1. Road Safety: Sleep and Circadian factors Teresa Paiva

2. Summary The Problem –Data from EU and Portugal The “Sleep- Circadian effect” –Sleep deprivation –Sleep disorders Portuguese and Brazilian truck drivers Recomendations and challenges

3. Salary loss$ 20.3 billions Medical expenses$ 5 billions Insurance$ 21.3 billions Material costs$ 23.6 billions Unit Costs Death$ 290.000 Disturbance$ 13.100 Incapacity$ 30.600 Sequelae$ 7.500 Possible trauma$ 1.000 Material damages$ 1.700

4. Road safety directly affects all of the territory of the EU and all its inhabitants In the 15 member EU, 375 million road users, 200 million of them driving licence holders, use 200 million vehicles on four million km of roads. Ever greater mobility comes at a high price: 1 300 000 accidents a year cause 40 000 deaths and 1 700 000 injuries on the roads. The direct and indirect cost of this carnage has been estimated at EUR 160 billion, i.e. 2 % of EU GNP. SAVING 20 000 LIVES ON OUR ROADS EUROPEAN COMMISSION A shared responsibility

5. The EU Picture per Country Portugal: the 9th worse in the 25 EU the worse in the 15 EU ranking

6. The EU Picture per Region

7. The Black picture

8. The main areas of action SAVING 20 000 LIVES... The 2001 White Paper, European transport policy for 2010: time to decide, sets out 60 practical measures designed to bring about significant improvements in the quality and efficiency of transport in Europe by 2010. Brusselshttp://europa.eu.int/comm/dgs/energy_transport/index_en.html (4-06- 2003) Encouraging road users to improve their behaviour –Complying with basic road safety rules –Driver licensing and training –Use of crash helmets Using technical progress to make vehicles safer –Progress made on vehicle design –Consumer information: the European new car assessment programme (EuroNCAP) –Accident protection or passive safety –Accident prevention or active safety –Periodic technical inspection Encouraging the improvement of road infrastructure –Drawing-up of technical guidelines concerning infrastructure safety –Trans-European road network –Safety of tunnels –The new ‘intelligent road’ concept and Galileo Safe commercial goods and passenger transport Emergency services and care for road accident victims Accident data collection, analysis and dissemination –The causes of accidents –The circumstances of accidents –The consequences of accidents –European road safety observatory

9. Effect of Age

10. Effect of Gender

11. Effect of Transport mode

12. Effect of Month

13. Road Death in Young Adults

15. The Sleep Wakefulness continuum Sleep and wakefulness have mutual influences “Bad sleep” “bad day” “Bad day” “bad sleep” Individual Sleep Wakefulness Environment

16. Alertness Sleepiness Capacity to respond adequately to different behaviour situations, both qualitatively and quantitatively Koella 1982 Selective and sustained attention Van Dongen 2005 State of sleep need manifest by sleep propensity (Broughton, 1989; Carskadon and Dement 1979)

17. Consequences of Sleep Deprivation Sleepiness Fatigue Anxiety and irritability Lack of concentration Confusion Perception Distorsions Hallucinations Paranoide states

18. (Dinges DF et al. 97) Psychomotor Vigilance test (Dinges DF et al. 97) 10 to 20 min to sustain attention and respond to a randomly appearing light in a computer screen by pressing a button Lapses: number of times subject failed to respond timely (before 500msec)

19. Driving simulator Sleepiness: Driving simulator Azim Eskandarian, Riaz Sayed The George Washington University

20. Estimates of the proportion of road traffic accidents (RTAs) due to sleepiness range from 3% to 33% - studies in France, United States, Australia and New Zealand.

21. Sleep / Sleepiness and Accidents Multiple logistic regression analyses revealed the following independent risk factors for driving accident (last three years): being younger; higher average weekly driving hours; never/rarely getting enough sleep (OR=1.26, 95% CI 1.06- 1.49); reporting any chance of dozing in a car while stopped in traffic (Epworth Sleepiness Scale question 8, OR=1.52, 95% CI 1.15-2.02). Epworth score was not significantly related to reported accident involvement. Gander et al Aust N Z J Public Health. 2005 Feb;29(1):16-21. Driver sleepiness/fatigue, distraction/inattention, age of 51 years of age and older, and nonuse of safety belts increase the odds that a CVC will be fatal. Bunn et al Accid Anal Prev. 2005 Sep;37(5):862-9.

22. Sleep / Sleepiness and Accidents Increasing sleepiness score was associated with increasing crossings during the next driving session in the sleep-restricted (IRR: 1.9; 95% CI: 1.4-2.4) but not in the non-restricted condition (IRR: 1.0; 95% CI: 0.8- 1.3)( Philip et al 2005 Accid Anal Prev;37(3):473-8 ). About 96% of sleep-related crashes involve passenger vehicle drivers and 3% involve drivers of large trucks. (Lyznicki et al 1998 JAMA. ;279:1908-1913). Acute sleepiness in car drivers significantly increases the risk of a crash in which a car occupant is injured or killed (Connor et al 2002 BMJ;324:1125). Acute sleepiness in car drivers significantly increases the risk of his/her own death About 10% (6770) of the crashes were related to fatigue and 23% (15 670) to alcohol. Alcohol related crashes were more likely to be fatal during the evening and early morning compared with the daytime (Wald's 2=4.88, P=0.02 for evening, 2=18.04, P< 0.01 for early morning), whereas fatigue related crashes were more likely to be fatal during the day than the early morning ( 2= 5.37, P=0.02). (Philip et al 2001 BMJ;322:829-830)

23. Sleep Disorders: OSAS and Narcolepsy OSAS patients had much longer RT than controls, leading to a lengthening of the vehicle's stopping distance of 8.8 meters at 40 km.h(-1) and to twice more collisions. Patients did not demonstrate objective sleepiness or selective and sustained attention deficits. Divided attention deficits were found. However, they did not allow the prediction of real driving impairment. After treatment, there was no longer any difference between patients and controls regarding driving and attention performances. Mazza et al Eur Respir J. 2006 Jul 26. The estimated minimum prevalence rates of sleep-disordered breathing and obstructive sleep apnoea syndrome were 8.4% and 5.4% respectively among the bus drivers. Home CPAP acceptance was low among bus drivers with sleep apnoea but there was significant improvement of subjective sleepiness and cognitive function among those on CPAP treatment. Hui et al Respirology. 2006 Nov;11(6):723-30.

24. The Risks SHIFT WORK In a nationwide survey, residents who had worked 24 hours or longer were 2.3 times more likely to have a motor vehicle crash following that shift than when they worked < 24 hours, and that the monthly risk of a crash increased by 16.2% after each extended duration shift. Interns working a traditional on-call schedule slept 5.8 hours less per week, had twice as many attentional failures on duty overnight, and made 36% more serious medical errors and nearly six times more serious diagnostic errors than when working on a schedule that limited continuous duty to 16 hours. Lockley et al- Harvard Work hours and safety group Clin Orthop Relat Res. 2006 Aug;449:116-27. Driving home from the night shift was associated with an increased number of incidents (two wheels outside the lane marking, from 2.4 to 7.6 times), decreased time to first accident, increased lateral deviation (from 18 to 43 cm), increased eye closure duration (0.102 to 0.143 s), and increased subjective sleepiness. Akerstedt et al J Sleep Res. 2005 Mar;14(1):17-20. The hourly number of accidents increased with homeostatic sleep pressure; the theoretical efficacy of napping was quantified in 48% accidents decrease. Napping before working a night shift is an effective countermeasure to alertness and performance deterioration associated with night work. Garbarino et al Sleep. 2004 Nov 1;27(7):1295-302.

25. The Risks MEDICAL DISORDERS The analyses identified the following significant risk factors: non-medicated diabetes (OR=3.08), a history of myocardial infarction (OR=1.77), using glasses when driving (OR=1.26), myopia (OR=1.22), sleep onset insomnia (OR=1.87), frequent tiredness (OR=1.36), anxiety (OR=3.15), feeling depressed (OR=2.43) and taking antidepressants (OR=1.70). Sagberg Accid Anal Prev. 2006 Jan;38(1):28-34. YOUNG PEOPLE Young drivers frequently drive while at risk of crashing, at times of predicted sleepiness (>7% of episodes) and at times they felt themselves to be sleepy (>23% of episodes). A significant relationship was found between perceived and predicted estimates of sleepiness. However, the participants nonetheless drove at these times. The results of this study may help preventative programs to specifically target factors leading to increased sleepiness when driving (particularly time of day), and to focus interventions to stop young adults from driving when they feel sleepy. Smith et al Accid Anal Prev. 2005 Nov;37(6):1066-73.

26. The Risks ALCOHOL Alcohol at legal blood alcohol concentrations appears to increase sleepiness and impair performance and the detection of crash risk following partial sleep deprivation. When partially sleep deprived, women appear to be either more perceptive of increased crash risk or more willing to admit to their driving limitations than are men. Alcohol eliminated this behavioral difference. Banks et al Sleep. 2004 Sep 15;27(6):1063-7.

27. Sleep / Sleepiness and Accidents

28. Recognizing sleepiness Participants who reported driving while sleepy in the previous 12 months "a few times" or "once a month or more often" were 1.5 (95% confidence interval 1.2 to 2.0) and 2.9 (1.3 to 6.3) compared with those who reported not driving while sleepy over the same period. These associations were not explained by any reported sleep disorders. Awareness of driving while sleepy and road traffic accidents: prospective study in GAZEL cohort. Nabi et al BMJ 2006;333:75

29. The ACCIDENT Drivers avoid refering to it Drivers tend to go on driving in spite of recognizing their own sleepiness There are other associated causes Authorities do not recognize them No attempts to avoid the accident They occur mostly at certain hours (night driving) The accident is “unexplainable” The road has good visibility Good weather and good visibility Normal alcohol levels... Car without technical problems No excessive speed No “known” medical disorder Policemen suspected sleepiness

30. “HT, 64 anos, o mais influente dos empresários têxteis portugueses, morreu cerca das seis da manhã de domingo depois de adormecer ao volante e esbarrar o Mini Cooper (dos novos) que conduzia, contra uma árvore da Avenida da Boavista”. DN, Julho de 2003

31. Truck drivers Count 0 10 20 30 40 50 60 17,52022,52527,53032,53537,54042,5 BMI Histogram N=200 Questionnaires EN1 Souza et al 2005

32. Truck drivers N=200 Questionnaires EN1 Souza et al 2005 -20246810121416 Count 0 5 10 15 20 25 30 35 40 45 50 Histogram EPW

33. Truck drivers N=200 Questionnaires EN1 Souza et al 2005 0 1 2 3 4 5 6 7 Driving Hours and Sleep questionnaires PSQI 3,94,8 ESE 5,16,3 <10>11

34. Truck drivers Count Souza et al 2005 Count

35. >9 <5 7a8 5a6 Hours of Sleep -Work >9 <5 7a8 5a6 Hours of Sleep -REST >9 <5 7a8 5a6 Hours of Sleep -Work >9 <5 7a8 5a6 Hours of Sleep -REST Variable 8a9 6a7 4a5 24às3 Waking hours -Work Brasiliens sleep less All compensate while resting Brasiliens wake up earlier 24às3 6a7 4a5 Waking hours REST 24às3

36. Truck drivers Souza et al 2005 CATEGORIASPORTUGALBRASILStatP Alcoholic beverages Yes73,550,9 21,8<0,0001 No26,549,0

37. Truck drivers Souza et al 2005 CATEGORIESPORTUGALBRASIL Chi 2 P Driving Hours 1 a 53,00,9 178,8<0,0001 6 a 1074,513,5 11 a 1520,542,2 >162,043,2

38. Truck drivers Souza et al 2005 CATEGORIASPORTUGALBRASILStatP Accidents with injuries or fatalities Yes20,013,1 10,8 <0,0614 NS No80,086,9

39. Truck drivers Souza et al 2005 (p=0,0083). Accidents had complex relations with PSQI and ESE. All the Brasilien with accidents had PSQIs >5 and ESE >13; in Portugal there are other associated factors. -,25 0,25,5,75 1 1,25 1,5 1,75 2 2,25 Number of Accidents -2,502,557,51012,51517,52022,525 ESE P B ACCIDENTS vs ESE

40. Medical Students -FML Paiva and Gonçalves 2006 YesNoP level Accidents11,08,40,045 Irreg meals9,98,00,0035 Tobacco10,98,30,0239 “Married”13,58,00,0322 Hypnotics16,58,50,0033

41. Recomendations Self assessed driving while sleepy was a powerful predictor of serious RTAs, suggesting that drivers' awareness of their sleepiness while driving is not sufficient to prevent them from having RTAs. Messages on prevention should therefore focus on convincing sleepy drivers to stop driving and sleep before resuming their journey Nabi et al BMJ 2006;333:75. Reductions in road traffic injuries may be achieved if fewer people drive when they are sleepy or have been deprived of sleep or drive between 2 am and 5 am (Connor et al 2002 BMJ;324:1125). Risk factors include youth, shift work, alcohol and other drug use, over-the-counter and prescription medications, and sleep disorders (Lyznicki et al 1998 JAMA. ;279:1908-1913).

42. Few Recomendations EU Driving under the influence of alcohol, drugs and medicines (6th FWP; 24 million) And sleep???? Challenges Introduce sleep restriction in the EU safety measures and research projects Introduce research into practical measures Propose driving legislation for Sleep Disorders Research on inequivocal an Sleep Measure similar to alcohol level Research on sleep monitoring devices Portugal Application of EU legislation Legislation concerning Sleep disorders and driving Legislation concerning sleep disorders and professional drivers Change Cultural Habits Fight corruption networks

43. Dino, dos Morangos com Açucar, morreu às 3:59 h porque após uma sessão de autógrafos seguiu em frente num cruzamento Verão de 2006