Editorial
Klaus Seidenstücker
News
Seafarers’ Charity — new film issued
Nebojša Nikolić
Particulars
New Secretary General at IMO
Klaus Seidenstücker
New Medical Director at the German Maritime Medical Service
Klaus Seidenstücker
President of the German Seafarer Mission re-elected
Klaus Seidenstücker
Reports
Towards harmonisation of data collection: a methodology for TMAS collaboration — project report
Luca Tommasi
16th International Symposium on Maritime Health — congress report
Ilona Denisenko, Brant Connors
Editorial
Dear Colleagues,
we finish 2023 with the 4th issue of your International Maritime Health journal and magazine hoping that all of you made it through an indeed memorable year safe and sound. We wish you a happy and healthy new year whether at sea or ashore — always fair winds and following seas!
For this magazine we have once again collected a number of articles, hoping that these will support your work in the maritime environment. A focus in this issue is telemedical advice/assistance. With the establishment of its expert panel the International Maritime Health Foundation (IMHF) has gone beyond its prior role as owner and publisher of this journal. In 2021 a series of workshops were started that addressed practical issues of maritime medicine. Reports were published in this journal that offer IMHF positions on actual standards for best medical practice at sea. Find below a recently published study under aegis of International Transport Workers’ Federation (ITF)-Seafarers’ Trust that provides some epidemiology. Extremely helpful for our foundation’s further work on pathways to manage medical incidents at sea. A report on IMHF’s most recent workshop on this topic will be published in this journal early next year!
It is our pleasure to also report on the 16th International Maritime Health Symposium held in October 2023 in Athens. After the pandemic we are back to normal!
Happy reading!
Klaus Seidenstücker
Temporary magazine editor
International Maritime Health Foundation’s Expert Panel
News
SEAFARERS’ CHARITY — NEW FILM ISSUED
Contributed by Nebojša Nikolić
The Seafarers’ Charity (formerly Seafarers United Kingdom) have been improving the lives of all seafarers and their families for over 100 years. Today, guided by the same powerful vision, they are publishing a series of films aiming to empower foreign crew members with insights into life in United Kingdom fishing fleets, legal rights, and avenues for support in case of abuse or exploitation.
In collaboration with Stella Maris and Waitrose, they have recently published: “Working in UK Fishing — Pre Departure”, available at: https://www.youtube.com/playlist?list=PLWglqT89t2fQAQ_B3vjFgAh-B6yAltZcE.
Particulars
NEW SECRETARY GENERAL AT IMO
Contributed by Klaus Seidenstücker
January 1st, 2024, Mr. Arsenio Dominguez from Panama will take up office as new Secretary General of the International Maritime Organization (IMO). He is to follow Mr. Kitak Lim from South Korea. Mr. Dominguez’ recent position was that of Head of IMO Environmental Department.
NEW MEDICAL DIRECTOR AT THE GERMAN MARITIME MEDICAL SERVICE
Contributed by Klaus Seidenstücker
July 1st, 2023, Doctor Jörg Abel took office as head of the German Maritime Medical Service. Doctor Abel is anaesthesiologist and emergency medicine specialist. He presently holds positions in the board of directors of the International Maritime Health Association (IMHA) and the board of the German Maritime Medical Association (Deutsche Gesellschaft für Maritime Medizin, DGMM).
(Photo provided by Dienststelle Schiffssicherheit/Seeärztlicher Dienst)
PRESIDENT OF THE GERMAN SEAFARER MISSION RE-ELECTED
Contributed by Klaus Seidenstücker
Doctor Clara Schlaich was recently re-elected as president of the German Seafarer Mission (www.seemannsmission.org), a global charity for seafarer’s welfare. Doctor Schlaich is a private practitioner serving especially seafarers at Hamburg harbour. She is medical consultant for a number of shipping companies.
(Photo provided by Clara Schlaich)
Reports
Courtesy of the ITF Seafarers’ Trust
TOWARDS HARMONISATION OF DATA COLLECTION: A METHODOLOGY FOR TMAS COLLABORATION — PROJECT REPORT
Contributed by Luca Tommasi
Background
Approximately 1.9 million seafarers are currently employed in international shipping1 and subject to the particular challenges and hazards of living and working on board vessels at sea. In addition, an estimated 58.5 million people are employed in the fishing industry2 working on board vessels for longer and shorter periods of time.
In May 2000 the International Maritime Organization (IMO) agreed guidelines on the provision of Medical Assistance at Sea highlighting the importance role of Telemedical Assistance Services (TMAS).3 The Guidelines state that such a system is essential:
- to alleviate the isolation at sea of both the victim (the sick or injured person on board) and the captain responsible for giving treatment;
- to avoid, as far as possible, the need for evacuation, which, although sometimes essential, is by its nature dangerous and expensive; and
- to assist Rescue Coordination Centres (RCCs), which are often the first contact with the captain in difficulty, to take an appropriate decision.
They further state that ‘a TMAS should be officially designated as such by the competent authority in the State concerned’, but they leave the mechanisms for providing such services wide open.
In August 2013 the International Labour Organization (ILO) Maritime Labour Convention (MLC), 2006 came into force with the requirement that seafarers must have access to prompt and adequate medical care whilst working on board. Regulation 4.1 requires ‘standards for measures aimed at providing seafarers with health protection and medical care as comparable as possible to that which is generally available to workers ashore.’4 This right is applicable to all seafarers covered under the convention as agreed by the 104 signatories of the MLC covering 96.6% of world gross tonnage.5
Standard A4.1 para 4 (d) states that ‘the competent authority shall ensure by a prearranged system that medical advice by radio or satellite communication to ships at sea, including specialist advice, is available 24 hours a day; medical advice, including the onward transmission of medical messages by radio or satellite communication between a ship and those ashore giving the advice, shall be available free of charge to all ships irrespective of the flag that they fly’.
The MLC sets out further guidance around international cooperation in the area of assistance, programmes and research in health protection and medical care — including collecting and evaluating statistics concerning occupational accidents, diseases and fatalities of seafarers and integrating and harmonizing the statistics with any existing national system of statistics on occupational accidents and diseases covering other categories of workers’.6
However, to date, in spite of the long existence of TMAS, there is still much room for improvement.
For more than 100 years some form of telemedicine service has been in operation. A number of national TMAS provide services internationally, but structures for coordination and formal cooperation are limited. In addition to the wide range of national services from primarily Search and Rescue (SAR) operations, to TMAS departments in hospitals and fully-manned 24/7 dedicated services, there is also a private market for companies providing supplemental medical services to companies on a commercial basis.
There are many factors which create potential obstacles for meaningful cooperation, including but not limited to variations in:
- culture and expectations of medical services;
- medical practices between countries and diagnostic systems;
- target populations — seafarers, fishers, passengers;
- languages spoken by the target population;
- organization of SAR services and integration or otherwise with TMAS;
- main means of communication;
- volume of contacts;
- training and recruitment of TMAS doctors;
- legal requirements for data protection.
The lack of standardised data collection on seafarers’ conditions is a missed opportunity to better compare services and improve the overall understanding of seafarers’ health issues and the ways in which they are addressed. A more systematic approach would allow for services to learn from each other, facilitate improvements to regulation and support better decision making around training of TMAS doctors and requirements for ship medical chests. It would also help stakeholders to develop informed strategies for prevention of ill health at sea.
The ITF Seafarers’ Trust TMAS Project
In order to tackle the challenges of limited harmonisation of reporting, the ITF Seafarers’ Trust (ITFST) together with the services from Germany, Italy, the Netherlands and Norway initiated the TMAS project.
During the first meeting in London in September 2019 a commitment was made to:
- cooperate with each other with facilitation and support of ITFST;
- share information with a view to producing an annual report on seafarers’ health;
- provide a named contact to deliver agreed outputs.
Subsequent meetings have focussed on the discrepancies in data collected by the different services.
Engagement in the project has expanded and now includes participants from Denmark, Finland, Germany, Italy, the Netherlands, Norway, Poland, Sweden, Turkey and the United Kingdom.
Of the services represented, the scale of involvement in telemedicine ranges from 50 cases per year to in excess of 7,500 cases per year. Some have a truly international scope, whilst others are focussed on national shipping and search and rescue areas. Some include significant numbers of passenger vessels, others fishing vessels, or offshore support vessels, others reflect more mainstream international shipping.
Agreed aims and methodology
- To agree common definitions and record comparable anonymised data sets.
- To follow an agreed methodology from which data can be extracted rather than sharing complete databases due to the sensitivity around holding and sharing medical data.
- To develop a standardised method of data collection with a view to facilitating an annual report of selected consolidated statistics from those TMAS services included in the project.
Whilst early discussions focused on the publication of an annual report, it became apparent that before such a project could be realised, considerable work would need to be undertaken to agree and implement standard elements for data collection.
From a diagnostic perspective, some services used the ICPC-2 coding system, others used ICD-10.
Of the other factors deemed relevant: age, gender, nationality, position on board, vessel location — not all elements were collected by all services. In addition not all services held full details on actions taken once advice had been given. Where information was held, definitions varied between services.
A balance needed to be struck in collecting information essential for meaningful interpretation of diagnostic data and outcomes, and information of more statistical interest. Given the challenges of existing disparity and concerns around data protection, the conclusion was to focus on the basics for collation with the option to include additional detail in individual reports.
Once agreement had been reached and refined on elements of data to collect along with definitions, a format for data collection was developed allowing each service to compile its complete data and submit it in disaggregated tables to ensure compliance with data protection regulations.
Agreed elements and definitions
ICPC-2 vs. ICD-10
Participating services agreed to use ICPC2 codes, recording complete codes but providing only the letter element to the ITFST report.
Age
It was agreed to group patient age as follows:
- 0–20;
- 21–40;
- 41–60;
- over 60.
Position
The agreed list for ‘position/rank’ was changed from a list reflecting the hierarchy of a crew list to a simplified designation more linked to the working environment.
|
Position |
Definition |
|
Captain |
Person in charge of the vessel |
|
Deck |
Navigational officer/rating working primarily on deck |
|
Engine |
Engineer, oiler, wiper crewmember working primarily in the engine room |
|
Galley |
Cooks and crew working primarily in the galley/kitchen |
|
Hotel |
Seafarers primarily working as chamber maids, croupiers, waiters and general hospitality |
|
Passenger |
Person travelling on board, not working in any capacity on board |
|
Fisher |
Person working on board a fishing vessel or fish factory vessel |
|
Other |
Specialist categories of worker such as guest entertainers, inspectors, repair technicians |
|
Unknown |
The status of the person is unknown |
|
Vessel type |
Definition |
|
Cargo |
Bulk carrier, general cargo and container ships |
|
Tanker |
Oil and chemical tankers |
|
Passenger |
Ferries, cruise ships |
|
Search and rescue |
Vessels engaged in search and rescue activities |
|
Fishing |
Fishing vessels and fish factory vessels |
|
Leisure |
Yachts, small boats |
|
Other |
Offshore supply and support vessels, scientific research vessels, pilot boats and tugs etc. |
|
Unknown |
The type of vessel is unknown |
Advice given
Following discussion it was agreed to reduce the number of options of advice given to three broad categories and to delete the category of ‘advice taken’ since this is not always known.
|
Advice given |
Definition |
|
Treatment on board only |
Treatment on board with no further immediate action advised |
|
Treatment ashore |
Treatment ashore advised but without need for urgent action |
|
Deviation/evacuation/disembarkation |
Recommendation to take urgent action including vessel deviation, evacuation by helicopter or rescue boat, ship to ship transfer or other means of immediate disembarkation |
Means of communication
It was agreed to retain means of communication as a data set given the significant variation between services and the recent introduction of video consultation. Where there is more than one form of communication, the most significant for the service is reported.
|
Means of communication |
Definition |
|
Video |
Video platform primarily |
|
Voice |
Contact primarily by telephone |
|
Written |
Contact primarily by email, text message or dedicated platform |
Location
The question of location was discussed with the following options noted:
- AIS position or coordinates;
- SAR area;
- coastal or deep sea;
- ocean/sea or geographic area.
This is a subject for further consideration with more work to be undertaken at the national level.
Data collected
The total number of records in the data set is 12,316.
All data is anonymous, and all elements were disaggregated to avoid data protection issues.
Each record represents a case handled by an individual TMAS service, not the total number of contacts.
The following series of charts presents combined data from 4 TMAS services for the year 2022 covering:
- diagnosis identified by the TMAS doctor, recorded using the ICPC-2 classification of disease;
- age groups;
- position;
- type of ship;
- medical advice given to the patient by the TMAS doctor;
- main means of communication between ship and TMAS service.
The largest category of medical condition was ‘Digestive’ (2,163) followed by ‘Musculoskeletal’ problems (1,3938). Most patients were at the lower end of the age categories: 21–40 (5,964). The majority of patients worked on ‘Deck’ (3,885), with ‘Engine’ not far behind (3,069). Vessel types were mainly cargo ships (5,503), followed by tankers (3,416). The majority of cases were treated on board (7,149) and the primary method of communication was written, either by email or within web based platforms (10,216).
Individual TMAS diagnosis recorded using ICPC-2 code
Age
Position
Ship type
Advice given
Means of communication
Concluding remarks
The TMAS environment is complex both in terms of practical responses to seafarers and in terms of overlapping and stringent regulatory requirements. Medical data is considered sensitive data and subject to particularly strict rules. In this age of technological advances there are different options for secure transmission and storage of data but also risks that have yet to be fully understood, let alone managed and regulated in a coherent fashion.
International mechanisms for maritime governance take decades to conclude and have a tendency to accommodate the lowest common denominator. Industry initiatives can be innovative but tend to be market-based and underpinned by commercial considerations. It is hoped that this project, with its core focus on seafarers, will pave the way for some practical solutions in the constantly evolving sphere of telemedicine.
The ITF Seafarers’ Trust
The ITFST is a United Kingdom registered charity funded by the Welfare Fund of the International Transport Workers’ Federation. With its remit to support initiatives that promote and preserve the health and safety of seafarers with the aim of preserving life, the Trust identified an opportunity to facilitate cooperation between interested national (not-for-profit) services providers.
16TH INTERNATIONAL SYMPOSIUM ON MARITIME HEALTH — CONGRESS REPORT
Report by Ilona Denisenko and Brant Connors (IMHA)
The 16th International Symposium on Maritime Health (ISMH) was held in Athens, Greece from October 5th until the 8th in 2023, marking a significant return to in-person gatherings post-pandemic. Drawing together over 120 professionals, including port medics, telehealth providers, pharmacists, and health researchers, the symposium delved into critical discussions ranging from the latest medical research findings to the mental health and welfare of seafarers. The symposium offered a unique platform to discuss the prevalence of cancers, allergies, colour vision capacity, and the pressing need for advancements in Pre-Employment Medical Examinations (PEME).
An ISMH has traditionally been held every 2 years since the first formal ISMH in Turku, Finland in 1991. ISMH16 was originally planned for June 2021 but was unfortunately delayed due to the COVID-19 pandemic. Not surprisingly, lessons from the pandemic and effects on physical and mental health of maritime workers were recurring issues throughout the four-day symposium.
The programme began with the pre-symposium meeting, which was held at the Byzantine Museum, located at the Villa Ilissia. It started with an excursion through the museum’s permanent exhibition and followed by the scientific meeting entitled Diabetes Type 2 and Hypertension Research, Educational and Prevention Plan 2023–2032. The 10-year research and educational plan constitutes a core issue for “Preventing Social Inequity in Health at Sea” as a high priority part in the MAHRE-Net programme. The content of the educational and intervention topics and research was discussed. Olaf Jensen, developer of the programme, chaired the meeting asked the participants for advance commitments to contribute with specific tasks. Luisa Canals, David Lucas, James Denham and Ilona Denisenko, the co-founders of the MAHRE.net group presented the programme. The vivid discussion of the participants expressed great interest to the topic.
The first day in Athens ended up with a get together party in the gardens of the Byzantine Museum. It is truly an oasis in the heart of Athens.
On October 5th, the official programme started at the Evgenidion Foundation. During the opening ceremony, Symposium Chair, Ilona Denisenko, set the tone for the event, expressing joy about the physical reunion and highlighting that the medical practitioners are metaphorically “a bit Greek” due to the influence of the Hippocratic oath. She promised that the 5 days would be full of conversations and scientific presentations and discussions as well as some exciting cultural programmes to show the hospitality of Greece, including Greek wine tasting, excursion to the Stavros Niarchos Foundation Cultural Centre and a visit to the Floating Naval Museum Battleship “Georgios Averof” and Olympias trireme.
Rob Verbist, International Maritime Health Association (IMHA) President, mentioned that in more than thirty years from the first symposium, it has become the most important gathering of maritime medical specialists in the world. He remarked that “Never has IMHA interacted more with the maritime industry than during COVID.”
ISMH16 continued the tradition of presenting scientific research in the field of maritime health. Under the guidance of Despina Andrioti Bygvraa, the Scientific Committee evaluated more than 200 submissions of abstracts and posters for presentation. Selected research presentations during the symposium included: occupational asthma and eczema among harvesting fishermen, the psychosocial burden and stress coping strategies among seafarers, diagnosis of latent tuberculosis, prevalence of depression among maritime workers during the COVID-19 pandemic, and more.
Selected posters highlighted topics such as: disease and injuries among seafarers and fishers using TMAS in Thailand, cardiovascular risk among Polish seafarers, European Union policy impact on fishermen, and the health impact of heavy oil on board vessels.
Simon Grainge, Chief of the International Seafarers/Welfare and Assistance Network (ISWAN), noted that a lot has happened since we all came together for the Symposium in Hamburg in 2019. We’ve seen the industry face its biggest crisis since the Second World War and as always, seafarers demonstrated their resilience and adaptability in keeping the world’s supply chains open throughout the crisis. From ISWAN’s perspective, the biggest lesson is that partnership works. It works because it makes the best use of all of your talents and achieves much more than we can do alone. ISWAN has been working with IMHA since long before I began in this role, learning from each other’s work and collaborating on the development of health and wellbeing resources for seafarers.
Ioannis K. Pappas, Deputy Minister of Shipping and Insular Policy, wished success to the Symposium and emphasized that Greece has a rich maritime tradition and history. Shipping and Greece are two identical concepts with a common course through the centuries.
“Above all, shipping is about its people, whether we are talking about our sailors, the women and men of the port corps or the professionals involved in maritime professions.
For all of them and for each one individually, the Ministry is planning and is going to take initiatives, so that the necessary changes can be made to protect their health. We need your cooperation and we will be in constant contact with your Association, to take the right initiatives and measures to achieve our goal, respecting the international rules.”
Elpi Petraki, President of WISTA International/WISTA Hellas, expressed her gratitude to the organizers for bringing such an important event to Greece and wished for the future cooperation between both Associations.
Antonios Doumanis from the Hellenic Coast Guard and Nikolaos Psaras from the Hellenic Navy mentioned the importance of the Symposium for Greece and for the whole maritime world.
Anatoliy Gozhenko, Ukrainian Institute of the Transport Medicine, sent his welcome address from Odessa. A keynote presentation from Jan De Boer of International Maritime Organization (IMO) highlighted the many guidance documents on health and welfare of seafarers, especially the recent documents of IMO/ILO Joint Working Groups on seafarer abandonment.
Natalie Shaw and Emily Yates, representatives from the International Chamber of Shipping, underscored the importance of international cooperation in addressing seafarers’ health and welfare. The launch of the International Medical Guide for Seafarers and Fishers in March 2023, with contributions from the IMHA members, highlighted the collaborative efforts in the industry.
Doctor Jason Zuidema discussed the role of seafarers’ welfare centers in global COVID-19 vaccination efforts, showcasing collaborative initiatives with health professionals worldwide.
For the first time in the history of ISMH, a session was dedicated to the Fisheries Health where Cor Blonk, director of the fishing industry’s safety and health platform talked about the different challenges in one of the most dangerous professions. The different problems of fishermen’s health were addressed by Tarik Ghalian, Head of the Moroccan Society of Maritime Medicine, Nikolaj Granild, University of Southern Denmark/Centre of Maritime Health and Society, David Lucas, Brest University, Olaf Jensen, University of Southern Denmark and others.
A pervasive theme throughout the symposium was the Mental Health and Wellbeing of Seafarers. Industry experts Imogen Stilz, Shell International, Peter Schellenberger, Lukas Belz, Camille Jego, Alexander Dimitrevich, Joanna Szafran-Dobrowolska, Nigel Griffiths and more delved into the challenges faced by seafarers. The call for increased research and awareness emphasized the growing importance of understanding and addressing mental health in the maritime sector. Against the backdrop of Athens’ cultural tapestry, impassioned discussions unfolded on strategies, support systems, and the imperative need for global collaboration to ensure the mental well-being of those navigating the seas.
Marta Gruman-Nowak and Maria Jeżewska, current and past editors of the International Maritime Health (IMH) journal, introduced the new achievements of the journal, current position, challenges and trends in publications. The IMH editorial team expects collaboration in the matter of acquiring new publications and reviewing process as a guarantee of high standards of publications. Participants of the Symposium warmly welcomed the future collaboration between IMHA and IMH.
Among the many daily highlights presented to the more than 120 participants from 30 countries were: a presentation on IMHF by Nebojša Nikolić; updates on colour vision testing by Antonello Campagna; an analysis of pre-employment clinic in Philippines by Margarita S. Huerta; maritime medicine in Thailand; a panel discussion “Solutions to medical pain points in shipping”, presented by Jens Tülsner, Vivian Andria, Imogen Stilz, Christos Dimopoulos, Mina Vlachandera, Nicholas Ioannidis, Kostas Katsoulieris, with a fireside chat hosted by Peter Schellenberger; panel discussion was organized in collaboration with the Maritime Clinics and Doctors Association of the Philippines (MARCDOC), where Joseph Abesamis, Rhoel Salvador, Susanna Salvador and Margarita Huerte discussed the surviving the pandemic.
Impressive research on 20+ years of teleconsultation support was presented by Konstantin Logunov; risk factors and cancer incidence in seafaring research by Kimmo Herttua. Telemedical assistance providers (TMAS) with Emilie Dehours, Katherine Sinclaire and Paulo Alves, Tony (Anton) Schmid were a focal point of discussion, with private companies presenting data and recommendations.
As the curtains fell on the Symposium in Athens, the city had witnessed a convergence of minds dedicated to shaping a healthier maritime future. The timeless backdrop of ancient ruins and the vibrant cityscape served as a metaphorical canvas for the multifaceted themes of maritime medicine, mental health, and cruise medicine. The discussions illuminated challenges, highlighted opportunities, and fostered collaboration that will resonate in the maritime industry for years to come. As the industry continues to chart new waters, the symposium’s Odyssey serves as a compass, guiding the way towards a harmonious and resilient future for those who brave the seas. The concluding remarks look forward to the next chapter in 2025 as ISMH17 sets sail for Netherlands, offering a glimpse of the continued exploration and evolution of maritime health on the horizon. Ilona Denisenko officially handed over the ISMH flag and Symposium chair bell to Walther Boon. The next International Symposium on Maritime Health ISMH17 will take place in Rotterdam in June 11–14, 2025.
Our sincere gratitude to the Organizing and Scientific Committees of the 16th International Symposium of Maritime Health, to all sponsors and partners and to all the participants, who came from all over the world to bring the maritime medicine to the next level.
Ευχαριστώ!
1 BIMCO-ICS 2021. Seafarer Workforce Report.
2 FAO 2022. The State of World Fisheries and Aquaculture 2022. Towards Blue Transformation. Rome, FAO. https://doi.org/10.4060/cc0461en.
3 https://wwwcdn.imo.org/localresources/en/OurWork/Safety/Documents/MSC.1-Circ.960%20-%20Medical%20Assistance%20At%20Sea.PDF.
4 https://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:91:0::NO::P91_SECTION:MLCA_AMEND_A4.
5 https://www.ilo.org/global/standards/maritime-labour-convention/lang--en/index.htm.
6 ILO. Maritime Labour Convention, 2006 Guideline B4.1.4 para 1.
