Jørgen Riis Jepsen:

Health and safety onboard. Experiences from recent Danish research

III International Scientific Congress of MARITIME, TROPICAL, HYPERBARIC and TRAVEL MEDICINE

20-24 May 2015Copenhagen/Oslo

jriis@cmss.sdu.dk

Themes Maritime deaths

Trends Priorities

Survival after maritime disasters Trends Priorities

Occupational accidents and ethnicity Can we learn from differences? Can we take action on lessons learnt?

Overweight and metabolic syndrome Significance Causes

Maritime register studies Strengths Weaknesses

Maritime deaths*• Previous studies have unanimously found an increased number of deaths among merchant seafarers

• A study of 147 maritime deaths among 20.000 seafarers during 1986-93 showed:

•11.5 times more fatal accidents than ashore•23 casualties due to shipwreck•26 casualties due to occupational accidents•24 fatal accidents during off duty hours including 6 self-intoxications

•Alcohol played a major role in 12 out of 18 fatal injuries during off-duty hours•Rough weather, inadequate safety awareness

* Hansen: Occup Environm Med 1996

Maritime deaths = Homicide and suicide, fatal occupational accidents including fatalities related to shipwreck, fatal non-occupational accidents, fatal disease on board and deaths ashore until 30 days after initial symptoms on board

This study has led to preventive initiatives:

• Extended inspection practice by authorities• Increased number of serious accidents investigated• Occupational Health Service 1993• Regular workplace risk assessments 1996• Alcohol policies• Improved maritime health care

• Radio Medical Denmark• Training of officers in health care on board• Communication with reference to the ships medical chest and the

Maritime Medical Manual

How has the incidence

of maritime deathsdeveloped

since 1986-93?

Maritime deaths 1986-2009

• 356 fatalities• All but four cases involved males• 59% occurred at sea• 6% during mooring or port operations• 31% while the ship was moored in port• 4% ashore

Borch et al.: Int Marit Health 2012

Results: Crude rates of fatal accidents (including shipwreck and fatalities occurring while signed onbut unrelated to work). Number per 100.000 person years

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

20

40

60

80

100

120

p=0,006

Results: Crude rates of fatal disease on board (recognized as sick and found dead). Number pr. 100.000 person years

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

20

40

60

80

100

120

p=0,017

Relative distribution of maritime deaths in the Danish merchant fleet 1986-2009

Incidence rates (IR) and incidence rate ratios (IRR) of fatal accidents. Seafarers compared with all Danish men in occupation

1996-1993 1994-2001 2002-2009

Occupational accidents

N IR IRR N IR IRR N IR IRR p

Seafaring except shipwrecks

27 24.3

5.24

28 24.2

5.18

12 10.5

3.21 0.015

Male workers ashore

541 4.6 542 4.7 385 3.3

Seafaring including shipwrecks

51 45.9

9.91

52 44.9

9.63

24 20.9

6.41 0.001

Male workers ashore

541 4.6 542 4.7 385 3.3

Maritime deaths: Conclusions• Maritime deaths reduced by 54% (130 – 60/100.000 person

years)• Major decline in the last 8-year observation period• The reduction involved all preventable modes of death, in

particular those linked to• vessel security • work environment• shore leaves

• Still, fatal accidents were • > 6 times more frequent than ashore• > 3 times more frequent when

fatalities related to shipwreck was excluded

Room for further improvement

DiscussionStrengths• Reflects all crew members

• foreign crew has increased from 10 to 50% in the

study period

• Reflects the “acute” consequences of seafaring (in contrast to national mortality registers)

Weaknesses• Do not reflect “chronic” effects of seafaring• Cannot explain the observed reductions of deaths

• Are they due to previous interventions?• Are they due to the composition of the merchant fleet?

• Danish fleet younger than the global fleet (2009: 6.9 vs. 11.4 years)• The proportion of coasters reduced by 58% from 1989-2009

• Are they due to new technology?• Are they due to shorter port turn-arounds?• Are they due to other factors?

Factors influencing survival in case of shipwreck and other maritime disasters in the Danish merchant fleet 1990-2009*

• 44 incidents involving a total of 267 seafarers. • 51 did not survive. • Fatality risk:

• Small ships 3.68 per 1000 years at risk• Large ships (> 2.999 GT) 0.64 per 1000 years at risk

• Fatalities:• One out of 171 seafarers who were rescued dry was injured and died• 18 out of 64 seafarers ending up in the water died (28%) • 23 were and 9 may have remained inside the sinking vessel

• Identified risk factors:• Small vessels• Suboptimal organization of the evacuation process• Survival suits and automatic emergency transmitters had limited influence

on survival statistics*Hansen et al. Safety Science 2012

Occupational accidents in the Danish merchant fleet and the nationality of seafarers*• Analysis of nationality differences in the risk of getting injured in an accident on Danish

merchant ships 2010-12. • Methods

• Data from notifications sent to the Danish Maritime Authority and records of contact with Danish Radio Medical.

• Matching by personal identification and accident data. • Accident rates calculated from stratified cumulative time spent on board• Incidence rates of different nationalities compared by Poisson regression

• Accident incidence rate ratio• Western Europeans: 17.5/100.000 person-days• Eastern Europeans: 0.53/100.000 person-days• South East Asians: 0.51/100.000 person-days• Indians: 0.74/100.000 person-days

• Smaller significant discrepancies for serious injuries• Back injuries more prevalent in Western Europeans• Eye injuries more prevalent in South East Asians

• Conclusions• Substantial differences between nationalities in the rate of reported accidents• Differences may be related to tasks and safety behavior• Investigation of special injury types and characterization of effective elements of safety culture can

contribute to improvements*Adam et al.: J Occup Med Tox 2014

Overweight (BMI > 25)* • Medical examination of 2,101 Danish seafarers • BMI calculated• Data from two other surveys used as

reference (All Danes, seafarers 2001-2002)• 1,379 (66%) were overweight• Relative risk of overweight:

• Male officers 1.33 (1.25 – 1.38)• Male ratings 1.30 (1.22 – 1.38) • Fishermen 1.45 (1.25 – 1.66)• Maritime students 1.44 (1.25 – 1.66)• Female seafarers 1.42 (1.23 – 1.65)

• Significant increase of overweight male seafarers since 2001/2002

• 64% 70,5%

* Hansen et al. Int Marit Health 2011

Overweight: Conclusions

• Danish merchant seafarers have a major and significantly increasing overweight problem

• Fishermen are even more overweight• Overweight constitutes a threat not only to health, but also

to the career at sea• The larger than expected incidence of overweight among

new employees in the industry is cause for concern • The problem is complex and interventions need to be

broad

Metabolic syndrome*• Increased waist circumference combined with dyslipidaemia,

hyperglycaemia, and/or raised blood pressure• Strong risk factor for chronic diseases, including diabetes and

cardiovascular conditions• Approximately 1/5 of Danish adults have MS• Etiological relation to

• nutrition• sleep patterns and fatigue• work-related stress• physical activity

all of which are critical issues at sea!

*Pedersen & Jepsen: Int Mar Health 2013

Metabolic syndrome

• 524 participants (mean age of 38.5 years) • Waist circumference measurements• Questionnaire information about their workplace on board

and their consumption of tobacco and alcohol • Blood samples taken if waist circumference was increased• MS was defined according to the International Diabetes

Federation

Metabolic syndrome• Crude baseline prevalence of MS:

• Males: 25.9%• Females: 10.7%

• Current smokers: 30.6% • Alcohol consumption exceeding recommendations: 18.6%.

• Conclusions: • MS was increased in this young group of seafarers.

• Seafarers with MS were advised to • 10% weight-reduction• physical activity 1/2 hour/day• reduced intake of saturated fat• increased fibers in diet• smoking cessation• control of alcohol consumption.

Health of Danish seafarers and fishermen 1970-2010: What have register-based studies found?*

• Elevated rates:• Mortality

• Male seafarers: Accidents, cirrhosis of the liver, cancer, and suicides• Fishermen: Accidents and cardiovascular disorders• Female seafarers in male-dominated occupations

• Hospitalization• Male seafarers: Endocrine/nutritional conditions, cervical discopathy, gastrointestinal and

cardiovascular diseases, cancers, hearing impairment, injuries• Female seafarers: Cancers, circulatory and genitourinary diseases injuries.• Fishermen: Cardiovascular diseases, bronchitis, emphysema, lung cancer, gonarthrosis,

thoracolumbar discopathy, rotator cuff syndrome, carpal tunnel syndrome, injuries, hearing impairment

• Specific diagnoses and conditions • Male seafarers: Tuberculosis, hepatitis B, certain cancers• Fishermen and seafarers: Obesity, occupational accidents

*Poulsen et al. Scand J Public Health 2014

Health of Danish seafarers and fishermen 1970-2010: What have register-based studies found?

• Conclusions In spite of safety measures and significant structural changes in the Danish merchant and fishing fleet, the

spectrum of health indicators continues to suggest that risk factors in the maritime environment and/or lifestyle of seafarers and fishermen has an influence on their health

and safety

From epidemiology to treatment and prevention

Epidemiological studies are conducted with the purpose of improving health

Therefore the main focus is to identify relations between exposures and health effects in order to make the best decisions relating to health

But to what extent can we use register studies to improve maritime health and safety?

To what extent can maritime register studies be used for prevention?• Limited to Danish seafarers• Historical data

• Exposures may have disappeared• Health effects may continue for a long time after

exposure• No control of selection in or out of the trade• No relation between duration of exposure and health effect

The work-related fraction concealed• Small populations

• Subdivision into strata not feasible• Only common conditions come out significantly• Follow-up studies may indicate a trend, which, however, is

mostly non-significant

Maritime register studies on health and safety

Almost exclusively conducted in countries with

relative reliable registers

with focus on fleets and crews from developed countries

Consequently They provide minimal

knowledge about the majority of the world’s seafarers

Global challenges?

Evidence based prevention?Are we studying

what we can study

rather than

what we should study?

Prevention in the maritime trade is rarely based on register studies • Prevention may, however, address specific issues:

• Ethnic characteristics• Eye and back lesions

• Vessel casualties• Focus on small vessels

• Keep dry

• Metabolic health• Nutrition

• Exercise

• Smoking

• General reduction of accidents through improved safety culture:• Maritime academies• Occupational Health Services• On board: Company culture, ships’ culture, captains’ attitude

• We need studies about • Work-related disorders• Fatigue• Disease and treatment on board• Psychosocial conditions – mental health, suicides• Vulnerable seafarers, e.g.

• From crewing nations – hopefully in cooperation• Elderly workers

Thank you for your attention!