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ENG1 and Allergies
Hatchorder
Posted: Monday, March 5, 2012 8:29 PM
Joined: 05/03/2012
Posts: 7


Hi Dr Ken,

I am an ex Deck Officer with Ocean Fleets and Maersk and my 17 year old son has just had an offer from Maersk to do a Foundation Degree Deck Officer apprenticeship.

We have one small problem.  When he was 4 he had a slight reaction to a doughnut and was diagnosed as having a nut allergy.  We have managed it over the years, but it was only in 2009 that he actually had a skin prick test.  This showed a reaction to Peanuts, Hazlenuts, Walnuts and Almonds.  Of these he eats all of them except Peanuts with no adverse effects.

First of all he has NEVER had an anaphylactic shock.  In 14 years he has only ever had a slight reaction to peanuts where his mouth itches slightly, no swelling and in about 10 reactions over the years he has taken 1 piriton tablet in half of the incidents and in has become effective within 10 minutes and no further action has been needed.

His first line of defence has always been avoidance and his second is Piriton.  He has never had to use an epipen.

He has always eaten other nuts and does not avoid foodstuffs that say "May contain traces of nuts" or "May contain traces of peanuts", he eats meals out, including Inmdian and Chinese.  He has never been sick or suffered skin reactions to any exposure.

First of all I would NEVER taker a risk and let him go to sea if I thought he would have an anaphylactic shock.  I believe that by avoidance and having piriton in the event of having a slight reaction he will certainly be safe at sea.  He is more likely to be at risk in a port eating food he is uncertain of it's origins.

We have studied the wording of the Seafarer Medical Examination System and Medical
and Eyesight Standards and according to the ADG 16 - ALLERGIES guidance:

1. Based on the answers to the above questions, is there a pattern of response which indicates that a rapid life-threatening incident while at sea is reasonably foreseeable? (e.g. established allergy to peanuts that is becoming more frequent and severe)

Yes – Permanently unfit category 4 Self-treatment of life-threatening reactions using ‘epi-pen’ or other immediate treatments is not acceptable as such devices are intended as an immediate measure in situations where medical care is available and not as definitive treatments remote from care  
No and they have a strongly suspected allergy – Go to 2
No and they do not have a strongly suspected allergy – consider in relation to pattern or impairment, symptoms or alternative diagnosis

2. Do they have a pattern of response that is impairing and may lead to incapacity for work but is not life-threatening (e.g. Coeliac disease with gluten – wheat protein – sensitivity; dermatitis attributed to nickel)?

Yes and exposure to allergen can be avoided by access to suitable diet or by avoidance of exposure to sensitising agent – Restricted category 2

  • list specific items to be avoided
  • consider near coastal restriction if complete avoidance is impracticable (e.g. traces or wheat in processed foods)
  • consider time limitation if regular surveillance needed to confirm lack of worsening in reactions
  • consider restriction of not working as sole expert in a field
Yes and avoidance of exposure is impossible Permanently unfit category 4
Yes but effects can be fully controlled by self-medication. If this is by the use of topical treatment (for non-occupational dermatitis) or long term non-steroidal medications that do not have safety critical adverse effects. Case by case assessment – Fit category 1
No – trivial response or cause of allergy unlikely to be encountered at sea - Fit category 1


We believe that the answer to 1 is No

2 the answer is Yes and in the first part Category 2 with a specific mention of peanuts on his ENG1.   We do not think that "Yes
but effects can be fully controlled by self-medication." is really safe because it then gives no mention of the item that can cause irritation.

Can you tell me, have we understood it properly and will he get an ENG1 certificate?

Thank you for taking the time to read a long winded first post!

Regards

Ian

Hatchorder
Posted: Tuesday, March 6, 2012 11:13 PM
Joined: 05/03/2012
Posts: 7


Is there anyone else who has an opinion on ths?  I have spoken to two different doctors in depth and they say that it is all about interpretation on the day by the doctor who carries out the medical.

As allergies are increasing will there have to be a change in the regulations?

Whilst some people may say we are mad to even consider letting him go to sea, (comment if you would like, I wont take offence unless people become nasty).

We have dealt with this as a family for 14 years and whilst we were very particular when he was younger, we have relaxed over the years.  For example he could have a 2 finger Kit Kat but not a 4 finger Kit Kat because they are manufactured on 2 different sites and they use peanuts in the factory that produces the 4 finger Kit Kat!  He has never had a reaction to a 4 finger Kit Kat, but that is because he has never had one!  Would he eat one? Sure, but why take the risk....

Once he is at sea and the ship knows he has this problem then it is easy to cater for it.  He can avoid certain foods when it is necessary and he is certainly safe from outside influences.

So where does anyone else stand on this?

Thanks and regards

Ian

Hatchorder
Posted: Wednesday, March 7, 2012 11:25 AM
Joined: 05/03/2012
Posts: 7


Nice of you to hide behind your anonimity!

My son has coped for years with having his diet restricted because we have avoided things in the house ourselves, but he is also affected when we go out for a meal.  He cannot have Satay - it is on the menu in a restaurant - we have it if we want - he chooses something else..... he copes

If a Chef has the skills to know what is in his food then he also has the ability to communicate - all he has to do is tell my son that the meal is not safe and he will go to the Suez mess and make himself a toasted sandwich, or have a salad, or have something else, of have one of a range of other options.  He is never going to starve....

Have you noticed how many airlines no longer serve bags of peanuts on the flights?  Airlines now serve savory snacks.  The reason is that people were having anaphylactic shocks on flights because the filtration system on the air was not capable of picking out the airborne particles of the peanuts when 200 people opened a bag of nuts.  It was not people who had known anaphylaxis who were being affected but people who did not know they were anaphylactic.  At that point it was easier to stop handing out bags of peanuts rather than having the problems.

It would be nice to know if you are a skipper, chef, crew or just a troll!  I also take it you would discriminate in other ways as well? Providing you can hide behind your anonimity of course.....

Thank you for adding to the debate!

Ian

Anonymous wrote:
Give way to the next person you are too difficult for the chefs too.


Mfowles
Posted: Thursday, March 8, 2012 4:12 PM
Joined: 08/03/2012
Posts: 1


hi, i am in a very similar situation, i have been allergic to nuts since i was 6 months old, i am now 18 and have just completed my yachtmaster ocean living on yachts for up to 4 weeks at a time having to cater around my allergy. i am about to enter the superyacht industry and am worried that my eng might fail wich a will be taking at the end of this month. my allergy does not affect me in any way. i carry 2 epi-pens on me at all times but have never had a anaphlalactic attack. is this going to affect me or should i not be worried that this doctor might fail me? any advice or tips would be greatly recieved! matt.
Dr Ken
Posted: Thursday, March 8, 2012 8:00 PM
Joined: 08/07/2008
Posts: 23


  • This cannot prejudge an examining doctor's opinion which would be based on a face to face interview and examination but this correspondence touches on a number of factors which are covered in the guidance to MCA doctors.
    In particular, a secure diagnosis from a relevant medical specialist (with relevant reports being made available to the MCA doctor), the severity of the impairment, an increasing severity, or not, with successive episodes, any need for medication to deal with an attack and particularly steroid treatment or adrenaline (Epipen - epinephrine).
  • Some people carry an Epipen "just in case" and this is of less concern than a proven requirement to need an Epipen which would be a cause for concern because "their adequacy in the absence of rapid medical support  will usually mean that they are not acceptable as mainstay of management at sea". MCA Medical Courses do address the management of anaphylaxis in some detail so "rapid medical support" may be nearer than imagined and the final decision on fitness will need to take account of this resource.
  • Time-limited certificates, with a restriction to avoid exposure to a particular agent such as peanuts, might be regarded as appropriate if the overall risk assessment justifies this - interestingly, candidates below age 18 are only entitled to a maximum 12 month certificate anyway and this automatically facilitates earlier review in younger candidates. 
  • These various considerations are intended to avoid the possibility of predictable  life-threatening allergic emergencies but life is never that simple. Last week I heard an experienced seafarer recount his experience of a serious (and first ever) anaphylactic reaction to a jellyfish sting. His life was probably saved by an Epipen in the emergency medical bag in the tender followed up by nearby on-shore support. "Best laid plans of mice and men....."


Hatchorder
Posted: Thursday, March 8, 2012 8:59 PM
Joined: 05/03/2012
Posts: 7


Dr Ken,

Thank you so much for commenting here.  It has been exceptionally helpful.

By chance we have been able to arrange a short notice ENG1 medical today in Liverpool and the examining doctor has agreed with both yourself and our findings.  She has however wanted to take advice from the MCA.  Therefore she will ring both the MCA and my sons sponsoring company before she issues the certificate as a category 2.

One fact I did not put in my original question was that when skin tests have been carried out his reaction time has gone from 30 seconds at age 4 to 8 minutes at age 14 and his last reaction was 2.3 to 3 years ago and it was treated by 1 single piriton tablet.

Matt, I do think that you will need a more complete reaction history before a doctor would consider a Cat 2.  Providing you can prove that any reaction is mild and treated by other means and that the epipen is not the mainstay of treatment and is only ther "just in case" I cannot see why you cannot get a cat 2 medical.  If however you have ever had a severe reaction, needed hospital treatment or reactions have got worse or more frequent I think you may struggle.

We now just have to wait to see what the MCA Doctors say.  Fingers crossed!

Dr Ken, I appreciate you taking the time to help.

Thanks and regards
 
Ian

Hatchorder
Posted: Monday, March 12, 2012 5:09 PM
Joined: 05/03/2012
Posts: 7


Just a partial update today.

On Thursday last week I wrote a long email to Maersk detailing all of the findings of the Doctor and my son's full medical history regarding his allergy. 

Today I got a phone call from the person responsible for his recruitment and they have said that they have absolutely no problems with him getting a category 2 ENG1 and that their offer still stands and they will still sponsor him.

Some companies have withdrawn offers in the past when people have got a category 2 on their medical so this is absolutely fabulous news.  We could not be more pleased with their response because they had 2000 applications for 55 jobs and they interviewed 150 people, so it is not as if they are short of applicants.  Thank you Maersk.

Now we are just waiting for the Doctor to come back to us with the result of the discussion with the MCA.

Still got everything crossed here.......

Ian.

Hatchorder
Posted: Wednesday, March 14, 2012 11:14 AM
Joined: 05/03/2012
Posts: 7


Dear Dr Ken,

We had an email late yesterday from Maersk.  They had received a phone call from the Doctor who had written to the MCA for clarification and she was able to agree with Maersk a form of words for the medical which do not restrict my son other than he must inform people of his condition.  The doctor did toy with the idea of not allowing sole charge watch keeping, but decided, on balance, that any allergy would show at the time of eating and not manifest itself hours later with a collapse into unconsciousness.

He is off to sea!

I have no idea what the MCA Doctors actually said in their letter to the Doctor.  What I do know is that the weight of evidence and the records we gave the doctor were enough for her to be able to ask the MCA to rule in the way both she and I were thinking after we had studied the ADG 16 - ALLERGIES guidance.  Whilst this is not a general ruling and the ruling was based on evidence presented, it does mean that people with things like nut allergies, providing they have never been life threatening, are able to go to sea and have a career.

I believe we were right in being open and honest, despite the roller coaster it gave us, and that the evidence presented meant that they did not ask to refer it to allergy specialists, or anyone else.  Future medicals will now be easier because the ruling has already been made and providing nothing else changes for him.

Thank you so much for your kind words and support during the last few weeks.  It has been encouraging to know that a medical professional could see that the weight of evidence pointed to the outcome we received and you made me feel like we were looking at it intelligently and getting the right conclusions.

But through all this I have to say a HUGE "Hats Off" to Maersk.  Without their support and acceptance of a Cat 2 for my son then his career with them would have been over before it started.

Thank you for your help.

Kind regards
 
Ian

For everyone else

If you have a food allergy that would have prevented you from going to sea in the past, you need to have all of the evidence to put in front of the examining Doctor.  You will need a copy of the  ADG 16 - ALLERGIES guidance to prove to the Doctor that you have understood the restrictions that your allergy pose.  However, if you have ever had an anaphylaxis in the past then I believe that you will probably not be able to gat a Cat 2.

Matt - go for it!

........but make sure you have everything evidenced including results of any skin prick tests, IgE test results etc. and be prepared for an agonising wait!

Hatchorder
Posted: Friday, March 16, 2012 5:24 PM
Joined: 05/03/2012
Posts: 7


We now have the wording that has been put on the ENG1 as well as a letter from the Doctor.

The wording on the ENG1 is:

Fit subject to restrictions as follows:
History of peanut allergy. To inform Company and Ship's Captain. To carry medication.To inform (MCA) approved Doctor in the event of future symptoms.

The letter introduces my son, describes his allergy and his treatment, details that he must carry both Piriton tablets and Epipens at all times and only restricts him from carrying out "safety Critical Work" for 12hours after taking Piriton.

This is a huge step forwards for the MCA in my mind as it basically is acknowledging that people with Epipens for food allergies can go to sea AND carry out watchkeeping duties.

I wonder if you feel the same way Dr Ken?

Thanks everyone.

Dr Ken
Posted: Saturday, March 17, 2012 12:33 PM
Joined: 08/07/2008
Posts: 23


Very pleased this has worked out well - my initial impression, as indicated above, was that the outlook is not as high-risk as it could have been with allergy and hopefully ongoing experience will reinforce the correctness of the ENG1 decision and also maybe lead to some relaxation in the future - and a good career at sea! I think the MCA guidace on Epipen remains appropriate in that any previous actual need to use one does also introduce the question of local and rapid medical support if it is needed again in the future and the availability of an Epipen is not to be regarded as the "mainstay of management at sea". A final decion on fitness in these circumstances will probably need to take account of the availability of acute medical support whether onboard or nearby. This thread has given me much food for thought and it will be interesting now to see if there are further examples around the corner - like the buses that come together after none for ages! We are teaching the Medical Care Onboard Ship course next week and I shall certainly be drawing from this thread when we look at anaphylaxis.
Cixot
Posted: Monday, September 15, 2014 10:08 AM
Joined: 15/09/2014
Posts: 1


Hi Ian

Could you let me know which Dr you used in Liverpool.

Trying to get my daughter onto the Yachts with me, similar problem with a nut allergy.


 
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