Insulin treated diabetes mellitus and safety critical work Insulin treated diabetes mellitus and safety critical work? Other than pilots… Dr Tim Sprott Aviation & Occupational Health ANZSOM & AMSNZ Conference Auckland 5 September 2015

Over riding principles… Safety fitness for work vs functional fitness for work Medical standards must be relevant to safety critical work Safety fitness for work decisions by qualified competent health professionals Disclosure of relevant health information only

Over riding principles… Inter-relationships with other health practitioners Privacy and confidentiality Anti discrimination / Human Rights legislation Reasonable adjustments and accommodations by employers

What is safety critical worker vs work? Safety Critical Worker means a worker whose action or inaction, due to ill-health, may lead directly to a serious incident affecting the public or the rail network (Kiwi Rail) Safety critical work ICAO – “activities where uncorrected errors have an immediate and negative effect” on safety. ‘Safety critical work’ involves any activity, process or work related factor that can put the worker, other workers, the general public, the environment or property at risk of significant harm if it is not carried out correctly. This can be used to identify ‘safety critical workers’ and classify them based on individual assessment of fitness for work.

How safe? What are acceptable maximum levels of risk of incapacitation? Professional pilots/ air traffic controllers 1-2% pa Professional drivers 2 % pa Aircraft engineers 2-5 % pa ? Airport ramp workers 2-5% pa ? Private vehicle drivers 20 -40% pa

Air NZ Guidelines… Ethical obligations Effects of Health on Work Meeting operational safety requirements, maintaining employment and not compromising the employee’s diabetes management Effects of Health on Work Effects of Work on Health Regulations Impact of co-existing medical conditions

Air NZ Guidelines Incapacitation Sudden – hypoglycaemia Subtle – hypoglycaemia and hyperglycaemia

Air New Guidelines Employee physically and mentally fit for their role Regular (minimum annual) review with a specialist or GP Diabetes under stable control Employees able to do SMBG and well motivated No disabling episodes of hypoglycaemia Hypoglycaemia awareness and management Absence of clinical evidence of microvascular complications that could cause functional incapacity Medic alert or similar Annual review with Aviation and Occupational Health services

Air NZ Guidelines Exclusion criteria In the last 12 months- One or more episodes of hospitalisation due to hypoglycaemia Hypoglycaemia resulting in a seizure , loss of consciousness, impaired cognition, or external intervention One or more episodes of hypoglycaemia unawareness Poor stability of control in the previous 3 months

Air NZ Guidelines Background health information Copies of all diabetes medical records as well as accident information (work & driving accidents) Completed medical report GP or specialist Two HBA1cs at least 90 days apart Details of diabetes management and insulin dosages/type Assessment of CVS risk and presence of microvascular complications Verification of employee education and understanding of diabetes, control and hypoglycaemia awareness/ management Verification that an employee has the ability and willingness to self monitor BGs

Air NZ Guidelines Decision making criteria Glycaemia control - HBA1c 48 – 70 mmol/mol - SMBGs < 5% below 4mmol/l 80% between 5-15 mmol/l Other factors – excessive frequency hypoglycaemia/ hyperglycaemia - documented hypoglycaemia unawareness - poor management and compliance

Air NZ Guidelines Operational requirements Encourage employees to tell peers or line managers Employee must carry during work glucometer (and access to back up one for cabin crew) adequate supplies of BM sticks Rapidly absorbable glucose Glucose testing 30-60 minutes before work Monitoring during work Maintain glucose concentrations in the 5-15 mmol/l range Cease working and take action if outside this range before returning to work Emergency situations

Other technologies

What are the challenges in the airline flying environment? Public and flight safety Acceptable rate of multicrew medical incapacitation of 1 x 10 -6/hrs Variable flight durations Critical phases of flight Subject to disrupted sleep and time zone changes In a variety of weather conditions Subject to changes in atmospheric pressure, noise, vibration and acceleration Reliant on support services including provision of food With little or no medical/health support With the potential for an emergency situations/mass casualty/survival situation to occur with little or no warning