CF 756

2021, Vol. 72, No.
3 nr ISSN 1641–9251
nr eISSN 2081-3252
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,
International Maritime Health, 2021, Vol. 72, No. 3

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
Medical assessment of fitness to dive
Tem Suzie-Solange Mbong, Despena Andrioti Bygvraa
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 Official scientific forum of the:
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, International
Yusuf Amuda Tajudeen, Don Eliseo Lucero-Prisno III
OCCUPATIONAL MEDICINE
Self-medication with antibiotics among seafarers: Maritime
a public health issue...................................................241
Original articles
Ali Mohamed Ali Ismail
Health
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 Foundation
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,
Nursultan Seksenbayev, Timur Moldagaliyev, Aigul Tokesheva, Indexed/abstracted in: CrossRef, DOAJ, EBSCO,
Om Prakash Yadav, Atanu Sarkar, Desai Shan, Arifur Rahman,
Lorenzo Moro Yersin T. Zhunussov, Nobuo Takeichi, Masaharu Hoshi, ESCI, FMJ, Google Scholar, Index Copernicus,
Occupational noise exposure and health impacts Yoshiyuki Ohira Medical Journals Links, Medline,
among fish harvesters: a systematic review....................199 The need for detailed study of course credit earned Polish Ministry of Education and Science,
and the comprehension of material by college Polish Medical Bibliography, Scopus, SJR,
Rune Djurhuus students as a result of major changes in university Ulrich's Periodicals Directory, WorldCat
Fumigation on bulk cargo ships: a chemical threat course formats due to COVID-19 and actions
to seafarers................................................................. 206 based on those findings............................................. 245
"International Maritime Health" is indexed at: CrossRef, DOAJ, EBSCO, ESCI, FMJ, Google Scholar, Index Copernicus, Medical Journals Links, Medline,
Polish Ministry of Education and Science, Polish Medical Bibliography, Scopus, SJR, Ulrich's Periodicals Directory, WorldCat.
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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-
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MARITIME AND DIVING MEDICINE
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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: mariajez@gumed.edu.pl, 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: eilifdahl@gmail.com
Stephen E. Roberts
School of Medicine Swansea University, United Kingdom
e-mail: Stephen.E.Roberts@swansea.ac.uk
HONORARY EDITOR: STATISTICAL EDITOR:

Bogdan Jaremin Paweł Zagożdżon
e-mail: bojar@gumed.edu.pl Department of Hygiene and Epidemiology
SECRETARY of the EDITORIAL BOARD: Medical University of Gdańsk, Poland
Leszek Mayer e-mail: pzagoz@gumed.edu.pl
e-mail: leszekm@gumed.edu.pl LANGUAGE EDITOR
PUBLISHER EDITOR: Tim Carter
Joanna Niezgoda NCMDM, Haukeland University Hospital,
Via Medica, Gdańsk, Poland Bergen, Norway
e-mail: joanna.niezgoda@viamedica.pl e-mail: tim.sea@doctors.org.uk
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: marit.gronning@helse-bergen.no e-mail: kktropmed@wp.pl
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: alf.magne.horneland@helse-bergen.no e-mail: travel-medicina@ri.htnet.hr
Francesco Amenta Cardiology, maritime emergencies and accidents
CIRM Rome, University of Camerino, Italy Marcus Oldenburg
e-mail: famenta@gmail.com
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: marcus.oldenburg@justiz.hamburg.de
University of Southern Denmark, Esbjerg, Denmark
e-mail: ocj@cmss.sdu.dk 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: rozanov@te.net.ua
e-mail: jriis@cmss.sdu.dk 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: jon.magnus.haga@gmail.com e-mail: smithap@Cardiff.ac.uk
EDITORIAL ADVISORY BOARD: Wacław Leszek Nahorski
Medical University of Gdańsk, Poland
Gregory Chan Chung Tsing e-mail: wnahorski@gumed.edu.pl
National University of Singapore, Singapore
e-mail: gregchan@nus.edu.sg Ralph Nilsson
Sahlgrenska University Goteborg, Sweden
Ilona Denisenko e-mail: Ralph.Nilsson@amm.gu.se
IMHA, WISTA, Russian Federation
e-mail: dr_denisenko@yahoo.com Marcin Renke
Medical University of Gdańsk, Poland
Jordi Desola e-mail: mrenke@gumed.edu.pl
CRIS-UTH, University of Barcelona, Spain
e-mail: jordi.desola@acmcb.es, cris@comb.es Giovanna Ricci
University of Camerino, Italy
Lucero Prisno Don Eliseo III e-mail: giovanna.ricci@unicam.it
University of Liverpool, UK
e-mail: d.prisno@liverpool.ac.uk Przemysław Rutkowski
Department of Nephrology, Transplantology
Karl Faesecke and Internal Diseases, MUG, Poland
Hamburg Hyperbaric Center, Germany e-mail: prut@gumed.edu.pl
e-mail: kp.faesecke@tunneldoc.de
Maria Luisa Sanchez
Marta Grubman-Nowak K Line Clinic, Manila, Philippines
IMTM, MUG, Gdynia, Poland e-mail: lmalacasanchez@yahoo.com
e-mail: mgrubman@gumed.edu.pl
Bernd Fred Schepers
Christos Hadjichristodoulou German Maritime Health Association
University of Thessaly, Larissa, Greece e-mail: berndfred.schepers@googlemail.com
e-mail: xhatzi@med.uth.gr
Klaus Seidenstuecker
Henrik Lyngbeck Hansen Chairman German Maritime Health Association
CMHS University of Southern Denmark, Denmark e-mail: klaus-h.seidenstuecker@T-Online.de
e-mail: hlhansen@dadlnet.dk
Suzanne Louise Stannard
Suresh N. Idnani NCMDM, Haukeland University Hospital, Bergen, Norway
IMHA, ICSW, Goa, India e-mail: sue@stannardmedical.com
e-mail: sureshidnani@hotmail.com
Robert Steffen
Dominique Jegaden ISPM, University of Zurich, Switzerland
FSMH, Brest University, France e-mail: roste@hspm.uza.ch
e-mail: dominique.jegaden@wanadoo.fr
Agnar Ström Tveten
Piotr Kajfasz NCMDM, Radio Medico Norway
Medical University of Warsaw, Poland e-mail: agnar.strom.tveten@helse-bergen.no
e-mail: piotr.t.kajfasz@gmail.com
Einar Thorsen
Jacek Kot Department Occupational Medicine,
IMTM MUG, Gdynia, Poland Haukeland University Hospital, Bergen, Norway
e-mail: jkot@ucmmit.gdynia.pl e-mail: einar.thorsen@helse-bergen.no
Raymond Lucas Arne Johan Ulven
George Washington, University Washington DC, USA NCMDM, Haukeland University Hospital, Bergen, Norway
e-mail: rlucas@mfa.gwu.edu e-mail: ajul@helse-bergen.no
Alessandro Marroni Donald A. Velasco
DAN Europe, Italy/Malta University of the Immaculate Conception,
e-mail: amarroni@daneurope.org Davao City, Philippines
Joanne McVeigh e-mail: donald.velasco@yahoo.com
Department of Psychology and Assisting Living Karin Westlund
and Learning (ALL) Institute, Maynooth University, Ireland Sahlgrenska University Hospital Gothenburg, Sweden
e-mail: jmcveigh@tcd.ie e-mail: radiomedical@medic.gu.uk
Bente Elisabeth Moen Stephen Williams
University of Bergen, Norway Institute of Cruise Ship Medicine, Miami Beach, USA
e-mail: bente.moen@isf.uib.no e-mail: stevewilliams@rccl.com
CONTENTS

after COVID-19............................................................ 223
Stefania Zampogna, Domenico Sinopoli, Ilaria Prosperi Porta, Wildlife trafficking and corruption at the maritime
area: the teacher's point of view............................... 193 Yusuff Adebayo Adebisi, Iyiola Olatunji Oladunjoye,
Self-medication with antibiotics among seafarers:
OCCUPATIONAL MEDICINE a public health issue...................................................241
Original articles
The relationship between work environment and good alternative options to control the high-tension
Om Prakash Yadav, Atanu Sarkar, Desai Shan, Arifur Rahman, Nursultan Seksenbayev, Timur Moldagaliyev, Aigul Tokesheva,
Lorenzo Moro Yersin T. Zhunussov, Nobuo Takeichi, Masaharu Hoshi,
Yoshiyuki Ohira
Occupational noise exposure and health impacts
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
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 tempo-
ral 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: chatard@univ-st-etienne.fr
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 XX 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 is-
lands 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, includ-
ing 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
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)
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
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,
(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.
Int Marit Health 2021; 72, 3: 155–162
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Int Marit Health
2021; 72, 3: 163–171
10.5603/IMH.2021.0032
www.intmarhealth.pl
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 uni-
variate 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 care-
fully 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: huseyinkocak@comu.edu.tr
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.
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.
Int Marit Health 2021; 72, 3: 163–171
14.00%
0.115 0.127
12.00%
10.00%
0.085
0.082 0.09
0.072 0.095
8.00% 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
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 acci-
Antalya 108 6.0%
dents/events and medical evacuations. While 58.7% of
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.
Total 1796 100%
A total of 150 people were injured in a period of 12 years
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
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-
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
Year of manufacture
Dimension 2
Environment
Pollution
Death
Operational Unit
Lost
–1 Salvation
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 evacua-
tion) and the differences in the vehicular traffic in the sea. tions indicated that Turkish flagged vessels ranked the
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
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
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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.).
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ger/personnel or staff in charge) and certain information Çalışmalar. 2011.
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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).
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to the evaluation of search, rescue and medical evacuations tikleri Deniz Taşıtları, Denizyolu Taşıma, Teşvik ve Gemi Sanayi İstatis-
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Int Marit Health
2021; 72, 3: 172–178
10.5603/IMH.2021.0033
www.intmarhealth.pl
eISSN 2081-3252

the seafarer’s views
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 reso-
urce 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 imple-
mentation 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: dab@health.sdu.dk
Tem Suzie-Solange Mbong, Despena Andrioti Bygvraa, The ISM Code and seafarers views
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.
Int Marit Health 2021; 72, 3: 172–178
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
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
Int Marit Health 2021; 72, 3: 172–178
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-
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 mar-
itime 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
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10.5603/IMH.2021.0034
www.intmarhealth.pl
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 vacci-
nation 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 par-
ticularities, 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: schlaich@hafenpraxis-hamburg.de; mail@faesecke.com
Int Marit Health 2021; 72, 3: 179–182
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.).
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 medica-
tion 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)
Roadmap for Vaccination of International Seafarers Published by
— Depending on the terminal traffic situation: rotating
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
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).
Int Marit Health
2021; 72, 3: 183–192
10.5603/IMH.2021.0035
www.intmarhealth.pl
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 wor-
king 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 se-
afarers’ 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 sour-
ces 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: ssabila@up.edu.ph
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.
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
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%)
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
www.intmarhealth.pl
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
Sanley Salvacion Abila, Iris Lavalle Acejo, Review of seafarers’ mental health
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
sailing; family members of seafarers held as hostages may suffer lasting distress
185
Table 1 cont. Twenty eight eligible studies organized under three research themes [Source: Authors]
186
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 understan-
ding 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
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
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.
www.intmarhealth.pl
witnessing suicide of crewmates)
Panganiban and Descriptive research 205 Filipino seafarers Four broad areas that contribute to stress and fatigue of seafarers are physical,
Int Marit Health 2021; 72, 3: 183–192
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; nationali-
ty 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 region ted anxiety, 20% had suicidal ideation
instruments
Æ
3. Of the materials considered, three themes illustrate
well-being. These negative effects have repercussions on health, work efficiency,

spondents, 15.4% report being depressed almost every day, 21.9% claims being
effects of the COVID-19 pandemic related to their physical, social and economic
major areas under which research on seafarers’ MH
tion have difficulties going back to sea to work. For seafarers on extended work
safety on-board and financial well-being of seafarers especially those who have
ation where seafarers have extended contracts whilst those who were on vaca-
Due to the COVID-19 pandemic, crew change developed into a crisis level situ-
Effects of COVID-19 on seafarers’ mental health are presented. Of the 671 re- are organized: medical repatriation of seafarers, system
Of the 752 respondents, majority of the respondents report some negative

of care for the MH of seafarers including diagnostic
standards, and seafarers’ experiences and conceptions
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;
anxious almost daily and 73.3% say they are mentally exhausted
of MH including studies examining the effects of the

on-going pandemic caused by the coronavirus disease
2019 (COVID-19) on seafarers’ MH. These themes are
discussed below.
Focus of study or relevant results/findings
KEY THEMES ON RESEARCH ON THE

contracts, they feel exhausted and anxious MENTAL HEALTH OF FILIPINO MARINERS
The first thematic finding focuses on the medical repatri-
not worked for an extended period
ation of seafarers. Repatriation of seafarers is the transport

of the seafarer from his/her home address to the port of
call of a vessel to be boarded. Under Philippine law, the
repatriation of seafarers is the responsibility of employers
including medical repatriation, which is the disembarkation
of a seafarer on medical grounds [23]. Medical repatriation
of Filipinos remains surprisingly understudied [24]. In Abaya
et al.’s study [24], between January 2010 and December
2014 there were 6,759 repatriated cases based on medical
reasons. Of these cases, 1.8% (n = 118) were categorised
land-based and sea-based personnel in the maritime sector
as psychiatric disorders (i.e. anxiety, depression, psycho-

Multi-nationalities including Filipinos but covered both
sis/schizophrenia or bipolar disorder) [24]. While 4 cases

671 multi-national seafarers including 215 Filipinos
Table 1 cont. Twenty eight eligible studies organized under three research themes [Source: Authors]
752 multi-national seafarers including 60 Filipinos
of disembarkation of Filipino ratings with mental illnesses

Sample description (number of participants,
were reported in a 2013 MH conference [25]. The same very

low reporting of mental illnesses can be seen in Bell and
Jensen’s [26] work where of the 25,039 cases of disembar-
kation due to various medical reasons, Filipinos accounted
for less than 1% of these cases (i.e. 105) but only one
psychiatric case [26]. Lastly, 1 study analysed repatriation
nationality of seafarers)
documents of 51,850 Filipinos who have worked for more

than 200 days on board from January 2014 to December
2016. They found less than 1% were repatriated due to
mental ill-health [27].
*The paper of Altaf Chowdhury et al., 2016 is based on the same ITF report.
The second theme centres on the system of mental

health care of seafarers, including diagnostic standards
used. Most of these studies under this theme were out-
puts related to the maritime piracy research of One Earth
Qualitative, online in-depth
Paper presentation, online
Future Foundation, a non-governmental organization. These

and similar studies came out at the height of the mari-
time piracy crisis particularly from 2009 to 2012, where
Type of study
a significant number of seafarers including Filipinos were

Pauksztat, Grech, Online survey
PTSD — post-traumatic stress disorder

interviews
taken as hostages and a number were killed in hostage

survey
situations. The foundation produced a series of annual re-

ports from 2010 to 2018 focusing on the state of maritime
piracy, where approximately more than 6,000 Filipinos have
publication year
Slišković, 2020
been subjected to pirate attacks and/or armed robberies

Jensen, 2020
Arslan, 2020
Stokes and
Kitada and
including being taken as hostages by pirates from 2009 to

Author(s),
2019 [28–36]. It is also reported that the families of sea-

farers especially those taken as hostages suffer as much
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
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
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
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2021; 72, 3: 193–194
10.5603/IMH.2021.0036
www.intmarhealth.pl
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 pro-
blems 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: ebaldas75@gmail.com
Int Marit Health 2021; 72, 3: 193–194
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
with scientific evidence. Turk Pediatri Ars. 2020; 55(4): 337–344,
a tailored approach for the single realities within a school, or
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.
3. Lakha F, King A, Swinkels K, et al. Are schools drivers of COVID-19
ern states, countries with a low population density such as
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.
Int Marit Health
2021; 72, 3: 195–198
10.5603/IMH.2021.0037
www.intmarhealth.pl
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 co-
astal 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: putri.a.a@fkm.unair.ac.id
Int Marit Health 2021; 72, 3: 195–198
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
2. Have had an accident while traveling to or from work.
by the presence of K3 among informal sector workers,
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 locat-
ed 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
Lighting
data processing software. Significance test between the
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.
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 re-
lationship 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
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:
Jurnal Kesehatan Masyarakat. 2019; 4(2): 79, doi: 10.24903/
only small. It is necessary to expand the criteria in taking
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.
Int Marit Health
2021; 72, 3: 199–205
10.5603/IMH.2021.0038
www.intmarhealth.pl
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: opyadav@mun.ca
Int Marit Health 2021; 72, 3: 199–205
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
Om Prakash Yadav et al., Occupational noise exposure and health impacts among fish harvesters
Records identified through Additional records identified

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

removed
(n = 746)
Screening
Records excluded (n = 718);

Records screened — Due to irrelevant topics (n = 685)
(n = 746) — Not related to fish harvesters (n = 28)
— 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
Eligibility
in the literature (n = 3)
Studies included in
qualitative synthesis
(n = 17)
Included
Studies included in
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 partic-
ipants [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,
Int Marit Health 2021; 72, 3: 199–205
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
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].
Int Marit Health 2021; 72, 3: 199–205
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 sev-
eral other unpublished projects that have not been included Conflict of interest: None declared
in this review. It is challenging to prove a direct relationship
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Int Marit Health
2021; 72, 3: 206–216
10.5603/IMH.2021.0039
www.intmarhealth.pl
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 un-
wanted 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 fumi-
gant 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: rune.djurhuus@bkkfiber.no
Rune Djurhuus, Fumigation on bulk cargo ships: a chemical threat to seafarers
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.
Int Marit Health 2021; 72, 3: 206–216
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
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
PubMed Gard MAIB
Scholar Mariner
N=9 N = 65 N=5
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
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 (s) + 3 H2O → Al(OH)3 + PH3 (g)
revealed an ejection fraction of only 10%. The third subject
II. Mg3P2 (s) + 6 H2O → 3 Mg(OH)2 + 2 PH3 (g)
showed an ejection fraction of 15%, with improvements to
Zn3P2 reacts similar as Mg3P2
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
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.
Int Marit Health 2021; 72, 3: 206–216
Due to rainfall during the operation, the floor was wet, and
since the ferrosilicon had a minor content of metal phos-
phide (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 fumiga-
tion 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
are from the bulk ship Arklow Meadow at port of Warrenpoint,
the fumigators have left the ship, the ship often sails. If the
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.
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.
Int Marit Health 2021; 72, 3: 206–216
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.
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.
2008; 5(2): 223–239, doi: 10.3109/08958379309034503.
tigation Branch (MAIB), Southampton, United Kingdom, for
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
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Int Marit Health
2021; 72, 3: 217–222
10.5603/IMH.2021.0040
www.intmarhealth.pl
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 compa-
rable. 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: pierre.lafere@erasme.ulb.ac.be
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]:
Pierre Lafère et al, Diver’s thermal balance in cold water
Dry suit divers Wetsuit divers General

39 39 39
Core temperature [°C]

Dry
Wet
temperature [°C] 38 38 38
C-SC skin
37 37 37
36 36 36
35 35 35
Hands temperature [°C]

Hands temperature [°C]
36 36 36
Dry
Wet
34 34 34
32 32
32
30 30
30 NS
28 28
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).
Int Marit Health 2021; 72, 3: 217–222
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
Pierre Lafère et al, Diver’s thermal balance in cold water
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Int Marit Health
2021; 72, 3: 223–227
10.5603/IMH.2021.0041
www.intmarhealth.pl
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 recre-
ational 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 decompres-
sion 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: kkorzeniewski@wim.mil.pl; 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: kkorzeniewski@gumed.edu.pl
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 typ-
ically 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 gen-
eral 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, in-
cluding 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
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 vas-
cular 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 inflamma-
tion 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 report-
ed 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
Int Marit Health 2021; 72, 3: 223–227
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
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
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).
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
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www.intmarhealth.pl
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 trans-
mission 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: kubra_ozgk@hotmail.com
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.
Int Marit Health 2021; 72, 3: 228–236
Table 1. The decisions on the continuation of treatment plans upon the official announcement of the first COVID-19 case announce-
ment 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 pa-
tient 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
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 arrange-
ments 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 cham-
ber, 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
Int Marit Health 2021; 72, 3: 228–236
120
■ PTT
■ Emergency sessions
100 ■ Elective sessions
12
80
18
6 8
1 1
0 11 5 11
60
12
8 11 6
1
4
40
0 68 67
61 58
5
49 51 50
20 42
0
25
18
0
ch
st
r
ril
ay
ne
ly
be
be
be
be
Ju
gu
Ap
M
ar
Ju
em
to
m
Au
M
Oc
ve
ce
pt
1
No
De
–3
Se
16
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
50
40 42
Patient number
30 32
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
Table 3. The demographic data of patients (missing data were
during the following week among the patients

not included into percentage calculations)
The number of SARS-CoV-2 diagnosed cases
who were together in the same session with

Parameter Evaluated pa- Number (%) or
HBO — hyperbaric oxygen; ALL — acute lymphoblastic leukaemia; DM — diabetes mellitus; HT — hypertension; CAD — coronary artery disease; PAD — peripheral arterial disease; CKF — chronic kidney failure; DFU — diabetic foot ulcer;
tient number median (min–max)
Age [year] 122 50 (2–83)
Sex: 122
Male 71 (52.8%)
Female 51 (41.8%)
the infected patient

Body-mass index 32 27.3 (16.8–50.7)
Chronic diseases: 100 55 (55%)
DM 100 39 (39%)
HT 100 22 (22%)
0
1
1
CAD 100 16 (16%)
same HBO session with

patients attending the
PAD 100 18 (18%)
The total number of

CKF 100 5 (5%)
Asthma 100 2 (2%)
the patient
Cancer 100 3 (3%)
Other 100 10 (10%)
Pregnancy 122 3 (2.5%)
1
6
6
6
Steroid 96 17 (17.7%)
Loss of smell and

Table 4. The data of patients diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
URTI symptoms
diagnosed with
SARS-CoV-2
Smoking: 68
SARS-CoV-2
symptoms
His spouse
High fever
or signs
Smoker 14 (20.6%)
related
None
None
None
taste
Ex-smoker 10 (14.7%)
Non-smoker 44 (64.7%)
Indications: 122
number
session
HBO
Emergency 68 (55.7%)
Peripheral ischaemia 39
20
30
15
5
3
5
Elective 54 (44.3%)
due to calcium extra-
The number of HBO 120 8.5 (1–60)

Non-healing ulcer
Radiation cystitis
HBO indication
vasation (hand)
sessions
Age, body mass index and the number of HBO sessions were not normally distri-
SSHL — sudden sensorineural hearing loss; URTI — upper respiratory tract infection
buted, therefore these data were given as median (minimum–maximum) in the
table; HBO — hyperbaric oxygen; DM — diabetes mellitus; HT — hypertension;
SSHL
DFU
DFU
DFU
CAD — coronary artery disease; PAD — peripheral artery disease; CKF — chronic
kidney failure
thropoietic anaemia
ALL, chemotherapy
Bladder cancer (in

Congenital dysery-
DM, HT, CAD, CKF
DM, CAD, PAD
session twice within 7 days before the diagnosis. The

Comorbidity
remission)
patients in the related session were followed for any

continues
DM, HT
SARS-CoV-2 symptoms or signs, but none of them was

DM
diagnosed with SARS-CoV-2 during the following week.

The personnel member returned from holiday 4 days be-
number [year] SARS-CoV-2
The date of
fore being diagnosed with COVID-19, so they might have

diagnosis
31/12/20
15/09/20
17/09/20
10/12/20
1/12/20
7/12/20
9/9/20
acquired the infection during the holiday. The other inside

attendant was diagnosed with COVID-19 on September
29th, 2020; that person accompanied the HBO session
3 times within 7 days before the diagnosis. The patients
Patient Age
49
38
61
22
53
48
2
in the same session were followed for SARS-CoV-2 symp-

toms or signs for a week, none of them was found to be
infected with SARS-CoV-2.
1
4
3
Int Marit Health 2021; 72, 3: 228–236
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
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.
Ann Intern Med. 2021; 174(1): 69–79, doi: 10.7326/M20-5008,
October. This decrease was also observed in the number
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.
JAMA. 2020 [Epub ahead of print]; 324(5): 441–442, doi: 10.1001/
sures taken to prevent the COVID-19 transmission in an HBO
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.
14. Lu J, Gu J, Li K, et al. COVID-19 Outbreak Associated with Air Con-
was almost no transmission during the sessions shows the
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-
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LETTER TO THE EDITOR ISSN 1641-9251
eISSN 2081-3252

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: tajudeenamudayusuf@gmail.com
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,
Maktav MD (eds) integration of information for Environmental Secu-
institutions such as International Maritime Organization
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.
https://doi.org/10.1787/9789264205277-en (August 04, 2021).
Conflict of interest: None declared
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:
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-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).
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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: tajudeenamudayusuf@gmail.com
Int Marit Health 2021; 72, 3: 239–240
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-
ked-southeast-asia-watchdog.amp (Accessed 24 August, 2021).
surrounding wildlife trafficking amongst traffickers, seafar-
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
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the Region. https://www.emro.who.int/about-who/rc61/zoonotic- Wildlife Trade in Southeast Asia: Institutional Capacities in Indonesia,
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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).
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2021; 72, 3: 241–242
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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
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COVID-19 management: a rapid review of national treatment guide-
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lines 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: adebisiyusuff23@yahoo.com
Int Marit Health 2021; 72, 3: 241–242
e/---sector/documents/normativeinstrument/wcms_174794.pdf Cove, South China. Sci Total Environ. 2020; 723: 138027,
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4. Li W, Su H, Cao Y, et al. Antibiotic resistance genes and bacterial (Basel). 2020; 9(4), doi: 10.3390/antibiotics9040162, indexed in
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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
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: ali.mohamed@pt.cu.edu.eg
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
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relaxed body response. In addition, in HTPOAG patients, medicine in a COVID-19 era. Am J Ophthalmol. 2020; 216: 237–242,
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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:
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and quality of life. during the second COVID wave: are physiotherapists able to help?
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9. Ismail AM. Robot-assisted rehabilitation: it is the time for utilisation in
tract, causing the open angle of the anterior chamber of
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
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elevated IOP [13]. tion, pulse rate and chest expansion in sedentary smoker students.
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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.
13. Ismail AM, Abd Elfatah Abo Saif HF, El-Moatasem Mohamed AM.
apists and yoga teachers to the home-based implemen-
Effect of on intraocular pressure, autonomic control, and blood
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Int Marit Health
2021; 72, 3: 245–246
10.5603/IMH.2021.0047
www.intmarhealth.pl
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: ke-inoue@med.shimane-u.ac.jp
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.
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ISSN: 1641-9251
eISSN 2081-3252
2021, Vol. 72, No. 3 nr ISSN 1641–9251
nr eISSN 2081-3252
CONTENTS

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

after COVID-19............................................................ 223
Stefania Zampogna, Domenico Sinopoli, Ilaria Prosperi Porta, Wildlife trafficking and corruption at the maritime Official scientific forum of the:
area: the teacher's point of view............................... 193 Yusuff Adebayo Adebisi, Iyiola Olatunji Oladunjoye, International
OCCUPATIONAL MEDICINE
Self-medication with antibiotics among seafarers: Maritime
a public health issue...................................................241
Original articles
Health
The relationship between work environment and good alternative options to control the high-tension Foundation
Nursultan Seksenbayev, Timur Moldagaliyev, Aigul Tokesheva, Indexed/abstracted in: CrossRef, DOAJ, EBSCO,
Om Prakash Yadav, Atanu Sarkar, Desai Shan, Arifur Rahman,
Lorenzo Moro Yersin T. Zhunussov, Nobuo Takeichi, Masaharu Hoshi, ESCI, FMJ, Google Scholar, Index Copernicus,
Occupational noise exposure and health impacts Yoshiyuki Ohira Medical Journals Links, Medline,
among fish harvesters: a systematic review....................199 The need for detailed study of course credit earned Polish Ministry of Education and Science,
and the comprehension of material by college Polish Medical Bibliography, Scopus, SJR,
Rune Djurhuus students as a result of major changes in university Ulrich's Periodicals Directory, WorldCat
"International Maritime Health" is indexed at: CrossRef, DOAJ, EBSCO, ESCI, FMJ, Google Scholar, Index Copernicus, Medical Journals Links, Medline,
Polish Ministry of Education and Science, Polish Medical Bibliography, Scopus, SJR, Ulrich's Periodicals Directory, WorldCat.
www.intmarhealth.pl

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2021, Vol. 72, No.

MARITIME MEDICINE DIVING/UNDERWATER MEDICINE

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

HONORARY EDITOR: STATISTICAL EDITOR:

MARITIME MEDICINE DIVING/UNDERWATER MEDICINE

Management of COVID-19 on board

INTRODUCTION Diamond Princess. In February 2020, a total of 634 cases

Islands Infirmary Medical centre Pharmacy Local hospital

1,800 passengers on board were confirmed positive and

N subjects tested Positive subjects Decision

Evaluation of maritime accident reports

Çanakkale Onsekiz Mart University Faculty of Health Sciences, Çanakkale, Turkey

INTRODUCTION related to transportation are a major source of injury and

•General Staff •Ministry of Internal Affairs

Ministry of Foreign Affaırs

Ministry of Internal Affaırs

Main Search and Rescue

Ministry of Transport, Maritime

Euclidean Distance Model

–1,5 –1,0 –0,5 0,0 0,5 1,5 1,5

Analysis of the implementation of the International

INTRODUCTION shipowner or any person, such as the manager, who

Procedural aspects of COVID-19 vaccinations

INTRODUCTION recommendations of STIKO (the German Permanent Com-

that the vaccine is transported smoothly and stored in VACCINES

Table 1. Equipment for corona vaccinations on cargo ships

Present on Bring with doctor’s bag

PROTECTIVE EQUIPMENT FOR REFERENCES

Published by Marisec Publications 38 St Mary Axe London EC3A uploads/2021/03/Coronavirus-COVID-19-Vaccination-for-

Mental health of Filipino seafarers and

INTRODUCTION flagged ships. A Filipino nationality-specific study on

THEME 1: MEDICAL REPATRIATION OF SEAFARERS

THEME 2: SYSTEM OF MENTAL HEALTH CARE OF SEAFARERS

Garcia, 2017 psychological, emotional and environmental

3. Of the materials considered, three themes illustrate

well-being. These negative effects have repercussions on health, work efficiency,

Of the 752 respondents, majority of the respondents report some negative

of MH including studies examining the effects of the

KEY THEMES ON RESEARCH ON THE

ation of seafarers. Repatriation of seafarers is the transport

as psychiatric disorders (i.e. anxiety, depression, psycho-

sis/schizophrenia or bipolar disorder) [24]. While 4 cases

752 multi-national seafarers including 60 Filipinos

of disembarkation of Filipino ratings with mental illnesses

were reported in a 2013 MH conference [25]. The same very

documents of 51,850 Filipinos who have worked for more

The second theme centres on the system of mental

Paper presentation, online

Future Foundation, a non-governmental organization. These

a significant number of seafarers including Filipinos were

PTSD — post-traumatic stress disorder

taken as hostages and a number were killed in hostage

situations. The foundation produced a series of annual re-

been subjected to pirate attacks and/or armed robberies

including being taken as hostages by pirates from 2009 to

2019 [28–36]. It is also reported that the families of sea-

Face-to-face versus distance learning in

The relationship between work environment and

INTRODUCTION Sepulu, Socah, Tanah Merah, Tanjungbumi, and Tragah

THE RELATIONSHIP BETWEEN NOISE

DISCUSSION THE RELATIONSHIP BETWEEN LIGHTING

Occupational noise exposure and health impacts