COVID-19 and French Medical Maritime Teleconsultation
Introduction
On March 11, 2020, the World Health Organization declared that the coronavirus disease 2019 (COVID-19) epidemic had reached pandemic proportions, impacting health services and the world’s economy.1 The maritime sector has not been spared.2,3 Within the context of its role described in the International Health Regulations,4 the Tele-Medical Assistance Service (TMAS) has witnessed a sudden surge in maritime medical consultations (65% increase in activity during March 2020 compared with the same month in the previous year). The purpose of this study was to describe the calls handled by the TMAS in relation to the COVID-19 epidemic.
Methods
Setting
The study was conducted by the French TMAS, a telemedicine center for ships across the globe, listing 4,979 consultations for 2,145 patients in 2019. The TMAS offers a 24-h emergency physician consultation and is part of a teaching hospital affiliated to Toulouse University (Toulouse Purpan Hospital, France).
Medical Assistance at Sea was set up in France in 1983 in accordance to a government decision, updated in 2011.5 The French protocol involves three partners: (1) French TMAS, (2) Maritime Rescue Coordination Centre (MRCC), and (3) Medical Maritime Coordination Service (SCMM) (Fig. 1). The captain is officially “responsible for medical care on board,” and as such he must examine the patient, collect any symptom, and medical data before calling French TMAS and transmit the results to the physician.
Fig. 1. Map of French Medical Assistance at Sea. CROSS = MRCC; SCMM = Medical Maritime Coordination Service; CCMM = French TMAS to Toulouse City. MRCC, Maritime Rescue Coordination Centre; TMAS, Tele-Medical Assistance Service.
In our institution, in 75% of the calls, the patient is supported, treated, and observed aboard thanks to repeated calls. In case the teleconsultation suggests that maintaining the patient on board is inappropriate, the French TMAS physician will give the captain the advice to organize the patient evacuation. Following the French TMAS advice, MRCC will organize evacuation together with the associated SCMM. The mission of SCMM is to provide the medical team involved in the evacuation, and to organize land rescue and reception of the patient in the appropriate hospital.
Study Design
Patient data were analyzed retrospectively during March and April 2020 by the TMAS of Toulouse University Hospital. Sixty-one medical records were collated.
In accordance with French Medical Ethics, patients were told that their encrypted data would be used for the study. According to French Ethics and Regulatory Legislation (Public Health Code), retrospective studies based on the exploitation of standard treatment data should not be submitted to an Ethics Committee but declared or covered by the reference methodology of the French National Commission for Informatics and Liberties (CNIL) (French Data Protection Agency). Personal and medical data were collected and processed electronically to analyze research results. Toulouse University Hospital agreed to comply with reference methodology MR-004 of the French National Commission for Informatics and Liberties (CNIL). After evaluation and validation by the Data Protection Officer and pursuant to the General Data Protection Regulation*, this study satisfies all of the relevant criteria, and is included in the Retrospective Study Register of Toulouse University Hospital and covered by MR-004 (CNIL number: 2206723 v 0).
This study was approved by local committee of Toulouse University Hospital under the RnIPH number 2020-116, stating that ethical requirement were met in full in the aforementioned report.
*Regulation (EU) 2016/679 of the European Parliament and of the Council of April 27, 2016.
Data Collection
All calls to the French TMAS are logged in a specific dedicated database (AppliCCMM®). During the epidemic, between March and April 2020, in particular, TMAS doctors coded all records linked to COVID as “influenza due to an unidentified virus.”
The data were extracted using this diagnostic coding. Anonymized records containing data relating to the patients’ age, gender, nationality, role on board, type of ship, navigation zone, reason for the teleconsultation, patient’s symptoms, whether or not a COVID test had been conducted (CRP: C-reactive protein) and treatment. The data were analyzed in two groups depending on the reason for the teleconsultation: teleconsultation for suspected COVID patients (i.e., presenting compatible symptoms), teleconsultation for non-COVID patients but the call for whom was nevertheless linked to the COVID epidemic (contact case, no backup, shortage of treatment, barrier measures, etc.).
Data Analysis
Data were automatically downloaded in a Microsoft Excel 2007 Spreadsheet (Microsoft Corporation, Redmond, WA). Statistical analysis was carried out using the Microsoft Excel 2007 Spreadsheet. Numerical data were expressed in terms of frequency and percentage. Measured data were expressed in terms of mean plus standard deviation and median with interquartile ranges.
Results
Between March and April 2020, the TMAS registered 378 records, taking all diseases into account (215 records in March and 163 records in April). Of these 378 records, 61 (16%) were COVID related (45 in March and 16 in April). Fifty-one of these records involved suspected COVID patients and 10 records were epidemic-related problems with no suspected cases. There were between 1 and 13 calls for each record, averaging 4 ± 4 calls.
Sociodemographic Data
Of the 61 medical records, 54 (89%) were for men and 7 (11%) for women. Their average age was 41 ± 13 years (Table 1). The population comprised 15 nationalities (Table 2). Most patients were French (n = 34; 56%) followed by Filipinos (n = 7; 11%). Twenty-five patients (41%) were on board passenger ships (ferries and ocean liners), 23 patients (37%) were on merchant ships, 7 patients (12%) were on fishing boats, and 6 patients (10%) were on pleasure boats. There were 49 professional sailors (80%) and 12 passengers or recreational sailors (20%).
| CHARACTERISTICS | VALUES |
|---|---|
| (n = 61) | |
| Mean age (SD) | 41 (13) |
| Gender | |
| Male, n (%) | 54 (89) |
| Function | |
| Sailors, n (%) | 26 (43) |
| Officers, n (%) | 12 (20) |
| Others professional seaman, n (%) | 11 (18) |
| Recreational sailors, n (%) | 7 (11) |
| Passengers, n (%) | 5 (8) |
| Type of ship | |
| Passenger ships, n (%) | 25 (41) |
| Ferries | 11 (18) |
| Ocean liners | 14 (23) |
| Merchant ships, n (%) | 23 (37) |
| Fishing vessels, n (%) | 7 (12) |
| Pleasure craft, n (%) | 6 (10) |
| NATIONALITY | VALUES |
|---|---|
| (n = 61) | |
| French, n (%) | 34 (56) |
| Filipino, n (%) | 7 (11) |
| Swedish, n (%) | 2 (3) |
| Polish, n (%) | 2 (3) |
| American, n (%) | 2 (3) |
| English, n (%) | 2 (3) |
| Portuguese, n (%) | 1 (1) |
| Nigerian, n (%) | 1 (1) |
| Romanian, n (%) | 1 (1) |
| South African, n (%) | 1 (1) |
| Togolese, n (%) | 1 (1) |
| Belgian, n (%) | 1 (1) |
| Honduran, n (%) | 1 (1) |
| Colombian, n (%) | 1 (1) |
| Indian, n (%) | 1 (1) |
| Ukrainian, n (%) | 1 (1) |
| Australian, n (%) | 1 (1) |
| Indonesian, n (%) | 1 (1) |
Description of Calls for Suspected Cases of COVID-19
Of the 51 suspected COVID-19 patients, 45 presented fever at the time of the initial call (88%) and 39 cough (76%). The other symptoms are described in Table 3.
| SYMPTOMS | VALUES |
|---|---|
| Fever, n (%) | 45 (88) |
| Cough, n (%) | 39 (76) |
| Respiratory distress, n (%) | 9 (15) |
| Headaches, n (%) | 8 (13) |
| Diarrhea, n (%) | 1 (2) |
| Loss of smell, n (%) | 1 (2) |
| Loss of taste, n (%) | 1 (2) |
TMAS doctors prescribed paracetamol for 24 patients (47%), antibiotics (amoxicillin and clavulanic acid) for 5 patients (10%) due to suspected bronchial superinfection, and antitussive agents for 1 patient (2%). Twenty-three patients (45%) were not given a prescription by the TMAS doctor, but 13 of them (25%) were attended to by a physician on board.
The vessels were within French territorial waters in 20 cases (40%) and outside in 31 cases (60%). On close-out, 33 patients were being treated on board (65%), 10 patients had disembarked (20%), 1 patient had disembarked after being rerouted (2%), and 7 had been evacuated (13%).
With regard to the CRP-COVID test, all 13 patients were tested (25%) in France, with 12 positive tests (24%) and 1 negative test (1%) being recorded.
TMAS doctors were confronted with six operational difficulties when treating these patients (five evacuations were refused by the land authorities, one COVID classification not recognized by the land authorities).
Description of Epidemic-Related Calls with no Suspected Cases
The 10 epidemic-related calls with no suspected cases involved 6 patients who had stopped treatment due to a shortage of medication, 1 patient reporting a psychiatric problem relating to isolation and 3 cases followed up as contact cases.
Discussion
Within the scope of the COVID-19 epidemic, telemedicine is a key factor in slowing down viral transmission through compliance with “social distancing” rules.6 It reduces person-to-person contact. For COVID-19 patients or those who think they may be infected, telemedicine assists in remote evaluations and prescriptions. For those who are not infected with COVID-19, telemedicine ensures practical access to routine treatment without any risk of exposure in a hospital or medical waiting room setting. It has also been stepped up in community medicine during the pandemic, with teleconsultations in France increasing from 40,000 in February 2020 to 1 million during the first week of April 2020.7
By definition, the TMAS is a tried and tested telemedicine service (in existence for 35 years), which has been contacted extensively by sailors during this difficult period. Teleconsultations have allowed suspected COVID patients to be treated and monitored long term on board ship to identify any complications. Thanks to teleconsultations, conditions traditionally treated on land have been managed on board as the conventional option proved impossible when disembarking was not authorized in some countries around the globe (mandatory quarantine).8
Telemedicine nevertheless has its limitations. Some consultations require physical examinations that are difficult to conduct remotely or several days’ medication and oxygen therapy, which are not available on board. Similarly, scans or COVID tests cannot be carried out remotely. This is precisely where it becomes difficult to quarantine sailors in isolation9 or without backup.10
To respond to calls about suspect COVID-19 patients, TMAS doctors have relied on their telemedicine experience and official guidelines for diagnosing suspected cases on board ship. This information gradually became more detailed as the epidemic intensified.11,12 Doctors have been constantly adapting. At the same time, they have been involved in drafting French procedures12 in line with the Ebola epidemic.13
If we look at the symptoms presented by the patients, they match those described in the literature with most patients experiencing fever and cough.14,15 The distribution of nationalities is the same as in previous publications, with French and Filipino patients dominating the scene.16
In contrast, teleconsultations have allowed doctors to explain isolation and barrier measures to sailors. Some studies have shown that isolation can have negative psychological repercussions and impact sleeping disorders.17 As far as the TMAS is concerned, doctors have only encountered a few psychological complications (only 1 in the 2 months studied). They were assisted in the management of this case by the Psychological Assistance Resource Centre based at Saint Nazaire.18
Another specific feature of this epidemic from a maritime perspective has been the management of suspected COVID patients on cruise ships. Several publications have highlighted the difficulties in deciding whether to disembark patients or treat them on board. The evacuation of seriously ill patients to countries with already saturated intensive care units has been very complex.19
Limitations
It may not be feasible to generally extrapolate the study results to other teleconsultation services. Nevertheless, this is the first study to be published in this particular setting and we believe it may add valuable information to the literature.
Conclusions
As a French reference center, the French TMAS has been affected by the COVID-19 epidemic in the same way as all health departments. However, it has been able to contribute to telemedicine per se and to logistical and operational strategies.
Authors’ Contributions
B.F., S.A., and R.P. helped to draft the article and to critically review its intellectual content. They have approved the final version to be submitted.
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received.
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