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Accepted for publication by the Journal INTERNATIONAL MARITIME HEALTH, Publisher: Medical University of Gdansk, on May 7th 2009 Guidance to the International Medical Guide for Ships 3rd edition:
Interim advice regarding the best use of the medical chest
for ocean-going merchant vessels without a doctor onboard
Joint Statement of WHO Collaborating Centres for the Health of Seafarers and the
International Maritime Health Association - 2009 Version
Schlaich C (1,5)*, Reinke A (1), Sevenich C (1), Oldenburg M (1,5), Baur X (1), Horneland A (2,5), Jaremin BM (3,5), P S Nielsen (4), Wichtmann E M (7,5), Ioannidis N (8,5), Brandal L (2,5), Puskeppeleit M (2,5), Denisenko I (9,5), Carter T (5), Nikolić N (5,6) (1) Institute for Occupational and Maritime Medicine, Hamburg, Germany, WHO Collaborating Centre for the Health of Seafarers (2) Centre for Maritime Medicine, Haukeland University Bergen, Norway (3) Interfaculty Institute of Maritime and Tropical Medicine Gdynia, Medical University of Gdańsk, Poland, WHO Collaborating Centre for the Health of Seafarers (4) Centre of Maritime Health and Safety, Institute of Public Health, University of Southern Denmark. WHO Collaborating Centre for the Health of Seafarers, (5) International Maritime Health Association (6) Medical Center for Occupational Health Rijeka, Croatia (7) Malteser-Apotheke, Hamburg, Germany (8) ShipMedical Ltd, Athens, Greece. (9) Regional Medical Office, German Embassy, Moscow, Russia Corresponding author: Dr. med.Clara Schlaich, MD, MPH, Head of Hamburg Port Health Center, Institute for
Occupational and Maritime Medicine, WHO Collaborating Center for the Health of Seafarers, Seewartenstraße
10, D- 22549 Hamburg. [email protected]
____________________________________________________________________________________

Background
Diagnosis and treatment of the sick and injured onboard is a challenge to seafaring. This has always
been true despite recent developments in telemedicine. Where no doctor is on board -as it is the case
in most merchant ships- a non-medical person holds the responsibility for medical care. He has to rely
on his medical training, written information, and -if appropriate- shore based radiomedical or
telemedical advise. This information will help him to make best use of the medical chest and
equipment on board. Appropriateness of the information available, adequacy, uniformity and quality of
the medical chest and equipment is a key to the safeguard of the seafarer’s health at his work-place.
The WHO International Medical Guide for Ships (IMGS) was first published in 1967. The IMGS has
widely been used in the maritime world. The second edition1, written in 1988 was recently replaced by
the third edition2 in 2007. Immediately after the publication of the current IMGS a discussion on the
best use of the tool and on further needs developed among experts from the WHO Collaborating
Centres3 for the Health of Seafarers and the International Maritime Health Association4.
1 International Medical Guide for Ships (2nd Edition). World Health Organization, Geneva.1988. 2 International Medical Guide for Ships (3rd Edition). World Health Organization, Geneva. 2007. 3 http://www.who.int/collaboratingcentres/ The WHO collaborating centres are institutions such as
research institutes, parts of universities or academies, which are designated by the Director-General of
the World Health Organization to carry out activities in support of the Organization's programmes.
Accepted for publication by the Journal INTERNATIONAL MARITIME HEALTH, Publisher: Medical University of Gdansk, on May 7th 2009
During a workshop of the INTERNATIONAL MARITIME HEALTH ASSOCIATION (IMHA) in Athens,
Greece, November 14th-15th 2008 the concerns were summarized as follows: “Flag states that do not
have national requirements for the contents of the medical chest have in the past relied on a list that
has been provided by WHO in the International Medical Guide for Ships (2nd Edition, 1988). This list
provided information on the quantities to be carried on board. It is not a formal international instrument
but the Guide is noted as a source of information in the non-statutory part of the relevant ILO
Convention. Port State Control Inspectors use the IMGS list as the minimum requirement for medical
supplies. The medication list is now very out of date and when WHO recently published a new edition
of the Guide it included updated lists of recommended medications that were derived from the WHO
Essential Medications List and of medical equipment taken from The Inter-agency Emergency Health
Kit 2006. While this was a rational approach for the WHO to ensure that well validated treatments
were available it did not take into account the need for remedies for minor ailments at sea – the sort
that can impair ability to work without being dangerous, nor did it cover all the medical equipment that
was needed in maritime situations. More significantly WHO did not consider that they could specify
quantities of medications to be carried as there was a lack of information on use and effectiveness of
medications at sea. In the absence of such data WHO considered that quantities should be related to
voyage pattern and to political / managerial decisions rather than being stated by WHO.This lack of
specification is not causing immediate problems where the flag state of the ship has its own national
regulations or guidelines but it has led to great difficulties for maritime pharmacists called on to check
and restock medical chests on ships from countries, including many of those with major open ship
registries, that have no national lists. Pharmacists cannot continue to work to the outdated list and
quantities in the old International Medical Guide, while they have no benchmarks for quantities
required from the new one, nor the authority to make consistent decisions on the quantities to supply”.

WHO Collaborating Centres for the Health of Seafarers and IMHA agreed that there are a number of
topics where improvements are needed. The aim is to produce a knowledge-base to specify the
contents of medical chests and the medical textbook. While this is a long-term approach requiring
research efforts it was also agreed upon the need to produce an interim guidance on the medical
chest to the current users of the IMGS even in the absence of further evidence. Symptom-oriented
algorithms for diagnosis and treatment as a supplement to the current IMGS 3rd edition will follow
soon.
In this paper the authors, who are experts from the International Medical Health Association and the
WHO Collaborating Centres for the Health of Seafarers publish recommendations to the medical chest
as given in the IMGS 3rd edition. This is an interim advice to be available to ship-owners, -masters and
maritime authorities and pharmacists for use on merchant ships not carrying a medical doctor of those
flags that do not follow the EU Directive 92/295 and do not have national requirements. The readers
and users of the interim advice need to be aware that the expert group does not judge on the content
of the current list as published by the World Health Organization in the 3rd edition of the IMGS.

The aim of the Interim Advice as given below is
to provide an aid for decision making for quantities required for seagoing and coastal vessels to add items named in the textbook of the IMGS 3rd edition but missing in the list of medicines or equipment to add page numbers from the medical textbook to the list of medicines for easier use.
The Interim Advice as given below is not
mandatory for ship-owners, suppliers or port health authorities. It is to the flag states responsibility to specify national requirements in a legally binding way. meant to substitute a qualified medical consulting. Owners and operators carry the final responsibility for the content of the medical chests on board of the ship. Owners and operators will need to seek qualified medical consulting for the content and quantities carried on board. 4 http://www.imha.net/ IMHA is the sole international association concerned exclusively with
Maritime Health. It is an association of professionals from a wide range of disciplines who are
committed to improving the health of seafarers by developing better approaches to health protection,
health promotion and health treatment.
5 Council Directive 92/29/ eec of 31 March 1992 on the minimum safety and health requirements for improved medical treatment on board vessels. Accepted for publication by the Journal INTERNATIONAL MARITIME HEALTH, Publisher: Medical University of Gdansk, on May 7th 2009 The particularities of the voyage will need to be considered by the consultant, like travel to malaria risk areas. The authors of the Interim Advice are solely responsible for the content of all additions made to The List of Recommended Medicines and Equipment of the International Medical Guide for Ships 3rd edition, pages 430-46. We appreciate the comments of the maritime community to this publication which will be continuously revised. All comments and suggestions need to be directed to the corresponding author. Please mail to [email protected] _________________________________________________________________________________ How to use the proposed list of recommended
medicines and equipment of the
International Medical Guide for Ships 3rd edition, pages 430-461
The Interim Advice is only to be used in conjunction with the International Medical Guide
for Ships 3rd edition2 as published by WHO in 2007.
All items suggested from WHO in the original list on pages 430 to 461 are included. Any additions to the original list (items and comments) are made visible by the use of italic letters. Reference pages from the medical textbook to the list of items which justify the additions are given. Running numbers have been given to the list of medicines and equipment including added items. Drugs, forms, books and equipment which are mentioned in the textbook but have not been displayed in the list of medicines are added to the list in alphabetical order. Reference pages to the medical textbook are given for all items to ease the use of the list. If an item may be omitted under special circumstances this is mentioned in italic letters in the last column. Suggestions for quantities have been included. Quantities are calculated on the basis of the following assumptions: Ocean-going merchant vessels without a doctor onboard. Maximum duration of travel of 3 weeks. Crew sizes of 10, 20, 30 or 40 persons. For merchant vessels without a doctor onboard engaged in coastal trade or going to nearby foreign ports, and not more than 24 hours away from a port of call, for fishing boats and private craft: Quantities may be adapted or omitted on the advice of a qualified medical practitioner or pharmacist with regards to the destination, medical facilities ashore, number of crew members and cargo. For dosage, contra-indications, unwanted effects, radiomedical advice and further
remarks the users needs to refer to original text of the IMGS 3rd edition.
Recommended quantities will not always reflect the standard packs in a given country. In this case the recommendation is for the nearest available dispensing sales pack above the minimum required quantity. Owners and operators may substitute exact equivalents on the advice of a qualified medical practitioner or pharmacist, provided they are satisfied that an equivalent level of treatment is assured. Specific items will not be available in certain countries, for example Chlorpyrifos was banned in the European Communion (Directive 98/8 eec of March 16th 1998). The pharmacist will have to supply an analogous drug in corresponding quantities. The same is true for items which have transport restrictions and can not be delivered locally. For ships carrying dangerous goods according to the IMDG Code6: Medicines and
equipment already available in the IMGS list may be counted toward the Medical First Aid
Guide (MFAG) numerical requirement, if appropriate.
______________________________________________________________________________
6 Medical First Aid Guide (MfAG) for use in accidents involving dangerous goods. International Maritime Organization, London, 2004. Accepted for publication by the Journal INTERNATIONAL MARITIME HEALTH, Publisher: Medical University of Gdansk, on May 7th 2009 Ocean-going merchant vessels without a doctor onboard.
Maximum duration of travel of 3 weeks.
Crew sizes of 10, 20, 30 or 40 persons.
Only to be used in conjunction with the International Medical Guide for
Ships 3rd edition
Comments in italic letters refer to added items for ocean-going the list of medicines. Remarks on items weeks inventory for a contra-indications, doctor consulting, crew complement of unwanted effects and remarks refer to per per Per per Indications (on board ships) 100 200 300 400 - high dose (600-900mg): to reduce pain, fever, inflammation - low dose (100-150mg) to inhibit formation of blood clots in angina pectoris, myocardial infarction, stroke See pages 17-25 and 113-116, 133-135, 137, 138 - treatment of primary or recurrent herpes simplex virus infection; - may be useful for severe varicel a and herpes zoster infection (doctor should be consulted) See pages 125-126, 198-199, 256 - to raise blood pressure in anaphylaxis - to dilate airways in severe asthma or anaphylaxis See pages 145-147 45 - to treat infections responsive to this See pages 7-776, 140-144, 181-183, 204, Accepted for publication by the Journal INTERNATIONAL MARITIME HEALTH, Publisher: Medical University of Gdansk, on May 7th 2009 Quantity dependent Prophylaxis and treatment of Malaria as of acquiring malaria www.who.int/malaria/publications.html in a given port and 265-269 required only for voyages to areas where malaria transmission is a risk required only for voyages to areas where - to treat slow heart rate in myocardial - to treat organophosphate insecticide poisoning See pages 141-144, 195-207, 260, 274, 277, 281 - to treat infections responsive to this See pages 16, 141-144, 153, 160-161, 172, - to treat al ergy symptoms in hay fever, hives, al ergic dermatitis, etc. See page 145 to absorb ingested poisons. See pages 93- - to treat infections responsive to this antibiotic See pages 77, 156-157, 181-183, 195-207, 221-223, 262 and 277 asthma - to treat anaphylaxis - to treat severe al ergic reactions 100 100 to treat alcohol withdrawal. See pages - to avoid straining in patients with anal fissure and haemorrhoids - to prevent constipation caused by opioid use See pages 168-169 as recommended in IMGS3 for the specific infection See pages 195-207, 209-210, 221-223, 271-272. Accepted for publication by the Journal INTERNATIONAL MARITIME HEALTH, Publisher: Medical University of Gdansk, on May 7th 2009 area stains yel ow/green See pages 33-34 to treat severe fluid retention in lungs (pulmonary oedema) due to cardiac failure, see pages 15, 136 to treat low blood sugar (hypoglycaemia) due to insulin when oral intake is impossible and intravenous glucose cannot be given. See pages 123, 125. It is recommended to carry a glucose measuring instrument on board. delusions - to treat severe agitation and aggressiveness See pages 126-132. inflammatory skin conditions. See pages 169, 212-213, 219-221 - to reduce mild-to-moderate pain, especial y if associated with inflammation See pages 17-25. Insect repel ent lotions for One vial per person skin. Vials for personal use in areas of risk of not effective for tapeworm infection or hydatid disease See pages 281-284 pressure) - to treat artrial fibril ation (irregular or rapid heart rate) - to treat angina pectoris (chest pain) - to prevent migraine See pages 133-137 to treat infections responsive to antibiotics See pages 203-204, 214 If women on board, supply also Miconazole vaginal cream. to terminate epileptic fits. See pages 121, Accepted for publication by the Journal INTERNATIONAL MARITIME HEALTH, Publisher: Medical University of Gdansk, on May 7th 2009 - to reduce pain not relieved by other analgesics See pages 17-25. to reduce severe pain likely to last several to reverse effects of opioids, especial y in - to treat peptic ulcer disease See pages 152, 163-167 and 173 to prevent or treat dehydration, especial y - to treat nasal obstruction due to al ergies - to improve sinus drainage in sinusitis 300 400 to reduce pain and fever (but not - to treat other inflammatory conditions (on medical advice) See pages 125-126, 145-147 -to treat chapped skin. See page 212, 261 - to treat chronic bronchitis - to treat emphysema - to treat other lung diseases See pages 145-147 Can also be used for sterile eye irrigation, For sterile eye bathing and application of to treat minor eye infections; to prevent infections fol owing damage to the cornea. Accepted for publication by the Journal INTERNATIONAL MARITIME HEALTH, Publisher: Medical University of Gdansk, on May 7th 2009 Part of wound care if state of vaccination Part of wound care if state of vaccination In severe pain use morphine; See pages 17-25 to reverse excessive or unwanted effects of warfarin or related drugs. See pages 96, reconstitution of injectable drugs provided Prophylaxis against HIV infections after needle-stick injury. One tablet daily twice radio-medical advice for risk assessment in http://www.who.int/hiv/p risk of infection with ub/prophylaxis/pep_guid exposure on board . elines/en/index.html http://www.cdc.gov/mm for infection in case wr/preview/mmwrhtml/rr appliance for the administration of oxygen See pages 4-5. If no additional equipment from the MFAG on board consider to increase amount of oxygen to 4 X 10l and flow meter with tubes such that ship's industrial oxygen can also Accepted for publication by the Journal INTERNATIONAL MARITIME HEALTH, Publisher: Medical University of Gdansk, on May 7th 2009 of choice: including simple face mask and non-rebreathing mask Oropharyngeal airway, see pages 4-5, 315 Oropharyngeal airway, see pages 4-5, 315 Mechanical aspirator, different sizes; see pages 4-5 Cannula for mouth-to-mouth resuscitation, 2. DRESSING MATERIAL AND SUTURING EQUIPMENT 2.1 or plaster strips, water resistant – slim and broad 60 cm / 90 cm my be substituted by gauze roll of smal er size Gauze dressing with non-adherent surface gauze-covered cotton pad sewn onto a cotton bandage (ambulance dressing) smal gauze-covered cotton pad sewn onto a cotton bandage (ambulance dressing) medium gauze-covered cotton pad sewn onto a cotton bandage (ambulance dressing) large Accepted for publication by the Journal INTERNATIONAL MARITIME HEALTH, Publisher: Medical University of Gdansk, on May 7th 2009 Triangular sling. See pages 43-58 and 77 Sterile sheet for burn victims. Different sizes available Otherwise use a hydrogel-burnkit. See pages 79-83 Skin adhesive for closing small wounds. See Disposable scalpels See pages 71-74, 216- Accepted for publication by the Journal INTERNATIONAL MARITIME HEALTH, Publisher: Medical University of Gdansk, on May 7th 2009 4. EXAMINATION AND MONITORING EQUIPMENT 4.1 100 100 100 100 Disposable tongue depressors 100 100 Reactive strips for urine analysis, see pages range 26°C to 42°C to differentiate between severe-moderate-mild hypothermia; see pages 343-344. Penlight (blue light) to detect damage to cornea. See pages 33-34 Use ass master copy. Should be filled in Use as master copy (see pages 455 - 461) Use as master copy (see pages 455 – 461) Ship´s identity and navigational status form Use as master copy (see pages 455 – 461) Use as master copy (see pages 455 - 461) International travel and Health, current or www.cdc.gov/travel/regionalmalaria/index.html See Page 266 5. EQUIPMENT FOR INJECTION, INFUSION, AND CATHETERIZATION 5.1 Equipment for injection, see pages 324-329 Accepted for publication by the Journal INTERNATIONAL MARITIME HEALTH, Publisher: Medical University of Gdansk, on May 7th 2009 Equipment for injection, see pages 324-329 Equipment for injection, see pages 324-329 Equipment for subcutaneous injection, see Luer connection, 16x0.5mm (23 G or 25 G), sterile, disposable Equipment for intramuscular injection, see (19G or 21G), Luer connection, 40x0.8mm, sterile, disposable Equipment for intravenous fluid infusion, 19G, Luer-lock connection, sterile, non-recap type + mandarin Equipment for intravenous fluid infusion, 21G, Luer-lock connection, sterile, non-recap type+mandrin Equipment for infusion, see pages 324-329 type, to be used with intravenous infusion cannula lubricant, drapes, cotton swabs, skin disinfection, forceps, sterile container 6. GENERAL MEDICAL AND NURSING EQUIPMENT Accepted for publication by the Journal INTERNATIONAL MARITIME HEALTH, Publisher: Medical University of Gdansk, on May 7th 2009 Plaster-of-Paris bandages, may be omitted Plaster-of-Paris bandages, may be omitted 100 100 100 100 70% alcohol swabs for skin cleansing prior chlorine effectively. See pages 359-360. For disinfection of used instruments* and *Caution: Al items entering the skin or are in direct contact with mucous membranes should be single use (i.e. injection needles, urinary catheters. Accepted for publication by the Journal INTERNATIONAL MARITIME HEALTH, Publisher: Medical University of Gdansk, on May 7th 2009 For disinfection of contaminated surfaces, hard-surface objects and floors (non-food- cutlery, dishes, plates, glasses), see page storage and preparation area, see pages 362-365 To use against cockroaches in other areas 7. IMMOBILIZATION AND TRANSPORTATION EQUIPMENT 7.1 Mal eable splints (smal ). See pages 43-58. Mal eable splints (medium). See pages 43- Malleable splints (large). See pages 43-58. Stretcher equipment (a system for trauma management, i.e. immobilization and stretcher equipment most suited for treatment in the vessel concerned. Preferably al owing crane/helicopter lifting. See page 7 for neck immobilisation. See pages 7, 45

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