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					                  Sleep Apnoea Test among Commercial Vehicle Drivers:
                  The need versus the challenges for the implementation


Table of Content


   1. Requirement for drivers to be medically certified as a precondition
      for licensing


   2. Mechanism for Medical Examination as a pre-condition for
      licensing


   3. Why Sleep Apnoea?


   4. Medical standards on OSA and Practices in Other Countries


   5. Criteria for Screening and diagnosis of Obstructive Sleep Apnoea


   6. Challenges for the implementation and the interim measures


   7. References
          Sleep Apnoea Test among Commercial Vehicle Drivers:
           The need versus the challenges for the implementation


1. Requirement for drivers to be medically certified as a precondition for licensing


Driving a motor vehicle is a complex task requiring the successful integration of a
range of functions including perception, appropriate judgment, adequate response
time and reasonable physical capability. A range of medical conditions, as well as
certain treatments, may impair any of these functions. Such impairment may
adversely affect driving ability, possibly resulting in a crash, causing death or injury.
Whilst many factors contribute to safety on the road, a driver’s health is an important
consideration and a driver must meet certain medical standards to ensure that his/her
health status does not increase crash risk.


Despite lack of evidence to support the association between a mandatory medical
testing for any age group and crash risk, most countries have some form of medical
examination in place, usually as a pre-condition for either a new application or
renewal of a commercial vehicle license (OECD, 2001).


In Malaysia, under the Road Traffic Ordinance (1958), all commercial vehicle drivers
are required to obtain a medical certificate (to certify that he is not suffering from any
disease or physical disability which is likely to interfere with the efficient discharge of
his duties as a driver or to cause his driving of a commercial vehicle to be a source of
danger to the public) for application and renewal of his license. Under the current
regulation (Public Service Vehicles (Licensing and Conduct of Drivers, Conductors
and Passengers) Rules 1959), the medical examination is required to be conducted on
a yearly basis for the purpose of license renewal. This general rule indicate that a
driving license should not be given or renewed to any candidate suffering from a
medical condition likely to compromise safety on the road, except if by certified
medically fit by a medical practitioner (Table 1). Unlike the regulation in the
Directive of the Council, EU, no specific medical conditions or disorders are
mentioned in the Road Traffic Ordinance (1958). Medically fit to drive are solely
based on the professional judgement of medical practitioners who examine the case.
Table 1: Requirement for medical certification under the Road Traffic Ordinance
(1958)
         Public Service Vehicles (Licensing and Conduct of Drivers, Conductors
         and Passengers) Rules 1959

         Rule (4): Fitness and competency of applicants.
                No license shall be granted unless the Registrar is satisfied that the
                applicant is a fit and competent person to be licensed and for that
                purpose the Registrar may require him to provide:
                (b) In the case of an applicant for a license to drive:
                a medical certificate that he is not suffering from any disease or
                physical disability likely to interfere with the efficient discharge of his
                duties as a driver or to cause the driving by him of a public service
                vehicle to be a source of danger to the public.




2. Mechanism for Medical Examination as a pre-condition for licensing


Since the regulation that require all commercial vehicle drivers to obtain a medical
certificate had been passed by the government many year ago, to date, there is no
medical standard established pertaining to the specific medical conditions and its
criteria for unfit to drive. Current practice, drivers can be certified by any medical
doctor registered with the Malaysian Medical Council (MMA), under the Medical Act
1971. However, there was no proper format and medical examination standard to be
used as guide by the examining doctor. Therefore, the thoroughness of the medical
examination conducted by medical practitioner may subject to query.


In view of the weakness of the current system, efforts have been made by Road
Transport Department in collaboration with Ministry of Health to come out with the
medical standard as a guide for the purpose of medication examination as a pre-
condition for licensing. Subsequently, in 2011, the standard called Medical
Examination Standard for Vocational Driver’s Licensing was published by Ministry
of Health. According to the standard, any applicant not fulfilling the criteria stated
will be considered as unfit to apply for a vocational driving license. One of the
medical conditions stated in the standard is the Respiratory Related Sleep Disorders
including Obstructive Sleep Apnoea (MOH, 2011). Other medical conditions include
vision, audition, locomotion, cardiovascular system, diabetes, neurological and mental
disorder, alcohol, drugs, and renal disorders.


3. Why Sleep Apnoea?


Sleep apnoea (OSA) is one of the causes for excessive sleepiness and fatigue among
commercial drivers. Many researches have been carried on the association of OSA
with crash risk. For instance, the significant increase in risk of MVC among people
with OSA has been reported in many studies (Hartenbaum et al. 2006; Mulgrew et al.
2008; Teran-Santos et al.1999). It was reported that the risk for crashes in patients
with OSA range from two to 10 times as compared to the normal subjects. Several
studies which based on crash records as well as self-report and poor performance on
driving simulators have shown that patients with OSA syndrome have high motor
vehicle crash rates (Young, 2002). Ruth et al. and his colleague (2007) had conducted
a systematic review on evidences related to the risk of involvement in road accident in
persons with sleep apnoea. Majority of research supports the finding that sleep apnoea
is a significant risk factor for road accident.


It is critical that persons with sleep apnoea fully use the treatment provided by their
doctor. They should not drive if they are not being treated. Being effectively treated,
and complying with that treatment, offers the best hope of a commercial driver with
sleep apnea to secure the ability to do his or her job safely and be fully alert (Pack &
Maislin, 2002).


Obstructive sleep apnoea (OSA) is a syndrome of sleep disordered breathing. It is
characterised by recurrent interruptions of breathing during sleep due to temporary
obstruction of the upper respiratory airway by lax, excessively bulky, or malformed
pharyngeal tissue. People with OSA stop their breathing for 10 seconds or more at a
regular interval whilst sleeping. Following this apnoeic episode, the person arouses
him or herself and started to breathe again with resultant of hypoxemia and chronic
lethargy (John, 2001). Sleep apnea, with its repeated episodes of breathes cessation
and sleep fragmentation, will produces diurnal and nocturnal symptoms. This include
excessive daytime sleepiness, fatigue sleep attacks, psychomotor deficits, and
disrupted night time sleep due to frequent arousal (Gurubhagavatula (2004),
Flemmons (2002), Kales, (1985)). Manifestation of sleepiness among persons with
sleep apnoea contributes to serious potential consequence. The most potential
consequence is impaired performance at the wheel while driving. Sleepiness is
regarded as a significant contributor to motor-vehicle crashes (Horne & Reyner
(1999), Philip (1999).


The above mentioned points, is highly relevant and further strengthen by the facts that
the prevalence of OSA is relatively common among commercial drivers in Malaysia,
as reported by MIROS’s study (Fadhli, et al., 2009), 28.7 % of commercial drivers
has mild form of sleep apnoea. Those with moderate form are 9.0% and those with
severe form are 6.6 %.


Knowing the fact that the OSA is only one cause for fatigue related crashes among
commercial drivers, therefore, any interaction with other work-related factors will
make driver fatigue problem worsen. Figure 1 shows the multiple factors contributing
to driver fatigue, poor alertness and finally leading to crash.


Figure 1, clearly describe that there are two major categories of factors; the work-
related factors and medical conditions related factors. Both categories of the factors
need to be addressed adequately in order to control and prevent driver fatigue issues.
Work-related factors can be adequately addressed with the implementation of SHE
COP by the operators. Whereas, medical condition, in this case, Obstructive Sleep
Apnoea (OSA) can only be addressed through medical screening and proper
treatment. If the OSA is not treated, the interaction with the work-related factors will
make the situation worsen. On the other hand, by addressing the work-related factors
alone, will not resolve the issues of fatigue among drivers with OSA. As it is a
medication condition, it can only be managed through clinical interventions. Scientific
evidences have shown that treatment decreases the risk of accidents in treated drivers
(Engleman et al (1996 ); Cassel et al., (1996); Krieger et al., (1997 ); George et al.,
(2001); Orth et al. (2005). Hence, there is a clear need to screen and treat drivers with
OSA regardless of their work environment and safety system putting in place by the
operators.
Figure 1: Factors contributing to poor alertness and fatigue risk among commercial drivers




       4. Medical standards on OSA and Practices in Other Countries


       According to “Expert Panel Recommendations: OSA and Commercial Motor Vehicle
       Driver Safety”, those with moderate and severe form of OSA pose the highest risk for
       road safety and need to be clinically certified before can be allowed for driving.
       Whereas, for those with mild form but has symptoms of sleepiness should also be
       investigated and certified by a medical doctor before can be allowed for renewal a
       license or given a new license.
In our country, based on the Medical Standard Published by Ministry Of Health
(MOH, 2011); a driver who is diagnosed with OSA and require treatment is advised
to have annual review by a sleep specialist to ensure adequate treatment is maintained.


A driver is not qualified for licensing;
   If a person has established Sleep Apnoea Syndrome with moderate to severe
    sleepiness until treatment is effective
   If there is a history suggestive of Sleep Apnoea in association with severe
    sleepiness, until investigated and treated
   Sleep Apnoea is diagnosed on a diagnostic sleep study test.
License may be granted, taking into account the opinion of a specialist in sleep
disorders and the nature of driving task and subject to annual review:
   For those with established Sleep Apnoea Syndrome who are on satisfactory
    treatment


In view of its important to public transportation safety, many of the developed
countries have implemented a screening program for sleep disorder as part of their
medical examination as a pre-condition for initial or renewal of a license for
commercial drivers. Out of 15 EU countries for which data is available, 10 countries
have specific regulation involving sleep apnoea and other sleep disorders. Among EU
countries which have specific regulatory standards and guidance pertaining to sleep
apnoea and commercial vehicle driving include the United Kingdom, Sweden,
Poland, Spain, Belgium, France, Denmark, Luxembourg, Portugal and
Germany. Non EU countries which also have specific regulations on OSA include
Australia, Canada, New Zealand, and the United State, The details of their
regulatory medical standards are presented in Appendix 1. Many countries in the
world do not have specific requirement for OSA under their law but the general rules
concerning fitness to drive applies. Should a medical practitioner think that a
particular driver has OSA, she has the right to certify she or he is unfit for driving and
a license cannot be granted.
Among those with specific regulation on OSA, the actual practice is varied. In
Belgium and the UK, license applicants just required to complete a form, which
includes questions concerning sleepiness. Those who have risk factors are required to
go for further check-up and a medical certificate must be produced before a license
can be granted. This self-declaration is subjected to the sincerity of the drivers.
However, many countries require an applicant to produce a medical certificate though
a systematic screening system. These countries include Denmark, Luxembourg,
Portugal, Spain, Sweden, Australia, and the U.S. In Germany, there is no mention of
the sleepiness in the law, but under the general rule that any driver should be fit,
recommendation were issued by the Ministry of Traffic stating that sleepy OSA
drivers should not be allowed to drive (Krieger, 2007).


5. Criteria for Screening and diagnosis of Obstructive Sleep Apnoea


OSA can only be diagnosed through the sleep study test. However, only those which
meet the criteria as a high risk individual will be subjected to sleep study. A validated
examination format will be used for the screening purpose. Commonly used tool for
screening is the Epworth Sleepiness Score (ESS) and Berlin Questionnaire which is
clinically and internationally validated screening tool. Some of the risk factors can
only be identified during physical examination by a medical doctor. Based on the risk
factors identified, a score can be derived from the tool and drivers will be classified as
high risk, moderate risk, and low risk group. Those with high risk and moderate risk
should be referred for the Sleep Study test at the designated centre.


The screening program is simple and it can be incorporated in the existing medical
examination system for the commercial drivers. However, to confirm a particular
person is having OSA require a sleep test to be conducted. Sleep test can only be done
at a designated centre that has the equipment for sleep test and patient is required to
overnight at the centre to complete the test.


6. Challenges for the implementation and the interim measures


From the scientific point of views, there is no doubt that the drivers need to diagnosed
and treated for OSA. However, measure to reduce the impact of sleep apnoea and the
related driver sleepiness on the road crashes have little meaning if there are
inadequate facilities available to investigate and manage drivers with the OSA.
According to JPJ database, nearly 2 million commercial vehicle driver’s license is
renewed every year. Out of these drivers, what percentage would be subjected to sleep
test? Can we cope with the volume of drivers that need to be tested every year? How
many sleep test facilities are in place? This is very important to match the number of
high risk drivers with the number of facilities available. Where are the centres for
sleep test located? Can they be accessed easily by the drivers and at what cost? How
long drivers have to wait before they can be certified? While waiting for the sleep test,
can they be allowed to continue driving? The longer they have to wait; there will be
more days they have to be away from work and more money would be lost?


As an interim measures, a few recommendations are proposed:
1) New Driver: Pre-employment medical screening for all new drivers
   Companies are recommended to screen their new drivers for risk of having OSA
   and those with high risk must be subjected to a sleep test to confirm the diagnosis.
   A driver must be informed clearly about the risk of crash before can be recruited
   as a driver.


2) Existing Driver
   Mandatory testing for commercial drivers who were involved in a fatal and non-
   fatal crash suspected due to fatigue and have risk factors for OSA should be
   subjected to sleep study test to check for OSA and medical interventions should
   be taken accordingly. A driving license can only be renewed if medically fit.


3) Awareness programme on the importance of identifying the risk factors of OSA as
   well as the risk of MVC related to OSA can be included as part of the good driver
   management programme as stipulated in the Industrial Code of Practice for
   Transportation Sector.


4) Pre-licensing medical screening for all commercial vehicle drivers who have risk
   factors for OSA would be the ultimate goal. However, adoption of the policy as a
   national policy can only be considered if the facilities that offer sleep test are
   widely available in the country. At present, availability of the service is very
   limited.


5) All work-related factors contributing to driver fatigue should be managed properly
   and this can be done by implementing the ICOP, 2010 in transportation industries.
   The interaction between work-related factors and biological factors will worsen
   the driver fatigue problem.
Appendix 1: Regulatory Medical Fitness related to sleep disorder in other countries;
Country     Regulation
Australia   The criteria for an unconditional license are NOT met:
                   If the person has established sleep apnea syndrome (sleep apnea on a
                    diagnostic sleep study and excessive daytime sleepiness), with moderate to
                    severe sleepiness, until treatment is effective. Consideration should be given to
                    how long-distance drivers will comply with treatment such as CPAP
                   If there is a history suggestive of sleep apnea in association with severe
                    daytime sleepiness, until investigated and treated. Severe sleepiness is
                    indicated by frequent self-reported sleepiness while driving, motor vehicle
                    crashes caused by inattention or sleepiness or an Epworth Sleepiness Scale
                    Score of 16 to 24
            A conditional license may be granted by the Driver Licensing Authority, taking into
            account the opinion of a specialist in sleep disorders, and the nature of the driving task,
            and subject to annual review:
                   For those with established sleep apnea syndrome (sleep apnea on diagnostic
                    sleep study and excessive daytime sleepiness) who are on a satisfactory
                    treatment.
            Assessing    Fitness    to    Drive    (2012).   (http://www.austroads.com.au/driver-
            licences/assessing-fitness-to-drive)
            http://www.austroads.com.au/images/stories/AFTD_reduced_for_web.pdf


Canada      The following recommendations should only be made by physicians familiar with the
            interpretation of sleep studies.
                   Regardless of apnea severity, all patients with OSA are subject to sleep
                    schedule irregularities and subsequent sleepiness. Because impairment from
                    sleep apnea, sleep restriction and irregular sleep schedules may be interactive,
                    all patients should be advised about the dangers of driving when drowsy
                   Patients with mild OSA without daytime somnolence who report no difficulty
                    with driving are at low risk for motor vehicle crashes and should be safe to
                    drive any type of motor vehicle.
                    Patients with OSA, documented by a sleep study, who are compliant with
                  CPAP or who have successful UPPP treatment, should be safe to drive any
                  type of motor vehicle.
                 Patients with moderate to severe OSA, documented by a sleep study, who are
                  not compliant with treatment and are considered at increased risk of motor
                  vehicle crashes by treating physician, should not drive any type of motor
                  vehicle.
                 Patients with a high apnea-hypopnea index, especially if associated with right
                  heart failure or excessive daytime somnolence, should be considered at a high
                  risk for motor vehicle crashes.
                 Patients with OSA who are believed to be compliant with treatment but who
                  are subsequently involve in a motor vehicle crash in which they were at fault
                  should not drive at least 1 month. During this period, their compliance with
                  therapy must be reassessed. After the 1-month period, they may or may not
                  drive depending on the results of the reassessment.


          DVLA Advice Page (http://www.sleeping.org.uk/dvla_advice.aspx)
United    Driving must cease until satisfactory control symptoms has been attained, with on-
Kingdom   going compliance with treatment, confirmed by consultant/specialist opinion. Regular,
          normally annual, licensing review required.


          Doctor who diagnose sleep apnoea in a patient obliged to inform the driving license
          issuing authority.
          A driver wishing to be approved as fit to drive following a sleep apnoea diagnosis has
          to provide medical certificate from a GP or specialist to the effect that the symptoms
          have disappeared as a result of treatment.
          Authorities also require a certificate stating that the patient is following the treatment
          correctly.
          Updated in 1998.
          Regulations           on           sleep          apnoea            and           driving
          The DVLA has regulations for people who have been diagnosed with sleep apnoea,
          because these drivers are much more likely to be involved in crashes by falling asleep
          at the wheel.
          Group 1 licence holders (car/ motorcycle) diagnosed with sleep apnoea must stop
          driving until the symptoms have been controlled and confirmed by medical opinion.
          Group 2 licence holders (LGV) diagnosed with sleep apnoea must stop driving until
          the symptoms have been controlled, and must have ongoing treatment. Licensing
          reviews will be carried out regularly, usually annually.
          DVLA Advice Page (http://www.sleeping.org.uk/dvla_advice.aspx)


New       Driving should cease for individuals who meet the high-risk driver profile as follows:
Zealand          Are suspected of having OSA syndrome where there is a high level of concern
                  regarding the risk of excessive sleepiness while driving while the individual is
                  waiting for the diagnosis to be confirmed by a sleep study
                 Complain of severe daytime sleepiness and a history of a sleep-related motor
                  vehicle crashes or equivalent level of concern
                 Have a sleep study that demonstrates severe OSA syndrome and either it is
                  untreatable or the individual is unwilling or unable to accept treatment
          Individuals may resume driving or can drive if their OSA syndrome is adequately
          treated under specialist supervision with satisfactory control of the symptoms.
          Consideration should be given to the type of driving and hours of driving an individual
          undertakes. If there is any residual risk of daytime sleepiness medical practitioners
          should recommend a restriction in working hours or shift work. The Director of Land
          Transport Safety or the Director’s Delegate may impose license conditions for regular
          medical assessment. Medical follow-up may be delegated to the General Practitioner.


          NZ Transport Agency (2009). Medical aspect of fitness to drive: A guide for medical
          practitioners (http://www.nzta.govt.nz/resources/medical-aspects/)
Sweden    Possession (holding a driving license, tractor license or taxi driver license)
                 OSA syndrome constitutes grounds for denial of possession. This, however,
                  does not apply in the case of successful treatment.
                 Regarding possession in Group II and III, due consideration shall be given to
                  the additional risks and dangers to traffic safety involved in such possession.
          Reappraisal (reappraisal of possession through the requirement on a medical certificate
          or other medical statement)
                 A reappraisal shall occur at intervals considered suitable in each individual
                  case


          Specific mention of sleep apnoea in legislation and consider sufferers unfit to drive
          unless they are following treatment.
          Specific regulations involving sleep apnoea or narcolepsy, in addition to idiopathic
          hypersomnia or insomnia.
          Krieger J., (2007). Sleep apnoea and driving: how can this be dealt with?, Eur
         Respir Rev December 1, vol. 16 no. 106 189-195
         (http://err.ersjournals.com/content/16/106/189.full)
U.S      Each state sets its own medical standards for driving a commercial motor vehicle
         in intrastate commerce. Many States have adopted the medical regulations found
         under Section 391.41(b)(5) of the FMCSRs and have determined that sleep apnea is a
         disqualifying condition. Each State has the jurisdictional authority to suspend a CDL if
         a person has sleep apnea. Medical examiners and CMV drivers should check with their
         Department of Motor Vehicles for more information about medical standards in their
         State.
         The disqualifying level of sleep apnea is moderate to severe, which interferes with safe
         driving. The medical examiner must qualify and determine a driver’s medical fitness
         for duty.
         A motor carrier may not require or permit a driver to operate a CMV if the driver has a
         condition, including sleep apnea, that would affect his or her ability to safely operate
         the vehicle.
         http://www.fmcsa.dot.gov/safety-security/sleep-apnea/tools/Driving-with-Sleep-
         Apnea.aspx
Poland   Specific mention of sleep apnoea in legislation and consider sufferers unfit to drive
         unless they are following treatment.
         Doctor who diagnose sleep apnoea in a patient obliged to inform the driving license
         issuing authority.
         A driver wishing to be approved as fit to drive following a sleep apnoea diagnosis has
         to provide medical certificate from a GP or specialist to the effect that the symptoms
         have disappeared as a result of treatment.


         Krieger J., (2007). Sleep apnoea and driving: how can this be dealt with?, Eur
         Respir Rev December 1, vol. 16 no. 106 189-195
         (http://err.ersjournals.com/content/16/106/189.full)
Spain    Specific mention of sleep apnoea in legislation and consider sufferers unfit to drive
         unless they are following treatment.
         Specific regulations involving sleep apnoea or narcolepsy, in addition to idiopathic
         hypersomnia or insomnia.
         Doctor who diagnose sleep apnoea in a patient obliged to inform the driving license
         issuing authority.
         A driver wishing to be approved as fit to drive following a sleep apnoea diagnosis has
         to provide medical certificate from a GP or specialist to the effect that the symptoms
         have disappeared as a result of treatment.
         License applicant must undergo a specific series of tests related to sleep apnoea.
          A medical certificate is mandatory to apply for a driving license and is usually
          completed by the general practitioner. This must be renewed after the age of 65 years
          for C, D, E license holders, which therefore indicates that the physician decides
          whether a patient is fit to drive.
          A psycho-technical examination is performed by a private office accredited by
          licensing authorities at the first application, then every 10 years before the age of 45
          years, every 5 years until the age of 60 years, every 3 years until an age of 70 years,
          then yearly. The examination includes a test on a driving simulator in addition to sight,
          hearing and blood pressure testing. A questionnaire on general health includes
          medication taken and possible sleepiness. If any abnormality is detected, a report to the
          licensing authorities is made and the candidate is referred to a sleep centre.
          Krieger J., (2007). Sleep apnoea and driving: how can this be dealt with?, Eur
          Respir Rev December 1, vol. 16 no. 106 189-195
          (http://err.ersjournals.com/content/16/106/189.full)
Belgium   Specific mention of sleep apnoea in legislation and consider sufferers unfit to drive
          unless they are following treatment.
          Specific regulations involving sleep apnoea or narcolepsy, in addition to idiopathic
          hypersomnia or insomnia.
          A driver wishing to be approved as fit to drive following a sleep apnoea diagnosis has
          to provide medical certificate from a GP or specialist to the effect that the symptoms
          have disappeared as a result of treatment.
          Authorities also require a certificate stating that the patient is following the treatment
          correctly.
          License applicant must submit response to a sleep apnoea questionnaire. The
          questionnaire is completed on the initial application for a license. If, at a later date,
          OSAHS is diagnosed, the driver must send their license to the licensing authority, but
          may get it back when able to provide a medical certificate stating that they are being
          adequately treated.
          Updated in 1998.
          Krieger J., (2007). Sleep apnoea and driving: how can this be dealt with?, Eur
          Respir Rev December 1, vol. 16 no. 106 189-195
          (http://err.ersjournals.com/content/16/106/189.full)
France    Specific mention of sleep apnoea in legislation and consider sufferers unfit to drive
          unless they are following treatment.
          Specific regulations involving sleep apnoea or narcolepsy, in addition to idiopathic
          hypersomnia or insomnia.
          A driver wishing to be approved as fit to drive following a sleep apnoea diagnosis has
          to provide medical certificate from a GP or specialist to the effect that the symptoms
              have disappeared as a result of treatment.
              Treatment has to be effective for at least 1 month, and, for Group 2 drivers, that
              efficacy has been confirmed by maintenance of wakefulness test.
              Updated in 2005.
              Krieger J., (2007). Sleep apnoea and driving: how can this be dealt with?, Eur
              Respir Rev December 1, vol. 16 no. 106 189-195
              (http://err.ersjournals.com/content/16/106/189.full)
Germany       Specific mention of sleep apnoea in legislation and consider sufferers unfit to drive
              unless they are following treatment.
              Under the general rule that any driver should be fit, recommendations were issued by
              the Ministry of Traffic stating that sleepy OSAHS drivers should not be allowed to
              drive and specify criteria for adequate treatment for Group 2 drivers.
              A driver wishing to be approved as fit to drive following a sleep apnoea diagnosis has
              to provide medical certificate from a GP or specialist to the effect that the symptoms
              have disappeared as a result of treatment.


              Krieger J., (2007). Sleep apnoea and driving: how can this be dealt with?, Eur
              Respir Rev December 1, vol. 16 no. 106 189-195
              (http://err.ersjournals.com/content/16/106/189.full)

Finland       Specific mention of sleep apnoea in legislation and consider sufferers unfit to drive
              unless they are following treatment.
              Doctor who diagnose sleep apnoea in a patient obliged to inform the driving license
              issuing authority.
              A driver wishing to be approved as fit to drive following a sleep apnoea diagnosis has
              to provide medical certificate from a GP or specialist to the effect that the symptoms
              have disappeared as a result of treatment.
              It has become mandatory, since the end of 2004, for physicians to declare unfit
              drivers, including sleepy drivers, to the licensing authorities. The impact of such a
              measure remains to be evaluated.

              Krieger J., (2007). Sleep apnoea and driving: how can this be dealt with?, Eur
              Respir Rev December 1, vol. 16 no. 106 189-195
              (http://err.ersjournals.com/content/16/106/189.full)

Netherlands   Specific mention of sleep apnoea in legislation and consider sufferers unfit to drive
              unless they are following treatment.
              Sleep disorders are included in a category of loss of consciousness other than
              epilepsy, and comprise narcolepsy as well as sleep apnoea.
              The duration of effective treatment is specified, ranging from 1–6 months, with the
              exception of a requirement of 5 years without an “attack” applying to narcolepsy as
              well as to sleep apnoea
              Updated in 1994.

              Krieger J., (2007). Sleep apnoea and driving: how can this be dealt with?, Eur
             Respir Rev December 1, vol. 16 no. 106 189-195
             (http://err.ersjournals.com/content/16/106/189.full)




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Description: A Brief Review on Sleep Apnea screening Implementation for drivers