Department for Transport
 
 

ADG 1 PULMONARY TUBERCULOSIS

Impairment and Risks

Reduced performance – debilitation and respiratory symptoms
Complications – secondary infection, haemoptysis, infection in other parts of body
Transmission to others on board

Rationale and justification

  • Historically TB has been a major problem from transmission of infection among ships crew. More recently, due to better accommodation standards, a low proportion of seafarer cases have arisen from strains present in other shipmates. Most infection is ashore.
  • Risk of transmission, mainly by droplet spread from coughing, in those with ‘open TB’- where bacterium is present in sputum.
  • Incidence varies widely, with generally low levels in high income countries with good nutrition and well developed health services but higher levels elsewhere.  There are annually updated maps showing incidence produced by WHO (see www.who.int/ith/maps).
  • Detectable using chest X-ray for established disease, skin (Mantoux) testing and by more recent immunological assay methods using blood.
  • Progression untreated leads to loss of functioning lung tissue, with associated poor health from presence of chronic infection.
  • Treatment is a prolonged course (several months to a year) of combined antibacterial therapy. Combinations used will depend on resistance of organism.  Some medications have side effects that need supervision and compliance with the long courses that are essential to cure and to avoid resistance developing is a challenge for the individual that may mean strict supervision is required.
  • Resistance is becoming more widespread.
  • Can develop as a secondary infection when immunity is compromised e.g. by HIV infection or by immuno-supressive therapies

Clinical assessment and decision taking

a) national policies on case identification, contact tracing and treatment protocols

b) international incidence data if someone from other country is to be seen

1. Does the seafarer come from a country with an incidence of pulmonary tuberculosis > 50/100,000 pa OR have recent regular contact at home or at work with an infectious case of TB OR a medical history of TB in the past OR suspicious symptoms (persistent cough with or without sputum or blood, continuing weight loss, continuing fever)?

No – Fit category 1
Yes – go to 2

2. Arrange for screening.
Do they have any positive screening tests: chest X ray, Mantoux skin test, immunological tests for TB infection (tests should be quality assured and chest X ray should be read by a radiologist)?

No –  Fit category 1,unless contact with infectious case in last three months then Fit category 1 time limited to three months with repeat of screening at this time
Yes – Temporarily unfit category 3 go to 3

3. Do they have pulmonary TB based on full clinical assessment (normally by specialist in chest diseases)?

No – Temporarily unfit category 3 investigate any alternative diagnosis and base fitness decision on findings
Yes – Temporarily unfit category 3 for initiation of appropriate treatment go to 4

4. Has the treatment been stabilised and is the person non-infectious, compliant with medication use and free from side effects?

Yes – Restricted time limited category 2 - near coastal only and limited to time until time of next clinical appointment at which progress will be assessed
No – Temporarily unfit category 3

5. Treatment completed (including from disease in distant past), non-infectious, no continuing disability?

Yes – Fit category 1 - subject to future surveillance requirements
No – Permanently unfit category 4 if continuing impairment or incomplete cure