pii: sp- 00234-16
http://dx.doi.org/10.5665/sleep.5822
COMMENTARY
Obstructive Sleep Apnea and Work Accidents: Time for Action Commentary on Garbarino et al. Risk of occupational accidents in workers with obstructive sleep apnea: systematic review and meta-analysis. SLEEP 2016;39(6):1211–1218. Stefanos N. Kales, MD, MPH1,2,3; Charles A. Czeisler, MD, PhD3,4 Department of Environmental & Occupational Medicine & Epidemiology, Harvard TH Chan School of Public Health, Boston, MA; 2Occupational Medicine, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA; 3Division of Sleep Medicine, Harvard Medical School, Boston, MA; 4Division of Sleep Medicine and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, MA 1
In this issue of SLEEP, Garbarino and colleagues1 contribute a review and meta-analysis of obstructive sleep apnea (OSA) and work accidents. This important work synthesizes recent evidence regarding the dangers of untreated OSA and occupational accidents, especially vehicular crashes. Despite the recognized excess risks of motor vehicle accidents among passenger car drivers with untreated OSA,2,3 US federal and other regulatory agencies have to date largely resisted calls to mandate rigorous methods to screen transportation operators for OSA.4–8 One of the arguments used against such regulation has been the paucity of data from occupational contexts. The Garbarino paper starts to fill this void. How did we get here, and where should we go? It was not until the 1960s and 70s that researchers first formally characterized OSA and its pathophysiology as a sleep disorder with significant diurnal consequences as well as the potential for causing serious comorbidities and early death.9–14 As more cases were studied, patients with severe OSA were noted to frequently have cognitive impairment on formal testing, and most reported difficulties at work due to lower productivity and falling asleep on the job.15 Initially, OSA was a relatively uncommon diagnosis, but with better recognition, OSA rapidly became the mainstay of clinical sleep medicine practices and a major focus of sleep research. The advent of the worldwide obesity epidemic in recent decades has only further increased the prevalence of OSA. Epidemiological studies have now confirmed that OSA is associated with an increase in the risks of hypertension, heart disease, diabetes, stroke, dementia, motor vehicle crashes, and early death.3,16–19 Fortunately, the evidence also supports that adequate treatment of OSA with continuous positive airway pressure (CPAP) mitigates these risks.17–20 While OSA is a non-occupational disease, given its frequency, comorbidities, and potential to impair performance, it was inevitable that it would manifest as an important health and safety issue in the workplace as well. As the general population has become more obese, so has the workforce. In fact, important occupational groups in the US such as firefighters, police, and emergency medical service personnel have prevalence rates of obesity that match or exceed those of the general population (33% to 40%), despite physical and medical selection criteria.21,22 Additionally, about one-third of public safety officers screen at high-risk of OSA, and have been demonstrated to have elevated risks for adverse health and safety consequences.23,24 Similarly, research has documented obesity in 50% or more of US commercial drivers,25–28 and hence, studies support quite conservative estimates of OSA prevalence (21% to 28%) in this occupational group.25,28,29 Moreover, most cases SLEEP, Vol. 39, No. 6, 2016
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of OSA in the population and the workforce remain undiagnosed and thus, untreated. Therefore, excessive daytime sleepiness (EDS) related to OSA has repeatedly been implicated in major transport accidents by the US National Transportation Safety Board.30,31 OSA has also been demonstrated to have adverse impacts on employees’ healthcare costs and workplace productivity.32 Now, the Garbarino paper demonstrates consistent evidence of about a two-fold excess in the risk of occupational accidents.1 The study by Garbarino and colleagues is a meta-analysis, which is subject to the inherent strengths and weaknesses of this study design. The authors’ literature search encompassed appropriate databases and search terms, as well as articles in three additional languages beyond English. They limited the studies included to ones in which OSA was diagnosed by polysomnography or a validated questionnaire, and they excluded confounding causes of EDS, both of which decrease some of the potential for misclassification bias. Meta-analyses are always limited by their component studies, and most of those included here were of fairly low quality, including a reliance on self-reporting of accidents and as above, some including suspect cases of OSA based on questionnaire responses rather than solely on polysomnographybased OSA diagnoses. Nonetheless, the aggregate results remained robust across all analyses using polysomnography versus questionnaire-diagnosed OSA, and showed no undue influence from any single study, consistently finding that OSA roughly doubled the risk of work accidents. Moreover, some of the limitations noted above, such as accident self-reporting and potential misclassification of OSA cases and controls would actually bias the results towards the null hypothesis. Thus, it is likely that the meta-analytic findings might underestimate the magnitude of the true risks. The meta-analytic findings are also highly credible for several other reasons. The approximate doubling in the risk of workplace accidents is consistent with previous findings of an about 2.5-fold increased risk associated with OSA in a meta-analysis of primarily non-professional drivers.3 The results are highly biologically plausible given the known effects of OSA on EDS, alertness and vigilance,2 as well as past studies of other forms of sleep restriction and declines in performamnce.33–35 Interestingly, Garbarino and colleagues also noted that “Given the limited number of retrieved studies, this should be considered a preliminary finding. The analysis of subsequent, high quality studies, will give a better estimate of the association.”1 Notably, following the completion of the meta-analysis, Burks et al.36 recently published the results of Commentary—Kales and Czeisler
the first large-scale employer program to screen, diagnose, and monitor OSA treatment adherence in the U.S. trucking industry. The latter study found that drivers with OSA who did not adhere to PAP treatment had a rate of preventable crashes five-fold greater than that of the control group matched on similar driving experience. They also found that drivers with OSA who were fully compliant with the company-mandated PAP treatment had a crash rate no different than that of the control group. Thus, as predicted, the Burks study showed a greater risk based on OSA that was diagnosed exclusively by polysomnography and a focus on accidents that were serious, preventable, as well as independently and objectively documented from the employer’s safety records, as opposed to self-report. Interestingly, if all reportable accidents were considered (preventable and non-preventable), the risk in the Burks et al study dropped to approximately two-fold.36 The new findings of Garbarino and Burks are timely. The US Federal Motor Carrier Safety Administration (FMCSA) and the Federal Rail Administration (FRA) recently announced a proposed rulemaking titled: “Evaluation of Safety Sensitive Personnel for Moderate-to-Severe Obstructive Sleep Apnea,” which calls for public comments “on the costs and benefits of requiring motor carrier and rail transportation workers in safety sensitive positions who exhibit multiple risk factors for OSA to undergo evaluation…” 37 While further research on the occupational risks of OSA will always be needed and welcome, there should now be sufficient evidence for the US FMCSA and FRA, as well as regulators of other modes of public transport to take action. The new findings build on a strong base of past expert recommendations for action to mandate OSA screening among transport operators from prominent medical societies,38 the NTSB,4–7 the Medical Expert Panel of the Federal Motor Carrier Safety Administration (FMCSA),39 and the Medical Review Board of the FMCSA.40 Moreover, given that OSA is readily treatable and adequate treatment decreases accident risk as well as comorbidities,17–20 mandated OSA screening, diagnosis, treatment, and monitoring of treatment compliance among transport operators should decrease accidents,20,36 as well as improve operators’ health and productivity.32 Workplace-specific data have arrived and untreated OSA at least doubles the risk of accidents. Now, is the time for action that will improve public safety and transport operators’ health. CITATION Kales SN, Czeisler CA. Obstructive Sleep Apnea and Work Accidents: Time for Action. SLEEP 2016;39(6):1171–1173. REFERENCES 1. Garbarino S, Guglielmi O, Sanna A, Mancardi GL, Magnavita N. Risk of occupational accidents in workers with obstructive sleep apnea: systematic review and meta-analysis. Sleep 2016;39:1211–8. 2. George CF. Sleep apnea, alertness, and motor vehicle crashes. Am J Respir Crit Care Med 2007;176:954–6. 3. Tregear S, Reston J, Schoelles K, Phillips B. Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis. J Clin Sleep Med 2009;5:573–81.
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4. National Transportation Safety Board. Safety Recommendation. October 20, 2009. Accessed April 23, 2016. http://www.ntsb.gov/safety/ safety-recs/RecLetters/H09_15_16.pdf. 5. National Transportation Safety Board. Most Wanted List. Require Medical Fitness for Duty. Accessed April 23, 2016. http://www.ntsb. gov/safety/mwl/Pages/mwl8_2015.aspx. 6. National Transportation Safety Board. Most Wanted List. Reduce Fatigue-Related Accidents. Accessed April 23, 2016. http://www.ntsb. gov/safety/mwl/Pages/mwl1-2016.aspx. 7. National Transportation Safety Board. Most Wanted List. Require Medical Fitness for Duty. Accessed April 23, 2016. http://www.ntsb. gov/safety/mwl/Pages/mwl9-2016.aspx. 8. Zhang C, Berger M, Rielly A, Malhotra A, Kales SN. Obstructive sleep apnea in the workplace. In: Kryger M, Roth T, Dement WC, eds. Principles and practice of sleep medicine. Philadelphia, PA: Elsevier, 2017. 9. Gastaut H, Tassinari CA, Duron B. Polygraphic study of the episodic diurnal and nocturnal (hypnic and respiratory) manifestations of the Pickwick syndrome. Brain Res 1966;1:167–86. 10. Lugaresi E, Coccagna G, Petrella A, et al. The disorder of sleep and respiration in the Pickwick syndrome. Sist Nerv 1968;20:38–50 11. Coccagna G, Mantovani M, Brignani F, Parchi C, Lugaresi E. Continuous recording of the pulmonary and systemic arterial pressure during sleep in syndromes of hypersomnia with periodic breathing. Bull Physiopathol Respir (Nancy) 1972;8:1159–72. 12. Pack AI. Advances in sleep-disordered breathing. Am J Respir Crit Care Med 2006;173:7–15. 13. Lavie P: Who was the first to use the term Pickwickian in connection with sleepy patients? History of sleep apnoea syndrome. Sleep Med Rev 2008,12:5–17. 14. Guilleminault C, Eldridge FL, Dement WC: Insomnia with sleep apnea: a new syndrome. Science 1973;181:856–8 15. Kales A, Caldwell AB, Cadieux RJ, Vela-Bueno A, Ruch LG, Mayes SD. Severe obstructive sleep apnea--II: Associated psychopathology and psychosocial consequences. J Chron Dis 1985;38:427–34 16. Montesi SB, Bajwa EK, Malhotra A. Biomarkers of sleep apnea. Chest 2012;142:239–45. 17. Maeder MT, Schoch OD, Rickli H. A clinical approach to obstructive sleep apnea as a risk factor for cardiovascular disease. Vasc Health Risk Manag 2016;12:85–103. 18. Bauters F, Rietzschel ER, Hertegonne KB, Chirinos JA. The link between obstructive sleep apnea and cardiovascular disease. Curr Atheroscler Rep 2016;18:1. 19. Osorio RS, Gumb T, Pirraglia E, et al. Sleep-disordered breathing advances cognitive decline in the elderly. Neurology 2015;84:1964–71. 20. Tregear S, Reston J, Schoelles K, Phillips B. Continuous positive airway pressure reduces risk of motor vehicle crash among drivers with obstructive sleep apnea: systematic review and meta-analysis. Sleep 2010;33:1373–80. 21. Tsismenakis AJ, Christophi CA, Burress JW, et al. The obesity epidemic and future emergency responders. Obesity (Silver Spring) 2009;17:1648–50. 22. Poston, WS, Haddock CK, Jahnke SA, Jitnarin N, Tuley BC, Kales SN. The prevalence of overweight, obesity, and substandard fitness in a population-based firefighter cohort. J Occup Environ Med 2011;53:266–74. 23. Rajaratnam SMW, Barger LK, Lockley SW, et al. Sleep disorders, health, and safety in police officers. JAMA 2011;306:2567–78. 24. Barger LK, Rajaratnam SMW, Wang W, et al. Common sleep disorders increase risk of motor vehicle crashes and adverse health outcomes in firefighters. J Clin Sleep Med 2015;11:233–40. 25. Berger MB, Varvarigou V, Rielly A, Czeisler CA, Malhotra A, Kales SN. Employer-mandated sleep apnea screening and diagnosis in commercial drivers. J Occup Environ Med 2012;54:1017–25.
Commentary—Kales and Czeisler
26. Thiese MS, Moffitt G, Hanowski RJ, Kales SN, Porter RJ, Hegmann KT. Commercial driver medical exams: prevalence of obesity, co-morbidities and certification outcomes. J Occup Environ Med 2015;57:659–65. 27. Thiese MS, Moffitt G, Hanowski RJ, Kales SN, Porter RJ, Hegmann KT. Repeated cross-sectional assessment of commercial truck driver health. J Occup Environ Med 2015;57:1022–7. 28. Gurubhagavatula I, Maislin G, Nkwuo JE, Pack AI. Occupational screening for obstructive sleep apnea in commercial drivers. Am J Respir Crit Care Med 2004;170:371–6. 29. Kales SN, Straubel M. Obstructive sleep apnea in North American commercial drivers. Ind Health 2014;52:13–24. 30. McKay MP. Fatal consequences: obstructive sleep apnea in a train engineer. Ann Fam Med 2015;13:583–6. 31. Marcus JH, Rosekind MR. Fatigue in transportation: NTSB investigations and safety recommendations. Inj Prev 2016 Feb 29. [Epub ahead of print]. 32. Hoffman B, Wingenbach DD, Kagey AN, Schaneman JL, Kasper D. The long-term health plan and disability cost benefit of obstructive sleep apnea treatment in a commercial motorvehicle driver population. J Occup Environ Med 2010;52:473–7. 33. Folkard S, Lombardi DA, Tucker PT. Shiftwork: safety, sleepiness and sleep. Ind Health 2005;43:20–3. 34. Folkard S, Lombardi DA. Modeling the impact of the components of long work hours on injuries and “accidents.” Am J Ind Med 2006;49:953–63. 35. Van Dongen HPA, Maislin G, Mullington JM, Dinges DF. The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep 2003;2:117–26. 36. Burks SV, Anderson JE, Bombyk M, et al. Non-compliance with employer-mandated sleep apnea treatment and increased risk of serious truck crashes. Sleep 2016;39:967–75. 37. Federal Motor Carrier Safety Administration (FMCSA) and Federal Railroad Administration (FRA). Advance notice of proposed rulemaking: Evaluation of Safety Sensitive Personnel for Moderateto-Severe Obstructive Sleep Apnea. Accessed April 23, 2016. https:// www.fmcsa.dot.gov/regulations/rulemaking/2016-05396. 38. Hartenbaum N, Collop N, Rosen IM, et al. Sleep apnea and commercial motor vehicle operators: statement from the joint Task Force of the American College of Chest Physicians, American College of Occupational and Environmental Medicine, and the National Sleep Foundation. J Occup Environ Med 2006;48(9 Suppl):S4–37. 39. FMCSA Medical Expert Panel. Obstructive Sleep Apnea and Commercial Motor Vehicle Driver Safety. Accessed April 23, 2014. https://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/Sleep-MEPPanel-Recommendations-508.pdf. 40. Federal Motor Carrier Safety Administration. Medical Review Board Proceedings. January 28, 2008. Accessed August 1, 2011. Available at: http://www.mrb.fmcsa.dot.gov/012808 meeting.aspx.
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SUBMISSION & CORRESPONDENCE INFORMATION Submitted for publication May, 2016 Accepted for publication May, 2016 Address correspondence to: Stefanos N. Kales, MD, MPH, FACP, FACOEM, The Cambridge Health Alliance – Occupational Medicine, Macht Building, Suite 427, 1493 Cambridge Street, Cambridge, MA 02139; Tel: (617) 6651580; Fax: (617) 665-1672; Email: [email protected]
DISCLOSURE STATEMENT Dr. Kales has served as a medicolegal consultant and expert witness on cases involving commercial drivers and has consulted with Circadies. Dr. Czeisler has received consulting fees from or served as a paid member of scientific advisory boards for: Amazon.com, Inc.; A2Z Development Center; Bose Corporation; Boston Red Sox; Cleveland Browns; Institute of Digital Media and Child Development; Jazz Pharmaceuticals; Merck & Co. Inc.; Novartis; Purdue Pharma; Quest Diagnostics; Samsung Electronics; Teva Pharmaceutical Industries Ltd.; Koninklijke Philips Electronics, N.V.; Novartis; and Vanda Pharmaceuticals, Inc.. Dr. Czeisler owns an equity interest in Somnus Therapeutics, Inc. and Vanda Pharmaceuticals, Inc. and received royalties from McGraw Hill, Penguin Press/Houghton Mifflin Harcourt, and from Philips Respironics, Inc. for the Actiwatch-2 and Actiwatch-Spectrum devices; and has received research/education support from Cephalon Inc., Jazz Pharmaceuticals, Mary Ann and Stanley Snider through Combined Jewish Philanthropies, National Football League Charities, Optum, ResMed, Philips Respironics and the San Francisco Bar Pilots, Simmons, Schneider, Inc., and Sysco and Vanda Pharmaceuticals, Inc. Dr. Czeisler’s interests were reviewed and are managed by Brigham & Women’s Hospital and Partners HealthCare in accordance with their conflict of interest policies. The Harvard Medical School Division of Sleep Medicine (HMS/DSM), which Dr. Czeisler directs, has received unrestricted research and educational gifts and endowment funds from: Boehringer Ingelheim Pharmaceuticals, Inc., Cephalon, Inc., GlaxoSmithKline, Jazz Pharmaceuticals, Merck & Co., Inc., Pfizer, ResMed, Philips Respironics, Inc., Sanofi-Aventis, Inc., Sealy, Inc., Sepracor, Inc., Simmons, Spring Aire, Takeda Pharmaceuticals, Tempur-Pedic, Walmart, Proctor and Gamble, Optum and has received Educational Grant funding from Apria Healthcare, Cephalon, Inc., Jazz Pharmaceuticals, Philips Respironics, Takeda Pharmaceuticals, ResMed Foundation, Sanofi-Aventis, Inc., Sepracor, Inc., Teva Pharmaceutical Industries Ltd and Wake Up Narcolepsy. Dr. Czeisler is the incumbent of an endowed professorship provided to Harvard University by Cephalon, Inc. and holds a number of process patents in the field of sleep/circadian rhythms (e.g., photic resetting of the human circadian pacemaker). Since 1985, Dr. Czeisler has also served as an expert witness on various legal cases related to sleep and/or circadian rhythms, including matters related to Bombardier, Citgo, HG Energy, Michael Jackson’s mother and children, Purdue Pharma, Stric Lan LLC, Valero and matters related to commercial drivers employed by Celadon, Crete Carrier Corporation, Fedex, United Parcel Service and other commercial carriers.
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Commentary—Kales and Czeisler
http://dx.doi.org/10.5665/sleep.5822
COMMENTARY
Obstructive Sleep Apnea and Work Accidents: Time for Action Commentary on Garbarino et al. Risk of occupational accidents in workers with obstructive sleep apnea: systematic review and meta-analysis. SLEEP 2016;39(6):1211–1218. Stefanos N. Kales, MD, MPH1,2,3; Charles A. Czeisler, MD, PhD3,4 Department of Environmental & Occupational Medicine & Epidemiology, Harvard TH Chan School of Public Health, Boston, MA; 2Occupational Medicine, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA; 3Division of Sleep Medicine, Harvard Medical School, Boston, MA; 4Division of Sleep Medicine and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, MA 1
In this issue of SLEEP, Garbarino and colleagues1 contribute a review and meta-analysis of obstructive sleep apnea (OSA) and work accidents. This important work synthesizes recent evidence regarding the dangers of untreated OSA and occupational accidents, especially vehicular crashes. Despite the recognized excess risks of motor vehicle accidents among passenger car drivers with untreated OSA,2,3 US federal and other regulatory agencies have to date largely resisted calls to mandate rigorous methods to screen transportation operators for OSA.4–8 One of the arguments used against such regulation has been the paucity of data from occupational contexts. The Garbarino paper starts to fill this void. How did we get here, and where should we go? It was not until the 1960s and 70s that researchers first formally characterized OSA and its pathophysiology as a sleep disorder with significant diurnal consequences as well as the potential for causing serious comorbidities and early death.9–14 As more cases were studied, patients with severe OSA were noted to frequently have cognitive impairment on formal testing, and most reported difficulties at work due to lower productivity and falling asleep on the job.15 Initially, OSA was a relatively uncommon diagnosis, but with better recognition, OSA rapidly became the mainstay of clinical sleep medicine practices and a major focus of sleep research. The advent of the worldwide obesity epidemic in recent decades has only further increased the prevalence of OSA. Epidemiological studies have now confirmed that OSA is associated with an increase in the risks of hypertension, heart disease, diabetes, stroke, dementia, motor vehicle crashes, and early death.3,16–19 Fortunately, the evidence also supports that adequate treatment of OSA with continuous positive airway pressure (CPAP) mitigates these risks.17–20 While OSA is a non-occupational disease, given its frequency, comorbidities, and potential to impair performance, it was inevitable that it would manifest as an important health and safety issue in the workplace as well. As the general population has become more obese, so has the workforce. In fact, important occupational groups in the US such as firefighters, police, and emergency medical service personnel have prevalence rates of obesity that match or exceed those of the general population (33% to 40%), despite physical and medical selection criteria.21,22 Additionally, about one-third of public safety officers screen at high-risk of OSA, and have been demonstrated to have elevated risks for adverse health and safety consequences.23,24 Similarly, research has documented obesity in 50% or more of US commercial drivers,25–28 and hence, studies support quite conservative estimates of OSA prevalence (21% to 28%) in this occupational group.25,28,29 Moreover, most cases SLEEP, Vol. 39, No. 6, 2016
1171
of OSA in the population and the workforce remain undiagnosed and thus, untreated. Therefore, excessive daytime sleepiness (EDS) related to OSA has repeatedly been implicated in major transport accidents by the US National Transportation Safety Board.30,31 OSA has also been demonstrated to have adverse impacts on employees’ healthcare costs and workplace productivity.32 Now, the Garbarino paper demonstrates consistent evidence of about a two-fold excess in the risk of occupational accidents.1 The study by Garbarino and colleagues is a meta-analysis, which is subject to the inherent strengths and weaknesses of this study design. The authors’ literature search encompassed appropriate databases and search terms, as well as articles in three additional languages beyond English. They limited the studies included to ones in which OSA was diagnosed by polysomnography or a validated questionnaire, and they excluded confounding causes of EDS, both of which decrease some of the potential for misclassification bias. Meta-analyses are always limited by their component studies, and most of those included here were of fairly low quality, including a reliance on self-reporting of accidents and as above, some including suspect cases of OSA based on questionnaire responses rather than solely on polysomnographybased OSA diagnoses. Nonetheless, the aggregate results remained robust across all analyses using polysomnography versus questionnaire-diagnosed OSA, and showed no undue influence from any single study, consistently finding that OSA roughly doubled the risk of work accidents. Moreover, some of the limitations noted above, such as accident self-reporting and potential misclassification of OSA cases and controls would actually bias the results towards the null hypothesis. Thus, it is likely that the meta-analytic findings might underestimate the magnitude of the true risks. The meta-analytic findings are also highly credible for several other reasons. The approximate doubling in the risk of workplace accidents is consistent with previous findings of an about 2.5-fold increased risk associated with OSA in a meta-analysis of primarily non-professional drivers.3 The results are highly biologically plausible given the known effects of OSA on EDS, alertness and vigilance,2 as well as past studies of other forms of sleep restriction and declines in performamnce.33–35 Interestingly, Garbarino and colleagues also noted that “Given the limited number of retrieved studies, this should be considered a preliminary finding. The analysis of subsequent, high quality studies, will give a better estimate of the association.”1 Notably, following the completion of the meta-analysis, Burks et al.36 recently published the results of Commentary—Kales and Czeisler
the first large-scale employer program to screen, diagnose, and monitor OSA treatment adherence in the U.S. trucking industry. The latter study found that drivers with OSA who did not adhere to PAP treatment had a rate of preventable crashes five-fold greater than that of the control group matched on similar driving experience. They also found that drivers with OSA who were fully compliant with the company-mandated PAP treatment had a crash rate no different than that of the control group. Thus, as predicted, the Burks study showed a greater risk based on OSA that was diagnosed exclusively by polysomnography and a focus on accidents that were serious, preventable, as well as independently and objectively documented from the employer’s safety records, as opposed to self-report. Interestingly, if all reportable accidents were considered (preventable and non-preventable), the risk in the Burks et al study dropped to approximately two-fold.36 The new findings of Garbarino and Burks are timely. The US Federal Motor Carrier Safety Administration (FMCSA) and the Federal Rail Administration (FRA) recently announced a proposed rulemaking titled: “Evaluation of Safety Sensitive Personnel for Moderate-to-Severe Obstructive Sleep Apnea,” which calls for public comments “on the costs and benefits of requiring motor carrier and rail transportation workers in safety sensitive positions who exhibit multiple risk factors for OSA to undergo evaluation…” 37 While further research on the occupational risks of OSA will always be needed and welcome, there should now be sufficient evidence for the US FMCSA and FRA, as well as regulators of other modes of public transport to take action. The new findings build on a strong base of past expert recommendations for action to mandate OSA screening among transport operators from prominent medical societies,38 the NTSB,4–7 the Medical Expert Panel of the Federal Motor Carrier Safety Administration (FMCSA),39 and the Medical Review Board of the FMCSA.40 Moreover, given that OSA is readily treatable and adequate treatment decreases accident risk as well as comorbidities,17–20 mandated OSA screening, diagnosis, treatment, and monitoring of treatment compliance among transport operators should decrease accidents,20,36 as well as improve operators’ health and productivity.32 Workplace-specific data have arrived and untreated OSA at least doubles the risk of accidents. Now, is the time for action that will improve public safety and transport operators’ health. CITATION Kales SN, Czeisler CA. Obstructive Sleep Apnea and Work Accidents: Time for Action. SLEEP 2016;39(6):1171–1173. REFERENCES 1. Garbarino S, Guglielmi O, Sanna A, Mancardi GL, Magnavita N. Risk of occupational accidents in workers with obstructive sleep apnea: systematic review and meta-analysis. Sleep 2016;39:1211–8. 2. George CF. Sleep apnea, alertness, and motor vehicle crashes. Am J Respir Crit Care Med 2007;176:954–6. 3. Tregear S, Reston J, Schoelles K, Phillips B. Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis. J Clin Sleep Med 2009;5:573–81.
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4. National Transportation Safety Board. Safety Recommendation. October 20, 2009. Accessed April 23, 2016. http://www.ntsb.gov/safety/ safety-recs/RecLetters/H09_15_16.pdf. 5. National Transportation Safety Board. Most Wanted List. Require Medical Fitness for Duty. Accessed April 23, 2016. http://www.ntsb. gov/safety/mwl/Pages/mwl8_2015.aspx. 6. National Transportation Safety Board. Most Wanted List. Reduce Fatigue-Related Accidents. Accessed April 23, 2016. http://www.ntsb. gov/safety/mwl/Pages/mwl1-2016.aspx. 7. National Transportation Safety Board. Most Wanted List. Require Medical Fitness for Duty. Accessed April 23, 2016. http://www.ntsb. gov/safety/mwl/Pages/mwl9-2016.aspx. 8. Zhang C, Berger M, Rielly A, Malhotra A, Kales SN. Obstructive sleep apnea in the workplace. In: Kryger M, Roth T, Dement WC, eds. Principles and practice of sleep medicine. Philadelphia, PA: Elsevier, 2017. 9. Gastaut H, Tassinari CA, Duron B. Polygraphic study of the episodic diurnal and nocturnal (hypnic and respiratory) manifestations of the Pickwick syndrome. Brain Res 1966;1:167–86. 10. Lugaresi E, Coccagna G, Petrella A, et al. The disorder of sleep and respiration in the Pickwick syndrome. Sist Nerv 1968;20:38–50 11. Coccagna G, Mantovani M, Brignani F, Parchi C, Lugaresi E. Continuous recording of the pulmonary and systemic arterial pressure during sleep in syndromes of hypersomnia with periodic breathing. Bull Physiopathol Respir (Nancy) 1972;8:1159–72. 12. Pack AI. Advances in sleep-disordered breathing. Am J Respir Crit Care Med 2006;173:7–15. 13. Lavie P: Who was the first to use the term Pickwickian in connection with sleepy patients? History of sleep apnoea syndrome. Sleep Med Rev 2008,12:5–17. 14. Guilleminault C, Eldridge FL, Dement WC: Insomnia with sleep apnea: a new syndrome. Science 1973;181:856–8 15. Kales A, Caldwell AB, Cadieux RJ, Vela-Bueno A, Ruch LG, Mayes SD. Severe obstructive sleep apnea--II: Associated psychopathology and psychosocial consequences. J Chron Dis 1985;38:427–34 16. Montesi SB, Bajwa EK, Malhotra A. Biomarkers of sleep apnea. Chest 2012;142:239–45. 17. Maeder MT, Schoch OD, Rickli H. A clinical approach to obstructive sleep apnea as a risk factor for cardiovascular disease. Vasc Health Risk Manag 2016;12:85–103. 18. Bauters F, Rietzschel ER, Hertegonne KB, Chirinos JA. The link between obstructive sleep apnea and cardiovascular disease. Curr Atheroscler Rep 2016;18:1. 19. Osorio RS, Gumb T, Pirraglia E, et al. Sleep-disordered breathing advances cognitive decline in the elderly. Neurology 2015;84:1964–71. 20. Tregear S, Reston J, Schoelles K, Phillips B. Continuous positive airway pressure reduces risk of motor vehicle crash among drivers with obstructive sleep apnea: systematic review and meta-analysis. Sleep 2010;33:1373–80. 21. Tsismenakis AJ, Christophi CA, Burress JW, et al. The obesity epidemic and future emergency responders. Obesity (Silver Spring) 2009;17:1648–50. 22. Poston, WS, Haddock CK, Jahnke SA, Jitnarin N, Tuley BC, Kales SN. The prevalence of overweight, obesity, and substandard fitness in a population-based firefighter cohort. J Occup Environ Med 2011;53:266–74. 23. Rajaratnam SMW, Barger LK, Lockley SW, et al. Sleep disorders, health, and safety in police officers. JAMA 2011;306:2567–78. 24. Barger LK, Rajaratnam SMW, Wang W, et al. Common sleep disorders increase risk of motor vehicle crashes and adverse health outcomes in firefighters. J Clin Sleep Med 2015;11:233–40. 25. Berger MB, Varvarigou V, Rielly A, Czeisler CA, Malhotra A, Kales SN. Employer-mandated sleep apnea screening and diagnosis in commercial drivers. J Occup Environ Med 2012;54:1017–25.
Commentary—Kales and Czeisler
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SLEEP, Vol. 39, No. 6, 2016
SUBMISSION & CORRESPONDENCE INFORMATION Submitted for publication May, 2016 Accepted for publication May, 2016 Address correspondence to: Stefanos N. Kales, MD, MPH, FACP, FACOEM, The Cambridge Health Alliance – Occupational Medicine, Macht Building, Suite 427, 1493 Cambridge Street, Cambridge, MA 02139; Tel: (617) 6651580; Fax: (617) 665-1672; Email: [email protected]
DISCLOSURE STATEMENT Dr. Kales has served as a medicolegal consultant and expert witness on cases involving commercial drivers and has consulted with Circadies. Dr. Czeisler has received consulting fees from or served as a paid member of scientific advisory boards for: Amazon.com, Inc.; A2Z Development Center; Bose Corporation; Boston Red Sox; Cleveland Browns; Institute of Digital Media and Child Development; Jazz Pharmaceuticals; Merck & Co. Inc.; Novartis; Purdue Pharma; Quest Diagnostics; Samsung Electronics; Teva Pharmaceutical Industries Ltd.; Koninklijke Philips Electronics, N.V.; Novartis; and Vanda Pharmaceuticals, Inc.. Dr. Czeisler owns an equity interest in Somnus Therapeutics, Inc. and Vanda Pharmaceuticals, Inc. and received royalties from McGraw Hill, Penguin Press/Houghton Mifflin Harcourt, and from Philips Respironics, Inc. for the Actiwatch-2 and Actiwatch-Spectrum devices; and has received research/education support from Cephalon Inc., Jazz Pharmaceuticals, Mary Ann and Stanley Snider through Combined Jewish Philanthropies, National Football League Charities, Optum, ResMed, Philips Respironics and the San Francisco Bar Pilots, Simmons, Schneider, Inc., and Sysco and Vanda Pharmaceuticals, Inc. Dr. Czeisler’s interests were reviewed and are managed by Brigham & Women’s Hospital and Partners HealthCare in accordance with their conflict of interest policies. The Harvard Medical School Division of Sleep Medicine (HMS/DSM), which Dr. Czeisler directs, has received unrestricted research and educational gifts and endowment funds from: Boehringer Ingelheim Pharmaceuticals, Inc., Cephalon, Inc., GlaxoSmithKline, Jazz Pharmaceuticals, Merck & Co., Inc., Pfizer, ResMed, Philips Respironics, Inc., Sanofi-Aventis, Inc., Sealy, Inc., Sepracor, Inc., Simmons, Spring Aire, Takeda Pharmaceuticals, Tempur-Pedic, Walmart, Proctor and Gamble, Optum and has received Educational Grant funding from Apria Healthcare, Cephalon, Inc., Jazz Pharmaceuticals, Philips Respironics, Takeda Pharmaceuticals, ResMed Foundation, Sanofi-Aventis, Inc., Sepracor, Inc., Teva Pharmaceutical Industries Ltd and Wake Up Narcolepsy. Dr. Czeisler is the incumbent of an endowed professorship provided to Harvard University by Cephalon, Inc. and holds a number of process patents in the field of sleep/circadian rhythms (e.g., photic resetting of the human circadian pacemaker). Since 1985, Dr. Czeisler has also served as an expert witness on various legal cases related to sleep and/or circadian rhythms, including matters related to Bombardier, Citgo, HG Energy, Michael Jackson’s mother and children, Purdue Pharma, Stric Lan LLC, Valero and matters related to commercial drivers employed by Celadon, Crete Carrier Corporation, Fedex, United Parcel Service and other commercial carriers.
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