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NEWSLETTER
THIS MONTH: Tuberculosis on Rig
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.

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.

First Things First

Background
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

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).

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Tuberculosis on Rig Page 2

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.

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.

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.

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).

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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.

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.

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.

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)

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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:

Thoroughly wash and disinfect his/her hands

before and after making a direct contact with the
infected patient.

Use examination gloves when administering

medical assistance, treatment or intervention to
the patient.

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.)

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.

Wear rubber gloves in all clean-up activities.

Make it a point to clean and disinfect all areas,

equipment and compartment surfaces that have
been visibly soiled.

Disinfect all touch surfaces of the aircrafts

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 clients
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).

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Tuberculosis on Rig Page 5

It is natural that the patients 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,

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Tuberculosis on Rig Page 6

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.

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
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

Smoking very considerably and effectively reduces the

respiratory tracts 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-Gurin (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 SOSs 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.

Topside Newsletter Tuberculosis on Rig

2014 AEA International Holdings Pte. Ltd. All rights reserved. Unauthorised copy or distribution prohibited.