The Coast Guard is seeking public comment regarding criteria for granting medical waivers to merchant mariners with a history of seizure disorders. Coast Guard regulations provide that convulsive disorders (also known as seizure disorders) are conditions that may lead to disqualification for a merchant mariner credential (MMC). Because a significant number of merchant mariner applicants have suffered from seizure disorders, it is important for the Coast Guard to develop and publish clear guidance regarding how such MMC applicants are evaluated. Prior to issuing a policy change on when waivers should be granted for seizure disorders, the Coast Guard will accept comments from the public on whether the proposed criteria adequately address safety concerns.
Comments and related material must either be submitted to our online docket via http://www.regulations.gov on or before April 24, 2013 or reach the Docket Management Facility by that date.
ADDRESSES: You may submit comments identified by docket number USCG-2013-0009 using any one of the following methods:
(1) Federal eRulemaking Portal: http://www.regulations.gov.
(2) Fax: 202-493-2251.
(3) Mail: Docket Management Facility (M-30), U.S. Department of
Transportation, West Building Ground Floor, Room W12-140, 1200 New
Jersey Avenue SE., Washington, DC 20590-0001.
(4) Hand delivery: Same as mail address above, between 9 a.m. and 5
p.m., Monday through Friday, except Federal holidays. The telephone
number is 202-366-9329.
To avoid duplication, please use only one of these four methods.
See the ``Public Participation'' portion of the SUPPLEMENTARY
INFORMATION section below for instructions on submitting comments.
FOR FURTHER INFORMATION CONTACT: If you have questions about this
notice, call or email Lieutenant Ashley Holm, Mariner Credentialing
Program Policy Division (CG-CVC-4), U.S. Coast Guard, telephone 202-
372-1128, email MMCPolicy@uscg.mil. If you have questions on viewing
material in the docket, call Docket Operations at 202-366-9826.
SUPPLEMENTARY INFORMATION:
Public Participation
You may submit comments and related material regarding this
proposed policy change. All comments received will be posted, without
change, to http://www.regulations.gov and will include any personal
information you have provided.
Submitting comments: If you submit a comment, please include the
docket number for this notice (USCG-2013-0009) and provide a reason for
each suggestion or recommendation. You may submit your comments and
material online or by fax, mail or hand delivery, but please use only
one of these means. We recommend that you include your name and a
mailing address, an email address, or a telephone number in the body of
your document so that we can contact you if we have questions regarding
your submission.
To submit your comment online, go to http://www.regulations.gov and
use ``USCG-2013-0009'' as your search term. Locate this notice in the
results and click the corresponding ``Comment Now'' box to submit your
comment. If you submit your comments by mail or hand delivery, submit
them in an unbound format, no larger than 8\1/2\ by 11 inches, suitable
for copying and electronic filing. If you submit comments by mail and
would like to know that they reached the Facility, please enclose a
stamped, self-addressed postcard or envelope.
We will consider all comments and material received during the
comment period.
Viewing the comments: To view comments, as well as documents
mentioned in this notice as being available in the docket, go to http://www.regulations.gov and use ``USCG-2013-0009'' as your search term.
Use the filters on the left side of the page to highlight ``Public
Submissions'' or other document types. If you do not have access to the
Internet, you may view the docket online by visiting the Docket
Management Facility in Room W12-140 on the ground floor of the
Department of Transportation West Building, 1200 New Jersey Avenue SE.,
Washington, DC 20590, between 9 a.m. and 5 p.m., Monday through Friday,
except Federal holidays. We have an agreement with the Department of
Transportation to use the Docket Management Facility.
Privacy Act: Anyone can search the electronic form of comments
received into any of our dockets by the name of the individual
submitting the comment (or signing the comment, if submitted on behalf
of an association, business, labor union, etc.). You may review a
Privacy Act system of records notice regarding our public dockets in
the January 17, 2008 issue of the Federal Register (73 FR 3316).
Background and Purpose
Coast Guard regulations in 46 CFR 10.215 contain the medical
standards that merchant mariner applicants must meet prior to being
issued an MMC. In cases where the MMC applicant does not meet the
medical standards in 46 CFR 10.215, the Coast Guard may issue a waiver
when extenuating circumstances exist that warrant special consideration
(46 CFR 10.215(g)).
On September 15, 2008, the Coast Guard issued Navigation and Vessel
Inspection Circular (NVIC) 04-08, ``Medical and Physical Evaluation
Guidelines for Merchant Mariner
Credentials.'' \1\ NVIC 04-08 provides that MMC applicants with a
history of seizure disorders should contact the National Maritime
Center (NMC) for guidance. Since the issuance of NVIC 04-08, a number
of MMC applicants have sought and received waivers for seizure
disorders in accordance with 46 CFR 10.215(g). However, because NVIC
04-08 does not identify waiver criteria associated with seizure
disorders, it has been difficult for Coast Guard personnel to
consistently evaluate MMC applicants with a history of seizures and
assess whether an individual applicant's medical condition warrants
granting a medical waiver under 46 CFR 10.215(g). Accordingly, the
Coast Guard is considering whether to change its policy regarding
waivers for seizure disorders, and under what criteria an MMC applicant
may be eligible for waiver consideration.
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\1\ NVIC 04-08 is available for viewing on the Coast Guard's Web
site at: http://www.uscg.mil/hq/cg5/nvic/2000s.asp#2008.
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The Coast Guard intends to consider public input as well as the
recommendations of the Merchant Mariner Medical Advisory Committee
(MMMAC), established under the authority of 46 U.S.C. 7115, prior to
establishing a final policy regarding which circumstances warrant
granting waivers for seizure disorders. Due to the complexity of the
medical and policy issues involved, the Coast Guard intends to
thoroughly analyze the issues prior to issuing the final policy.
Because there is no medical literature that specifically addresses
the safety implications that seizure disorders in mariners might have
on both mariners and the public, the Coast Guard reviewed the
guidelines and recommendations of the Federal Motor Carrier Safety
Administration (FMCSA) Medical Review Board (January 28, 2008) and
FMCSA's Medical Expert Panel (MEP) (October 15, 2007) with regard to
commercial motor vehicle drivers with seizure disorders. Although the
FMCSA provides guidelines and medical regulations specific to drivers
of commercial motor vehicles, the FMCSA's mission of promoting public
safety by evaluating the medical fitness of drivers is similar to the
Coast Guard's mission of promoting public and maritime safety by
evaluating the medical fitness of merchant mariners. While the FMCSA
standards are not binding on the Coast Guard, they provide a sound
basis for the Coast Guard to use in formulating policy with respect to
evaluating merchant mariner applicants with seizure disorders and
assessing whether an MMC applicant's condition warrants granting a
medical waiver. We used the FMCSA standards as a starting point in
formulating our proposed policy detailed below.
In October 2007, the MEP conducted a review of the medical
literature and revised its recommendations for medical certification of
commercial motor vehicle drivers with seizure disorders. The MEP
presented the following recommendations and findings to the FMCSA
Medical Review Board on January 28, 2008: \2\
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\2\ Seizure Disorders and CMV Driver Safety: Recommendations of
the MEP, October 15, 2007; available for viewing at http://www.fmcsa.dot.gov/rules-regulations/TOPICS/mep/report/Seizure-Disorders-MEP-Recommendations-v2-prot.pdf.
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(1) On the basis of the medical literature review, the MEP
concluded that the longer an individual remains seizure-free, the less
likely the individual is to have a recurrent seizure. Specifically, the
MEP found that individuals who have been seizure-free for at least 8
years have less than a 2 percent risk of seizure recurrence per year,
while those who have been seizure-free for 10 years have less than a 1
percent chance of seizure recurrence per year.
(2) The MEP asserted that a seizure recurrence risk of less than
two percent was sufficiently low so as to permit an individual to be
certified to drive a commercial motor vehicle. The MEP recommended that
an individual with a history of epilepsy (a type of seizure disorder)
may be granted conditional certification to drive, provided that the
individual meets certain criteria. Although the MEP recommended an 8-
year seizure-free period, the FMCSA Medical Review Board opted to
retain stricter guidelines, recommending a minimum 10-year seizure-free
period, to reduce the risk of seizure recurrence to less than 1
percent.
Proposed Policy
The Coast Guard is considering granting waivers to MMC applicants
with seizure disorders under the conditions delineated below. The Coast
Guard has been using an interim policy of an eight-year seizure-free
period for determining whether or not a waiver is warranted. The Coast
Guard recognizes that in some situations, a shorter period may be
justified. The Coast Guard requests public comment on whether the
criteria listed below are appropriate and sufficient for determining
whether an MMC applicant should be eligible for consideration for a
medical waiver under 46 CFR 10.215(g).
Unprovoked Seizures
Unprovoked seizures are those seizures not precipitated by an
identifiable trigger. Mariners with a history of unprovoked seizure(s)
may be considered for a waiver.
(1) Mariners with a history of epilepsy or seizure disorder may be
considered for a waiver if the mariner has been seizure-free for a
minimum of eight years (on or off anti-epileptic drugs (AEDs)); and
(a) If AEDs have been stopped, the mariner must have been seizure-
free for a minimum of eight years since cessation of medication; or
(b) If still using AEDs, the mariner must have been on a stable
medication regimen \3\ for a minimum of two years.
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\3\ As used in this document, a stable medication regimen is
considered to be a dosage within the therapeutic range that is
consistent given changes in the mariner's weight or other factors
such as drug interactions. Significant dosage reductions or tapering
of the medication dosage would not be considered stable.
Additionally, changes in the type or classification of anti-
epileptic medication utilized would not be considered stable.
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(2) Mariners with a single unprovoked seizure may be considered for
a waiver if the mariner has been seizure-free for a minimum of four
years (on or off AEDs); and
(a) If all AEDs have been stopped, the mariner must have been
seizure-free for a minimum of four years since cessation of medication;
or
(b) If still using AEDs, the mariner must have been on a stable
medication regimen for a minimum of two years.
Provoked Seizures
Provoked seizures are those seizures precipitated by an
identifiable trigger. Mariners with a history of provoked seizure(s)
may be considered for a waiver. Mariners in this group can be divided
into those with low risk of recurrence and those with a higher risk of
recurrence (e.g., with a structural brain lesion).
(1) If a mariner is determined to be low-risk for seizure
recurrence, does not require AEDs, and the precipitating factor is
unlikely to recur, a waiver may be considered when the mariner has been
seizure-free and off AEDs for a minimum of one year.
(2) Generally, mariners with one of the following precipitating
factors will be considered low-risk for recurrence:
(a) Lidocaine-induced seizure during a dental appointment;
(b) Concussive seizure, loss of consciousness <=30 minutes with no
penetrating injury;
(c) Seizure due to syncope not likely to recur;
(d) Seizure from an acute metabolic derangement not likely to
recur;
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(e) Severe dehydration;
(f) Hyperthermia; or
(g) Drug reaction or withdrawal.
(2) If a mariner is determined to be at higher risk for seizure
recurrence, a waiver may be considered if the mariner has been seizure-
free for a minimum of eight years (on or off AEDs); and
(a) If all AEDs have been stopped, the mariner must have been
seizure-free for a minimum of eight years since cessation of
medication; or
(b) If still using AEDs, the mariner must have been on a stable
medication regimen for a minimum of two years.
(3) Generally, mariners with a history of provoked seizures caused
by a structural brain lesion (e.g., tumor, trauma, or infection)
characterized by one of the following precipitating factors will be
considered at higher risk for recurrence:
(a) Head injury with loss of consciousness or amnesia >=30 minutes
or penetrating head injury;
(b) Intracerebral hemorrhage of any etiology, including stroke and
trauma;
(c) Brain infection, such as encephalitis, meningitis, abscess, or
cysticercosis;
(d) Stroke;
(e) Intracranial hemorrhage;
(f) Post-operative brain surgery with significant brain hemorrhage;
or
(g) Brain tumor.
(4) Under exceptional circumstances in which a mariner has had
provoked seizures with structural brain lesions, individuals may be
considered for a waiver once they have been seizure-free for a minimum
of four years, provided that objective evidence supports extremely low
risk of seizure recurrence.
Additional Specific Questions
The Coast Guard also specifically requests public comment on the
following questions:
(1) Is there evidence that the chronic use of AEDs for the
treatment of epilepsy impairs judgment or reaction time?
(2) Is there evidence that individuals who have been seizure-free
and off AEDs for a period of time have a lower likelihood of seizure
recurrence than individuals who have been apparently seizure-free and
on stable AED dosing?
(3) What is the risk of seizure recurrence as a function of time
since last seizure among individuals on AEDs who are apparently
seizure-free?
(4) What is the likelihood of seizure recurrence as a function of
time in individuals who are seizure-free following removal of a benign
brain tumor?
(5) Are there instances in which the Coast Guard should issue
credentials to mariners with seizure disorders, provided that the
credentials contain operational limitations that would allow such
mariners a limited role in industry without causing an undue safety
risk?
(6) Should mariners who are granted a waiver be restricted from
solo-watchkeeping in ports, harbors, and other waters subject to
congested vessel traffic or other hazardous circumstances?
(7) Are there individuals with seizure disorders due to a
structural brain lesion that are at low-risk for seizure recurrence?
In addition to submitting public comments in response to this
notice, the public may also wish to participate in the MMMAC public
meetings. MMMAC meetings are advertised separately in the Federal
Register and on the NMC's Web site at http://www.uscg.mil/nmc.