Medical Waivers for Merchant Mariner Credential Applicants With a History of Seizure Disorders

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 This email address is being protected from spambots. You need JavaScript enabled to view it.. 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;

 

[[Page 17919]]

 

    (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.

 

 

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