ointments, cosmetics and showering for 4 hours before summer [5], or among Belgian recreational divers when the the assessment. winter is particularly cold [6]. All measurements were performed on the same day Because most of the waters of the world are below ther- and dive site (Rochefontaine, Belgium), a flooded quarry moneutral (34–35°C) temperature for humans, and there with a maximal depth of 52 metres of fresh water (mfw). is no evidence that humans can increase their metabolism Participants dived according to their own dive plan (depth- high enough to maintain core temperature during whole- -time-breathing mixture). No specific dive profiles were im- body exposure to cold [7], insulating the body remains the posed but subjects were asked to swim slowly to maintain only way to allow divers a prolonged stay under water [8]. a low to moderate-intensity energy expenditure related Although the merit of different immersion suits has been to exercise. extensively discussed as lifesaving appliance certified by Based on their own dive gear that needed to be in good the International Maritime Organization to ensure survival condition (no wear and tear) to participate, divers were al- in case of accidental immersion in harsh conditions [9], less located to two different groups: wetsuit divers (wet, n = 15: is known about diving suits especially among recreational full 7 mm thick neoprene wetsuit combined with a 1.5 mm divers. According to an older study, “dry” garments provide rash-guard undergarment [long sleeve top and pants], hood, better protection than “wet” garments independently of sea boots, and gloves) or dry suit divers (dry, n = 15: trilaminate conditions, and tight-fitting “wet” garments provided better membrane dry suit with high density polyester/merino wool protection than loose-fitting “wet” garments in rough but fleece undergarment [top, legging, and socks] with neoprene not in calm seas [10]. 5 mm gloves and hood). Depth, total dive time and water Therefore, evaluating the performance of clothing under temperature as measured by diver’s own personal dive severe cold environments becomes of great significance for computer were noted to compare the level of cold exposure divers’ safety, hence this field study designed to compare of the two groups. body temperature variation related to insulation provided During the examinations, the conditions were kept as by wet or dry suits among recreational divers during an identical as possible using the same procedure and type of immersion of medium duration in very cold water (< 5°C). equipment [14]. Since the condition of the skin surface may influence emissivity values, the skin was dried before the MATERIALS AND METHODS post-dive measurement. To limit the influence of friction on This study was conducted in accordance with the Decla- blood flow participants from both groups had to wipe oneself ration of Helsinki [11] and was part of a series of non-inva- with a towel. More, to ensure a thermal sensitivity lower than sive studies carried out by the Environmental, Occupational, 0.3°C, all measurements were done in a heated dressing Ageing (Integrative) Physiology Laboratory, Haute Ecole Brux- room, with a room temperature above 21°C. There were elles-Brabant (HE2B), Brussels, Belgium, approved by the no fans, and the doors were kept closed during the testing, Academic Bioethical Committee of Brussels (B200-2011-5). so air movement was minimal. Then subjects were placed After being informed of the purpose and experimental in a seated relaxed and upright position with arms adduct- procedures of the study, 30 male divers, with a minimal ed, away from all heat-emitting objects. Pictures of hands certification according to European norm EN 14153-2 or and left cervical-supraclavicular region (C-SC) at a 1.0-m ISO 24801-2 and at least 60 dives in the last 2 years, distance from an IR thermal imaging camera (FLIR i7, FLIR volunteered and signed a written informed consent. They System Inc, Wilsonville, Oregon, USA, thermal resolution at were recruited from a large diver population after visual 19,600 (140 × 140) pixels, thermal sensitivity < 0.1°C and pre-selection of possible candidates, to obtain a low varia- noise equivalent temperature difference (NETD) < 100 mK) tion in participants’ anthropometric profiles to reduce the were obtained from two different time points: one before potential between-participant effect of body mass on pre- and one within 10 minutes after completing their dive. to post-dive core temperature measurements. To ensure The stored thermographic images were analysed with that only reasonably healthy participants were included in R&D FLIR Software (FLIR System Inc, Wilsonville, Oregon, the study, all participants completed a medical disclaimer. USA). During data collection, the software was set to control Age, height, weight, and dive experience were recorded for the temperature scale limits between 28°C to 40°C, which further analysis. Body fat percentage (%BF) was derived is the typical range of human body temperature. To allow from body circumference measurements (made in cm) the accurate, efficient, and reproducible identification of the according to the US Navy formula [%BF = 86.010 × log10 region of interest (ROIs) they were defined as follow [15]:

218 www.intmarhealth.pl Pierre Lafère et al, Diver’s thermal balance in cold water

Dry suit divers Wetsuit divers General 39 39 39 Dry Wet 38 38 38

37 37 37 perature [°C] C-SC skin perature [°C] 36 36 em 36 em t

35 35 Core t 35

36 36 36 Dry Wet 34 34 34 perature [°C]

perature [°C] 32 32 32 em em 30 30 30 NS 28 28 Hands t Hands t Pre-dive Post-dive Pre-dive Post-dive Pre-dive Post-dive

Figure 1. Comparison between pre- and post-dive cervical-supraclavicular (C-SC) and hands temperature after 40 minutes of exposure in cold water (4°C). Divers were equipped either with a dry suit (dry) or a wetsuit (wet); NS — not significant; *p < 0.05; **p < 0.01; ***p < 0.001 for the C-SC region, the limits of the ROI was calculated Table 1. Group’s anthropometrics and dive experience as straight lines from the neck and shoulder apices to the (unpaired t-test, df = 28) central apex and the shoulder contour between the shoulder Dry Wet and neck apices. The hottest 10% of points within this ROI Age [years] 36 ± 6 36 ± 6 were identified, and the supraclavicular temperature was Weight [kg] 77 ± 8 80 ± 10 defined as the median temperature of the hotspot [16, Height [cm] 180 ± 6 181 ± 6 17]; hand’s temperature was assessed along a straight line positioned at the mid-dorsal side of all fingers. Each line ex- Body mass index 23.7 ± 1.7 24.4 ± 1.8 tended from the middle of the nailbed and to the interdigital Body fat percentage 18.9 ± 6.3 18.7 ± 5.5 web which gave 10 average individual finger-temperatures Logged dives (n) 595 ± 218 458 ± 247 that were used to calculate a mean temperature of the hands for each time point [18]. ± 4.1 min, unpaired t test, p = 0.049, df = 28). Although STATISTICAL ANALYSIS just statistically significant, this might be not practically Statistical analysis was performed using GraphPad relevant. Prism (version 5.0f for Mac, GraphPad Software, San Di- Pre-dive C-SC (dry: 36.9 ± 0.5°C vs. wet: 37.0 ± 0.4°C, ego, California, USA). Since all data passed the Kolmogor- unpaired t-test, p = 0.39, df = 28) and hands (dry: 34.7 ± ov-Smirnov test, allowing us to assume a Gaussian distri- ± 0.6°C vs. wet: 34.7 ± 0.4°C, unpaired t-test, p = 0.97, bution, comparison between variables was carried out with df = 28) temperatures were similar in both groups. paired t-test for intragroup comparison and unpaired t-test Variations of C-SC and hands temperatures are de- for intergroup comparison. Data are expressed as mean ± scribed in Figure 1. Immediately after the dive, C-SC tem- ± standard deviation (SD). Differences between groups were perature was increased by 0.6 ± 0.6°C in dry suit divers considered significant at p < 0.05. to 37.5 ± 0.7°C (paired t-test, p = 0.004, df = 14), while it was significantly decreased by 0.8 ± 0.6°C in wetsuit RESULTS divers to 36.2 ± 0.7°C (paired t-test, p = 0.0001, df = 14). As far as age, weight, height, body mass index (BMI), The post-dive C-SC temperature difference between groups %BF or numbers of logged dives are concerned; both groups was highly significant (unpaired t-test, p < 0.0001, df = 28). were comparable (Table 1). Cold exposure was also similar Hand’s temperature decreased significantly in both groups in terms of water temperature (4.3 ± 0.6 vs. 4.3 ± 0.7, (dry: 30.3 ± 1.2°C vs. wet: 29.8 ± 0.8°C, paired t-test, unpaired t-test, p = 0.835, df = 28) and maximal depth p < 0.0001, df = 14). Although dry suit divers had slightly (43 ± 4.6 vs. 40.3 ± 4.0 mfw, unpaired t-test, p = 0.101, warmer hands than wetsuit divers after the dive, this differ- df = 28). Nonetheless, there is a 3-minute difference in ence between groups was not significant (unpaired t-test, total dive time between groups (39.6 ± 4.0 min vs. 36.5 ± p = 0.33, df = 28).

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DISCUSSION %BF, even if not perfectly accurate, provides sufficiently Evaluating the performance of clothing under severe valid results also demonstrating no difference between our thermal environments is not an easy task, especially in two groups. Therefore, there is a reasonable assumption to the field. The most appropriate method for measuring the neglect any in-between group’s bias related to fat insulation thermal resistance provided by the garments would be to or measurements conditions. Indeed, a compromise must measure heat flow across the insulation layer. That would be made between increasing measurement accuracy and typically be done in a laboratory setup using the most com- maintaining validity of the protocol, when trying to transfer mon tool: the thermal manikin [19]. However, it is associated otherwise valid tools to applied situations. with significant discrepancies between results obtained Our results are consistent with previous observations, from the three proposed calculation methods either global, demonstrating that wetsuit diving in cold-water results in serial, or parallel, which are particularly relevant with cold a drop-in body temperature and may not provide adequate exposure [20], as in the present setting. Also, from the thermal protection in such condition [25, 26]. The next physiological standpoint, this might not be adapted as we expected observation should have been a slowing down are more interested on how the divers’ thermal balance to of heat loss with a limited drop of skin temperature while cold exposure is modified by any type of diving suit rather wearing a dry suit compared to a wetsuit. Surprisingly, we than the insulation per se. Then, alternative means would be observed the opposite, namely an increased C-SC skin to measure skin temperature at multiple sites as body heat temperature among dry suit divers. loss will depend on the heat flux from different sites [21]. Al- Two hypotheses may explain these results. First, cold though, these thermocouples are non-invasive, the required immersion is known to increase heat production as a func- hard-wired connections to a datalogger limit its validity and tion of both core/skin temperature and exercise (in our fail to address questions and applications outside the lab- case, finning) [27]. This production in combination with oratory. Therefore, we opted for infra-red thermal imaging fabrics with a higher thermal insulation such as fleece used as a surrogate method for body temperature monitoring. in the present setting, would allow a higher temperature Although this technique has been shown to be valid than neoprene or other membrane fabric. Although one and reliable [22], and recommended for clinical use in could argue that human-clothing-environment simulator is inflammatory diseases, complex regional pain syndrome, less relevant than the use of cold water due to the thermal Raynaud’s phenomenon, as well as for fever screening [23], properties of water, similar results have been demonstrated some limitations must be acknowledged. First, large errors for outdoor undergarments [28]. Second, the reduction of versus a thermocouple during rest and exercise have been C-SC skin temperature among wetsuit divers could be due reported, making it unclear within which situations it may to vasoconstricted skin on the chest, which would result in have application. One study whose aims was to investigate cooler skin temperatures. Therefore, the gradient between the validity and reliability of skin temperature measure- core and skin may not have been established and it is ments using different portable system against a certified not certain that deep body cooling occurs in wet suited thermocouple, demonstrated that thermal cameras did not divers. However, based on previous literature [25, 26], perform as well as the other devices when providing live, this hypothesis is unlikely and does not explain the results handheld measurements of skin temperature during exer- observed among dry suit divers. Indeed, this has recently cise. However, it also demonstrated that thermal cameras been demonstrated among spinal cord injured divers wear- are useful tools for measuring skin temperature in static ing a wetsuit while exposed to 6°C water dive. Although the and controlled environments [24], as in our study. Second, drop was variable, the decrease in core temperature was the principle of thermal cameras is based on emissivity, significantly increased in the absence of thermoregulatory namely the ability of the skin to emit energy by radiation, control below the lesion compared to able-bodied diver [29]. which is processed to calculate the temperature of the Based on the starting and ending cylinder pressures, studied surface. Although, this method limits inter-indi- equivalent surface air consumption was calculated around vidual variation and the consequential non-uniform heat 17.5 L/min in both groups. Exercise intensity inferred from production [24], heat transfer and temperature gradients these estimates corresponds to a moderate-intensity energy from body core to skin surface is under the influence of expenditure (5.3 to 5.8 MET) [30]. Since both groups showed many factor such as skin wettedness, ambient tempera- similar exposure, the difference in C-SC skin temperature be- ture once disrobed, duration of exposure to the ambient tween groups is likely to be due to the suit worn. Because of temperature or subcutaneous fat and skin. Most of these a positive association between surface and core body [31], it parameters were accounted for. For instance, there are no seems a reasonable assumption to consider that C-SC skin gender, ethnic, age or BMI differences in our population. temperature reflects core body temperature patterns, but It can be considered that the selected method to estimate not necessarily absolute core temperature [32]. Then, as

220 www.intmarhealth.pl Pierre Lafère et al, Diver’s thermal balance in cold water a conclusion, compared to wetsuits, it would be logical to REFERENCES assume that dry suit better preserve core temperature as 1. Ferretti G, Veicsteinas A, Rennie DW. Regional heat flows of resting this condition is associated with both an increase of C-SC and exercising men immersed in cool water. J Appl Physiol (1985). skin temperature and an alleged increased core-to-skin 1988; 64(3): 1239–1248, doi: 10.1152/jappl.1988.64.3.1239, indexed in Pubmed: 3366739. temperature gradient. 2. McArdle WD, Toner MM, Magel JR, et al. Thermal responses of men It is also known that cold exposure is associated with hand and women during cold-water immersion: influence of exercise dysfunction unless body heat content is maintained [10]. intensity. Eur J Appl Physiol Occup Physiol. 1992; 65(3): 265–270, Therefore, it is paramount to preserve both core and hand’s doi: 10.1007/BF00705092, indexed in Pubmed: 1396657. temperature. This can be achieved either by insulation or by 3. Gerth W, Ruterbusch V, Long E. The influence of thermal exposure on diver susceptibility to decompression sickness. Panama City: using some heating device, but both seem to be ineffective. Navy Experimental Diving Unit, 2007 Contract No.: NEDU TR 06-07. Indeed, according to previous literature, neither manual dex- 2007, doi: 10.21236/ada480118. terity nor finger temperature could be rescued using whole 4. Pollock NW, editor Thermal physiology and diver protection. Re- body active heating [21], while in wet-suited subjects, wearing breather Forum 3; 2013; Durham, NC: AAUS/DAN/PADI. gloves and boots seems to increase the overall rate of body 5. Lundell RV, Arola O, Suvilehto J, et al. Decompression illness (DCI) heat loss [8, 33]. Consistently with these findings, no differ- in Finland 1999-2018: Special emphasis on technical diving. Diving Hyperb Med. 2019; 49(4): 259–265, doi: 10.28920/dhm49.4.259- ence in hand’s temperature among groups was observed 265, indexed in Pubmed: 31828744. and pain in the hands with major discomfort was the main 6. Lafère P, Balestra C, Caers D, et al. Patent Foramen Ovale (PFO), Per- complaint in both groups at the end of the dive. Although hy- sonality Traits, and Iterative Decompression Sickness. Retrospective pothetical, similar hand’s temperature could paradoxically be Analysis of 209 Cases. Front Psychol. 2017; 8: 1328, doi: 10.3389/ explained by a better preservation of core temperature among fpsyg.2017.01328, indexed in Pubmed: 28824507. 7. Senn JR, Maushart CI, Gashi G, et al. Outdoor temperature influ- dry suit divers associated with a reduction of cold-induced ences cold induced thermogenesis in humans. Front Physiol. 2018; vasoconstriction. This mechanism has been proposed after 9: 1184, doi: 10.3389/fphys.2018.01184, indexed in Pubmed: an experiment comparing two forms of hand heating, either 30190681. direct hand heating with electrically heated gloves or indirectly 8. Park YS, Kim JS, Choi JK. Increase of heat loss by wearing gloves by actively heating the torso with an electrically heated vest, and boots in wet-suited subjects working in cold water. Ann Physiol while exposed to minus 25°C in air. Despite a similar finger Anthropol. 1992; 11(4): 393–400, doi: 10.2114/ahs1983.11.393, indexed in Pubmed: 1388402. skin temperature, the finger blood flow was significantly higher 9. Power J, Tikuisis P, Ré AS, et al. Correction factors for assessing during the heated vest condition [34]. Indeed, compared to the immersion suits under harsh conditions. Appl Ergon. 2016; 53 Pt A: C-SC skin temperature, which is thought to reflect core body 87–94, doi: 10.1016/j.apergo.2015.08.009, indexed in Pubmed: temperature patterns, we observed a greater magnitude of the 26674408. changes in the dry suit condition (dry: –7.2 ± 1.2°C vs. wet: 10. Steinman AM, Hayward JS, Nemiroff MJ, et al. Immersion hypothermia: comparative protection of anti-exposure garments in calm –6.3 ± 0.8°C). Consequently, comfort and dexterity may be versus rough seas. Aviat Space Environ Med. 1987; 58(6): 550–558, the limiting factor in performance/endurance irrespective of indexed in Pubmed: 3606516. how well the rest of the body is protected. It is indeed a known 11. World Medical Association. World Medical Association Declaration fact that manual gross and fine dexterity decreases by 71.6 ± of Helsinki: ethical principles for medical research involving hu- ± 22.9% and 44.5%, respectively during cold water (10°C) im- man subjects. JAMA. 2013; 310(20): 2191–2194, doi: 10.1001/ mersion and continue to decrease with immersion time [21]. jama.2013.281053, indexed in Pubmed: 24141714. 12. Hodgdon JA, Beckett MB. Prediction of percent body fat for U.S. Navy men from body circumferences and height. 1984, doi: 10.21236/ CONCLUSIONS ada143890. In conclusion, medium-duration immersion in cold wa- 13. Hodgdon J, Friedl K. Development of the DoD Body Composition ter less than 5°C, of healthy and fully protected subjects Estimation Equations. San Diego, CA: US Navy, 1998 Technical was well tolerated. It was demonstrated that insulation Document No. 99-2B. 1998, doi: 10.21236/ada370158. 14. Moreira DG, Costello JT, Brito CJ, et al. Thermographic imaging in based on a three-layer strategy (a base layer to wick water sports and exercise medicine: A Delphi study and consensus state- away from the skin to reduce conductive heat loss to the ment on the measurement of human skin temperature. J Therm liquid; a mid-layer to provides insulation; and the dry suit Biol. 2017; 69: 155–162, doi: 10.1016/j.jtherbio.2017.07.006, membrane to provide a barrier to convective heat loss) indexed in Pubmed: 29037377. might maintain or even slightly increase body tempera- 15. Tipton MJ, Collier N, Massey H, et al. Cold water immersion: kill or ture. However, cooling of the hands, with impairment cure? Exp Physiol. 2017; 102(11): 1335–1355, doi: 10.1113/ EP086283, indexed in Pubmed: 28833689. of dexterity in such conditions, may constitute a major 16. Larsen T, Kumar S, Grimmer K, et al. A systematic review of guide- safety issue. lines for the prevention of heat illness in community-based sports participants and officials. J Sci Med Sport. 2007; 10(1): 11–26, doi: Conflict of interest: None declared 10.1016/j.jsams.2006.07.008, indexed in Pubmed: 16952483.

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17. Law J, Morris DE, Izzi-Engbeaya C, et al. Thermal imaging is Eur J Appl Physiol Occup Physiol. 1997; 76(1): 69–74, doi: 10.1007/ a noninvasive alternative to PET/CT for measurement of brown s004210050214, indexed in Pubmed: 9243172. adipose tissue activity in humans. J Nucl Med. 2018; 59(3): 26. Shiraki K, Sagawa S, Konda N, et al. Energetics of wet-suit diving 516–522, doi: 10.2967/jnumed.117.190546, indexed in in Japanese male breath-hold divers. J Appl Physiol (1985). 1986; Pubmed: 28912148. 61(4): 1475–1480, doi: 10.1152/jappl.1986.61.4.1475, indexed 18. Norheim AJ, Borud E, Wilsgaard T, et al. Variability in peripheral in Pubmed: 3781961. rewarming after cold stress among 255 healthy Norwegian 27. Parsons KC. Human Thermal Environments. The effects of hot, army conscripts assessed by dynamic infrared thermogra- moderate and cold environments on human health, comfort and phy. Int J Circumpolar Health. 2018; 77(1): 1536250, doi: performance. . 2nd ed. Taylor & Francis, London 2003. 10.1080/22423982.2018.1536250, indexed in Pubmed: 28. Kim E, Yoo SJ, Shim H. Performance of selected clothing systems 30444464. under subzero conditions: determination of performance by 19. Ergonomics of the thermal environment. Estimation of thermal a human-clothing-environment simulator. Text Res J. 2016; 76(4): insulation and water vapour resistance of a clothing ensemble. ISO 301–308, doi: 10.1177/0040517506057529. 9920. 2010, doi: 10.3403/30125323. 29. Gajsek U, Sieber A, Finderle Z. Thermal balance of spinal cord injured 20. Oliveira AV, Gaspar AR, Quintela DA. Measurements of clothing insu- divers during cold water diving: a case control study. Diving Hyperb lation with a thermal manikin operating under the thermal comfort Med. 2020; 50(3): 256–263, doi: 10.28920/dhm50.3.256-263, regulation mode: comparative analysis of the calculation methods. indexed in Pubmed: 32957128. Eur J Appl Physiol. 2008; 104(4): 679–688, doi: 10.1007/s00421- 30. Buzzacott P, Pollock NW, Rosenberg M. Exercise intensity inferred 008-0824-5, indexed in Pubmed: 18633635. from air consumption during recreational scuba diving. Diving Hyperb 21. Wheelock CE, Hess HW, Schlader ZJ, et al. Whole-body active Med. 2014; 44(2): 74–78, indexed in Pubmed: 24986724. heating does not preserve finger temperature or manual dexterity 31. McFarland R, Barrett L, Fuller A, et al. Infrared thermography cannot during cold-water immersion. Undersea Hyperb Med. 2020; 47(2): be used to approximate core body temperature in wild primates. 253–260, indexed in Pubmed: 32574442. Am J Primatol. 2020; 82(12): e23204, doi: 10.1002/ajp.23204, 22. Roy R, Boucher JP, Comtois AS. Validity of infrared thermal mea- indexed in Pubmed: 33043502. surements of segmental paraspinal skin surface temperature. 32. van der Vinne V, Pothecary CA, Wilcox SL, et al. Continuous and J Manipulative Physiol Ther. 2006; 29(2): 150–155, doi: 10.1016/j. non-invasive thermography of mouse skin accurately describes core jmpt.2005.12.004, indexed in Pubmed: 16461175. body temperature patterns, but not absolute core temperature. Sci 23. Ring EFJ, Ammer K. Infrared thermal imaging in medicine. Physiol Rep. 2020; 10(1): 20680, doi: 10.1038/s41598-020-77786-5, Meas. 2012; 33(3): R33–R46, doi: 10.1088/0967-3334/33/3/ indexed in Pubmed: 33244132. R33, indexed in Pubmed: 22370242. 33. Riera F, Horr R, Xu X, et al. Thermal and metabolic responses of mil- 24. James CA, Richardson AJ, Watt PW, et al. Reliability and validity itary divers during a 6-hour static dive in cold water. Aviat Space En- of skin temperature measurement by telemetry thermistors and viron Med. 2014; 85(5): 509–517, doi: 10.3357/asem.3077.2014, a thermal camera during exercise in the heat. J Therm Biol. 2014; indexed in Pubmed: 24834564. 45: 141–149, doi: 10.1016/j.jtherbio.2014.08.010, indexed in 34. Brajkovic D, Ducharme MB. Finger dexterity, skin temperature, and Pubmed: 25436963. blood flow during auxiliary heating in the cold. J Appl Physiol (1985). 25. Arieli R, Kerem D, Gonen A, et al. Thermal status of wet-suited divers 2003; 95(2): 758–770, doi: 10.1152/japplphysiol.00051.2003, using closed circuit O2 apparatus in sea water of 17-18.5 degrees C. indexed in Pubmed: 12730145.

222 www.intmarhealth.pl Int Marit Health 2021; 72, 3: 223–227 10.5603/IMH.2021.0041 www.intmarhealth.pl Copyright © 2021 PSMTTM REVIEW ARTICLE ISSN 1641-9251 eISSN 2081-3252 Medical assessment of fitness to dive after COVID-19

Jarosław Krzyżak1, Krzysztof Korzeniewski2, 3

1Polish Society of Hyperbaric Medicine and Technology, Gdynia, Poland 2Department of Epidemiology and Tropical Medicine, Military Institute of Medicine, Warsaw, Poland 3Department of Tropical Medicine and Epidemiology, Institute of Maritime and Tropical Medicine, Medical University of Gdansk, Poland

ABSTRACT Since the global pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiological agent of a coronavirus disease 2019 (COVID-19) infection started, millions of people globally have become infected. It must not be forgotten that thousands of those affected are commercial or recreational divers. A severe COVID-19 seriously affects the respiratory system and the pulmonary parenchyma but it may also involve the cardiovascular and the blood coagulation system. For this reason, many divers and hyperbaric medicine specialists are becoming increasingly concerned about a diver’s ability to safely return to diving after a SARS-CoV-2 infection. The article presents current guidelines for diving fitness health assessment after a COVID-19 both for active and prospective divers, with particular emphasis on the types of diagnostic procedures and tests to be performed in cases of asymptomatic infection with SARS-CoV-2 as well as in patients who have recovered from a symptomatic COVID-19. (Int Marit Health 2021; 72, 3: 223–227) Key words: diving, fitness, health assessment, COVID-19, recommendations

INTRODUCTION The regulations applicable to commercial diving are clear: It has been over a year since the coronavirus disease it is within the competence of an employer to refer a diver who 2019 (COVID-19) pandemic broke out, but so far there have has had a COVID-19 infection for fitness to dive re-assess- been no in-depth population-based studies on long-term se- ment. The employer is legally bound to refer their employee quelae of the disease, especially with respect to divers. How- for periodic examination by an occupational health physician ever, a better understanding of clinical and radiological certified as a diving doctor in order to identify or reduce any signs and symptoms of the disease allowed researchers potential risk of sequelae associated with the severe acute to formulate a list of guidelines for medical assessment of respiratory syndrome coronavirus 2 (SARS-CoV-2) infection divers who recovered from a COVID-19 infection in order and, if there are no contraindications, to issue a certificate to evaluate whether or not they can safely return to scuba of medical fitness to dive. Regrettably, there is no such re- diving. Understanding the pathophysiology of COVID-19 is quirement for recreational divers. Recreational divers who critical to ensuring diving safety; the infection does not only tested positive for COVID-19 should be recommended consult increase the risk of pulmonary barotrauma and arterial gas a competent specialist out of concern for their own safety. embolism, but it also raises the susceptibility to decompression sickness or pulmonary edema due to cardiological, RESPIRATORY COMPLICATIONS pulmonary and hematological changes. In fact, the ongoing OF COVID-19 COVID-19 pandemic may contribute to improving the quality Symptomatic SARS-CoV-2 infection and a COVID-19 man- of diving fitness health assessment [1–4]. ifest as a typical upper respiratory tract infection; in more

Prof. Krzysztof Korzeniewski, MD, PhD, Military Institute of Medicine, Head of the Department of Epidemiology and Tropical Medicine, Szaserów St. 128, 04–141 Warsaw, Poland, e-mail: [email protected]; Medical University of Gdansk, Institute of Maritime and Tropical Medicine, Department of Tropical Medicine and Epidemiology, * Powstania Styczniowego St. 9B, 81–519 Gdynia, Poland, e-mail: [email protected]

www.intmarhealth.pl 223 Int Marit Health 2021; 72, 3: 223–227 severe cases the infection progresses into a bilateral viral pneumonia often leading to death. Lung damage occurs due to a massive inflammatory reaction coupled with the injury caused by assisted mechanical ventilation, high airway pressure and exposure to hyperoxia [3, 4]. A chest X-ray or a computed tomography (CT) scan typically show ground-glass opacities, crazy paving pattern or peripheral (subpleural) parenchymal densities. Bilateral lesions are most pronounced on the 10th day of onset, and then they gradually disappear. The crazy paving pattern tends to resolve after approximately 4 weeks of onset, but the ground-glass opacities are likely to persist for a longer period. During the initial stage of the infection, 15–20% patients have normal chest radiogram; however, as the infection progresses, peripherally distributed multifocal densities and opacities, air space opacification (cavitation) and lymphadenopathy tend to occur. Radiograms performed at a later stage of the infection often reveal progressing pulmonary fibrosis. A severe COVID-19 infection leaves permanent radiological changes on a chest X-ray [5, 6]. Figure 1. An X-ray image showing pulmonary lesions in mild COVID-19 (foci of peripheral parenchymal densities). Source: It may be assumed that the long-term effects of COVID-19 will X-ray Laboratory at the St. Vincent de Paul Hospital in Gdynia resemble the much better-studied complications of the SARS- -CoV-1 infection. Approximately 20% of patients, who recovered from a SARS-CoV-1 infection, had residual lesions on a chest X-ray and abnormal results of pulmonary function tests (Figs. 1, 2) 3 weeks after recovery. The patients also complained of general weakness, decreased exercise tolerance, shortness of breath and breathing difficulties. It was found that in patients who have recovered from a COVID-19 infection abnormalities revealed by pulmonary function tests appear to be a more sensitive indicator of lung damage than CT scanning [7]. Even as long as 140 days after the onset of first symptoms, some patients had persistent abnormalities on their chest CT scan, including opacities, reticulation and air trapping (Figs. 3, 4) [3, 6]. If a COVID-19 infection turns out to have a similar course, we might expect that it will potentially have some negative effects on divers’ physical health, especially their exercise capacity. The load to the respiratory system during a dive, i.e. under hyperbaric conditions is obviously different from the respiratory load experienced in normal conditions, which is associated with increased breathing resistance of the regulator, the density of breathing gases and the depth of Figure 2. An X-ray image showing pulmonary lesions in severe immersion. For this reason, in order to be able to safely COVID-19 (bilateral foci of massive and consolidated parenchymal return to scuba diving after a COVID-19 infection, a diver densities). Source: X-ray Laboratory at the St. Vincent de Paul will have to demonstrate good exercise capacity. Also, it Hospital in Gdynia should be remembered that residual parenchymal lesions such as scars, calcifications, blebs or air trapping may be CIRCULATORY COMPLICATIONS associated with an increased risk of a pulmonary barotrau- OF COVID-19 ma [8]. Additionally, the lesions which have developed in Although a COVID-19 infection manifests primarily as the lung parenchyma and pulmonary vessels can facilitate pneumonia, increasing data suggest that cardiac involve- the transfer of asymptomatic gas embolism to the arterial ment is also characteristic for the disease. So far, no car- part of the circulatory system. diovascular symptoms have been identified as specific for

224 www.intmarhealth.pl Jarosław Krzyżak, Krzysztof Korzeniewski, Medical assessment of fitness to dive after COVID-19

conditions including isolated increase in cardiac biomarkers, acute coronary syndrome, arrhythmias, myocarditis and pericarditis [1, 3]. Post-mortem examinations revealed that heart damage was not directly attributable to SARS-CoV-2, but rather that it was secondary to systemic inflammation and hypercoagulable states which occurred in the course of the infection. The virus has, however, been found in the vascular endothelium, suggesting direct invasion. Between 8% and 28% of the infected individuals showed elevated cardiac biomarkers — troponin and B-type natriuretic peptide, which was associated with higher mortality from COVID-19 [1, 9]. Both commercial and recreational diving will require a work rate of 6–7 MET (which is approximately 21 mL

O2/kg/min), or higher in typical emergency situations. Cur- rently, the guidelines recommend at least 10 MET for com-

mercial divers (approximately 35 mL O2/kg/min) and 6 MET for recreational divers. It is advisable, however, that divers should be required to reach the rate of 13 MET; this would be a good reserve in case of an emergency [2]. It is important that divers who had recovered from a COVID-19 infection Figure 3. A chest computed tomography scan showing lesions in undergo a thorough cardiological evaluation. Apart from mild COVID-19 (foci of small peripheral parenchymal densities). electrocardiogram and echocardiogram, an exercise tol- Source: X-ray Laboratory at the St. Vincent de Paul Hospital in Gdynia erance test to estimate maximum oxygen consumption should be performed. Oligosymptomatic cardiac inflammation could be unmasked by a higher physical effort and the stress associated with diving, thus resulting in dangerous arrhythmias or decompensated heart failure [2, 4].

THROMBOEMBOLIC COMPLICATIONS OF COVID-19 Coronavirus disease, unlike other conditions of a similar type, was found to significantly increase the susceptibility to venous thromboembolism. COVID-19 has been widely reported to cause hypercoagulable states and elevated levels of D-dimers and troponins, which are associated with a much worse prognosis. In its acute phase, the disease may induce a number of thromboembolic complications as well as acute coronary syndrome [3]. In light of the above, the question aris- es whether or not the hypercoagulable state would predispose a diver who had COVID-19 to decompression sickness, which is considered a generalized inflammatory and pro-thrombotic condition. It seems unlikely that the hypercoagulable state could persist after the acute phase of the disease is over and when a patient has fully recovered from the infection [4].

Figure 4. A chest computed tomography scan showing lesions CURRENT RECOMMENDATIONS in severe COVID-19 (near complete involvement of the lung FOR DIVERS AFTER COVID-19 parenchyma, ground-glass opacity). Source: X-ray Laboratory at According to the current guidelines, a person can- the St. Vincent de Paul Hospital in Gdynia not be medically cleared to scuba dive if they have had a cough, shortness of breath, difficulty breathing, fever, a COVID-19 infection. Cardiovascular involvement which chills, myalgia, a loss of smell or taste within 14 days prior occurs in the course of infection covers a wide spectrum of to a dive session [2]. The clinical criteria for the diagnosis

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Table 1. Classification of COVID-19 [4]

Category COVID-19 Symptoms 0 Asympto- No clinical symptoms matic Positive screening PCR or antibody test 1 Mild Mild clinical symptoms No health care or outpatient treatment only Without evidence of hypoxemia, not required supplemental oxygen Chest X-ray or CT scan normal or not required 2 Moderate Clinical symptoms with hypoxemia required supplemental oxygen Abnormal chest X-ray or CT scan Hospital treatment not required intubation and assisted mechanical ventilation Normal cardiac work including normal electrocardiogram and cardiac biomarkers (troponin or CK-MB and BNP) 3 Severe Hospital treatment required intubation and assisted mechanical ventilation Cardiac involvement (abnormal electrocardiogram or echocardiogram, or elevated cardiac biomarkers: troponin or CK-MB and BNP) Thromboembolic complications (pulmonary embolism, deep vein thrombosis, or other coagulopathy) CK-MB — creatine kinase MB fraction; CT — computed tomography; BNP — B-type natriuretic peptide; PCR — polymerase chain reaction; X-ray — X radiation, radiograph

Table 2. Recommendations for diving fitness health assessment after COVID-19 for commercial and recreational divers [4]

Category COVID-19 Tests 0 Asympto- Initial/periodic exam by specialist of hyperbaric medicine/diving doctor matic Chest X-ray only, if required by specialist of hyperbaric medicine/diving doctor No additional testing required 1 Mild Initial/periodic exam by specialist of hyperbaric medicine/diving doctor Spirometry Chest X-ray (PA and lateral) Chest CT, if abnormal chest X-ray If unknown or unsatisfactory exercise tolerance, performing exercise tolerance test with oxygen saturation 2 Moderate Initial/periodic exam by specialist of hyperbaric medicine/diving doctor Spirometry Chest X-ray (PA and lateral) Chest CT, if abnormal chest X-ray Electrocardiogram Echocardiogram If unknown or unsatisfactory exercise tolerance, performing exercise tolerance test with oxygen saturation Investigation and treatment of any other complications by specialist of hyperbaric medicine/diving doctor 3 Severe Initial/periodic exam by specialist of hyperbaric medicine/diving doctor Spirometry Chest X-ray (PA and lateral) Chest CT, if abnormal chest X-ray Electrocardiogram Repeat cardiac biomarkers (troponin or CK-MB and BNP) to ensure normalization Echocardiogram Exercise echocardiogram with oxygen saturation Investigation and treatment of any other complications by specialist of hyperbaric medicine/diving doctor BNP — B-type natriuretic peptide; CK-MB — creatine kinase MB fraction; CT — computed tomography; PA — postero-anterior; X-ray — X radiation, radiograph of a COVID-19 infection include at least two of the above potentially affect a divers’ physical health and diving safety, symptoms, regardless of the result on a polymerase chain it is strongly recommended that all divers who have recov- reaction or antibody test for SARS-CoV-2 [10]. Depending ered from a COVID-19 infection should undergo a compre- on its severity, COVID-19 infection has been classified into hensive diving health assessment before they return to four categories (Table 1). scuba diving. The spectrum of diagnostic tests which are Because COVID-19 is a systemic disease which can necessary to evaluate an individual’s health and fitness to involve multiple organs and is likely to cause long-term dive will primarily depend on the course and the severity of respiratory and cardiovascular complications which may a COVID-19 infection (Table 2).

226 www.intmarhealth.pl Jarosław Krzyżak, Krzysztof Korzeniewski, Medical assessment of fitness to dive after COVID-19

The recommendations of the European Underwater and Conflict of interest: None declared Baromedical Society (EUBS) and the European Committee for Hyperbaric Medicine (ECHM) [4] with respect to recreational and REFERENCES commercial diving after SARS-CoV-2 pandemic are as follows: 1. Akhmerov A, Marbán E. COVID-19 and the Heart. Circ Res. 2020; — divers who have tested positive for COVID-19, but 126(10): 1443–1455, doi: 10.1161/CIRCRESAHA.120.317055, were asymptomatic, are recommended to wait at least indexed in Pubmed: 32252591. 2. Bennett PB, Cronje FJ, Campbell ES. Assessment of Diving Medical 1 month before they return to diving; Fitness for Scuba Divers and Instructors: Medical, Physical, Physio- — divers who had symptoms of a COVID-19 infection, but logical, Psychological. Best Publishing Company, USA 2006. did not require hospital treatment, should wait at least 3. Polak SB, Van Gool IC, Cohen D, et al. A systematic review of patho- three months before having their fitness to dive as- logical findings in COVID-19: a pathophysiological timeline and sessed by a hyperbaric medicine/diving doctor; possible mechanisms of disease progression. Mod Pathol. 2020; — divers with a COVID-19 infection who required hospital 33(11): 2128–2138, doi: 10.1038/s41379-020-0603-3, indexed in Pubmed: 32572155. treatment due to pulmonary symptoms are recommend- 4. Sadler C, Alvarez Villela M, Van Hoesen K, et al. Diving after ed to wait at least 3 months before having their fitness SARS-CoV-2 (COVID-19) infection: Fitness to dive assessment to dive assessed under the supervision of a hyperbaric and medical guidance. Diving Hyperb Med. 2020; 50(3): 278– medicine/diving doctor; their fitness to dive examination 287, doi: 10.28920/dhm50.3.278-287, indexed in Pubmed: should include a full lung function evaluation, including ex- 32957131. 5. Pan F, Ye T, Sun P, et al. Time course of lung changes at chest CT ercise tolerance test with oxygen saturation and chest CT; during recovery from coronavirus disease 2019 (COVID-19). Radiol- — divers with COVID-19 who required hospital treatment ogy. 2020; 295(3): 715–721, doi: 10.1148/radiol.2020200370. due to cardiac symptoms must wait at least 3 months 6. Spagnolo P, Balestro E, Aliberti S, et al. Pulmonary fibrosis second- before they can be examined by a hyperbaric medi- ary to COVID-19: a call to arms? Lancet Respir Med. 2020; 8(8): cine/diving doctor; their fitness to dive assessment 750–752, doi: 10.1016/s2213-2600(20)30222-8. should include a full cardiac evaluation including echo- 7. Hall WJ, Hall CB. Clinical significance of pulmonary function tests. Alterations in pulmonary function following respiratory viral infec- cardiogram and exercise echocardiogram [11]. tion. Chest. 1979; 76(4): 458–465, doi: 10.1378/chest.76.4.458, Commercial divers who have developed symptoms of indexed in Pubmed: 225132. a COVID-19 infection and have abnormal test results should 8. Germonpré P, Balestra C, Pieters T. Influence of scuba diving on be declared ‘unfit to dive’, while recreational divers should asymptomatic isolated pulmonary bullae. Diving Hyperb Med. 2008; be strongly discouraged from resuming diving activities. This 38(4): 206–211, indexed in Pubmed: 22692754. especially applies to individuals with visible damage to the 9. Shi S, Qin Mu, Shen Bo, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA lung parenchyma, air trapping, heart damage or decreased Cardiol. 2020; 5(7): 802–810, doi: 10.1001/jamacardio.2020.0950, exercise capacity [2]. Asymptomatic individuals who feel indexed in Pubmed: 32211816. perfectly healthy but exhibit subtle radiographic changes and 10. Centers for Disease Control and Prevention. Coronavirus disease whose spirometry and exercise tolerance test results remain 2019 (COVID-19) 2020 interim case definition. https://www. within the lower limit values should refrain from scuba diving cdc.gov/ nndss/conditions/coronavirus-disease-2019-covid-19/ for at least 3 months after recovery, until all pathological le- case-definition/2020/ (Approved: April 5, 2020). 11. European Underwater and Baromedical Society, European Commit- sions disappear. Only then can the tests listed in Table 2 be tee for Hyperbaric Medicine. EUBS & ECHM position statement on repeated and a patient can be referred for re-examination by recreational and professional diving after the Coronavirus disease a hyperbaric medicine/a dive doctor who will assess whether (COVID-19) outbreak. http://www.echm.org/documents (Accessed: or not they have any contraindications to scuba diving [4, 11]. 05 Jan 2021).

www.intmarhealth.pl 227 Int Marit Health 2021; 72, 3: 228–236 10.5603/IMH.2021.0042 www.intmarhealth.pl Copyright © 2021 PSMTTM ORIGINAL ARTICLE ISSN 1641-9251 eISSN 2081-3252 The outcomes of COVID-19 measures in a hyperbaric oxygen therapy centre during the pandemic

Kubra Ozgok-Kangal1 , Taylan Zaman1 , Bayram Koc2

1Department of Undersea and Hyperbaric Medicine, Gulhane Training and Research Hospital, University of Health Science, Ankara, Turkey 2Department of Internal Medicine, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Turkey

ABSTRACT Background: A hyperbaric oxygen (HBO) treatment session carries a high risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission since patients stay in a closed area for 2 hours. The primary aim of this study was to evaluate the effects of the preventive measures taken in the HBO centre. Materials and methods: This study evaluated the measures taken during the coronavirus disease 2019 (COVID-19) pandemic for multiplace hyperbaric chamber operated in department (Health Sciences Universi- ty-Gulhane Research and Training Hospital, Ankara, Turkey) between March 16th, 2020 and December 31st, 2020. The medical records of patients who underwent HBO treatment during this period were evaluated retrospectively. Their demographic attributes, the presence of risk factors, HBO indications, HBO session data, and COVID-19 inquiry forms were analysed. Results: A total of 122 patients underwent HBO treatment, and 150 people were subjected to pressure tolerance test (PTT). No COVID-19 case was treated with HBO in our department. The hyperbaric chamber was operated 608 times in total. Of these, 9.7% (n = 59) procedures were carried out under emergency conditions, and 10% (n = 61) were PTTs. Accordingly, 59.8% (n = 73) of the HBO-treated patients were considered at risk for a severe clinical presentation of SARS-CoV-2. SARS-CoV-2 was detected in 5.7% (n = 7) of the HBO-treated patients during the HBO treatment period. Besides, two inside attendants (14.3%) were diagnosed with COVID-19. There were only two concurrent cases in the same session among SARS-CoV-2 positive cases. The records revealed that these patients were sitting three seats away from each other. Another patient was sitting in between the two infected patients but was not diagnosed with SARS-CoV-2. Conclusions: There is no clear evidence that these two patients infected each other; on the contrary, since no other patient was infected with SARS-CoV-2 in the same session, we may suspect that the infections were coincidental. The measures taken in our department seem to suffice in preventing in-session transmission of COVID-19 and similar infectious diseases in an HBO centre. (Int Marit Health 2021; 72, 3: 228–236) Key words: hyperbaric oxygen, COVID-19, SARS-CoV-2, transmission, measures

INTRODUCTION causing a huge increase in the number of cases worldwide. A new type of coronavirus was reported as the cause The World Health Organization (WHO) announced that the of a series of pneumonia cases in Wuhan city in the Hubei official name of the new infection would be COVID-19 dis- province, China in 2019. Starting from China, it rapidly ease, which stands for “2019 coronavirus” in February spread to other countries and created a global emergency by 2020 [1–3]. The pathogen responsible for the infection was

Dr. Kubra Ozgok-Kangal, Department of Undersea and Hyperbaric Medicine, Gülhane Training and Research Hospital, Health Science University, Ankara, SBÜ-Gülhane * Eğitim ve Araştırma Hastanesi, Sualtı Hekimliği ve Hiperbarik Tıp Kliniği, Etlik, 06010 Ankara, Turkey, e-mail: [email protected]

228 www.intmarhealth.pl Kubra Ozgok-Kangal et al., COVID-19 transmission inside hyperbaric chambers named severe acute respiratory syndrome coronavirus 2 We, as Health Sciences University Gulhane Research (SARS-CoV-2) by the International Committee on Virus Tax- and Training Hospital, Undersea and Hyperbaric Medicine onomy (ICTV) since the genome of the newly identified Department, are providing services to Ankara and neigh- virus is very similar to severe acute respiratory syndrome bouring provinces. Our clinic has one multiplace hyperbaric coronavirus (SARS-CoV) [4]. chamber. As a rule, a routine HBO treatment performed in Patients infected with SARS-CoV-2 may show symp- the multiplace hyperbaric chamber takes 2 hours, there toms such as dry cough, fever, headache and shortness are 11 patients and one inside attendant in each session. of breath, and some patients may get diagnosed with viral Every day, there are three HBO treatment sessions per- pneumonia [5, 6]. Besides, asymptomatic cases have also formed in our department. With the onset of the pandemic, been reported [7, 8]. appropriate preventive measures have been introduced SARS-CoV-2 is mainly spread by droplet transmission [9]. in all clinics of our hospital. However, due to the nature of Transmission is believed to mainly occur by close-distance HBO treatment (12 people staying close to one another for contact (approx. 6 feet or 2 m) through inhalation of respira- 2 hours) we had to implement some additional preventive tory particles. When an infected person coughs, sneezes, or measures. Besides the general measures proposed by the speaks, the virus, which spreads through respiratory secre- Infection Control Committee at our hospital, the Undersea tions, may infect others when inhaled or by direct contact and Hyperbaric Medicine Department has taken additional with mucosal membranes. Although contaminated surfaces preventive measures in line with the guidelines recommend- are not believed to be the primary mode of transmission, ed in ECHM and the UHMS reports; the restrictions are still it is possible that a person may get infected by touching being followed in our department. We believe it is essential contaminated surfaces. . to share the information on the preventive measures with SARS-CoV-2 can be transmitted long distances by air regard to personnel safety, patient safety, COVID-19 trans- (by inhaling airborne particles), yet it is disputable how this mission which we had implemented in our clinic at the transmission mode affects the pandemic [10–13]. The beginning of the pandemic, in order to determine their study on SARS-CoV-2 transmission (e.g., in a restaurant effectiveness. It is important to share our department’s or a bus) underlined the potential of airborne infection at experience with others because HBO treatment requires longer distances in poorly ventilated environments [14–16]. a different set of preventive measures than other treatment The sessions in multiplace hyperbaric chambers are modalities especially that there are relatively few HBO treat- performed under direct supervision of a health care pro- ment centres in our country and abroad in comparison to fessional (an inside attendant) employed at our hyperbaric other health care centres. oxygen (HBO) treatment department. Although the masks The primary aim of this study was to evaluate the and other personal protective equipment used during the SARS-CoV-2 transmission inside the hyperbaric chamber treatment in all centres are carefully cleaned and disinfect- during HBO treatment sessions despite preventive mea- ed, HBO treatment creates a risk of coronavirus cross-in- sures by determining the number of COVID-19 cases among fection among patients participating in the same session. patients undergoing HBO treatment as well as among inside This is a serious cause for concern for the patients receiving attendants supervising the HBO sessions. HBO treatment since most of them are elderly people with comorbidities or immunosuppressed patients. MATERIALS AND METHODS With a view to respond to the newly emerging threats This study evaluated the measures taken in the course new measures should be considered in HBO treatment of the COVID-19 pandemic at the Health Sciences Univer- centres. With the onset of the pandemic, the European sity, Gulhane Research and Training Hospital, Undersea Committee for Hyperbaric Medicine (ECHM) Society and and Hyperbaric Medicine Department (Ankara, Turkey) be- Undersea and Hyperbaric Medicine Society (UHMS) in the tween March 16th, 2020, and December 31st, 2020. All United states of America (USA) have published recommen- measures adopted between the dates mentioned will be dation reports discussing issues such as patient selection presented in detail in the Results section. The number of for HBO treatment, precautions to be taken during the ses- HBO sessions, demographic data of patients who underwent sion or cleaning of the pressure chamber [17, 18]. In line HBO treatments, and the HBO treatment indications were with these reports, the location of the treatment centre, the analysed. The medical records of the patients were analysed urgency of HBO treatment, the age and general condition retrospectively, and their demographic attributes, the pres- of the patient, dimensions of the pressure chamber, and ence of COVID-19 risk factors (chronic diseases, smoking, the possibility to maintain social distance between patients obesity, age over 65 years), HBO treatment indications, should be evaluated carefully before patients are qualified HBO treatment session data (the lists of patients and inside for HBO treatment. attendants) and COVID-19 inquiry forms were analysed.

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Table 1. The decisions on the continuation of treatment plans upon the official announcement of the first COVID-19 case announcement in our country

Indications Patients whose Patients whose tre- Patients whose tre- Patients who- Total number treatment was atment was suspen- atment was suspen- se treatment of patients terminated (n) ded for 3 weeks (n) ded for a week (n) continued (n) (n) Diabetic foot ulceration 3 5 0 2 10 Other chronic wounds 3 2 0 0 5 Chronic refractory 1 2 0 1 4 osteomyelitis Sudden sensorineural 0 0 1 2 3 hearing loss Prosthesis infection 1 2 0 0 3 Crush injury 1 0 0 1 2 Avascular necrosis 0 1 0 0 1 Psoas abscess 0 0 0 1 1 Spondylodiscitis 0 1 0 0 1 Total number of patients 9 13 1 7 30

We have chosen not to include the demographic data of performed on that day in the Health Sciences University, patients who underwent pressure tolerance test (PTT) in Gulhane Research and Training Hospital, Undersea and our department as the PTT takes no more than 10 minutes Hyperbaric Medicine Department (Ankara, Turkey), each and is performed once only. We have, however, included the session including 10 patients. Upon the official announce- data regarding the overall number of PTT sessions carried ment of the first case, a clinical meeting was held on March out during the study period. 17th, 2020, and treatment options for the patients with The ethical approval was obtained from Health Sciences SARS-CoV-2 risk factors were discussed. All patients were University- Gulhane Research and Training Hospital Non-In- informed about the risk of SARS-CoV-2 transmission during vasive Research Ethics Committee (Ankara, Turkey, number HBO session. A decision was taken to discontinue treatment of approval: 2020-505, date: 29/12/2020 ). of 9 out of 30 patients. In addition, the treatment of a patient with sudden hearing loss was suspended for a week, PARTICIPANTS and the treatments of 13 other patients were suspended The participants were the patients who underwent HBO for 3 weeks. Detailed data of these patients are given in treatment and inside attendants who participated in HBO Table 1. sessions between 16.03.2020 and 31.12.2020 at our de- We decided to continue treatment of seven patients partment. only. Starting from March 17th, 2020, HBO sessions in our clinic were organized twice a day, each session including STATISTICAL ANALYSIS 7 patients. The measures taken in our clinic to prevent the We used IBM SPSS Statistics version 21 (IBM Corp., Ar- transmission of COVID-19 are summarised in Table 2. These monk, New York, USA) for statistical analysis. The data were measures were put into action 5 days after the first case presented as number (%). The data which were normally dis- of COVID-19 was officially confirmed. In the course of the tributed were expressed as mean ± standard deviation. The pandemic, the initially introduced preventive measures were data which were not normally distributed were expressed as changed twice. Firstly, the inside attendants were admitted median (minimum–maximum). The normal distribution of to accompany the sessions at the end of the first month the data were analysed with The Kolmogorov-Smirnov test. of the pandemic. However, they had to stay in the person- However, due to a low number of positive COVID-19 cases, nel lock and were not allowed to enter the main chamber further statistical analysis was not possible. A p-value less during the sessions. Inside attendants were obliged to wear than 0.05 were considered as statistically significant. N95 masks and face shield for protection as well as a safety uniform with gloves in case any intervention to the patients RESULTS is necessary. Secondly, a detailed COVID-19 checklist to The first official SARS-CoV-2 case in our country was be completed before each HBO session was drawn up. On reported on March 11th, 2020. Three routine sessions were the other hand, disinfectants placed around the hyperbaric

230 www.intmarhealth.pl Kubra Ozgok-Kangal et al., COVID-19 transmission inside hyperbaric chambers

Table 2. Precautions inside the hyperbaric chamber against COVID-19 transmission in the department (Health Sciences University, Gulhane Research and Training Hospital, Undersea and Hyperbaric Medicine Department)

1. Patients are seated with at least one empty seat in between to provide a minimum of 1-metre social distance inside the hyperbaric chamber 2. The disinfection procedure is repeated after each HBO sessions and then the chamber is ventilated. 3. Patients must use hand sanitizer or wash their hands with soap for at least 20 seconds just before and after the HBO sessions. 4. The names of the patients are written on the lockers where their masks are kept and a special locker is reserved for each patient. No partition changes will be made until HBO therapy is completed. 5. Patients’ masks will be washed, rinsed with soapy water and dried every day. While being dried, they cannot touch one another. The masks are sterilised once a week. 6. Before each HBO session, the temperature of each patient will be measured and they will be asked about any recent symptoms and COVID-19 contact history. 7. Any suspected patient will not be accepted to the hyperbaric chamber and will be referred to the COVID-19 outpatient clinic immediately. 8. The patients have to continue in the same HBO session until the treatment ends. There will be no changes in the session arrangements of the patients. 9. When there is a patient diagnosed with COVID-19, no new patient will be enrolled in that session for the following week. Other patients can continue HBO treatment but will be closely monitored for COVID-19. Patients will be informed and referred for PCR testing if they wish. 10. Patients will be seated in the chamber one by one. It is forbidden for patients to touch anything other than their seat. It is forbidden for patients to change seats after they have sat down. 11. The inside attendant will not accompany the patients inside the hyperbaric chamber. He/She will wait outside the hyperbaric chamber, and in case of an emergency, he/she will enter the hyperbaric chamber from the personnel locker with N95 mask, visor, surgical uniform and gloves on. 12. Only one person can accompany the patient while the patient is seated in the hyperbaric chamber. COVID-19 — coronavirus disease 2019; HBO — hyperbaric oxygen; PCR — polymerase chain reaction chamber have been removed to reduce the risk of fire due sions or PTTs. SARS-CoV-2 was detected in 5.7% (n = 7) to high oxygen concentration. There have been no other of the HBO-treated patients and 2 of 14 inside attendants changes to other preventive measures. (14.3%) in the study period (Table 4). HBO treatment of the A total of 122 patients underwent HBO treatment ses- patients diagnosed with SARS-CoV-2 or those in contact with sions, and another 150 people were subjected to PTT, thus, SARS-CoV-2-infected individuals was discontinued; (repeat- the hyperbaric chamber was operated 608 times between ed information) those who were in the same sessions were March 16th, 2020, and December 31st, 2020. Of these, closely followed for SARS-CoV-2 symptoms and signs. For 9.7% (n = 59) sessions were carried out under emergency a week, no new patient was enrolled in that session. The conditions, and 10% (61 times) were PTTs. The number of data of the patients isolated due to COVID-19 diagnosis sessions carried out in each month is given in Figure 1. or in contact with an infected person, as well as the num- Demographic attributes of 122 patients receiving HBO ber of COVID-19 cases occurring within 7 days after an HBO treatment in our clinic between March 16th, 2020, and session are given in Table 4. There were only two concurrent December 12th, 2020 are given in Table 3. The presence SARS-CoV-2 cases (transmission may have occurred during the of a chronic disease, smoking, obesity (body mass index session) in the same session. As can be seen from the data 30 and above), or age 65 years and above are considered presented in Table 4, patients number 2 and 7, both receiving to be a significant risk factor for severe clinical presenta- HBO treatment in the same session, were diagnosed with tion of SARS-CoV-2 [19]. Accordingly, 59.8% (n = 73) of the SARS-CoV-2 a week apart. Patient number 2 last participated HBO-treated patients were considered at risk for a severe in the session on December 1st, 2020, and was excluded clinical presentation of SARS-CoV-2. Among the patients from HBO session taking place on December 2nd, 2020 due considered not to be at risk, 3 patients were pregnant, and to a high fever. Patient number 7 was present in the same 5 patients were receiving temporary steroid treatment due session with patient number 2 on November 30th, 2020, to sudden hearing loss. The distribution of the patients by and December 1st, 2020. Patient number 7 showed upper HBO indications is shown in Figure 2. respiratory infection-like symptoms, COVID-19 was confirmed Any patients diagnosed with SARS-CoV-2 or suspected by high-resolution computed tomography (HRCT) on Decem- of the infection were excluded from HBO treatment ses- ber 7th, 2020. The remaining 4 patients who took part in

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120 ■ PTT ■ Emergency sessions 100 ■ Elective sessions

80 18 6 8 1 1 11 60 0 11 5 12 8 6 11 1 4 40 0 68 67 61 5 58 49 51 50 42 20 0 25 18 0 y ch Ma July April June ugust ober A ember ember 1 Mar Oct v Sept No December 16–3 HBO sessions

Figure 1. The overall number of hyperbaric oxygen (HBO) sessions by months (dates between March 16th, 2020 and December 31st, 2020); PTT — pressure tolerance test

40 42

30 32 Patient number 20

17 14 10 11

4 2 0 Complicated Acute CO CRAO SSHL Other AVN Chronic wounds intoxication refractory osteomyelitis HBO indications

Figure 2. The distribution of patients according to hyperbaric oxygen (HBO) indications (brain abscess, radiation injury, decompression illness, spondylodiscitis, malignant otitis externa, haemorrhagic cystitis, testicular torsion were classified as “other”); CO — carbon monoxide poisoning; CRAO — central retinal artery occlusion; SSHL — sudden sensorineural hearing loss; AVN — avascular necrosis the same session were followed for a week, but manifested However, two inside attendants were diagnosed no COVID-19-related symptoms or signs. New patients were with SARS-CoV-2 between March 16th, 2020, and De- admitted to the ongoing session after a week of isolation, and cember 12th, 2020. The first person was diagnosed on no other SARS-CoV-2 cases were detected in that session. August 21st, 2020, that person accompanied the HBO

232 www.intmarhealth.pl Kubra Ozgok-Kangal et al., COVID-19 transmission inside hyperbaric chambers

Table 3. The demographic data of patients (missing data were not included into percentage calculations)

Parameter Evaluated pa- Number (%) or tient number median (min–max) Age [year] 122 50 (2–83) Sex: 122 Male 71 (52.8%) Female 51 (41.8%) Body-mass index 32 27.3 (16.8–50.7) Chronic diseases: 100 55 (55%) DM 100 39 (39%) HT 100 22 (22%) The number of SARS-CoV-2 diagnosed cases cases diagnosed of SARS-CoV-2 The number patients the among week following the during session with same in the together who were patient infected the 0 0 0 0 1 0 1 CAD 100 16 (16%) PAD 100 18 (18%) CKF 100 5 (5%) Asthma 100 2 (2%) Cancer 100 3 (3%) Other 100 10 (10%) The total of number the attending patients HBO session with same patient the 6 1 6 6 6 6 Pregnancy 122 3 (2.5%) 6 Steroid 96 17 (17.7%)

Smoking: 68

Smoker 14 (20.6%) Ex-smoker 10 (14.7%) related related symptoms or signs diagnosed with SARS-CoV-2 SARS-CoV-2 SARS-CoV-2 None None Loss of smell and taste High fever None His spouse URTI symptoms Non-smoker 44 (64.7%) Indications: 122

Emergency 68 (55.7%) session number HBO 39 20 3 5 30 5 15

Elective 54 (44.3%) - The number of HBO 120 8.5 (1–60) sessions Age, body mass index and the number of HBO sessions were not normally distributed, therefore these data were given as median (minimum–maximum) in the table; HBO — hyperbaric oxygen; DM — diabetes mellitus; HT — hypertension; CAD — coronary artery disease; PAD — peripheral artery disease; CKF — chronic Peripheral ischaemia due to calcium extra vasation (hand) Non-healing ulcer DFU HBO indication DFU Radiation cystitis DFU kidney failure SSHL - session twice within 7 days before the diagnosis. The patients in the related session were followed for any SARS-CoV-2 symptoms or signs, but none of them was ALL, chemotherapy continues thropoietic anaemia DM Comorbidity DM, CAD, PAD Bladder cancer (in remission) Congenital dysery DM, HT, CAD, CKF diagnosed with SARS-CoV-2 during the following week. DM, HT The personnel member returned from holiday 4 days before being diagnosed with COVID-19, so they might have acquired the infection during the holiday. The other inside attendant was diagnosed with COVID-19 on September 31/12/20 The date of The date SARS-CoV-2 diagnosis 15/09/20 1/12/20 9/9/20 10/12/20 17/09/20 7/12/20 29th, 2020; that person accompanied the HBO session 3 times within 7 days before the diagnosis. The patients 2 Age [year] 38 49 53 22 61 in the same session were followed for SARS-CoV-2 symp- 48 toms or signs for a week, none of them was found to be infected with SARS-CoV-2. Patient Patient number 1 4 2 6 5 3 7 Table 4. The data of patients diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Table HBO — hyperbaric oxygen; ALL acute lymphoblastic leukaemia; DM diabetes mellitus; HT hypertension; CAD coronary artery disease; PAD peripheral arterial CKF chronic kidney failure; DFU diabetic foot ulcer; SSHL — sudden sensorineural hearing loss; URTI upper respiratory tract infection

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DISCUSSION tected as of February 11th, 2020, were asymptomatic [20]. Since the official announcement of the first case on The community-based proportion of seropositivity among March 11th, 2020, additional preventive measures for HBO healthy people was 4.8% in Switzerland, 5.0% in Spain and treatments were introduced in our department immediately. 8.3% in Brazil [21–23]. As can be seen from the data above, The rapid spread of the pandemic worldwide has caused the rate of asymptomatic cases is not stable and cannot some serious problems in terms of SARS-CoV-2 diagnosis be precisely estimated. It is known that COVID-19 infection and treatment methods. Thus, it became necessary to take can be seen in all age groups, and most cases are mild or precautions before the contagiousness potential was clearly asymptomatic [20]. However, people aged over 65 and those identified. Obviously, the effects of the preventive mea- with underlying diseases (obesity, cardiovascular diseases, sures taken during HBO treatment sessions had never been chronic renal failure, diabetes, chronic lung disease, smok- evaluated before. The measures taken in hyperbaric cham- ers, cancer patients, solid organ or hematopoietic stem cell bers should be different from those taken in other hospital transplant patients) are at risk of severe disease [19, 24]. wards. As a result of the precautions taken in our depart- Such patients are much more likely to require hospitalisation ment (in line with the UHMS and ECHM recommendations) compared to patients without comorbidities (45.4% vs. 7.6%). only 7 (5.7%) out of 122 patients receiving HBO treatment Also, the same study showed that patients with comorbidity and only 2 (14.3%) out of 14 inside attendants got infected are 12 times more likely to succumb to the disease [20]. with SARS-CoV-2 between March 16th, 2020 and December Considering HBO indications, most patients receiving HBO 12th, 2020 [17, 18]. Among the nine COVID-19 cases, only treatment are expected to be in the risk group. Remarkably, 2 people took part in the same session; they were diagnosed a majority of patients (59.8%) among those receiving HBO with COVID-19 a week apart. treatment in the course of our study were considered to be The transmission of SARS-CoV-2 by aerosols and con- at risk for severe COVID-19 presentation. It must be noted tact with contaminated surfaces poses the biggest chal- that high-risk patients were not included in HBO treatment lenge for HBO centres [19]. Patients who stay together unless there was a significant risk of organ loss. Thus, we in a closed area for about 2 hours during a routine HBO can conclude that most patients receiving HBO treatment treatment in a multiplace hyperbaric chamber are defi- were unlikely to get over COVID-19 asymptomatically. We nitely at risk from transmission. In our clinic, HBO patients believe that unidentified asymptomatic COVID-19 cases are are not routinely given a polymerase chain reaction (PCR) very rare among patients treated in our department. test for SARS-CoV-2. The patients are only asked about Carbon monoxide intoxication and central retinal artery their symptoms and contact history with COVID-19 pa- occlusion, considered HBO emergencies, constituted the tients. The study showed that 5.7% patients receiving HBO most common indications for HBO treatment after compli- treatment and 14.3% inside attendants were diagnosed with cated wounds. In general, most of the patients (55.7%) re- COVID-19. The inside attendants and patients were isolated ceived treatment on emergency basis. Therefore, we believe after being diagnosed, and the patients they contacted were that we have effectively managed patient selection criteria followed for symptoms and signs for a week. Among the for the first 9 months of the COVID-19 pandemic. After nine COVID-19 cases, there were only 2 (22.2%) concurrent analysing the number of monthly HBO treatment sessions, cases; the patients were diagnosed with COVID-19 a week it is clear that we had the lowest number of sessions in the apart. However, after examining the sessions in which they first 2 months (March and April 2020) of the COVID-19 pan- had both participated it turned out that these 2 patients demic. This can be explained by the restrictions imposed were sitting 3 seats away from each other. Another patient throughout our country. On March 21st, 2020, people aged was sitting in between them but did not get infected with 65 and over and those with chronic diseases were prohibit- SARS-CoV-2. Therefore, there is no clear evidence that these ed from leaving their homes. On March 22nd, 2020, flexible two patients infected each other; on the contrary, since no working arrangements, working from home and rotational other patient was infected with COVID-19, we may assume shift work were introduced in all public institutions. On April that this was a pure coincidence. Therefore, we believe 3rd, 2020, a curfew was imposed on those aged 20 years that the measures implemented in our department suffice and under. Additional curfew measures (a 48-hour curfew to prevent in-session transmission of COVID-19 and other during weekends) were imposed in 30 metropolitan cities similar infectious diseases that are transmitted from aero- by the Ministry of Internal Affairs on April 11th, 2020. These sols and contaminated surfaces. restrictions lasted by mid-May 2020, and controlled nor- On the other hand, the frequency of asymptomatic cases malisation was initiated on May 11th, 2020, and afterward. is controversial, and the studies on asymptomatic cases Because of the restrictions there were fewer applications limited. The China Centre for Disease Control and Prevention for HBO treatment and therefore the number of sessions report reported that 889 (1%) of 72,314 COVID-19 cases de- was the lowest in March and April 2020 [25]. The number

234 www.intmarhealth.pl Kubra Ozgok-Kangal et al., COVID-19 transmission inside hyperbaric chambers of sessions carried out in our clinic was at a similar level 7. Vetter P, Vu DL, L’Huillier AG, et al. Clinical features of covid-19. in the period between May and October, and the highest BMJ. 2020; 369(m1470), doi: 10.1136/bmj.m147. 8. Kim GU, Kim MJ, Ra SH, et al. Clinical characteristics of asymp- number of sessions (n = 97) was recorded in November tomatic and symptomatic patients with mild COVID-19. Clin 2020. This is mainly attributable to the winter season, when Microbiol Infect. 2020; 26(7): 948.e1–948.e3, doi: 10.1016/j. carbon monoxide intoxication cases are frequent throughout cmi.2020.04.040, indexed in Pubmed: 32360780. the country. However, there was a decrease in the number 9. Meyerowitz EA, Richterman A, Gandhi RT, et al. Transmission of of sessions in December (n = 77) and between May and SARS-CoV-2: A Review of Viral, Host, and Environmental Factors. October. This decrease was also observed in the number Ann Intern Med. 2021; 174(1): 69–79, doi: 10.7326/M20-5008, indexed in Pubmed: 32941052. of emergency sessions. 10. Morawska L, Milton DK. It is time to address airborne transmission The main limitation of our study is the low number of of coronavirus disease 2019 (COVID-19). Clin Infect Dis. 2020; COVID-19 patients, so the transmission of infections during 71(9): 2311–2313, doi: 10.1093/cid/ciaa939, indexed in Pubmed: HBO sessions was not evaluated statistically. Also, the lack 32628269. of long-term follow-up of COVID-19 patients, besides the lack 11. World Health Organization Web Site [homepage on the Internet]. Publications: Transmission of SARS-CoV-2: implications for infection of information on the course and severity of COVID-19 cases prevention precautions. https://www.who.int/publications/i/item/ are other study limitations. modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc- -precaution-recommendations (cited 2021 May 09). CONCLUSIONS 12. Klompas M, Baker MA, Rhee C, et al. Airborne Transmission of Our study was the first to evaluate the effects of mea- SARS-CoV-2: Theoretical Considerations and Available Evidence. sures taken to prevent the COVID-19 transmission in an HBO JAMA. 2020 [Epub ahead of print]; 324(5): 441–442, doi: 10.1001/ jama.2020.12458, indexed in Pubmed: 32658248. centre. There is no data available in the literature regarding 13. Chagla Z, Hota S, Khan S, et al. International Hospital and Commu- this issue. Consequently, we believe that the measures nity Epidemiology Group. Airborne Transmission of COVID-19. Clin taken in our department are sufficient to prevent SARS- Infect Dis. 2020 [Epub ahead of print], doi: 10.1093/cid/ciaa1118, -CoV-2 transmission in an HBO centre. The fact that there indexed in Pubmed: 32780799. was almost no transmission during the sessions shows the 14. Lu J, Gu J, Li K, et al. COVID-19 Outbreak Associated with Air Con- ditioning in Restaurant, Guangzhou, China, 2020. Emerg Infect Dis. efficiency of the precautions taken. Furthermore, instead of 2020; 26(7): 1628–1631, doi: 10.3201/eid2607.200764, indexed performing a PCR test in every case, asking about symptoms in Pubmed: 32240078. and contact history seems to be a sufficient precaution. 15. Hamner L, Dubbel P, Capron I, et al. High SARS-CoV-2 Attack Rate Besides, the risk of a false positive results on the PCR test Following Exposure at a Choir Practice - Skagit County, Washing- and limited transmission in the sessions eliminate the PCR ton, March 2020. MMWR Morb Mortal Wkly Rep. 2020; 69(19): 606–610, doi: 10.15585/mmwr.mm6919e6, indexed in Pubmed: test requirement in each case. Thus, unnecessary financial 32407303. burden can be prevented. 16. Shen Ye, Li C, Dong H, et al. Community Outbreak Investigation of SARS-CoV-2 Transmission Among Bus Riders in Eastern China. JAMA REFERENCES Intern Med. 2020; 180(12): 1665–1671, doi: 10.1001/jamainter- 1. Zhou P, Yang XL, Wang XG, et al. A pneumonia outbreak associa- nmed.2020.5225, indexed in Pubmed: 32870239. ted with a new coronavirus of probable bat origin. Nature. 2020; 17. Undersea and Hyperbaric Medical Society Web site. [homepage on 579(7798): 270–273, doi: 10.1038/s41586-020-2012-7. the Internet]. “Guidelines for infection control, patient treatment, and 2. Wu F, Zhao Su, Yu B, et al. A new coronavirus associated with human staff safety considerations related to Hyperbaric Oxygen Therapy in respiratory disease in China. Nature. 2020; 579(7798): 265–269, monoplace and multiplace hyperbaric chambers during the novel doi: 10.1038/s41586-020-2008-3. coronavirus disease (COVID-19) outbreak”. Created March 2020. 3. Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with https://www.uhms.org/images/MiscDocs/UHMS_Guidelines_-_CO- pneumonia in China, 2019. N Engl J Med. 2020; 382(8): 727–733, VID-19_V4.pdf (cited 2021 May 25). doi: 10.1056/nejmoa2001017. 18. European Committee for Hyperbaric Medicine (ECHM) Web Site. 4. Coronaviridae Study Group of the International Committee on [homepage on the Internet].“EUBS & ECHM position statement Taxonomy of Viruses. The species Severe acute respiratory syn- on the use of Hyperbaric Oxygen Therapy (HBOT) for the treatment drome-related coronavirus: classifying 2019-nCoV and naming it of COVID-19 patients (30th April 2020). http://www.echm.org/ SARS-CoV-2. Nat Microbiol. 2020; 5(4): 536–544, doi: 10.1038/ documents/English-ECHM-EUBS-position-on-the-use-of-HBOT-for- s41564-020-0695-z, indexed in Pubmed: 32123347. -COVID-19-1st-May-2020.pdf (cited 2021 May 25). 5. Huang C, Wang Y, Li X, et al. Clinical features of patients infected 19. Cascella M, Rajnik M, Aleem A, et al. Features, Evaluation, and with 2019 novel coronavirus in Wuhan, China. Lancet. 2020; Treatment of Coronavirus (COVID-19) [Updated 2021 Apr 20]. In: 395(10223): 497–506, doi: 10.1016/S0140-6736(20)30183-5, StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; indexed in Pubmed: 31986264. 2021 Jan. 6. Xu Z, Shi L, Wang Y, et al. Pathological findings of COVID-19 asso- 20. Wu Z, McGoogan JM. Characteristics of and Important Lessons ciated with acute respiratory distress syndrome. Lancet Respir Med. From the Coronavirus Disease 2019 (COVID-19) Outbreak in 2020; 8(4): 420–422, doi: 10.1016/S2213-2600(20)30076-X, China: Summary of a Report of 72 314 Cases From the Chinese indexed in Pubmed: 32085846. Center for Disease Control and Prevention. JAMA. 2020; 323(13):

www.intmarhealth.pl 235 Int Marit Health 2021; 72, 3: 228–236

1239–1242, doi: 10.1001/jama.2020.2648, indexed in Pubmed: 23. Stringhini S, Wisniak A, Piumatti G, et al. Seroprevalence of anti-SAR- 32091533. S-CoV-2 IgG antibodies in Geneva, Switzerland (SEROCoV-POP): a 21. Borges LP, Martins AF, de Melo MS, et al. Seroprevalence of population-based study. Lancet. 2020; 396(10247): 313–319, doi: SARS-CoV-2 IgM and IgG antibodies in an asymptomatic popu- 10.1016/S0140-6736(20)31304-0, indexed in Pubmed: 32534626. lation in Sergipe, Brazil. Rev Panam Salud Publica. 2020; 44: 24. Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus Dise- e108, doi: 10.26633/RPSP.2020.108, indexed in Pubmed: ase 2019 Case Surveillance - United States, January 22-May 30, 33042199. 2020. MMWR Morb Mortal Wkly Rep. 2020; 69(24): 759–765, doi: 22. Pollán M, Pérez-Gómez B, Pastor-Barriuso R, et al. ENE-COVID Study 10.15585/mmwr.mm6924e2, indexed in Pubmed: 32555134. Group. Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nation- 25. Wikipedia Web site. [homepage on the Internet]. “Türkiye’de CO- wide, population-based seroepidemiological study. Lancet. 2020; VID-19 pandemisi zaman çizelgesi” . https://tr.wikipedia.org/wiki/ 396(10250): 535–544, doi: 10.1016/S0140-6736(20)31483-5, Türkiye%27de_COVID-19_pandemisi_zaman_çizelgesi#Mart_2020 indexed in Pubmed: 32645347. (cited 2021 May 25).

236 www.intmarhealth.pl Int Marit Health 2021; 72, 3: 237–238 10.5603/IMH.2021.0043 www.intmarhealth.pl Copyright © 2021 PSMTTM LETTER TO THE EDITOR ISSN 1641-9251 eISSN 2081-3252 Zoonotic infectious diseases and maritime seaport: areas of concern

Yusuf Amuda Tajudeen1 , Iyiola Olatunji Oladunjoye1 , Yusuff Adebayo Adebisi2

1Department of Microbiology, Faculty of Life Sciences, University of Ilorin, Nigeria 2Faculty of Pharmacy, University of Ibadan, Nigeria

Over the millennia, several pandemics including bu- transport of a large number of passengers and heavy car- bonic plague and Spanish flu have been reportedly spread go including trafficking of wildlife across the world, and aboard ships including the recent coronavirus disease this reflected on the constant high demands for maritime 2019 (COVID-19) [1, 2]. These diseases are known to be transports for international travel and trade — which are as- zoonotic in origin. This is because of their ability to circulate sociated with globalisation. According to United Nations Con- initially in other vertebrate animals before circulating in the ference on Trade and Development (UNCTAD) in 2020, mar- human population as a result of cross-species transmis- itime transport accounts for ~80% of international trade [4]. sion of pathogenic microbes during human-animal contact. Cruise ships bring large numbers of passengers from many However, zoonosis is a public health threat that accounts countries, including asymptomatic carriers, on board — as for about 60% of emerging infectious diseases across the in the case of the 1918/1919 influenza pandemic [7]. This globe, and its ease on global transmission is facilitated by may lead to both direct person-to-person transmission and the physical interconnectedness of our world through effi- indirect transmission through contaminated surfaces and cient intercontinental transport chains, especially via the in turn, increases the influx of diseases to new countries maritime — being the most demanding transport route [3, 4]. — as happened with COVID-19 [2]. Increased demand for The rising challenges of zoonotic infectious diseases being wild animals and their parts has led to the trafficking of linked with maritime seaport; particularly on factors including wildlife. Wild animals including pangolin and donkeys are ballast water, travel and trade, and seafarers are important threatened due to the constant demand for their scale areas of public health concern. This is to increase the level of and skin respectively in traditional Chinese medicine, from preparedness and response to any future outbreaks of pan- 2000 to 2019, about 895,000 pangolins are traded across demic potential that may stem from the maritime seaport. the world [8–10]. These animals, usually transported via To maintain stability on the sea, all ships carry ballast the ocean and declared as cargo, are known to harbour water — this untreated water, which is being discharged from various zoonotic pathogens including viral zoonosis which one part of the world to the other may contain aquatic inva- can spill over to humans during human-animal contact along sive species including the green crab that harbours zoonotic the trade chain, thus contributing to zoonotic infectious pathogens (such as Vibrio cholerae) of public health signifi- diseases outbreaks. cance [5]. Annually, an estimated 3–5 billion tons of ballast The risk of spread of zoonosis by seafarers is facilitated water containing 7000–10,000 aquatic invasive species by their vulnerability to various climatic changes favouring are being carried by ship from one part of the world to the the spread of infectious diseases due to the nature of their other [5]. The cholera epidemic in Peru in 1991 has been on-board work. Increased visits to numbers of ports across linked with untreated ballast water from Bangladesh [6]. The the world exposed them to various outbreaks including outbreak later spread to Latin America in 1994 causing an epidemics and pandemics that may be transmitted to pas- estimate of about 10,000 deaths. sengers and other crew members on board as well as to Advancement in technology has made available differ- other parts of the world. It is noted that seafarers are usu- ent kinds of cruise ships which may be used for efficient ally vaccinated against internationally notifiable diseases

* Dr. Yusuf Amuda Tajudeen, Department of Microbiology, Faculty of Life Sciences, University of Ilorin, Ilorin, Nigeria, e-mail: [email protected] This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

www.intmarhealth.pl 237 Int Marit Health 2021; 72, 3: 237–238 including plague and cholera. However, seafarers are more climate change and biodiversity loss on zoonotic diseases outbre- vulnerable to new infectious diseases outbreaks in docks, aks. Public Health in Practice. 2021; 2: 100095, doi: 10.1016/j. puhip.2021.100095. ports, and countries where they visit as a result of the con- 4. United Nations Conference on Trade and Development. UNCTAD stant evolution of novel pathogenic zoonoses. Review of Maritime Transport. https://unctad.org/topic/transport- The global transmission of zoonotic infectious diseases -and-trade-logistics/review-of-maritime-transport (August 04, 2021). through the maritime seaport is an area of public health 5. Satir T. Ship’S Ballast Water And Marine Pollution. Integration of concern. To address this public health threat, maritime legal Information for Environmental Security. In: Coskun HG, Cigizoglu HK, institutions such as International Maritime Organization Maktav MD (eds) integration of information for Environmental Secu- rity. NATO Science for Peace and Security Series C: Environmental should work with public health institutions like Global Out- Security. Springer, Dordrecht. 2008: 453–463, doi: 10.1007/978- break Alert and Response Network to curb the global spread 1-4020-6575-0_30. of zoonotic infectious diseases tied to the maritime seaport. 6. Organisation for Economic Co-operation and Development. The Competitiveness of Global Port-Cities, OECD Publishing, Paris. Conflict of interest: None declared https://doi.org/10.1787/9789264205277-en (August 04, 2021). 7. Summers JA. Pandemic influenza outbreak on a troop ship--diary of a soldier in 1918. Emerg Infect Dis. 2012; 18(11): 1900–1903, REFERENCES doi: 10.3201/eid1811.AD1811, indexed in Pubmed: 23092739. 1. The Inside History Newsletter. Pandemics That Changed History. . 8. African donkeys threatened with extinction: export boom to China. https://www.history.com/topics/middle-ages/pandemics-timeline http://www.asianews.it/news-en/African-donkeys-threatened-with- (August 04, 2021). -extinction:-export-boom-to-China-44690.html (August 04, 2021). 2. The Guardian News and Media limited. Australia News: More than 9. Wang Y, Turvey S, Leader‐Williams N. Knowledge and attitudes about 400 coronavirus cases-10% of Australia’s total-are from Ruby the use of pangolin scale products in Traditional Chinese Medicine Princess cruise ship. https://www.theguardian.com/australia- (TCM) within China. People and Nature. 2020; 2(4): 903–912, doi: -news/2020/mar/31/more-than-400-coronavirus-cases-australia- 10.1002/pan3.10150. -total-ruby-princess-cruise-ship (August 04, 2021). 10. PHYS.ORG. Nearly 900,000 pangolins trafficked worldwide: 3. Tajudeen Y, Oladunjoye I, Adebayo A, et al. The need to adopt pla- watchdog. . https://phys.org/news/2020-02-pangolins-trafficked- netary health approach in understanding the potential influence of -southeast-asia- watchdog.amp (August 04, 2021).

238 www.intmarhealth.pl Int Marit Health 2021; 72, 3: 239–240 10.5603/IMH.2021.0044 www.intmarhealth.pl Copyright © 2021 PSMTTM LETTER TO THE EDITOR ISSN 1641-9251 eISSN 2081-3252 Wildlife trafficking and corruption at the maritime port: a global health threat

Yusuf Amuda Tajudeen , Iyiola Olatunji Oladunjoye

Department of Microbiology, Faculty of Life Sciences, University of Ilorin, Nigeria

The insatiable demand of bushmeat for human con- the world is carried out by the shipping industry through its sumption and traditional Chinese medicine for therapeutic over 50,000 registered merchant ships across an estimate use has led to an increase in wildlife trafficking across the of 150 nations, this facilitates the ease of transport of world. Wildlife trafficking — which involves illegal trading, wildlife through the sea that could result in human-animal smuggling, poaching, and capturing of endangered species contact and spillover of viruses to humans during trading of animals including the products (skin and organ) derived at the live market thereby resulting in transmission of dis- from them, is one of the most lucrative illegal business- eases between countries [6]. Civet cats are known to harbor es across the world with cost estimates that ranges from coronaviruses, and their trading in live animal markets has US$10 billion to US$20 billion per annum [1]. Illegal trading resulted in the outbreaks of severe acute respiratory syn- of wildlife creates an opportunity for infectious diseases out- drome coronavirus (SARS-CoV) in Guangdong Province [7]. breaks, including zoonoses (diseases transmitted between The outbreak of monkeypox outside Africa has been linked humans and animals) that account for an estimated 60% with pet prairie dogs infected with the virus from the African of emerging diseases circulating between the human and rodents imported to the United States [8]. The outbreaks of the animal population, to occur, and thus, a global health the coronavirus disease 2019 (COVID-19) caused by SARS- threat [2]. The maritime seaport plays an essential role in CoV-2 has also been associated with trading of live wild ani- wildlife trafficking through its ease on the transportation of mals at Wuhan wet market in China, which play an important wild animals and their products between countries which is role in the spread the disease to humans. Though, the zoonot- mostly associated with corruption at the port, and in part, ic source of its transmission has not been well established. with the decrease in the rate of arrest and prosecution of Over the years, several cases of corruption issues in- traffickers. However, despite the effort of anti-corruption cluding commercial extortion by shipping companies in compliance initiatives like Maritime Anti-Corruption Network, form of bribery, weak ethics infrastructure in port agencies, corruption persists. and smuggling of wildlife have been reported [9]. However, Globally, the rate of wildlife trafficking is on the rise and despite the seizures of illegal wildlife at the port of entry of recent studies show that from 2012–2016, over 11 million countries like Thailand, Singapore, Indonesia, and Nigeria, live wild animals and more than 8 million live animals were wildlife trafficking still continues [9, 10]. As a result of this, exported and imported, respectively [3]. Wildlife trafficking there is a need for the development of strategies aimed falls into different categories such as birds, reptiles, am- at banning or reducting demand for wildlife as seen in the phibians, and fishes. It also includes large mammals such new bill “Preventing Future Pandemics Act of 2020” of the as elephants, rhinoceros, donkeys, and pangolins which United States. Consequently, there is a need for capacity are facing serious extinction threats and this is evident building (knowledge, skills, and use of surveillance tech- from their increased death rate from poaching. According nologies) amongst the maritime law enforcement agencies to the Proportion of Illegally Killed Elephants data, about and wildlife trade monitoring networks, with support from 157,000 elephants were poached between 2010 and the government. This would facilitate strict compliance of 2018 while ~900,000 pangolins were poached between seaports across each countries with Convention on Inter- 2000 and 2019 [4, 5]. Since about 90% of trade across national Trade in Endangered Species of Wild Fauna and

* Dr. Yusuf Amuda Tajudeen, Department of Microbiology, Faculty of Life Sciences, University of Ilorin, Ilorin, Nigeria, e-mail: [email protected]

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Flora list of imported and exported species. There is also 5. PHYS.ORG (2020). Nearly 900,000 pangolins trafficked worldwi- a need for increased advocacy on the public health threat de: watchdog. https://phys.org/news/2020-02-pangolins-traffic- surrounding wildlife trafficking amongst traffickers, seafar- ked-southeast-asia-watchdog.amp (Accessed 24 August, 2021). 6. OECD (2019). Ocean shipping and shipbuilding. https://www.oecd. ers, and consumers. org/ocean/topics/ocean-shipping/ (Accessed 24 August, 2021). 7. Poon L, Guan Y, Nicholls JM, et al. The aetiology, origins, and dia- Conflict of interest: None declared gnosis of severe acute respiratory syndrome. Lancet Inf Dis. 2004; 4(11): 663–671, doi: 10.1016/s1473-3099(04)01172-7. REFERENCES 8. Bernard SM, Anderson SA. Qualitative assessment of risk for 1. Wilson-Wilde L. Wildlife crime: a global problem. Forensic Sci Med monkeypox associated with domestic trade in certain animal spe- Pathol. 2010; 6(3): 221–222, doi: 10.1007/s12024-010-9167-8, cies, United States. Emerg Infect Dis. 2006; 12(12): 1827–1833, indexed in Pubmed: 20512431. doi: 10.3201/eid1212.060454, indexed in Pubmed: 17326932. 2. WHO (2020). Zoonotic disease: emerging public health threats in 9. OECD (2019). Corruption Risks and Illegal Wildlife Trade, The Illegal the Region. https://www.emro.who.int/about-who/rc61/zoonotic- Wildlife Trade in Southeast Asia: Institutional Capacities in Indonesia, -diseases.html (Accessed 24 August 2021). Singapore, Thailand and Viet Nam. https://www.oecd-ilibrary.org/ 3. Macdonald DW, D’Cruze N, Can ÖE. Dealing in deadly pathogens: sites/9bac2383-en/index.html?itemld=/content/component/9bac- Taking stock of the legal trade in live wildlife and potential risks 2383-en (Accessed 23 August, 2021). to human health. Glob Ecol Conserv. 2019; 17: e00515, doi: 10. UNODC (2021). Wildlife Trafficking Through Nigerian Ports Continues 10.1016/j.gecco.2018.e00515, indexed in Pubmed: 32289050. Despite COVID-19. https://www.unodc.org/nigeria/en/wildlife- 4. UNODC, World Wildlife Crime Report. Trafficking in Protected -trafficking-through-nigerian-ports-continues-despite-covid-19.html Species. 2020. (Accessed 24 August, 2021).

240 www.intmarhealth.pl Int Marit Health 2021; 72, 3: 241–242 10.5603/IMH.2021.0045 www.intmarhealth.pl Copyright © 2021 PSMTTM LETTER TO THE EDITOR ISSN 1641-9251 eISSN 2081-3252 Self-medication with antibiotics among seafarers: a public health issue

Yusuff Adebayo Adebisi1 , Iyiola Olatunji Oladunjoye2 , Yusuf Amuda Tajudeen2 , Don Eliseo Lucero-Prisno III3

1Faculty of Pharmacy, University of Ibadan, Nigeria 2Department of Microbiology, Faculty of Life Sciences, University of Ilorin, Nigeria 3Department of Global Health and Development, London School of Hygiene and Tropical Medicine, United Kingdom

Self-medication is the use of drugs by individuals for seafarers [3]. Furthermore, antibiotic-resistant pathogens of self-diagnosed illnesses or symptoms without proper di- public health implications in humans have been discovered agnosis and therapeutic interventions by qualified health on the sea [4] and in sea animals [5]. This implies there is professionals. A major driver of antibiotic resistance in an urgent need to build research capacity on issues pertain- humans is the act of self-medication which leads to the ing to antibiotic misuse among seafarers and to formulate overuse, underuse, and misuse of antibiotics [1]. With the measures to curb the misuse and promote antimicrobial emergence of the coronavirus disease 2019 (COVID-19) stewardship. pandemic, the use of antibiotics has gained rapid usage, fur- We strongly recommend that an awareness campaign ther complicating the fight against antimicrobial resistance is carried out among seafarers to understand the impli- [1]. Therefore, it is essential that we continue to monitor cation of misuse and overuse of antimicrobials and urge antibiotics usage and strengthen surveillance in different strong monitoring on the usage of antimicrobials. We also communities, including among seafarers. To the best of our recommend that maritime scientists perform research on knowledge, and searches conducted across major scientif- the prevalence of self-medication among seafarers as there ic databases (Medline, Scopus, PubMed, Google Scholar, are no reports on this and encourage relevant stakeholders and PubMed Central), there is a major dearth of studies or to provide adequate support and funding. The editors of the reported data on self-medication with antibiotics among “International Maritime Health” journal should also call for seafarers globally. articles aimed at this research. There is a possibility of significant self-medication prac- In conclusion, the International Maritime Organization tices with medicines, including antibiotics among seafarers should collaborate with public health institutions to as- since medications are allowed on board. Additionally, lim- certain the risk of antibiotic usage among seafarers and ited knowledge of antibiotics use and lack of awareness of also understand the extent to which it is occurring to as the possible dangers of its misuse can also fuel pervasive to set up measures that can curb this public health issue, misuse of antibiotics for all kinds of illnesses, including viral antibiotic resistance. diseases, among seafarers. In the International Labour Orga- nization/International Maritime Organization Guidelines on Conflict of interest: None declared Seafarer Medical Examinations, seafarers that require the use of prescription and over-the-counter drugs are advised REFERENCES to always inform the master of any medications brought on 1. Adebisi YA, Jimoh ND, Ogunkola IO, et al. The use of antibiotics in board, to avoid a violation of drug and alcohol policy [2]. COVID-19 management: a rapid review of national treatment guidelines in 10 African countries. Trop Med Health. 2021; 49(1): 51, doi: However, the guideline does not cover monitoring of the 10.1186/s41182-021-00344-w, indexed in Pubmed: 34162445. usage of these drugs and strategies towards preventing 2. Guidelines on the medical examinations of seafarers. International needless antibiotic usage on the sea [2]. This is concerning Labour Organization and International Maritime Organization. because alcohol and drug abuse have been reported among 2013. https://www.ilo.org/wcmsp5/groups/public/---ed_dialogu-

* Dr. Yusuff Adebayo Adebisi, Faculty of Pharmacy, University of Ibadan, 200 Ibadan, Nigeria, e-mail: [email protected] This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

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e/---sector/documents/normativeinstrument/wcms_174794.pdf Cove, South China. Sci Total Environ. 2020; 723: 138027, (August 12, 2021). doi: 10.1016/j.scitotenv.2020.138027, indexed in Pubmed: 3. Stoll E, Püschel K, Harth V, et al. Prevalence of alcohol consumption 32224396. among seafarers and fishermen. Int Marit Health. 2020; 71(4): 265– 5. Blasi MF, Migliore L, Mattei D, et al. Antibiotic resistance of gram-ne- –274, doi: 10.5603/IMH.2020.0045, indexed in Pubmed: 33394491. gative bacteria from wild captured loggerhead sea turtles. Antibiotics 4. Li W, Su H, Cao Y, et al. Antibiotic resistance genes and bacterial (Basel). 2020; 9(4), doi: 10.3390/antibiotics9040162, indexed in community dynamics in the seawater environment of Dapeng Pubmed: 32268481.

242 www.intmarhealth.pl Int Marit Health 2021; 72, 3: 243–244 10.5603/IMH.2021.0046 www.intmarhealth.pl Copyright © 2021 PSMTTM LETTER TO THE EDITOR ISSN 1641-9251 eISSN 2081-3252 Physical training and ocular yogic exercise in home: good alternative options to control the high-tension form of primary open angle glaucoma during the repeated COVID-19 waves

Ali Mohamed Ali Ismail

Department of Physical Therapy for Cardiovascular/Respiratory Disorder and Geriatrics, Faculty of Physical Therapy, Cairo University, Giza, Egypt

A defected visual field of optic nerve degeneration is causing glaucoma to worsen [6]. During the first, second, referred to as glaucoma. Glaucoma is caused by diabetes and third waves of the COVID-19 disaster, there were re- mellitus, aging, black ethnicity, and family history, but the peated demands for health professionals, including phys- most important modifiable risk factor is elevated intraocular iotherapists, to engage in home-based exercise services for pressure (IOP). The most common type of glaucoma-induc- patients with chronic diseases to reduce tension, mental ing irreversible blindness, high-tension primary open angle restlessness, and psychological distress caused by social glaucoma (HTPOAG), is described by an IOP > 21 mmHg isolation [7–9]. and an open angle of the anterior chamber of the eye [1]. Simple recommendations to perform low- or moder- Lowering IOP is the most evidence-based technique ate-intensity home-based dynamic exercise (limb stretching, for slowing the progression of HTPOAG. Aside from the treadmill walking, ergometer riding, and jogging) must be unfavourable outcomes in many glaucoma patients, the introduced to HTPOAG patients to control their IOP under use of IOP-lowering medications has been linked to several the remote online-supervision of physiotherapists. negative side effects [2]. Dynamic exercise [3], acupuncture, Aerobic exercise has been shown to lower catecholamine yoga, meditation, and yogic ocular exercises [4] are exam- levels, especially norepinephrine concentrations. Regular ples of non-pharmacological complementary therapies. activity increases the parasympathetic-sympathetic input The implementation of routine medical follow-up of IOP ratio at rest, enhancing the relative release of acetylcho- measurements, IOP-lessening pharmacotherapies, and line-norepinephrine. The IOP can be reduced by these au- HTPOAG progression during outpatient- or hospital-cen- tonomic changes after routine exercise [10]. tred face-to-face interviews during the coronavirus disease Complementary treatments are often used to treat 2019 (COVID-19) can trigger a large risk of viral infection [5]. chronic diseases [11]. Yoga is a commonly used old Indian Patients with chronic diseases are less enthusiastic method that is used as a supportive therapeutic technique about the face-to-face long-term treatment facilities offered in the treatment of long-term chronic pathologic conditions in physiotherapy centres, gyms, and alternative medicine like primary open angle glaucoma with the aim of lowering centres as a result of repeated government and health IOP, enhancing body-mind spiritual reunion, reducing mental warnings not to leave homes unless absolutely necessary tension, reducing ocular exhaustion and restlessness, and to reduce the risk of COVID-19 cross-contamination. reducing eye strain [12]. During the COVID-19 disaster, imposed or self-selected During the COVID-19 pandemic, yoga teachers and social distance has a number of negative mental and psy- physiotherapists are being asked to include the compo- chological stressors. Isolation-induced tension raises IOP, nents of a home-based yogic ocular exercise to glaucoma

Ali Mohamed Ali Ismail, PhD, Department of Physical Therapy for Cardiovascular/Respiratory Disorder and Geriatrics, Faculty of Physical Therapy, Cairo University, Giza, * Egypt, tel: 0201005154209, e-mail: [email protected]

www.intmarhealth.pl 243 Int Marit Health 2021; 72, 3: 243–244 patients. A regular yogic ocular exercise session (5 rounds Conflict of interest: None declared of 2-minute maximal vertical, to-side, and circular eyeball movements plus a 1-minute in-between-round palming ex- REFERENCES ercise) will increase the maximum constant stretching of 1. Wang Yi, Lu W, Xie Y, et al. Functional alterations in resting-state bulbomotor or extraocular muscles. visual networks in high-tension glaucoma: an independent component analysis. Front Hum Neurosci. 2020; 14: 330, doi: 10.3389/ The ocular venous return and metabolic ocular muscular fnhum.2020.00330, indexed in Pubmed: 32903668. demand increase as these muscles are stretched and con- 2. Dada T, Yadav RK, Faiq MA. Effect of yoga-based ocular exercises in tracted repeatedly. Palming exercise (covering the eyes with lowering of intraocular pressure in glaucoma patients: an affirmative cupped hands after rubbing them together) often improves proposition. Int J Yoga. 2018; 11(3): 239–241, doi: 10.4103/ijoy. the warming and relaxing feeling in the eyes. As a result, by IJOY_55_17, indexed in Pubmed: 30233118. 3. Zhu MM, Lai JS, Choy BN, et al. Physical exercise and glaucoma: providing more blood, warming, relaxation, and oxygenation a review on the roles of physical exercise on intraocular pressure to the eyes, the elevated IOP in HTPOAG can be decreased. control, ocular blood flow regulation, neuroprotection and glaucoma- Due to the inhibited over-activation of the sympathetic -related mental health. Acta Ophthalmol. 2018; 96(6): e676–e691, nervous system, guiding the patient to begin and end the doi: 10.1111/aos.13661, indexed in Pubmed: 29338126. home-based session of yoga ocular exercise with breathing 4. Rhee DJ, Spaeth GL, Myers JS, et al. Complementary and alternative exercise (slow deep inspiration followed by slow relaxed medicine for glaucoma. Surv Ophthalmol. 2001; 46(1): 43–55, doi: 10.1016/s0039-6257(01)00233-8, indexed in Pubmed: 11525790. expiration) will bring the patient to the maximum level of 5. Saleem SM, Pasquale LR, Sidoti PA, et al. Virtual ophthalmology: tele- relaxed body response. In addition, in HTPOAG patients, medicine in a COVID-19 era. Am J Ophthalmol. 2020; 216: 237–242, this relaxed response may help to lower their elevated IOP. doi: 10.1016/j.ajo.2020.04.029, indexed in Pubmed: 32360862. Yoga teachers can also advise patients on how to per- 6. Jiménez R, Vera J. Effect of examination stress on intraocular form trataka, a yogic exercise that lowers IOP. The contin- pressure in university students. Appl Ergon. 2018; 67: 252–258, doi: 10.1016/j.apergo.2017.10.010, indexed in Pubmed: 29122197. uous and prolonged visual gazing at a specific point of an 7. Ismail A. Cancelled elderly exercise sessions during the COVID-19 cri- object, such as a candle flame, is known as this exercise. sis: can physical therapists help from their homes? Eur J Physiother. Trataka can lower elevated levels of IOP in glaucoma pa- 2020; 22(4): 235–235, doi: 10.1080/21679169.2020.1775293. tients [2], in addition to improved mental stress, insomnia, 8. Ismail AA. Online exercise rehabilitation to stable COPD patients and quality of life. during the second COVID wave: are physiotherapists able to help? Trataka causes the ciliary muscles of the eye to con- Adv Rehab. 2020; 34(4): 48–49, doi: 10.5114/areh.2020.101592. tract, causing the open angle of the anterior chamber of 9. Ismail AM. Robot-assisted rehabilitation: it is the time for utilisation in in-patient health care facilities to maintain the activity of the elderly the eye to extend. The trabecular mesh tissue of the eye is during the COVID-19 pandemic. Int Marit Health. 2021; 72(1): 80–81, unlocked by this stretch, allowing the aqueous humour to doi: 10.5603/IMH.2021.0013, indexed in Pubmed: 33829479. flow freely. Long-term drainage and/or outflow of aqueous 10. Ali Ismail AM, Abdelghany AI, Abdelhalim Elfahl AM. Immediate humour in response to trataka may help to lower HTPOAG’s effect of interscapular cupping on blood pressure, oxygen satura- elevated IOP [13]. tion, pulse rate and chest expansion in sedentary smoker students. The previous recommendations must be stated on var- J Complement Integr Med. 2021 [Epub ahead of print], doi: ious media (Facebook, television, Instagram, and website 10.1515/jcim-2020-0050, indexed in Pubmed: 33544517. 11. Passo MS, Goldberg L, Elliot DL, et al. Exercise training reduces of national health ministry) with the constant clarification intraocular pressure among subjects suspected of having glauco- of the value of a healthy mental and psychological ex- ma. Arch Ophthalmol. 1991; 109(8): 1096–1098, doi: 10.1001/ istence in addition to preventing dangerously elevated archopht.1991.01080080056027, indexed in Pubmed: 1867551. IOP levels. 12. Gupta S, Aparna S. Effect of yoga ocular exercises on intraocular pressu- Additionally, continuous monitoring from physiother- re. Yoga Mimamsa. 2019; 51(2): 48, doi: 10.4103/ym.ym_13_19. apists and yoga teachers to the home-based implemen- 13. Ismail AM, Abd Elfatah Abo Saif HF, El-Moatasem Mohamed AM. Effect of on intraocular pressure, autonomic control, and blood tation of these instructions is simple to do by pre-ar- glucose in diabetic patients with high-tension primary open-angle ranged group appointments on Zoom video-conference glaucoma: a randomized-controlled trial. J Complement Integr sessions to improve glaucoma patients’ adherence to Med. 2021 [Epub ahead of print], doi: 10.1515/jcim-2021-0041, the exercise. indexed in Pubmed: 34303323.

244 www.intmarhealth.pl Int Marit Health 2021; 72, 3: 245–246 10.5603/IMH.2021.0047 www.intmarhealth.pl Copyright © 2021 PSMTTM LETTER TO THE EDITOR ISSN 1641-9251 eISSN 2081-3252 The need for detailed study of course credit earned and the comprehension of material by college students as a result of major changes in university course formats due to COVID-19 and actions based on those findings

Yasuyuki Fujita1 , Ken Inoue2 , Noriyuki Kawano3 , Yoshihiro Noso4 , Nailya Chaizhunusova5 , Nargul Ospanova5 , Nursultan Seksenbayev5 , Timur Moldagaliyev5 , Aigul Tokesheva5 , Yersin T. Zhunussov5 , Nobuo Takeichi3, 6 , Masaharu Hoshi3 , Yoshiyuki Ohira7

1Shimane University, Shimane, Japan 2Kochi University, Kochi, Japan 3Hiroshima University, Hiroshima, Japan 4Hiroshima International University, Hiroshima, Japan 5Semey Medical University, Semey, Kazakhstan 6Takeichi Clinic, Hiroshima, Japan 7International University of Health and Welfare, School of Medicine, Chiba, Japan

As of May 15, 2021, over a year has passed since the -face classes in 2019 and earlier. Moreover, various aspects coronavirus disease 2019 (COVID-19) pandemic struck of the comprehension of material in online classes and face- worldwide. As of this point, about 162 million people have -to-face classes also need to be compared. The advantages been infected and about 3.4 million people have died world- and disadvantages of online classes need to be identified wide [1]. People in many countries around the world have based on those findings, and the necessity for specific experienced hardships in the intervening year, and a study improvements in online classes needs to be considered. has cited the plight of college students [2]. In addition, we These aspects need to be studied in Japan by focusing on have described the experience of conducting online lectures reasonable accommodations for college students, which is for students abroad, and we have also suggested advantag- a topic that has garnered attention over the past few years. es of that format and areas for improvement [3]. A major Instructional approaches and their positive and nega- change due to COVID-19 is that many universities around tive outcomes need to be examined in detail. Personnel in the world have quickly shifted to conducting classes online. multiple relevant fields, and not just in a single field, need Having looked at online classes, we noted the increasingly to work together to consolidate those findings. When nec- isolated nature of everyday life and the potential for mental essary, approaches that are internationally applicable also distress to occur [4]. need to be devised. Online classes spread worldwide in 2020, and various modifications need to be made to online classes this year, FUNDING AND ACKNOWLEDGMENTS i.e. 2021. Accordingly, that first year of online classes in This work was supported by JSPS KAKENHI Grant-in-Aid 2020 needs to be reviewed. Online classes have increased for Scientific Research (C) Number 17K09194 awarded to sharply, and there may have been major changes in course K.I., JSPS KAKENHI Grant-in-Aid for Scientific Research (A) credit earned by college students mainly attending face-to- Number 19H01149 awarded to M.H., JSPS KAKENHI Grant-

Ken Inoue, MD, PhD, Research and Education Faculty, Medical Sciences Cluster, Health Service Centre, Kochi University, 2-5-1, Akebono-cho, Kochi-shi, Kochi 780-8520, * Japan, tel: +81-88-844-8158, fax: +81-88-844-8089, e-mail: [email protected]

www.intmarhealth.pl 245 Int Marit Health 2021; 72, 3: 245–246 in-Aid for Scientific Research (B) Number 19H04355 award- the world? Int Marit Health. 2020; 71(2): 150, doi: 10.5603/ ed to N.K., and JSPS KAKENHI Grant-in--Aid for Scientific IMH.2020.0027, indexed in Pubmed: 32604461. 3. Inoue K, Chaizhunusova N, Seksenbayev N, et al. The realities of Research (C) Number 21K02383 awarded to K.I. a new era featuring truly international lectures during the prolonged COVID-19 pandemic: international collaboration and advances in Conflict of interest: None declared medical education. Int Marit Health. 2021; 72(1): 79, doi: 10.5603/ IMH.2021.0012, indexed in Pubmed: 33829478. REFERENCES 4. Inoue K, Seksenbayev N, Moldagaliyev T, et al. Changes in univer- 1. NHK. https://www3.nhk.or.jp/news/special/coronavirus/world-da- sity classes as COVID-19 continues and new findings regarding ta/ (cited 2021 May 15). future university instruction methods: from the perspective of 2. Inoue K, Takeshita H, Ohira Y. The current effects of the spread Japan and Semey, Republic of Kazakhstan. Int Marit Health. of COVID-19 in learning environments involving Japanese college 2020; 71(4): 297, doi: 10.5603/IMH.2020.0051, indexed in students: What is the state of those environments elsewhere in Pubmed: 33394497.

246 www.intmarhealth.pl INFORMATION FOR AUTHORS

The International Maritime Health will publish original papers on medical and health problems of seafarers, fishermen, INTERNATIONAL MARITIME HEALTH divers, dockers, shipyard workers and other maritime workers, as well as papers on tropical medicine, travel medicine, Former: Bulletin of the Institute of Maritime and Tropical Medicine in Gdynia, issued since 1949 epidemiology, and other related topics. Owner: International Maritime Health Foundation Typical length of such a paper would be 2000–4000 words, not including tables, figures and references. Its construc- The international multidisciplinary journal devoted to research and practice in the field of: maritime medicine, travel and tropical medicine, tion should follow the usual pattern: abstract (structured abstract of no more than 300 words); key words; introduction; hyperbaric and underwater medicine, sea-rescue, port hygienic and sanitary problems, maritime psychology. participants; materials; methods; results; discussion; and conclusions/key messages. Supported scientifically and/or financially by: Case Reports will also be accepted, particularly of work-related diseases and accidents among maritime workers. All papers will be peer-reviewed. The comments made by the reviewers will be sent to authors, and their criticism and proposed amendments should be taken into consideration by authors submitting revised texts. Review articles on specific topics, exposures, preventive interventions, and on the national maritime health services will also be considered for publication. Their length will be from 1000 to 4000 words, including tables, figures and references.

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