Tropical diseases...some like it hot (and humid)!

Following on from the latest edition of our monthly newsletter, Worse Things Happen at Sea, this is the second blog taking a closer look at the most common tropical diseases that you might encounter. Last week we focused on Malaria, this week it’s the turn of Dengue Fever, Tuberculosis and the rather delicious sounding Cutaneous Larva Migrans!

Dengue Fever

Dengue is a viral infection, with four different types, spread by infected mosquitoes, usually the Aedes aegypti and Aedes albopictus varieties. It can’t be spread from person to person.

The mosquitoes bite during the day, usually early morning or in the early evening just before dusk. They're often found near still water in built-up areas, such as in wells, water storage tanks or in old car tyres.

While we’re not at risk in the UK, it’s widespread in many parts of the world such as Southeast Asia, the Caribbean, the Indian subcontinent, South and Central America, Africa, the Pacific Islands and Australia. There is no vaccination or specific treatment available, so it’s important to take steps to prevent infection in the first place.

Dengue normally presents as a mild infection that develops suddenly, around 5-8 days after being infected, and passes in around a week with no lasting damage other than maybe feeling tired and a bit unwell for a few weeks. So it can normally be managed without needing hospital treatment by managing the symptoms. But occasionally it can become life threatening and in rare cases, severe Dengue can develop after the initial symptoms.

Symptoms can include:


  • a high temperature, feeling hot or shivery 
  • a severe headache
  • pain behind the eyes 
  • muscle and joint pain
  • feeling or being sick 
  • a widespread red rash 
  • tummy pain and loss of appetite 


These suggestions may help to relieve symptoms:


  • Take paracetamol to relieve pain and fever. 
  • Do NOT take aspirin or ibuprofen, as these can cause bleeding problems in people with dengue. 
  • Drink plenty of fluids to prevent dehydration – bottled water is safer than tap water in many locations. 
  • Get plenty of rest.


You should start to feel better after about a week, although it may be a few weeks before you feel your normal self again. Get medical advice if your symptoms don't improve and be aware that you can get it again if you've had it before, as you'll only be immune to one type of the virus.


In rare cases Dengue can be very serious and potentially life threatening. This is known as severe dengue or dengue haemorrhagic fever. It’s thought that people who've had dengue before are at most risk of severe dengue if they become infected again. So this makes it a bigger risk for mariners working particular routes, than for tourists or travellers.


Signs of severe dengue can include:


  • Severe abdominal pain.
  • Swollen or distended abdomen. 
  • Vomiting repeatedly, vomiting blood.
  • Bleeding gums or bleeding under the skin. 
  • Breathing difficulties or fast breathing. 
  • Cold, clammy skin. 
  • A weak but fast pulse. 
  • Drowsiness or loss of consciousness.


As we said earlier, prevention is the best attack and these actions can reduce your risk of being bitten:


  • Use insect repellent – products containing 50% DEET are most effective, but a lower strength (15 to 30% DEET) should be used on children, and alternatives to DEET should be used on children younger than 2 months. 
  • Wear loose but protective clothing – those pesky mosquitoes can still bite through tight-fitting clothes. Trousers, long-sleeved shirts, and socks and shoes (not sandals) are best.
  • Sleep under a mosquito net – ideally one that has been treated with insecticide. 
  • Be aware of your environment – mosquitoes that spread dengue breed in still water in urban areas.


Tuberculosis (TB)


The most common questions the Red Square Medical team get asked about TB are, ‘is it contagious?’ and ‘how can I get tested for it?’. But as more and more companies are introducing TB screening, we thought we’d share some ‘need to knows’ about TB.


TB is a bacterial disease that can be transmitted by breathing in the bacteria that cause it, such as minute droplets in the air coughed out from an infected person.


In most cases, the body’s immune system is able to kill the bacteria and the person remains healthy. But some people will become ill. It can take weeks, months or years to show symptoms after becoming infected and this is called ‘active TB’.


In other cases, the bacteria aren’t killed, but can live at low levels in the body. The person doesn’t get ill and isn’t infectious. This is called ‘latent TB’.


But if the bacteria start to multiply again, months or even years later, it can develop into active TB. This can happen if the person's immune system is compromised - such as chemotherapy treatment or by other diseases such as HIV. 


TB mainly affects the lungs, so the main symptoms are listed below. But it can also affect the abdomen, glands, bones and nervous system.


  • Persistent cough for more than 3 weeks.
  • The cough may be productive, with bloody phlegm.
  • Extreme tiredness.
  • Loss of appetite.
  • Weight loss.
  • Fever.
  • Night sweats.
  • Swelling in the neck


Of course, this sounds like so many other diseases, it can be hard to diagnose. So your travel history and who you have been in contact with is an important part of the background information. 


Your healthcare professional will decide if you are at high risk of contracting TB and will refer you for testing if it’s needed. There are a number of ways to test for TB.


Mantoux test: where a small amount of harmless TB protein is injected under the skin and the area checked 48-72 hours later to see if your body has reacted normally. Be warned… it stings a bit! But you can’t catch TB from this test.

Interferon-gamma release assay: this is a blood test that can be done at the same time, after or instead of the Mantoux test. A positive result means more tests are needed to find out if you have TB.

Sputum smear: a specimen of sputum that has been coughed up is examined for TB in a laboratory.

Chest X-ray: an x-ray can establish whether there is any TB in the lungs.


What happens if you do test positive for TB? 


With treatment, TB can almost always be cured and if you test positive, you’ll be started on a combination of different antibiotics to treat the bacterial infection causing the TB. The length of treatment will depend on whether it’s latent or active TB but they normally need to be taken for 6 months. Several different antibiotics are needed because some forms of TB are resistant to certain antibiotics. 


If you’re diagnosed with pulmonary (in the lungs) TB, you’re still contagious for 2-3 weeks into treatment and while you don’t need to isolate, you do need to take precautions to prevent spreading it. 


You should:


  • Stay away from work, school or college until your TB treatment team advises you it's safe to return.
  • Always cover your mouth when coughing, sneezing or laughing. 
  • Carefully dispose of any used tissues in a sealed plastic bag. 
  • Open windows when possible to ensure a good supply of fresh air in the areas where you spend time. 
  • Avoid sleeping in the same room as other people. 


If you have been in close contact with someone who has TB, you may need to have tests to see whether you're also infected. 


The BCG vaccination was used routinely to protect from TB. But as TB rates are generally low in the UK, it’s no longer offered to children in secondary schools. It was replaced in 2005 with a more targeted programme for babies, children and young adults at higher risk of TB. This means that those born after 2005 won’t have been vaccinated and may have lower resistance to TB. 


 

And finally… drum roll please, for possibly the ‘icky-est’ of our tropical disease features!


Cutaneous Larva Migrans


Cutaneous Larva Migrans is a soil transmitted helminth and more commonly known as Hookworm which is a parasitic worm. 


It’s estimated that up to 740 million people are infected with hookworm across the world, and there are many types of hookworm for you to hook up with! 


Hookworm is most common in warm, moist climates and where sanitation and hygiene are poor and it’s normally through walking barefoot on contaminated soil, beaches or other surfaces where skin is in contact with the contaminated soil or sand. 


*Icky Alert…* Hookworms live in the small intestine and eggs are passed on in the faeces of an infected person. If the faeces lands outside (due to humans taking an ‘al fresco’ poop!), it’s used as fertiliser which helps the eggs to mature and hatch larvae. The larvae then mature into a form that can penetrate human skin. 


Most people who are infected will have no symptoms. Other symptoms include:


  • Itching and a localised rash where the larvae penetrate the skin. This can appear similar to a mosquito bite.
  • Abdominal pain.
  • Loss of appetite.
  • Weight loss.
  • Fatigue.
  • Anaemia in serious cases. 


Treatment is normally a short course of antibiotics over 1-3 days. 


In our example, the patient was walking barefoot on a beach in Antigua when they were bitten on the instep of their foot. The initial itchiness made them think it was nothing more than a mosquito bite. 


However the wound remained itchy and the patient sought advice after noticing that a red line had developed from the wound across the sole of their foot. The line didn’t follow the circulatory system as you would expect in the case of infection, but it was raised and firm on palpation. Hookworm was diagnosed and treated with a 3 day course of Mebendozol, an oral antibiotic. This killed the parasite and the wound healed with no secondary infection. 

The Recovery Position - an STCW refresh

by Rachel Smith • 18 December 2024
Welcome to our December blog, which is all about the recovery position and how to manage an unconscious casualty who is breathing normally. Unconsciousness is a medical emergency as the person is very vulnerable and may not be able to manage their own airway effectively. We also need to think about the cause of unconsciousness. Is it a simple fainting episode due to illness? Is it a massive hemorrhage causing hypovolemic shock? Or is it due to some kind of external factor or injury? This blog looks at how to manage an unconscious casualty. So, if we have a casualty who is unconscious, but who is breathing normally for themselves, and we’re not suspecting a serious injury, the recovery position is the best position to use while monitoring them. The recovery position keeps their airway open and makes sure that vomit or liquid won’t cause them to choke.

Revisiting our guest blogs

by Rachel Smith • 11 December 2024
All the guest blogs! When we started adding blogs to our website back in early 2021, we did a little feature on each of our instructors of the time. They’re quite a fascinating bunch and the series proved quite popular amongst our followers. In addition to our amazing instructors, we work with some utterly incredible human beings all over the world, and the idea of sharing their stories grew and developed into what eventually became a monthly guest blog. It’s been interesting to find out more about how medical care at sea or in remote locations features in their work, and to discover a few fun facts along the way. This month, we thought that it might be a fun idea to give you a chance to go back into the archives and review all the guest blogs over the last few years! Maybe even let us know which your favourite one is?

Cayman Maritime Report 2023

by Rachel Smith • 27 November 2024
We’ve taken a look at the 2023 Casualty Summary Report from the Maritime Authority of the Cayman Islands (MACI) to see what kind of incidents and trends their data shows us, even with relatively small data sets, and how this may be able to transfer to our own risk assessments and actual practice. You can find the report here: Cayman Maritime Report 2023 The first thing we noted was the authors note that the data is split out into incidents. This means that one incident may include a number of events. So a collision and any resulting injury is one incident, but is reported as two events, or more, if more than one person is injured. It made us wonder whether this method of reporting by an authority represents how incidents are reported onboard and whether it should be a consideration? Of course, for any set of statistics presented at the moment, we also have to consider the COVID-19 pandemic and the impact this has on trends including that period. While essential shipping continued, the cruise and superyacht sectors reduced activity and staffing, often to a skeleton crew while anchored somewhere. So this will be reflected in the historic data sets that we analyse from 2019 to 2021 and may not accurately reflect increases and decreases during and since then. In some situations, we may need to look further back for accurate data. We also need to consider whether increases in incidents and events is also down to increased reporting - suggesting an improvement in the awareness of reporting requirements and greater engagement from the industry and individual sectors - this can only be a good development. Since 2020, the type of injury has been recorded in 8 different categories, with hand and foot injuries topping the leaderboard, closely followed by head, body, and back injuries. So if you were looking to run drills, or practise medical skills, these would be the key areas to cover. Only one death was an occupational accident, and is being investigated here: MAIB Investigations (search for case #9229607). It relates to a fall down a ventilation shaft on a bulk carrier in a Greek shipyard. The full report was still pending at the time of writing. Merchant ships are heavily regulated by a number of authorities, and the requirements for personal protective equipment and safe systems of work are enforced and applied to reduce accidents and incidents onboard. This has led to a lower reporting of incidents than in the commercial yacht sector. Could there be room for improvement here in this area? We certainly think so. Many of the hand and foot injuries reported can be career ending or life changing, but are preventable. Follow up has shown that there is a link here with injuries being sustained when inappropriate or no PPE was used. The supply and use of appropriate PPE is mandatory on vessels subject to the MLC and it’s worth remembering that some PPE can be produced in styles and designs compatible with the aesthetics of a yacht if required! On a much wider scale, a lack of transparency and standardisation globally can affect the collection of data and the issue of under reporting. While the MACI figures may be accurate, we need other accurate figures to compare them to, in order to build a bigger picture across the world as we have in aviation. From December 2024, the Maritime Labour Convention (MLC) will be enforcing an amendment so that seafarer deaths will be recorded and reported annually. The MACI and Cayman Islands Shipping Registry produces a number of safety flyers that are publicly available HERE that may be useful. In summary, analysing data can sometimes result in more questions than answers. But even this can lead to interesting and important developments that result in improved safety and reduced incidents and accidents onboard. Key points to take from this report are: Use the correct PPE for the task. Employ approved systems of work and risk assessments for the task. Reporting is key for safety in the future of our industry. Enjoy a night ashore, but don’t over do the cocktails! As always, if you’d like any input on medical training onboard or ashore, or drills that you can run yourselves, please just get in touch. References: https://www.lloydslist.com/LL1145359/Increase-in-incidents-of-deaths-at-sea

James Griffiths - Guest Blog

by Rachel Smith • 6 November 2024
Welcome to our latest guest blog where we’ve been chatting to James Griffiths, General Manager of Ocean Operations for Scenic Group and finding out more about what happens behind the scenes in order to keep a fleet of luxury expedition ships running. Here’s what James told us… As General Manager of Ocean Operations, I’m responsible for the operations of our fleet which includes four ships in service with around 850 colleagues. I currently live in Mumbles, near Swansea in the UK, but due to the nature of my work I spend a significant amount of time living in Croatia. Prior to this role, I spent many years working at sea and worked up through the ranks to Captain and over the last 15 years, my main focus has been on polar expedition travel. I hold a master mariner certificate of competency in addition to a degree in engineering and a post graduate diploma in law. Part of my job is to work with our medical service provider (Red Square Medical) to ensure that our ships are offering medical services that are appropriate for their deployment, and this can often be to some of the most extreme and remote locations around the world. It’s extremely varied, though during the COVID-19 pandemic, I came ashore when our operations paused for a significant period of time. I was fortunate enough to be given the opportunity to lead the restart of our Ocean Operations, which included setting up everything from a company to manage the ships, to selecting our crewing, medical, helicopter and submarine partners and providers, amongst many other things. Our areas of operation, and the nature of our cruises (expedition), plus having aircraft and submersibles onboard some, do mean additional elements involved in the management of these ships. You could say that this current position is more of a happy coincidence than one that I actually planned for! In some ways this is a great positive - I do think it’s possible to plan a little too much and then be disappointed if things don’t go quite the way you had imagined. But there’s no danger of that here!

Paramedic on tour - Simon Lawton heads to Mexico

by Rachel Smith • 3 October 2024
Back in February 2022, we brought you one of our very first guest blogs from Simon Lawton, a Paramedic who has swapped out his ambulance for a Superyacht! You can read the original blog here: https://www.redsquaremedical.com/superyacht-paramedic-a-guest-blog-from-simon-lawton Over the last 2+ years, we’ve followed Simon’s career, and some of you may even recognise him as he does put a Red Square Medical instructor hat on from time to time. But, as for all healthcare professionals, Simon has to keep his skills up to date. So, we asked him to tell us a bit more about how he juggles this along with a rota onboard. Here’s what he told us… I’m originally from Stoke-on-Trent in the UK and trained as a HCPC registered Paramedic. I’ve spent almost 5 years working at sea now, with almost continuous employment on three different vessels, after leaving the ambulance service in 2019. My first role was as a Paramedic/Deck hand on Superyachts, and I now work as a Medical Officer on a maritime vessel. Even before I applied to become a Paramedic, I intended to complete my studies to help find employment in a remote or offshore environment. I had always been attracted to the idea of being able to travel the world while earning a salary. Working at sea has meant that I have travelled extensively, earnt a higher salary, and have a better work/rest balance than would be possible in a role on land. Note: At the time of writing, a qualified Paramedic’s starting pay in the UK was £28,407 and Simon’s old rota was 2 days, 2 nights (all 12 hours) and 4 days off with very inflexible annual leave. This year I decided to carry out some continual professional development (CPD) at a hospital in Mexico, to keep my skills up to date. I was interested in travelling to find out more about how healthcare services are provided outside the UK and Europe. The CPD activity in Mexico allowed me to do exactly that, while caring for and treating a wide variety of patients who had either self-presented in the emergency department, or been conveyed to hospital by ambulance.

Inequalities in CPR on Women

by Rachel Smith • 25 September 2024
Welcome to our September blog, and as we all start (in the UK at least!) to think about adding a few layers for warmth, we’d like to talk about getting naked! Well, to be more specific, getting bra’s off. Fact: Women are dying because bystanders are less likely to carry out CPR on women than men. Research shows that women are 27% less likely to receive CPR than men and if a defibrillator is used, their chance of survival is affected by bra’s being left on. Most of us have never had the chance to train using a female manikin. The #BraOffDefibOn campaign aims to address the inequality in CPR for women and we’re supporting it.

Dr. Will Duffin - Joint Medical Director WEM

by Rachel Smith • 4 September 2024
In August, we brought you a Guest Blog from Mark Hannaford, the founder of World Extreme Medicine. This month, it’s the turn of another of the key WEM faculty members… introducing Dr Will Duffin. Hello everyone, I’m Dr Will Duffin and I’m a GP in Devon in the UK. I’m the Joint Medical Director of World Extreme Medicine (WEM) and the Lead Medic for the US CBS TV show ‘Survivor’ - for Seasons 43, 44, 46 and 48, which is also through WEM. Extreme Medicine is healthcare that is delivered across the full spectrum of remote, austere and challenging environments. This includes high mountains, deep oceans, jungles, deserts, polar, low earth orbit and refugee camps… the list is endless. Being a part of the wider Extreme Medicine community through WEM has been a portal into new worlds of possibility and opportunity in my medical career as an NHS GP. It’s a huge privilege to treat patients in a remote setting. You get to do proper ‘hands on’ medicine that truly tests your clinical skills, risk management and decision making. Even basic techniques and principles done well can transform patient outcomes. That’s the big reward. I graduated from Bristol Medical School in 2008 and completed my GP Training in Cornwall, UK in 2016. In between, I spent 18 months in Australia to gain as much emergency department experience as I could, whilst doing Wilderness Medicine Courses. I landed my first expedition gig 12 years ago when I was post-FY2 (Foundation Years follow on after qualifying as a doctor). I covered a Kilimanjaro Trek after another doctor dropped out at the last minute. Once I had this under my belt, I was able to leverage this experience to get the next trip. So, I soon found myself providing regular medical cover for various commercial and charity sector expeditions. These expeditions have taken me all over the world: Kilimanjaro, the Peruvian Andes, the Himalayas, Northern China, Eastern Europe, Myanmar and Madagascar. One highlight was working as the private doctor for a Luxury Trans-Siberian Train! Though I became frustrated having to constantly wrangle annual leave to go away, so I made the switch to being a freelance (locum) GP, which has given me the flexibility I need. I joined WEM in 2018 after responding to a Facebook Ad for the ‘Survivor’ job. I was invited to a selection weekend in the Peak District, which is when I first met Mark Hannaford WEM founder and CEO and Dr Joe Rowles, WEM’s other Medical Director, and it all went on from there. Early on, I was given the opportunity to lead on the content for the annual World Extreme Medicine Conference and our various podcasts and webinars. Through doing this, I have met a colourful cast of characters; other extreme medics who are as audacious as they are inspirational! We have a lot of fun at the conference every year, learning from one another. https://worldextrememedicine.com/registration/wem-conference-2024 (Note from the RSM team – the conference is highly recommended and well worth a visit!)

Mark Hannaford - Founder and CEO of World Extreme Medicine

by Rachel Smith • 5 August 2024
Last year, the Red Square Medical team descended on the World Extreme Medicine (WEM) conference for the very first time. We’d been aware of this unique organisation for many years, but just not had the chance to get involved. Liz was involved in a panel discussion and spoke at the conference, and we came away literally buzzing with enthusiasm - our first impressions were that WEM is a place with no ego’s, where everyone wants to learn, and is willing to share. We met some of the most fascinating people ever and can’t wait to go back this year. But what about the person who started it all… We spoke to Mark Hannaford, founder of World Extreme Medicine and its far reaching impact. Here’s what he had to say. I’ve been involved in expeditions, working in low resource environments and extreme medicine for the past three decades! My family was made up of generations of seafarers from Cornwall although I was brought up variously in Devon, Antigua in the Caribbean and the Middle East; reflecting my father’s job as a Master Mariner. My father was at one time the youngest captain aboard the UK’s largest registered vessel, and my grandfather was Harbour Master for Malta and the first in that role in Plymouth at the start of Queen Elizabeth’s reign. I wear a number of hats but primarily I am the founder and CEO of World Extreme Medicine, and the annual WEM Conference. I also founded the MSc in Extreme Medicine at the University of Exeter and Graduate Certificate program at Bouvré College of Health Sciences, Northeastern University, Boston.

Women's Health

by Rachel Smith • 3 July 2024
Women’s health is a huge topic, while it’s true that in the maritime sector women make up just 2% of seafarers at sea, up to 34% of the shore based staff are female. Looking at the bigger picture, women’s health directly affects just under half of our population globally, and indirectly (whether you like it or not!) the other half, we thought it was worth a blog about some of the issues, and the taboo’s, that could be affecting our maritime workforce and the women in our lives. It's common knowledge that women experience huge hormonal changes at puberty and menopause, both of which can have significant physical and mental health impacts. In the UK, there is a growing discussion and openness about peri-menopause (the years before periods stop altogether) and how for some women, this has devastating effects across all aspects of their lives, including work. Of course men experience changes at puberty, but their later life changes are less significant and generally don’t affect their ability to work. In December 2023 the World Health Organisation (WHO) issued a statement to advise that every year, at least 40 million women are likely to experience a long term health problem caused by childbirth. So there’s a good chance that we all know one or more women affected, or if you are female… this could be you. As part of a special series on maternal health, the study showed a high burden of postnatal conditions that persist in the months and years after giving birth. These issues include more than a third of women experiencing pain during intercourse, urinary incontinence (8-31%), anal incontinence (19%), anxiety (9-24%), depression (11-17%), perineal pain (11%), a fear of childbirth (6-15%) and secondary infertility (11%). All in all it doesn’t paint a great picture of life after childbirth for some women. If any of your workers experience these issues, either on or off shore, it could have a significant impact on areas of their working life and it’s something they may be reluctant to open up about. Even before childbirth, we may take it for granted that contraception is available, certainly in the developed world. But in developing countries where sexual violence is not uncommon, contraception is considered lifesaving due to the high level of unsafe abortions carried out. Around 13 million women (and girls) under 20 give birth annually and complications in the pregnancy and birth is a leading cause of death. Consequently abortion is an option, but this carries its own huge risks.

Guest Blog - Wendy Sullivan

by Rachel Smith • 25 June 2024
We just love speaking to and finding out more about the people who inspire us and we guarantee that this month’s blog will not disappoint! We first got in touch with Wendy Sullivan via LinkedIn and thought she seemed like a pretty awesome human. Wendy and her company, Maritime Medical Solutions in Australia, certainly share the same outlook as Red Square Medical. Fast forward a couple of years and we’re now collaborating on a project in Australia and the Pacific Islands. What we’ve learnt along the way is simply fascinating and Wendy has kindly agreed to share her story with us… Here is Wendy’s Guest Blog: I was born in Canada, grew up in Africa and now call Australia my home. I feel lucky to live in paradise where the weather allows us to be on the water year-round. I had to work hard to gain my Australian citizenship and I credit my work in the marine industry with giving me a pathway to stay in Australia permanently. It took years of hard work and uncertainty to gain my residency and is still one of the achievements I am most proud of. I started sailing in Canada and since emigrating to Australia gained my professional and commercial qualifications as a vessel master, marine engine driver, trainer and assessor. I also have a Diploma of Paramedical Science, ship masters medical qualifications, business administration and development and there is still so much more to come.
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