Seadrill Topside Support Newsletter May 2014 on Tuberculosis on Rig

Topside Newsletter – Tuberculosis on Rig

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Topside Support

NEWSLETTER

Topside Support Newsletter on

Tuberculosis on Rig

“My patient has a cough, weight loss, is sweaty and feels

unwell. I think he may have TB…!”

… And the patient may well have TB. It needs to be part

of the differential diagnosis for this presentation, but it

does not mean that the diagnosis is confirmed severe

because the patient has this triad of symptoms.

First Things First

Before telling "the world" that you think the patient may

have tuberculosis, sit with the patient in your clinic, thus

reducing his/her exposure to other employees; take a

detailed and relevant history; conduct an appropriate

examination; and call the Assistance Centre to speak to

the doctor on duty.

First Response

Points to note at the first encounter with the patient:

• While the patient is in your clinic/sickbay, the patient

is in isolation. There is no need to "spread the word"

to anybody else until we have a better idea of how

likely or unlikely the diagnosis of tuberculosis is.

• Before we move the patient out of the clinic/sickbay,

we need to assess the risk of the diagnosis, and the

mode and speed of transport. Fortunately, it is

actually quite difficult to contract tuberculosis by

droplet spread.

• While the patient is in the sickbay, make sure that

he/she uses the bathroom in the sickbay. Take such

personal precautions, as you feel comfortable with,

for yourself. If the patient has a productive cough,

then it is more useful for the patient to wear a mask,

then for you to wear a mask, but if you also want to

wear an N95 mask, please wear it. However, bear in

mind that as soon as you start wearing a mask

around a patient, everybody who sees you and

the patient will assume that the patient is highly

contagious.

Our medical services colleagues have prepared a

comprehensive document that outlines the response to a

tuberculosis health incident. The response can of course

only start after the case is notified and the diagnosis of

tuberculosis has been confirmed to an acceptable

standard. The diagnosis will not be confirmed while the

patient is offshore and/or on a remote site.

Background

Tuberculosis is one of the most important global infectious

diseases, with more than 8 million new case each year,

and about 1.3 million deaths. Most concerning is the

increase in multi-resistant cases, not responding to the

common drug regimes against tuberculosis.

Tuberculosis is a treatable disease caused by bacteria,

Mycobacterium tuberculosis. Human tuberculosis is

usually transmitted from patients to an individual by

“droplet spread”. After inhalation of infected droplets, the

bacteria may settle in the lungs and cause disease in the

chest (as well as in other parts of the body, should spread

by the lymphatic system or the bloodstream).

Because of the mode of spread, it therefore follows that if

the patient can be prevented from coughing out infected

droplets, other people are not at risk. This is the main

reason for ensuring that the patient wears the N95 mask.

Tuberculosis is not contagious by skin-to-skin contact.

Common presentations are that tuberculosis includes

persistent cough, fever and unexplained weight loss. It is

important that if the patient complains of weight loss,

other causes of weight loss are explored. Again to

emphasise, it is unexplained weight loss that is a

concern to us (and not just in terms of the diagnosis of

tuberculosis; unexplained weight loss should raise the

concern for other insidious diagnoses).

THIS MONTH: Tuberculosis on Rig



Tuberculosis on Rig –

While the triad of symptoms above, persistent cough,

fever and unexplained weight loss, is the most common

presentation, less commonly, other symptoms may

present. These include an unusual degree of fatigue for

activity expended, vague pains in the chest, and sweating

at night. The diagnosis of tuberculosis can be present

without any of these 3 later symptoms, but none of these

later symptoms are a definitive diagnosis of tuberculosis.

In addition to pulmonary tuberculosis, the disease can

involve virtually every organ in the body (brain, skin, bone,

abdominal organs, etc.), with the accompanying

symptoms.

It is important to understand that suspecting and

diagnosing tuberculosis is completely different. As

tuberculosis has significant public health implications, as

well as implications for the employee himself/herself,

people may be reluctant to communicate their concerns

because they fear they may lose their job, permanently. It

is important, therefore, to observe maximum medical

confidentiality (medical and of course legal should always

be observed whether the problem is potentially

tuberculosis or not), and communicate the background

and examination findings of the patient to the Assistance

Centre doctor on duty before saying anything to anybody

on the rig or installation.

Assessment

Every diagnosis starts with history.

One of the most important parts of the history is the origin

of the patient; does he/she live in an endemic country, or

has he/she been in contact with patients with tuberculosis

or is there tuberculosis in the family history.

Important parts of the history in assessing tuberculosis

risk are as follows (to repeat):

• If a cough is present: The nature of the cough, when

the cough most commonly presents (at night, during

daytime, when lying down or when active, is the

cough productive, is there blood in the sputum, etc.).

• If weight loss is present: How much weight has been

lost over which period, what objective measurements

of weight can be provided over weeks or months to

confirm that weight loss has taken place, and there is

no other explanation for the weight loss (such as

other illness, dieting or exercise), and if possible,

confirmation of weight loss by ‘shrinkage’ inside

clothes, as well as measurements taken at previous

pre-employment medicals and routine health

screening.

• If fever is present: Has the patient had temperature

checks that confirm fever. Is the fever cycle according

to biorhythms/circadian rhythms, and is the fever

generally more noticeable in the late afternoon or

early evening, or potentially through the night. (If the

patient says he/she "feels hot" this is not a fever…)

That said, patients complaining of rigors (“chills”) are

generally providing us with a believable and useful

symptom.

• If night sweats are present: Do these occur every

night, do these occur at a particular time of the night,

and thus the patient wakes up with pyjamas or

bedclothes ‘soaked’.

• If chest pain is present: Make sure the pain is

adequately described in localised context, including

drawing the pain presentation on a diagram/picture, if

needed. Make sure the pain is not (or is) related to a

dermatome; chest pain from tuberculosis does not

mimic or follow anatomical/dermatome distributions.

Make sure you take a very thorough history, which you

must document, of any apparent contact between the

patient and any other potentially contagious people. The

history should include times of exposure, duration of

exposure, and location of exposure (e.g. there is of

course a considerably different risk profile when eating in

a communal mess hall, and observing that some other

diners are coughing, than living in the same rooms and

sleeping in the same bed as a partner who is persistently

coughing…).




Look at the patient, from top to bottom, front to back, left

to right. Examine for tickly chest signs, skin rashes and

presence of pale conjunctivae; if clubbing is present and

is significant, although it is a very late presentation sign.

Bringing the Patient Ashore

Clearly, all patients suspected of having tuberculosis

should be disembarked as soon as feasible. Note that

emergency disembarkation is not usually necessary, as

long as the patient is isolated from other workers.

History and examination findings will have established as

above the likelihood of communicability of tuberculosis (or

any other respiratory) disease. Just because there is a

suspicion that a patient has tuberculosis, does not of

course mean that the patient is spreading or at risk of

spreading the disease by droplet spread. If the patient

does not have a productive cough, even if he does have

tuberculosis, it is not going to be spread. Please

remember that tuberculosis is much more difficult to

spread than, for example, a less scary but more

immediately serious disease such as (adult) measles.

• When it is possible (and it is not always possible for

obvious reasons), a patient with an established and

agreed-upon risk of transmission of contagious illness

by the respiratory route should travel on his own in

the cabin other than the necessary flight crew. The

patient (and the accompanying medical escort, if

there needs to be one) should sit to the rear of the

passenger compartment, if possible, with at least 3

rows of seats* between them and any other

passenger. (*This distance has been determined to

be appropriate and sufficient following the

investigation of passenger-to-passenger airborne

transmission on commercial airliners during the

SARS epidemic). Before any decision is made about

allocating a helicopter transport for 1 patient alone,

the Regional Medical Director must be involved via

the Assistance Centre.

• Helicopters used for disembarkation generally have

excellent cabin airflow characteristics better than

those of fixed-wing aircraft, over short distances.

Additionally, to allay concerns about droplet spread,

front cockpit windows and the rear windows and/or

doors can be adjusted by the pilot so that there is free

flow of air from front to back.

• If masks are deemed to be necessary either for

clinical risk or psychological comfort, the obvious

person to wear the N95 mask is of course the patient

(and again, any medic). If the aircrew wish to wear

one during flight, it is their prerogative. However, they

are not at significant risk. To reiterate, everybody

involved in planning this should be extremely

cautious about the visible effect of a group of

people coming from a rig or site, and all wearing

masks, on the authorities and the general public

at any (public) point of arrival.

• In general, ground handling of all such patients

should be a tarmac transfer directly to an

appropriately sourced and briefed ambulance, out of

sight of the general public. This will be organised by

the Assistance Centre. Making such arrangements

and referring the patient to an appropriate medical

facility for medical history, examination and accurate

diagnostic tests takes time, so the Assistance Centre

must be notified early.

Standard Operating Procedure for Handling the

Medical Transport of a Potentially Contagious

Patient

…within the same country* (*please note that an entirely

different set of concerns arise if we are trying to transport

a patient who has a communicability across of

order/frontier. This procedure is not at all to be used for

that problem…)




The entire team is required to observe International SOS’

infectious control protocols, when handling the medical

transport of a person who is suspected to be infected with

a communicable disease. Although this concerns mostly

the medical crew on the charter, the rest of the flight crew

should likewise have an awareness of the following basic

procedures:

• All crew on the mission should have adequate

immunisation as their first line of defence.

• Any open wound among the flight and medical crew

should be kept adequately covered.

• The medic, nurse or doctor who will attend to the

patient should make it a point to:

o Thoroughly wash and disinfect his/her hands

before and after making a direct contact with the

infected patient.

o Use examination gloves when administering

medical assistance, treatment or intervention to

the patient.

o Wear eye protection, gown and mask or face

shield when in the process of administering

treatment; these serve as protection against

possible expulsion or splattering of bodily fluids,

such as blood, saliva, mucus and similar bodily

secretions that the patient may discharge. (As

above, this requirement is CONTEXTUAL.)

o Avoid needlestick injuries during any medical

intervention or treatment that is usually sustained

by manually recapping the needle and extracting

needles from syringes. Dispose all used needles

and syringes in sharps disposable containers,

instead.

• All the cleaning crew should take the following

precautions when in the process of cleaning the

compartment where the infected patient was placed

during the aeromedical transportation:

o Check the expiration date of the disinfecting and

cleaning materials to be used. In addition, all

cleaning materials must meet the required

specifications for aerospace standards.

o Wear rubber gloves in all clean-up activities.

o Make it a point to clean and disinfect all areas,

equipment and compartment surfaces that have

been visibly soiled.

o Disinfect all touch surfaces of the aircraft’s

compartment, such as the stretcher, handles,

sled system, outlets, oxygen valves, tanks, seats

and bars.

What will Happen Once the Patient is Ashore?

In addition to repeated history taking examination and

routine chest X-ray (and occasionally sputum*

examination), diagnosis will need to be confirmed by

blood testing.

*Sputum testing is laborious, inherently inaccurate and

takes considerable time to produce either a positive or

negative result. Skin testing takes days and is not

extremely accurate, particularly for people who have been

previously exposed to tuberculosis either by previous

repeated skin tests and/or vaccination. Blood testing is

very much more sensitive, extremely useful, and is

currently "the gold standard" for diagnosis (or excluding

the diagnosis). Therefore, the Assistance Centre will

almost always want to refer the patient to a facility that

has this diagnostic technique available, rather than to the

nearest medical centre from the disembarkation point,

which may be the client's preference. This will be

discussed by the Assistance Centre with the client’s

Authorised Person (AP). It is not a discussion that should

be carried out on the rig or installation.

Tuberculosis is of course treatable. For "standard"

tuberculosis, patients are usually able to travel (and even

work again if physically well) within 2 weeks of the

diagnosis being made after Directly Observed Therapy,

i.e. the patient being seen to take the medicine every day

for 2 weeks, has been carried out according to the

appropriate standards of the World Health Organization

(WHO), provided they can produce 3 consecutive

negative sputum samples, meaning that they are no

longer infectious.

The International SOS Medical Services division with the

regional Medical Services Medical Director will take

charge of reviewing contact tracing (as per diagram

below), onshore and offshore follow-up, and other

remedial actions required with and by the clients to

reduce the risk to contacts of the index patient (if

tuberculosis is confirmed in that index patient).




It is natural that the patient’s co-workers will be extremely

apprehensive about the possibility that the patient could

have infected them, especially if they have seen the

patient depart with a mask on… Nevertheless, medical

confidentiality must be observed and communications

with co-workers and clients about the risk of tuberculosis

of the specific patient or case must be handled by senior

medical staff in the Assistance Centre and/or Medical

Services division. Please do make sure the offshore

installation manager (OIM) is involved in an early stage,




as an infectious tuberculosis case on a rig can have

severe implication on the crew and on the operational

aspects of the rig. In the worst case, if there are multiple

infected patients on board, the local health authorities

might decide to shut down the rig, which of course has

huge (financial) implications for the client.

Reducing the Risk of Tuberculosis in any

Workplace

This information is provided for guidance. Workplace

tuberculosis programmes cannot operate in isolation;

preventive programmes should be aimed at preventing

transmission and acquisition of tuberculosis well before a

potential patient turns up at the workplace to start or

restart work.

Screening

This is a specialist occupational medicine activity and is

not within the scope of this newsletter. Appropriate

physical and (when required) radiological/immunological

screening should be done well before the worker is

deployed. That said, everybody should be screened upon

arrival at the installation. If people have respiratory

symptoms coming back from shore leave, they need to be

seen and examined regardless of the likely underlying

diagnosis, not just because tuberculosis is a (remote)

possible reason for the presentation…

Living Conditions

Adequate space must be provided within accommodation

areas, with appropriate ventilation and air filtration, and

both living and sleeping areas. In the modern industry,

this is generally carried out to a high standard. That said,

when a patient has a respite presentation, it is a medical

responsibility to ensure that the risk of cross infection

inside sleeping and living quarters is reduced under

medical supervision, even when the living quarters are

appropriately set-up. Therefore again, necessary

housekeeping must be carried out to ensure good

hygiene conditions even when there are no present

patients of concern.

Nutrition

A considerable component of a strong immune system is

both, a well-rounded diet and sufficient calorie intake.

Again, in the modern industry, catering arrangements on

installations are generally good to excellent. Dietary

components are all present, if workers choose to take

them. It is highly unlikely that milk and dairy products

come from an unsafe source (should they do so, this

raises the risk of bovine tuberculosis), but very

occasionally this may need to be checked. It is much

more likely that this type of problem would arise during

the off-duty cycle, at the patient's home location.

Smoking

Smoking very considerably and effectively reduces the

respiratory tract’s natural defences against inhaled

infection. It is not by itself a risk factor for tuberculosis, but

significantly reduces the mechanical/physical resistance

to tuberculosis infection being acquired by droplet spread

deep into the lungs. Should a smoker be exposed to

tuberculosis, the usual “smoker's cough”, plus the usual

sneezing, morning throat clearing, spitting, etc. absolutely

increases the rapid spread of tuberculosis.

Immunisation

In brief, this is not an effective strategy to minimise

tuberculosis spread between unvaccinated adults.

However, previous Bacillus Calmette-Guérin (BCG)

vaccination (and previous skin (tuberculin) testing) must

be reported as part of the patient history.

Education

Without unduly causing Fear, Uncertainty and Doubt

(FUD), education programmes make everybody more

aware of the signs and symptoms of tuberculosis and can

emphasise the fact that tuberculosis can be cured. Thus,

people feel encouraged and are able to come forward if

they have concerns about themselves or their family

members.

Contact Tracing

In general, this is done as a collaborative effort between

the company, public health authorities at or near the

location, and International SOS’s incident/outbreak team.

Contact tracing is a specialised task and is not something

that will be carried out on the installation by installation

personnel operating alone. For contact tracing to work

however, it must be able to be clearly established where

the patient has been working and sleeping over previous

weeks and months. This information should form part of

the case notification when the concern is first raised.

Disclaimer

This information has been developed for educational purposes only. It is not a

substitute for professional medical advice.

Should you have questions or concerns about any topic described here,

please consult your healthcare professional.

Seadrill Topside Support Newsletter May 2014 on Tuberculosis on Rig

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