Subcategories

• Introduction

  The 2012 ILO/IMO International Guidelines on the Medical Examination of Seafarers recommend criteria for taking decisions on the fitness of seafarers for work at sea. They also provide an internationally agreed basis for ensuring that the medical certification requirements in the ILO Maritime Labour Convention 2006 and the ILO Convention on Standards for Training, Certification and Watchkeeping 2012 are met. The Guidelines also include recommendations on the conduct of medical examinations and information for maritime authorities about appropriate national arrangements for seafarer medical examinations.

   The Guidelines reflect a shared view of what is good practice for medical examination prior to the issue of a statutory seafarer certificate of fitness. They have been agreed by national maritime authorities, by seafarer trade unions and by employer organisations with advice from maritime health professionals.

  Some employers, insurers (P&I Clubs) and social insurance authorities require additional criteria to be used prior to acceptance of a seafarer for employment. These additional criteria are usually applied only in the lower-cost crewing countries and are often unacceptable in countries with well-developed laws on discrimination in employment. Such additional criteria do not necessarily represent a consensus of all the above groups, as their aim may be to reduce the costs to employers or insurers from illness in seafarers rather than safeguard maritime safety and the health of those working at sea. Such criteria are not considered in this handbook but the advice provided here may also assist doctors who are using these criteria, although these do tend to be more restrictive than statutory ones, are less accommodating to requirements for limitations to duties and sometimes lack the clarity of documentation found in the better statutory systems.

  While some of the criteria in the Guidelines are self-explanatory, a number of those that apply to common conditions found in seafarers are concise summaries about complex conditions and their risks. The aim of this handbook is to provide additional detailed information for doctors conducting such examinations, both to guide them on decision taking and to provide theme with background information on the reasons for the criteria to enable them to explain the criteria to seafarers, employers, trade unions and others who may find additional information useful.

  The material included is not static, changes in diagnostic and treatment methods and new results from population studies of disease will need to be considered in the future as they become relevant to maritime health practice.

  This handbook had its origins in the work of the International Maritime Health Association working group on Evidence Based Medical Fitness Criteria. Much of this material was subsequently included in guidance for doctors approved by the United Kingdom Maritme and Coastguard Agency and it was then re-edited to be compatible with the ILO/IMO Guidelines. The author of this handbook was closely involved in all these stages.

  Preparation of this Handbook has been made possible by a grant from the ITF Seafarers' Trust made to the International Maritime Health Association. It was prepared by the Norwegian Centre for Maritime Medicine, in association with Sixty AS.

  This handbook provides information for maritime health professionals on what constitutes good practice for seafarer medical examinations and may help examining doctors to apply the Guidelines more fairly and consistently. It does not have any formal status. The Guidelines and the conventions on which they are based should be used as the definitive statements of international requirements and their interpretation. Where national standards are set that are compatible with the requirements and recommendations of the conventions and guidelines these should be followed, again this handbook may be used as a benchmark for good practice.

• The knowledge base for seafarer medical examinations
• Using this handbook
• VISION
• HEARING
• ASSESSMENT OF PHYSICAL CAPABILITIES
• MEDICATION
• PULMONARY TUBERCULOSIS (PTB)
• INFECTIONS TRANSMITTED IN BODY FLUIDS: HIV
• INFECTIONS TRANSMITTED IN BODY FLUIDS: HEPATITIS (NON A)
• CANCER, INCLUDING SARCOMA, LEUKAEMIA ETC.
• DIABETES AND ITS TREATMENT
• OBESITY
• MENTAL DISORDERS, INCLUDING COGNITIVE AND BEHAVIOURAL IMPAIRMENT, ALCOHOL AND SUBSTANCE MISUSE
• LOSS OF CONSCIOUSNESS, ALTERED AWARENESS, EPILEPSY AND SLEEP DISORDERS
• BLOOD PRESSURE AND ITS MEASUREMENT
• CARDIAC EVENTS
• ASTHMA
• ORAL HEALTH AND DENTAL INSPECTION
• URINE TESTING ABNORMALITIES

  Urine testing abnormalities (ILO/IMO Guidelines Appendix E R 31,18,82)

  Background

  Urine testing, normally by dipstick, forms an essential part of the medical assessment. The rationale for this is as an indicator of kidney and other disease and that positive findings require certification of temporary unfitness until fully investigated, with their causes resolved. Recent studies and reviews indicate that the excess risk of serious or sudden illness after some sorts of positive results is very low and cessation of routine testing for blood and protein has even been advocated. In medical fitness assessment simple urine testing can still be justified as the pressures to obtain and retain work may be sufficient to mean that past urinary tract or other disease is not otherwise disclosed. Recent general recommendations about follow up to positive urine tests enable the requirements for investigation and determination of cause to be specified in more detail for seafarers and in a way which will enable many to return to sea immediately. In the case of recruits, the low rate of abnormality associated with findings of trace proteinuria or haematuria mean that these findings, without any other signs or symptoms are not a reason for failure.

  Notes:

  1. These recommendations are based on the pattern of medical conditions in seafarers from North Western Europe. Where there is a different national pattern of renal and urinary tract disease, for instance a high incidence of renal calculi or parasitic infections, then local criteria for investigation should be followed.
  2. The guidance only relates to decision taking about fitness to work at sea. If abnormal results are found on any test it will normally be appropriate to either advise the seafarer to see their general practitioner or to write them a letter stating the result.

  HAEMATURIA - Impairment and risk

  May be an indicator of the potential for a medical emergency at sea from renal colic or from recurrence of urinary tract infection. May identify longer term risk from the development of a urinary tract cancer.

  • Dipstick tests are highly sensitive and there are only weak links between positive findings and subsequent disease. The extrapolation of prognosis from visible to dipstick haematuria is not justified. Haematuria can be present in urinary tract infection, with calculi, from prostatic disease or from a carcinoma of the urinary tract. Blood may also be present in a urine sample from menstruation or from minor lower tract trauma.
  • Detection of urinary tract cancers based on detailed investigation of all cases of dipstick haematuria does not appear to improve prognosis as compared with action taken when they first present with visible haematuria or other signs.
  • Haematuria associated with proteinuria, even at quite low levels, can be an indicator of early glomerular disease.

   PROTEINURIA - Impairment and risk

  Proteinuria may be an indicator of kidney pathology. In this case there is a risk of progressive kidney failure. This may lead to illness at sea. It may also indicate that the kidney has less than the normal ability to deal with dehydration or fluid overload.

  Rationale and justification

  • The dipstick tests for protein are very sensitive. Levels +++ are likely to indicate significant renal or metabolic problems, lower levels are rarely indicative of serious pathology. The presence of both haematuria and proteinuria together can be an indicator of the early stages of glomerular disease.
  • The presence of casts on urine microscopy increases the likelihood that the proteinuria (with or without haematuria) is an indicator of renal pathology. The ratio of protein to creatinine is an indicator of whether there is a normal pattern of urinary excretion from the kidney. The laboratory used can advise on reference values.
  • The presence of semen or vaginal fluids and urinary tract infection can all lead to the detection of protein in the urine.
  • The presence of proteinuria + + + indicates a risk in the short term from depletion of protein or from the presence of severe renal damage.
  • Progression from minor degrees of kidney impairment to serious kidney disease that could lead to an emergency at sea does not always occur and when it does it normally takes place over a period of several years. Progression can be monitored.

  GLYCOSURIA - Impairment and risks

  Glycosuria is a common presenting feature of diabetes (see ILO/IMO Guidelines Appendix E E10-14) . The risks are those of the condition. Untreated it may indicate a short term risk of diabetic keto-acidosis and coma.

  Rationale and justification

  • Glycosuria occurs when the threshold for glucose re-absorption by the kidney has been exceeded. It is not as reliable a way of screening for diabetes as measuring fasting blood glucose or looking at the effects of an acute glucose load on blood and urine levels.
  • The presence of glycosuria in a person with diabetes indicates that the control of their blood glucose levels is poor and their treatment needs reviewing.
  • The presence of ketones on dip stick testing indicates that changes that are a consequence of altered glucose metabolism are present.

   

  Decision trees

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• ALLERGIES