Saving Lives or Saving Dollars: The Trump Administration Rescinds Plans to Require Sleep Apnea Testing in Commercial Transportation Operators

In another move favoring business interests and against the common good, the Trump administration’s Department of Transportation announced recently that they are rescinding plans to require testing for obstructive sleep apnea (OSA) in train and commercial motor vehicle operators (1). As exemplified by its withdrawal from the Paris climate accords, this decision is another example of how the current administration disregards scientific findings and present-day events in establishing policy that will be detrimental to Americans.

Let us step back for a moment and briefly review the evidence that the Trump administration has ignored.

• It is well established that obstructive sleep apnea (OSA) can result in daytime sleepiness (2) and that sleepiness is detrimental to safe operation of a train or motor vehicle.
• Many studies have established that persons with OSA have an increased risk of motor vehicle crashes (3).
• Studies in commercial truck drivers have observed that this population has a high prevalence of OSA (4).
• It is estimated that OSA costs the American economy $150 billion annually (5).
• There now are relatively easy and inexpensive protocols to screen high risk individuals for OSA (4).
• Obstructive sleep apnea is a treatable condition, and treatment mitigates OSA impairment in sleepiness and reduces crash risk (6,7). In contrast, non-compliance with treatment is associated with a five-fold increase in crash risk (6).
• The costs of diagnosis and treatment are much lower than the costs that ensue when OSA persists untreated (5). For example, significant healthcare savings result from successful treatment of truck drivers (8).
• Failure to recognize and treat OSA has resulted in several high-profile transportation accidents. The following are some recent incidents:
  • September 2016: A commuter rail train slammed into the station at Hoboken, NJ killing a female bystander and leaving a child without a mother. The engineer had undiagnosed severe OSA (9).
  • December 2013: A Metro North commuter rail engineer fell asleep and his train sped around a curve resulting in a crash that killed 4 and injured 70 (10). The National Transportation Safety Board determined that undiagnosed severe OSA was the probable cause of the accident. The lack of a policy which required sleep disorder screening was further determined to be a contributing factor (11).
  • September 2013: A Greyhound bus overturned on Interstate 70 because the driver fell asleep resulting in multiple injuries. The driver was later found to have untreated OSA (12).
  • June 2009: A tractor-trailer traveling at a high speed did not see stopped cars ahead on Interstate 44 resulting in a crash that killed 10 and injured 6. It was later determined that the truck driver had mild OSA contributing to fatigue (13).

Despite the weight of the aforementioned evidence, the current administration has chosen to ignore it in favor of letting private industry regulate itself implying the current regulations are sufficient. As illustrated by the incidents cited above, recent events have proven them wrong. As Sir Winston Churchill once said “Those who fail to learn from history are doomed to repeat it”. Continuing with the current policy will inevitably result in further preventable disasters and more loss of life.

What can be done? At the federal level, one should consider advocating to your own congressional representatives for reconsideration of this poorly considered policy. On a personal level, federal policy is ultimately guided by the “ballot box”, which is something to consider for the next election. Finally, be aware that the next time you are driving down the interstate, the truck or bus driver approaching you from behind may have untreated OSA!

Stuart F. Quan, M.D.^1,2, Laura K. Barger, Ph.D.¹, Matthew D. Weaver, Ph.D.¹, and Charles A. Czeisler, Ph.D., M.D.¹

¹Division of Sleep and Circadian Disorders

Brigham and Women’s Hospital

Harvard Medical School, Boston, MA USA

²Asthma and Airway Disease Research Center

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Federal Register. Evaluation of safety sensitive personnel for moderate-to-severe obstructive sleep apnea. Last updated: 2017. Available at: https://federalregister.gov/d/2017-16451 (Accessed: August 10, 2017)
2. Committee on Sleep Medicine and Research Board on Health Sciences Policy. Sleep disorders and Sleep Deprivation--An Unmet Public Health Problem. Washington, D.C.: National Academies Press, 2006; 404.
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 Dec 15;5(6):573-81. [PubMed]
4. Kales SN, Straubel MG.Obstructive sleep apnea in North American commercial drivers. Ind Health. 2014;52(1):13-24. [CrossRef] [PubMed]
5. Anonymous. Hidden health crisis costing America billions. Underdiagnosing and undertreating obstructive sleep apnea draining healthcare system. Last updated: 2016. Available at: http://www.aasmnet.org/sleep-apnea-economic-impact.aspx (Accessed: August 15, 2017)
6. Burks SV, Anderson JE, Bombyk M, et al. Nonadherence with employer-mandated sleep apnea treatment and increased risk of serious truck crashes. Sleep. 2016 May 1;39(5):967-75. [CrossRef] [PubMed]
7. 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 Oct;33(10):1373-80. [CrossRef] [PubMed]
8. 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 motor vehicle driver population. J Occup Environ Med. 2010 May;52(5):473-7. [CrossRef] [PubMed]
9. Anonymous Hoboken train crash investigation hampered by heavy damage. CBS News. 2016; Available at: http://www.cbsnews.com/news/hoboken-train-crash-investigation-hampered-heavy-damage/ (Accessed: August 15, 2017)
10. Anonymous. December 2013 Spuyten Duyvil derailment. Last updated: 2017. Available at: https://en.wikipedia.org/wiki/December_2013_Spuyten_Duyvil_derailment (Accessed: August 10 , 2017)
11. National Transportation Safety Board. ​Metro-North Railroad Derailment. Last updated: 2014. Available at: https://www.ntsb.gov/investigations/AccidentReports/Pages/RAB1412.aspx (Accessed: August 15, 2017)
12. Lee D.  Sleep Test Leads to $6M Greyhound Settlement. Last updated: 2016. Available at: http://oldarchives.courthousenews.com/2016/03/09/sleep-test-leads-to-6m-greyhound-settlement.htm (Accessed: March 9, 2017)
13. National Transportation Safety Board. Highway Accident Report: Truck‐Tractor Semitrailer Rear‐End Collision Into Passenger Vehicles on Interstate 44 Near Miami, Oklahoma June 26, 2009. Last updated: 2010. Available at: https://www.ntsb.gov/investigations/AccidentReports/Reports/HAR1002.pdf (Accessed: August 10, 2017)

Cite as: Quan SF, Barger LK, Weaver MD, Czeisler CA. Saving lives or saving dollars: The Trump administration rescinds plans to require sleep apnea testing in commercial transportation operators. Southwest J Pulm Crit Care. 2017;15:84-6. doi: https://doi.org/10.13175/swjpcc102-17 PDF 

Disclosures 

Editor's note: In 2016 Dr. Quan authored an editorial titled "Screening for Obstructive Sleep Apnea in the Transportation Industry—The Time is Now" in SWJPCC. The editorial encouraged screeening of transportation workers for sleep apnea.

Screening for Obstructive Sleep Apnea in the Transportation Industry—The Time is Now

Stuart F. Quan, M.D.

Division of Sleep and Circadian Disorders

Brigham and Women’s Hospital

and

Division of Sleep Medicine

Harvard Medical School

Boston, MA USA

and

Asthma and Airway Disease Research Center

University of Arizona College of Medicine,

Tucson, AZ USA

On September 29, 2016, a New Jersey Transit train failed to slow down and stop at the station in Hoboken, New Jersey. The resulting crash injured a number of passengers and killed a young mother who happened to be near the crash site. Subsequently, it was learned that the train engineer who apparently had blacked out was diagnosed as having severe obstructive sleep apnea (OSA) (1). Unfortunately, this was not an isolated incident. Over the past few years, there have been several other well-documented incidents of train, truck and bus crashes resulting from their operators falling asleep from OSA. In 2013, a Metro-North commuter train derailed outside of New York City because of excessive speed approaching a curve, the train engineer reported being “dazed” and was subsequently found to have OSA (2). Four passengers were killed and numerous others were injured. In another well-documented accident in 2013, the driver of a Greyhound bus fell asleep. The bus ran off the road, rolled on its side and injured 35 passengers. The driver had been told to get tested for OSA, but did not have the study done. A subsequent court-ordered polysomnogram showed OSA (3). In another incident in 2009, a truck-tractor semitrailer operator failed to notice slowing and stopped cars in front of him and collided with a passenger vehicle. This led to a series of rear end vehicle collisions resulting in 10 fatalities. The cause of the accident was operator fatigue related in part to OSA (4). These well-publicized incidents are only a few of the sleepiness/fatigue related accidents caused by unrecognized OSA in the transportation industry.

One of the most common symptoms attributed to OSA is daytime sleepiness which can be uncontrollable and unpredictable. Numerous studies have demonstrated that persons with OSA have an increased rate of motor vehicle accidents with up to a 4.9 fold higher risk (5). Accidents involving only a single vehicle are particularly frequent suggesting that the crashes are caused by the operators having fallen asleep. Truck drivers are at even greater risk, most likely because they are disproportionately male, middle aged and overweight, all of which are risk factors for OSA. Over a ten year span from 2004 to 2013, it has been estimated that 3,133 to 8,952 deaths and 77,000 and 220,000 serious injuries have resulted from sleepy operators of commercial motor vehicles, many of whom most likely had undiagnosed and untreated OSA (6).

Given the severe consequences of unrecognized OSA on public safety and the high prevalence of unrecognized OSA among operators of trains, buses and commercial trucks, the imperative to screen and treat these persons for OSA is high. The advisory boards to the Federal Motor Carrier Safety Administration (FMCSA) have recommended that commercial truck drivers be screened for OSA if their body mass index is > 40 kg/m², or >33 kg/m² and have 3 or more conditions or findings associated with OSA, but adoption of these recommendations has not occurred (7). More recently, the Department of Transportation, Federal Railroad Administration and the FMCSA have taken the first steps to mandate screening and treatment of rail and commercial motor vehicle operators for OSA by soliciting public comment (8). Airline pilots are already screened. However, there is substantial opposition from the trucking industry and drivers themselves, the latter because of potential job loss. However, such a screening program in one large trucking company has demonstrated a 5 fold reduction in accident rates in drivers who were adherent to CPAP treatment for OSA (5).

With the development of relatively simple to use ambulatory devices that can identify most persons with OSA, screening for OSA can be done easily and cost-effectively. In the vast majority of cases, referral to a sleep lab is not necessary. Persons diagnosed with OSA can be treated with several different modalities and are able to return to work. Employers may actually experience a reduction in their costs related to fewer accidents and improved employee health. Thus, there is no reason to delay requiring OSA screening programs for all persons working in occupations where public safety is at risk. For regulators, policy makers, and the various industries affected, the time is now. Failure to act places the responsibilities for the ensuing economic costs, injuries and deaths on your shoulders.

References

1. Marsh R, Shortell D. NJ. Train Engineer in Crash had Undiagnosed Sleep Apnea. CNN. October 17, 2016. Available at: http://www.cnn.com/2016/11/17/us/njt-engineer-sleep-apnea/ (accessed 12/2/16).
2. National Transportation Safety Board. Metro-North Railroad Derailment. October 24, 2014. Available at: http://www.ntsb.gov/investigations/accidentreports/pages/RAB1412.aspx (accessed 12/2/16).
3. Five Passengers hurt in 2013 Greyhound Bus Crash Win $6 Million Settlement Attorneys Say. WCPO Cincinnati. http://www.wcpo.com/news/local-news/hamilton-county/cincinnati/five-passengers-hurt-in-2013-greyhound-bus-crash-win-6-million-settlement-attorneys-say (accessed 12/2/16).
4. National Transportation Safety Board. Truck-Tractor Semitrailer Rear-End Collision Into Passenger Vehicles on Interstate 44. September 28, 2010. http://www.ntsb.gov/investigations/AccidentReports/Pages/HAR1002.aspx (accessed 12/2/16).
5. 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 (6):573–81.[PubMed]
6. Burks SV, Anderson JE, Bombyk M, et al. Nonadherence with Employer-Mandated Sleep Apnea Treatment and Increased Risk of Serious Truck Crashes. Sleep. 2016 May 1;39(5):967-75. [CrossRef] [PubMed]
7. Miller E. FMCSA Medical Review Board Issues Sleep Apnea Guidelines. Transport Topics. August 24, 2016. Available at:  http://www.ttnews.com/articles/basetemplate.aspx?storyid=42963&page=1 (accessed 12/2/16).
8. Federal Motor Carrier Safety Administration. U.S. DOT Seeks Input on Screening and Treating Commercial Motor Vehicle Drivers and Rail Workers with Obstructive Sleep Apnea. March 8, 2016. Available at: https://www.fmcsa.dot.gov/newsroom/us-dot-seeks-input-screening-and-treating-commercial-motor-vehicle-drivers-and-rail-workers (accessed 12/2/16).

Cite as: Quan SF. Screening for obstructive sleep apnea in the transportation industry—the time is now. Southwest J Pulm Crit Care. 2016;13(6):285-7. doi: https://doi.org/10.13175/swjpcc132-16 PDF