Regulatory Screening for Obstructive Sleep Apnea in Safety Sensitive Positions

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Because sleep apnea is a relatively common medical condition which, if untreated, contributes to daytime sleepiness and impaired job performance (2), public policy suggests that certain industries directly affecting public safety screen employees in safety-sensitive positions for sleep apnea or other fatigue-enhancing sleep disorders. Thus, each of the air, rail, ferry, distance trucking, and nuclear power industries have or propose regulatory fitness for duty programs addressing OSA.

The National Transportation Safety Board (NTSB) has issued three investigation reports finding that the undiagnosed or untreated OSA of a train or ship operator contributed to the subject incident (104). The latest, in 2004, involved a 2001 collision of two trains arising from the crewmembers' fatigue caused primarily by the engineer's untreated and the conductor's insufficiently treated OSA (105). The 2004 NTSB Report recommended that the Federal Railroad Administration (FRA) take remedial steps regarding employee fatigue (106), and the FRA issued its Safety Advisory 2004-04 on September 21, 2004 in response. The Advisory suggests that railroads adopt procedures to recognize sleep disorders, screen employees, and permit impaired persons to perform safety-sensitive tasks only after proper treatment (107).

Federal regulations require that only physically fit persons are eligible to operate a commercial motor vehicle in interstate commerce (108). Persons are considered physically fit if they obtain medical certification from a physician certifying that the applicant does not have an established medical history or clinical diagnosis of, among other ailments, a respiratory dysfunction or other condition which is likely to cause loss of consciousness or any other loss of ability to control a commercial motor vehicle safely (109). The current Medical Examination Form, updated in 2000, makes specific inquiry whether the applicant suffers from "sleep disorders, pauses in breathing while asleep, daytime sleepiness, (or) loud snoring (110)."

In 1991, the Federal Motor Carrier Safety Administration published advisory criteria to assist medical examiners determine a driver's physical qualifications for commercial driving. The guidance regarding pulmonary/respiratory disorders identifies OSA as a condition which, if untreated, renders applicants unqualified to operate a commercial vehicle:

Individuals with suspected or untreated sleep apnea (symptoms of snoring and hyper-somnolence) should be considered medically unqualified to operate a commercial vehicle until the diagnosis has been dispelled or the condition has been treated successfully. In addition, as a condition of continuing qualification, commercial drivers who are being treated for sleep apnea should agree to continue uninterrupted therapy as long as they maintain their commercial driver's license. They should also undergo yearly multiple sleep latency testing (MSLT) (111).

Guidance respecting seizures, epilepsy and interstate commercial driving reaches a similar conclusion as to chronic sleep apnea:

Patients with sleep apnea syndrome having symptoms of excessive daytime somnolence cannot take part in interstate driving, because they likely will be involved in hazardous driving and accidents resulting from sleepiness. Even if these patients do not have the sleep attacks, they suffer from daytime fatigue and tiredness. These symptoms will be compounded by the natural fatigue and monotony associated with the long hours of driving, thus causing increased vulnerability to accidents. Therefore, those patients who are not on any treatment and are suffering from symptoms related to EDS should not be allowed to participate in interstate driving. Those patients with sleep apnea syndrome whose symptoms (e.g., EDS, fatigue, etc.) can be controlled by surgical treatment, for example, permanent tracheostomy, may be permitted to drive after three-month period free of symptoms, provided there is constant medical supervision. Laboratory studies (e.g., polysomnographic and MSLTs) must be performed to document absence of EDS and sleep apnea (112).

As to pilots, the Federal Aviation Administration Guide for Aviation Medical Examiners provides that any degree of sleep apnea is disqualifying for medical certification for all classes of pilots (113). However, aviation medical examiners may reissue a pilot's medical certificate without administrative appeal if the pilot presents a current report of a treating physician that the pilot's OSA treatment therapy has eliminated symptoms of the disease along with specific comments regarding the pilot's daytime sleepiness (114).

In 1989, the Nuclear Regulatory Commission (NRC) adopted its first Fitness for Duty Program focusing on detection of drug and alcohol impairments on personnel with access to protected areas of nuclear power reactors licensed by the NRC (115). Congressmen and others petitioned the NRC to expand the regulations to expand the program to include screening for sleep apnea and other disorders. The NRC published proposed rules to that effect in August 2005 (116).

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