Dr. David Salisbury Director Medicine Civil Aviation ICAO Medical Briefing 2014 Issue is the application of preventive medicine practices in regulatory/aviation medicine. Dr. David Salisbury Director Medicine Civil Aviation

Disclosure Information 85th AsMA Annual Scientific Dr. David Salisbury I have the following financial relationships to disclose: Employee of: Transport Canada I will not discuss off-label use and/or investigational use in my presentation Facts are facts. Opinions are mine and not the official position of TC or the Government of Canada

Further Disclosures I’m a Canadian Board certified in Aerospace Medicine by Am. Brd. Of Preventive Medicine FRCPC in Public Health and Preventive Medicine 28 years in the CF as a flight surgeon, 5 years in Public Health as a Medical Officer of Health, 6 years at TC as Director Non-smoker, normotensive, minimal drinker who exercises hard 3 times a week and always wears his seatbelt. Immunized against most vaccine preventable diseases and all my first degree relatives have lived to 80+

Aerospace Medicine Branch of Preventive Medicine that deals with the clinical and preventive medical requirements of man in atmospheric flight and space Traditional definition from Aerospace Medical Association.

Approach to Aerospace Medicine Traditionally we have also stressed the issue that we are often dealing with normal physiology but in an abnormal or changed environment from what we as humans have adapted to and what our classical medical research base has investigated. AEROSPACE Normal Physiology Abnormal environment CLASSICAL Abnormal Physiology Normal environment 3 3 3

Aerospace and Regulatory Medicine Abnormal Physiology Abnormal environment Now due to an increasing movement of accommodation and rights we are having to deal more and more with abnormal physiology in the abnormal environment.

Figure 2. The evolutionary CVD pyramid Figure 2.  The evolutionary CVD pyramid.  Unhealthy lifestyle practices lead to risk factors, the progression of CVD, and, ultimately, adverse outcomes or clinical endpoints.  Prevention can be divided into 3 types: primordial (prevention of risk factors); primary (treatment of risk factors); and secondary (prevention of recurrent cardiovascular events), which can be modulated by environmental (e.g., air pollution) and psychosocial stressors, lifestyle change, and cardioprotective medications, if appropriate.  The first-line strategy to prevent initial or recurrent cardiac events is to favorably modify unhealthy lifestyle habits or practices, including poor dietary habits, physical inactivity, and cigarette smoking.  CVD signifies cardiovascular disease; MI indicates myocardial infarction; CHF, congestive heart failure; and PAD, peripheral arterial disease.  Sources: Mozaffarian et al and Franklin et al.13,14 Source: http://my.americanheart.org/professional/ScienceNews/Foundational-Factors-for-Cardiovascular-Disease-Behavior-Change-as-a-First-Line_UCM_457215_Article.jsp

Aviation Regulatory Medicine Clinical Medicine Human Rights Aerospace Medicine Preventive Medicine

Medical Standards applied by RFC Canada: WW I Most Canadians flew with the Royal Flying Corps or The Royal Naval Air Service. Over 22,000 served. Canadian Air Force formed at end of war. RCAF given “Royal” designation 1924. Medical Standards applied by RFC Canada: “Perfect Vision Under 25 Hear a whisper at 20 Ft.” All MO’s from RAMC (Army)

Civil Aviation in Canada & the World Convention on International Civil Aviation Chicago 1944 Establishment of ICAO 1947 Canada Original Contracting State ICAO sets rules and regulations for its 188 Contracting States. These are published as Standards and Recommended Practices (SARPs) for international civil aviation. The SARPs concerning medical provisions are contained in Annex 1 to the Convention on International Civil Aviation. ICAO SARPs are minimum requirements that Contracting States have to abide to. A State, however, may set higher or stricter national standards. In the context of regulatory civil aviation medicine, Aviation Medicine Section deals with the medical requirements for licensing of flight crew and air traffic controllers and others. To keep abreast with new technological developments and innovations and advances in medical knowledge, the SARPs in Annex 1 to the Convention on International Civil Aviation have to be revised and updated regularly. Standards & Recommended Practices (SARP) Canadian Aviation Regulations (CARs) Annex 1 Personnel Licensing Medical Standards CARs 404 & 424 (Medical Standards)

Annex 1 Chapter 1 ‘Medical Fitness’ ICAO Annex 1 All ICAO Contracting States must be in compliance How they achieve ‘compliance’ may differ New Manual of Civil Aviation Medicine 2012 responsibilities of the Aviation Medicine Section are: monitoring the developments within the field of aviation medicine worldwide; keeping the medical provisions of Annex 1 - Personnel Licensing up to date, reviewing and maintaining current the Manual of Civil Aviation Medicine (Doc 8984) and the Manual on Prevention of Problematic Use of Substances in the Aviation Workplace (Doc 9654); providing guidance to licensing authorities in Contracting States on medical problems associated with flight operating conditions and flight crew performances and licensing standard, air traffic control staff performance, licensing standards and conditions of work; biological and psychological problems relating to passengers and crew; equipment, first aid and survival, and the medical aspects of accident investigation and prevention; and conducting regional civil aviation seminars and ICAO sessions at international aviation medicine congresses, scientific meetings, etc. + WHO AsMA IAASM - civil aviation authorities Medical Directors of airline companies

TC Civil Aviation Medicine Minister of Transport Established by ‘Order in Council’ 1946 " To provide medical advice & assistance in setting up physical standards for civil aviation personnel; To advise on all problems connected with the health of travelers by air". Transport Canada Deputy Minister Safety & Security ADM Civil Aviation Director General PRIVY Council:, CANADA Certified to be a true copy of a Minute of a Meeting of the Treasury Board, approved by His Excellency the Governor General in Council, on the 30th Oct., 1946.   NATIONAL HEALTH AND WELFARE The Board had under consideration the following memorandum from the Honourable the Acting Minister of National Health and Welfare:- "The undersigned, on the advice of the Deputy Minister of National Health, has the honour to report. THAT the Department of Transport hat requested the Department of National Health and Welfare to provide medical advice and assistance in setting up physical standards for civil aviation personnel; to advice on all problens connected vith the health of travellers by air; THAT there are no present facilities in the Department of National Health and Welfare to render such services and a Division of Civil Aviation Medicine of the Department of National Health and Welfare should be established, to be headed by a Chief of Division vith such other officers, clerks, and employees as Bay be necessary therefore, to provide services in the foregoing connection; NOW, THEREFORE, the uadarsigned, on the recommendation of the Deputy Minister of National Health, has the honour to reconnend to Your Excellency in Council that a Division of Civil Aviation Medicine of the Department of • National Health and Welfare be established to be headed by a Chief of Division, with such other officers, darks, End employees as may be necessary, therefore, to provide services as aforesaid." Civil Aviation Medicine

Civil Aviation Medicine Principal function - medical certification of aviation personnel Medical advisors to the Minister of Transport Custodians of confidential medical information                                                                                                                                                                                                                                                                                                      Hx -after World War I - International Commission on Air Navigation (ICAN) - established following the Paris Air Convention of 1919. This organization was set up to establish rules and regulations for the safe conduct of civil aviation. ICAN established a medical sub-commission which set about producing the first ever medical standards for civil aircrew which were extremely strict. In 1944, towards the end of World War II, the International Civil Aviation Organization (ICAO), an agency of the United Nations, was formed to carry on the work of ICAN, which had ceased to exist during World War II.

Fitness Criteria Concern : Sudden The risk of incapacitation Subtle During the validity period of the Medical Certificate

“ Accredited medical conclusion” ‘Flexibility’ CAR 424.05 ICAO Annex 1 1.2.4.8 “ Accredited medical conclusion” Used for medical certification cases which are ‘technically’ outside the standards but are not deemed to be a threat to aviation safety

1% Rule Evans ADB, Rainford DJ. Medical Standards for Aircrew in Aviation Medicine III Edition. 1999 Goal is 1 in 107 for all cause fatal accidents Crew failure should contribute no more than 10% of risk Medical Incapacitation should contribute no more than 10% of crew failure risk Therefore Pilot Incapacitation should cause an accident no more often than one in 1000 million flying hours

1% Rule Continued CVD Mortality of 1 in 109 or annual rate of 1:100,000 is not achievable at any age, hence need for two pilots Simulator Studies (Chapman 1984) indicate successful takeover rate 1:100 Critical Area of flight (T/O and Landing) only 10% of time Incapacitation occurs randomly This gives a protection fact of 1000 sooooo…… Incapacitation Rate of 1 in 106 or annual rate of 1% is acceptable

1% Rule Summary

Human Rights Issues CHRC is a quasi-judicial body empowered under the Canadian Human Right Act CHRC investigates and tries to settle complaints of discrimination in employment and in the provision of services within federal jurisdiction CHRC is also empowered under the Employment Equity Act to ensure that federally regulated employers provide equal opportunities for four designated groups: women, Aboriginal people, the disabled and visible minorities CHRC acts as an advocate for human rights and issues, reports on various aspects of discrimination as well as educational materials designed to promote human rights and inform employers and the general public about human rights regulations

Human Rights II Prohibited Grounds of Discrimination Race Colour National or ethnic origin Sex (includes pregnancy) Marital status Family status Age Religion Sexual Orientation Pardoned Conviction Disability (physical or mental, including drug or alcohol dependence)

Human Rights III There is a Duty to Accommodate : it is the LAW The right to accommodation of needs is statutory Supreme Court of Canada: accommodation of needs is necessary to ensure equality under the Charter and statutory human rights legislation (Meiorin + Grismer) Accomodation can be denied if The rule, standard or practice is based on a bona fide occupational requirement (BFOR) or bona fide justification (BFJ), It is made in good faith (bona fide), and Putting aside the BFOR to accommodate would cause undue hardship to the provider, considering health, safety and cost To establish BFOR: Meiorin- 3 stage test

Latest Framingham CVD Prediction Tool Performance The top sex-specific quintiles of predicted CVD risk identified ≈48% of men and 58% of women who experienced a first CVD event on follow-up (sensitivity). Proportions of men and women without events who were not in the top quintile of risk were 85% and 83%, respectively (specificity). Source: http://circ.ahajournals.org/content/117/6/743.full

+ - FRS 48 135 52 765 100 900 1000 Sensitivity .48 Specificity .85 +PV Prev. 10% An Event + - FRS 48 135 52 765 100 900 1000 Sensitivity .48 Specificity .85 +PV .26 -PV .94

Figure 2. The evolutionary CVD pyramid Figure 2.  The evolutionary CVD pyramid.  Unhealthy lifestyle practices lead to risk factors, the progression of CVD, and, ultimately, adverse outcomes or clinical endpoints.  Prevention can be divided into 3 types: primordial (prevention of risk factors); primary (treatment of risk factors); and secondary (prevention of recurrent cardiovascular events), which can be modulated by environmental (e.g., air pollution) and psychosocial stressors, lifestyle change, and cardioprotective medications, if appropriate.  The first-line strategy to prevent initial or recurrent cardiac events is to favorably modify unhealthy lifestyle habits or practices, including poor dietary habits, physical inactivity, and cigarette smoking.  CVD signifies cardiovascular disease; MI indicates myocardial infarction; CHF, congestive heart failure; and PAD, peripheral arterial disease.  Sources: Mozaffarian et al and Franklin et al.13,14 Source: http://my.americanheart.org/professional/ScienceNews/Foundational-Factors-for-Cardiovascular-Disease-Behavior-Change-as-a-First-Line_UCM_457215_Article.jsp

Figure 3.  The 5 A’s to facilitate effective health behavior change counseling during a medical visit.  Although more providers now perform the first 2 A’s, that is, assess the risk behavior and advise behavior change, it is the latter, less frequently performed 3 A’s (shaded) that have the greatest impact on healthful behavior change.  Effective clinician behavior change strategies include using motivational interviewing along with rewards or incentives, asking patients to self-monitor behaviors, enhancing patients’ self-efficacy (confidence), accessing social support from family and friends, and scheduling regular follow-up communications/meetings to assess progress. Sources: Chase et al and Alexander et al.77,78. http://my.americanheart.org/professional/ScienceNews/Foundational-Factors-for-Cardiovascular-Disease-Behavior-Change-as-a-First-Line_UCM_457215_Article.jsp

Conclusions Aerospace Medicine is Preventive Medicine Prevention is effective Regulatory Medicine will need more than a paradigm shift to effectively practice primordial prevention There are legal, human rights and logistical barriers to practicing prevention in a regulatory framework

How can you help? Accurate and complete MERs Good understanding of requirements Thorough history taking Synthesis of issues

Some Other Points If one of your pilots has received a letter with special conditions or investigation requirements you can make their application much more efficient if you order the extra tests. Cardiovascular screening. If there are other risk factors please get a lipid profile.