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  • ACOEM Responds to ANPRM on Evaluating Safety-Sensitive Personnel for OSA

    June 8, 2016

    Docket Management Facility
    U.S. Department of Transportation
    Room W12-140
    1200 New Jersey Avenue, SE
    West Building, Ground Floor
    Washington, DC 20590-0001

    Re: Docket Numbers FMCSA–2015–0419 and FRA–2015–0111

    To Whom It May Concern:

    The American College of Occupational and Environmental Medicine (ACOEM) is pleased to respond to several of the questions asked in the Advance Notice of Proposed Rulemaking (ANPRM), Evaluation of Safety Sensitive Personnel for Moderate-to-Severe Obstructive Sleep Apnea.

    ACOEM is well aware of the concerns expressed by transportation workers, their unions, certain industry representatives, and elected officials regarding the utilization of screening for obstructive sleep apnea (OSA) as a tool for the reduction of accident risk in the transportation environment. We recognize that, as with all medical conditions, not everything is known about OSA and its potential effects. However, ACOEM is not aware of any medical condition that is as well researched and documented with regard to its risk in the transportation environment and the effect of adequate treatment. Indeed, OSA treatment is highly effective, with almost all workers able to return to their safety-sensitive positions once diagnosed and treated. Implementation of a systematic screening and treatment program has been shown to reduce accidents, decrease health care costs, and increase worker retention. The vast majority of health plans will cover diagnosis and treatment of patients at elevated risk for OSA but many commercial motor vehicle (CMV) operators may be uninsured. Finally, and perhaps most significantly from the workers' perspectives, effective treatment of OSA reduces the risk of multiple serious acute medical conditions (e.g., stroke, pulmonary embolism, heart attack, etc.), and improves the management of chronic disease (e.g., diabetes, hypertension), in addition to the substantial improvement in subjective well being that is typically seen with treatment.

    Many of the proposed questions in the Federal Register have been addressed in the FMCSA Medical Expert Panel’s 2008 Evidence Report: Obstructive Sleep Apnea and Commercial Motor Vehicle Driver Safety and its 2011 Update. We encourage the Administration to reference these documents during their deliberations.

    The Problem of OSA
    1. What is the prevalence of moderate to severe OSA among the general adult U.S. population? How does this prevalence vary by age? 
    OSA is a relatively common disorder with estimates of 12 million to as many as 20 million individuals in the United States with the majority undiagnosed. It is estimated that approximately 4% of men and 2% of women in the U.S are suffering from symptomatic sleep apnea. The break out of moderate to severe is unclear, but some studies indicate that 9% of men and 4% of women have an apnea-hypopnea index (AHI) >15. It is estimated that between 17-28 % of CMV operators have OSA, most undiagnosed and untreated. (FMCSA Medical Expert Panel 2011 Update report).

    2. What is prevalence of moderate-to severe OSA among individuals occupying safety sensitive transportation positions? If it differs from that among the general population, why does it appear to do so? If no existing estimates exist, what methods and information sources can the agencies use to reliably estimate this prevalence?Compared to the general population, OSA is approximately 10 times more prevalent among commercial drivers.

    • Pack A, Dinges D, Maislin G. FMCSA, Publication No DOT-RT-02-030. 2002. A Study of Prevalence of Sleep Apnea among Commercial Truck Drivers.
    • The American Transportation Research Institute found a 10.5% prevalence of moderate to severe OSA among commercial truck drivers.
    •  Prevalence of Sleep Apnea Among Commercial Truck Drivers. [cited 2011 October 20], available at http://www.atri-online.org/research/results/sleep_apnea_white_paper.pdf.
    • The increased risk may be due to the increase of comorbid disease and risk factors. Increased incidence of conditions such as diabetes mellitus (DM), heart disease, and hypertension (HTN) may be due to unhealthy lifestyles, lack of exercise, etc.

     3. Is there information (studies, data, etc.) available for estimating the future consequences resulting from individuals with OSA occupying safety sensitive transportation positions in the absence of new restrictions? For example, does any organization track the number of historical motor carrier or train accidents caused by OSA? With respect to rail, how would any OSA regulations and the current PTC requirements interrelate?
    There appears to be substantial evidence that drivers with adequately treated OSA are at a reduced crash risk compared to untreated or inadequately treated drivers. A recent study by Burks estimated a five-fold increased crash risk in those that are inadequately treated compared to those that are adherent to treatment or at low risk of having OSA.

    • Tregear S, Reston J, Schoelles K, et al. 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.
    • George CF. Reduction in motor vehicle collisions following treatment of sleep apnea with nasal CPAP. Thorax. 2001;56:508-12.
    • Vakulin A, Baulk SD, Catcheside PG, et al. Driving simulator performance remains impaired in patients with severe OSA after CPAP treatment. J Clin Sleep Med. 2011;7:246-53.
    • Burks SV, Anderson JE, Bombyk M, et al. Nonadherence with employer-mandated sleep apnea treatment and increased risk of serious truck crashes. Sleep. 2016;39(5):967-75.
    • 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;Feb 29: sp-00566-15.
    • 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.

    There is also evidence of decreased morbidity and mortality due to other conditions if OSA is adequately treated. While PTC (positive train control) may positively impact safety and address some of the concerns of railroad operators who may be impaired by OSA, it is not yet fully implemented and is not anticipated to be on 100% of the railroad. Any potential OSA regulations should consider safety needs of transportation personnel in the event that PTC fails or is not present on the system. PTC should not be a substitute for OSA regulations. Guidance is still needed, and people should be held to standard regardless of PTC

    4. Which categories of transportation workers with safety sensitive duties should be required to undergo screening for OSA? On what basis did you identify those workers?
    For consistency, it should be the same workers covered by the Federal Motor Carrier Safety Regulations: CMV operator as defined by 390.5, which is the same group required to meet FMCSA medical standards. For railroad workers, it should include those Hours of Service employees who require certification under FRA regulations such as engineers and conductors it should be those already defined as safety sensitive with respect to drug testing. The FRA has designated its safety-sensitive employees to be those who perform service covered under the hours of service laws (covered service). This includes “contracted” hours of service employees and also individuals who may volunteer to perform hours of service duties for a railroad. These generally include train and engine service employees involved in the movement of trains or engines (e.g., conductors, brakemen, switchmen, engineers, locomotive hostlers/helpers), dispatching employees who issue mandatory directives (e.g., train dispatchers, control operators), and signal employees who inspect, repair or maintain signal systems.

    Cost & Benefits
    5. What alternative forms and degrees of restriction could FMCSA and FRA place on the performance of safety sensitive duties by transportation workers with moderate-to-severe OSA, and how effective would these restrictions be in improving transportation safety? Should any regulations differentiate requirements for patients with moderate, as opposed to severe, OSA?
    No restrictions would be adequate to ensure safety. Adequate treatment is the answer and anything short of adequate treatment would not necessarily mitigate risk. While there are, in general, certain times of day where the risk of fatigue-related crashes is greater in the overall population, individuals with untreated OSA have an increased risk throughout the day, so avoiding these times does not mitigate risk.

    While limiting scope or hours of duties may reduce potential risk, it is impossible at this time to determine if this reduction would bring it to an acceptable risk level. In addition, it would be operationally and economically difficult for all stakeholders. Currently there is insufficient data to differentiate the crash risk of those with moderate and severe OSA. It is likely that those with the most severe condition (AHI>50), if untreated, would be at highest risk of impairment or incapacitation. This may be an appropriate reason to differentiate between those with more severe conditions compared to others.

    6. What are the potential costs of alternative FMCSA/FRA regulatory actions that would restrict the safety sensitive activities of transportation workers diagnosed with moderate to severe OSA? Who would incur those costs? What are the benefits of such actions and who would realize them?
    Restricting safety sensitive activities for those with moderate to severe OSA will have potential costs across multiple stakeholders. Any actions restricting activities could conceivably impact collective bargaining agreements, and could have economic impacts on both the individuals and employers.

    That said, OSA should be treated no differently than any other medical condition that may cause the operator to experience sudden or gradual impairment or incapacitation. An operator identified at high risk for the condition should be referred to a treating provider for additional evaluation. Similarly, drivers with multiple risk factors for heart disease, with inadequate vision or hearing, who are spilling sugar in their urine or have other abnormal findings are currently referred to personal health care providers. Employers could choose to cover some or all of the costs, but we should be careful that OSA should not be singled out as significantly different from other chronic medical conditions.

    This position recognizes that some drivers may not have insurance. This situation, however, is no different from past ones, such as when a driver had a myocardial infarction many years ago with no recent follow up. Most examiners would agree that follow-up is necessary to determine certification status. At some point the need to ensure public safety may outweigh the issue of cost.

    7. What are the potential improved health outcomes for individuals occupying safety sensitive transportation positions and would receive OSA treatment due to regulations?
    In addition to the safety risks, adequate treatment has been shown to be associated with decreased fatal/non-fatal cardiovascular events, decreased number of arrhythmias, decreased blood pressure, improvement in glucose levels and better control of diabetes, improvement in insulin sensitivity and insulin responsiveness, improvement of depression and ADHD, decrease in headaches and a decrease in mortality risk with patients who have ischemic stroke.

    8. What models or empirical evidence is available to use to estimate potential costs and benefits of alternative restrictions?
    None

    9. What costs would be imposed on transportation workers with safety sensitive duties by requiring screening, evaluation, and treatment of OSA?
    The costs imposed upon the transportation workers would potentially include the cost of testing, evaluations, and treatment as dictated by their particular insurance/co-pay coverage.

    10. Are there any private or governmental sources of financial assistance? Would health insurance cover costs for screening and/or treatment of OSA?
    There are no private or governmental sources of financial assistant that we are aware of, although specifics would vary by industry and situation. If the individual has insurance, testing and treatment may be covered in part once deductibles and co-pays are met.

    Screening Procedures & Diagnostics
    11. What medical guidelines other than the AASM FAA currently uses are suitable for screening transportation workers with safety sensitive duties that are regulated by FMCSA/FRA for OSA? What level of effectiveness are you seeing with these guidelines?
    There are currently multiple resources available for consideration of screening guidelines. The key point is to determine desired sensitivity/specificity. The initial criteria selected should be focused on identifying those operators at highest risk of OSA and highest risk of impairment. Criteria should be re-evaluated as data on the adequacy of the selected criteria can be evaluated. Platt evaluated drivers using criteria based on the 2006 Joint Tri-Medical Society Task Force and found that many drivers with OSA were missed. Adding a confidential symptom-based screening increased diagnosis, but had a low specificity (many drivers tested did not have OSA), leading them to recommend universal testing of all commercial drivers.

    As pointed out in the FMCSA’s Medical Expert Panel’s 2011 update – “Prioritizing commercial drivers with a higher risk of moderate-to-severe OSA could be helpful in minimizing the costs of OSA diagnosis by PSG. One expects that a higher proportion of these priority individuals would be diagnosed with OSA [35], thereby reducing the frequency of “needless” PSG, i.e., PSG procedures performed on individuals without OSA. This evidence review considered the available algorithms and found problems with many of those. And concluded – we are unable to recommend any one algorithm as an appropriate screening tool to aid in OSA diagnoses. The algorithms investigated in this report (and any future algorithms developed) need to be tested among CMV drivers, in order to better determine their suitability in screening for moderate-to-severe OSA among this population.” Implementing the above recommendations for determining PSG referrals for commercial drivers may prove problematic because they could result in large numbers of drivers being referred to PSG. The test performance characteristics of newer, next generation home sleep apnea tests (HSAT) may usher in a lower cost and more accessible tool for diagnosing and managing OSA.

    When assessing acceptable risk, consider that exemptions are being given for drivers whose diabetes is stable and well controlled on insulin, in drivers with a well-controlled seizure disorder, and in drivers with compensated hearing deficits. The acceptable risk of crash should be determined for all medical conditions and should be applied consistently across conditions.

    Some of the available guidelines for screening vehicle operators for OSA include:

    • Hartenbaum N, Collop N, Rosen IM, Phillips B, 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-S37.
    • Ancoli-Israel S, et al. Expert Panel Recommendations: Obstructive Sleep Apnea and Commercial Motor Vehicle Driver Safety. 2008.
    • 2012 -– FMCSA Medical Review Board/Motor Carrier Safety Advisory Committee report, at https://www.fmcsa.dot.gov/meeting-summaries-2012.
    • Platt -– recommends universal screening of all commercial motor vehicle operators – Platt AB, Wick LC, Hurley S, et al. Hits and misses: screening commercial drivers for obstructive sleep apnea using guidelines recommended by a joint task force. J Occup Environ Med. 2013;55(9):1035-40.
    • Colvin LJ, Collop NA. Commercial motor vehicle driver obstructive sleep apnea screening and treatment in the United States: an update and recommendation overview. J Clin Sleep Med. 2016;12(1):113-125.
    • American Thoracic Society came out with an update in 2013 on their guideline for non-commercial drivers: http://www.thoracic.org/statements/resources/sleep-medicine/Sleep-Apnea-Sleepiness-Driving.pdf.
    • American College of Physicians also has guidelines from 2014: http://annals.org/article.aspx?articleid=1892620.
    • The ESS has been shown to not be effective in evaluating who would might be at risk of OSA – Talmage JB, Hudson TB, Hegmann KT, Thiese MS. Consensus criteria for screening commercial drivers for obstructive sleep apnea: evidence of efficacy. J Occup Environ Med. 2008;50:324-9.
    • The Canadian Thoracic Society and Canadian Sleep Society reviewed the recommendation of the 2008 FMCSA Medical Expert Panel and adopted those recommendations for Canadian Commercial Motor Vehicle Operators. Ayas N, Robert Skomro R, Blackman A, et al. Obstructive sleep apnea and driving: a Canadian Thoracic Society and Canadian Sleep Society position paper. Can Respir J. 2014;21(2):114-23.
    • Berger, et al., recommends universal screening using an online screening questionnaire. Of the drivers they screened, 30% were deemed as high risk and of those 68% had AHI >10 and 80% had AHI of 5 or more – Berger M, Varvarigou V, Rielly A, et al. Employer-mandated sleep apnea screening and diagnosis in commercial drivers. J Occup Environ Med. 2012;54(8):1017-25.

    12. What were the safety performance histories of transportation workers with safety sensitive duties who were diagnosed with moderate-to-severe OSA, who are now successfully compliant with treatment before and after their diagnosis?
    Most available studies show that adequate treatment of OSA significantly mitigates crash risk in drivers. Examples of supporting studies include:

    • Burks SV, et al. Non-adherence with employer-mandated sleep apnea treatment and increased risk of serious truck crashes. Sleep. 2016;39(5):967-75 (finding that drivers who were adherent with OSA treatment had crash risk similar to controls at low risk of OSA).
    • Tregear S, Reston J, Schoelles K, et al. 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.
    • George CF. Reduction in motor vehicle collisions following treatment of sleep apnea with nasal CPAP. Thorax. 2001;56:508-12.

    13. When and how frequently should transportation workers with safety sensitive duties be screened for OSA? What methods (laboratory, at-home, split, etc.) of diagnosing OSA are appropriate and why?
    Each mode should be considered individually based upon current medical guidelines for medical examinations. Examiners should be given latitude to require more frequent exams or limited certification periods as determined based on risk factors and any prior diagnostic evaluations. If prior adequate studies have been conducted with no change in risk factors (BMI, neck circumference, Mallampati score, symptoms or co-morbid medical conditions; hypothyroid, DM, HTN, then repeat referral for testing would not be indicated.

    Diagnostic testing could be in lab (full or split night) or home sleep apnea testing (HSAT). Type II or III portable HSAT studies can be utilized as a screening tool with either APAP for treatment or an in-lab PSG/CPAP titration should be considered acceptable. Post-testing, face-to-face evaluations with a sleep specialist are also preferable to other or no form of follow-up.

    • HSAT could be utilized to “rule in” OSA and initiate APAP treatment in those at high pre­‐test probability of OSA.
    • But, HSAT should only be used to rule out OSA if an appropriate method was used, the test was preceded by an evaluation by a sleep specialist, and that study is interpreted by a board certified sleep specialist.
    • Use of a traditional HSAT to rule out OSA should be done with caution as these studies tend to underestimate the presence and severity of OSA and are often unable to assess the time asleep, only the time of testing. Other confounding issues include chain of custody not necessarily being ensured, and no documentation of whether individual was attempting to sleep or was awake, either voluntarily or through use of stimulants such as caffeine.
    • When one takes into account the fact that the HSAT portable equipment is more prone to damage and sleep studies are more likely to be inconclusive or fail (meaning that these failed studies will need to be repeated), the costs associated with sleep studies based on portable systems may ultimately exceed those associated with assessment in a sleep lab.
    • HSAT technology is evolving. Results from some devices quantify sleep and therefore have higher correlation with facility based sleep study results. These newer technologies could help not only rule in, but also rule out, sleep apnea when applied appropriately. However, until these newer technologies are available and there is universal understanding of which HSAT technology can be used to rule out OSA, some retesting will be required for certain individuals resulting in higher costs. In aggregate, HSAT when performed with the right equipment and under right supervision can reduce costs and lower access barriers to care.

    14. What, if any, restrictions or prohibitions should there be on a transportation workers’ safety sensitive duties while they are being evaluated for moderate-to-severe OSA?
    The determination of restricting duties during evaluation should be on a case-by-case, interactive basis. Conditions and symptoms may vary significantly, and availability of testing may cause significant hardship. While the initial criteria for diagnostic testing should be focused on those at highest risk and most will actually have OSA, many being tested will not and should not be removed from service unless deemed to be at truly highest risk -– history or prior fall asleep crash, previously diagnosed but non-compliant, or other unsafe behaviors. There should be some degree of flexibility in determining restrictions to minimize operational and economic impact to both the employee and the employer while focusing on safety risks.

    15. What methods are currently employed for providing training or other informational materials about OSA to transportation workers with safety sensitive duties? How effective are these methods at identifying workers with OSA?
    This will vary across industries and companies -- company websites, health screenings, brochures, etc. The culture of the rail industry is such that many employers can and do offer resources and opportunities. The North American Fatigue Management Program (NAFMP) has 2 excellent modules on OSA, but there is no evidence that it is in use by rail, trucking or bus companies.There are several companies that provide training to supervisors and operators.

    16. What qualifications or credentials are necessary for a medical practitioner who performs OSA screening? What qualifications or credentials are necessary for a medical practitioner who performs the diagnosis and treatment of OSA?
    OSA screening should be only be done by those whose licensure would permit them to diagnose and treat OSA. Due to the risk to the public, the final determination of whether an operator at highest risk of OSA does or does not have OSA, and the treatment of those diagnosed, should only be done by those with additional training in the diagnosis and treatment of sleep disorders. 

    17. With respect to FRA should it use railroad MEs to perform OSA screening, diagnosis, and treatment?
    Railroad MEs should be able to perform OSA screening. They may be well informed about OSA and associated occupational risk, and therefore, they are well-suited for screening for sleep apnea. However, diagnosis and treatment of OSA should be left to physicians who are board certified sleep specialists. The field continues to evolve rapidly with new diagnostic and therapeutic options. Maintaining high levels of positive airway pressure (PAP) adherence, which is critical to safety, also requires some degree of expertise in troubleshooting difficulties with PAP therapy.

    18. Should MEs or other agencies’ designated medical practitioners impose restrictions on a transportation worker with safety sensitive duties who self-reports experiencing excessive sleepiness while performing safety sensitive duties?
    Yes, drivers tend to underreport their degree of impairment for any condition, including OSA (see Talmadge). If the severity is sufficient for the operator to report excessive daytime sleepiness (EDS), they should be removed form service pending evaluation AND resolution of the EDS whether due to OSA or another cause such as medication, another sleep disorder such as periodic limb movement disorder (PLM), or some other unidentified sleep disorder. There is significant increased crash risk due to fatigue. Untreated or inadequately treated OSA is only one condition (see NAS recent document). 

    Treatment Effectiveness
    19. What should be the acceptable criteria for evaluating the effectiveness of prescribed treatments for moderate to-severe OSA?
    While more treatment is likely ideal, there is insufficient data to definitively state whether 4 to 6 or more hours on70, 75 or 80% of nights would bring the risk of crash to an acceptable level. The amount of treatment required will differ for each individual, just as the minimal amount of sleep before which an individual is considered too impaired to drive (see NSF Task Force). In an effort to focus on those that are at highest risk and definitely have inadequate treatment, a start might be 70% of nights with 4 hours of use per night. Further studies may be needed in individual cases to determine if more treatment would lead to a significant reduction in crash risk. The option of MWT might be considered in select cases – perhaps significantly severe cases (AHIs >50 or so).

    20. What measures should be used to evaluate whether transportation employees with safety sensitive duties are receiving effective OSA treatment?
    Transportation employees with safety sensitive duties should be required to utilize equipment which is able to measure adherence to treatment. While it is recognized that more treatment may be better, it appears that at least 4 hours per night for at least 70% of nights would be a reasonable minimal criterion. Some individuals may take a prolonged time to acclimate to the use of PAP equipment and failure should not be assumed until at least 90 days of adequate fitting equipment has passed. In some cases, longer than 90 days may be appropriate. Measures to monitor adherence to treatment should be of a type that ensures that the equipment is actually being used and not just turned on.

    Summary
    FMCSA has invested in 2 evidence-based studies on OSA which clearly showed the link between OSA and motor vehicle crashes. The studies also showed that there is a reduction in risk with adequate treatment. An expert panel, two medical review boards, and the motor carrier safety advisory committee have offered recommendations on which drivers should be referred for additional testing. BMI has been identified as the single objective factor, but should not be the only one. However, as BMI increases, the risk of OSA also increases, so a BMI of 35 should not be considered the same risk factor as a BMI of 50. Using multiple risk factors, both subjective and objective, and factors aside from BMI should also be considered as there will be many operators with OSA who have lower or even normal BMIs.

    While no specific BMI or other criteria will definitively identify all drivers with OSA nor exclude those without the chronic condition, it is time for DOT to aid examiners and employers by issuing at least a starting point of guidance that all can agree upon to identify those drivers and railroad workers at highest risk of OSA and crashing due to the OSA. Using a BMI of 40 as the point at which a driver must be referred, and a BMI between 30 and 40 as the point at which a driver should be considered for referral, in conjunction with other factors, serves as a reasonable initial criteria to aid in identifying those operators at highest risk of OSA. However, we urge the agencies in the Notice of Proposed Rulemaking to request comments on whether there is an evidence base for supporting a lower BMI threshold.

    While the literature clearly shows that drivers with untreated OSA are at an increased risk of MV crash, there is not agreement on how to best identify those workers at greatest risk of OSA AND at greatest risk of crash. At this point, it is essential that a starting point be identified that all stakeholders, drivers, employers, examiners and labor can agree is most likely to identify the worker at highest risk of OSA and highest risk of crash due to the OSA. There also must be flexibility in those guidelines as not every driver who meets the criteria for testing would actually require testing and not every worker who does not is at low risk of OSA. While a single factor alone would not be the determinant, the severity of each factor should also be considered. A worker with a BMI of 33 and mild hypertension has a very different risk than one with a BMI of 55 and normal blood pressure. Just as a Mallampati of 2 carries a very different risk than a Mallampati of 4.

    The issue of payment must also be addressed. In most cases, employers will pay for the basic assessment but refer workers to their personal physician for any additional evaluation where the worker is felt to be at risk of sudden or gradual impairment or incapacitation, whether a stress test for heart disease, labs for diabetes, or an MRI for neurologic abnormalities. Evaluation for OSA should be no different.

    The challenge is to identify not only those at highest risk of OSA but also at highest risk of a MV crash due to the OSA. When assessing acceptable risk, consider that exemptions are being given for drivers with DM on insulin, with seizures, or who have hearing deficits. The acceptable risk of crash should be determined for all medical conditions and should be relatively consistent from condition to condition. Whatever criteria are selected, it is essential that education be an integral part of any OSA program. Just because an individual does not meet the specified criteria does not mean that they have no risk for OSA.

    ACOEM is an organization of more than 4,000 occupational physicians and other health care professionals, which provides leadership to promote optimal health and safety of workers, workplaces, and environments.

    Thank you for your consideration of our comments. Please do not hesitate to contact me or Patrick O’Connor, ACOEM’s Director of Government Affairs at 202/223-6222, should you have any questions.

    Sincerely,

    James A. Tacci, MD, JD, MPH
    President

    Natalie P. Hartenbaum, MD, MPH, FACOEM
    Chair, Transportation Section