Australia National Standard for Health Assessment of Rail Safety Workers 2024 4.3: Diabetes: screen Category 1 workers by non-fasting HbA1c at every assessment (below 48 mmol/mol or 6.5 per cent not diabetic; 53 mmol/mol or 7 per cent and above diabetic; intermediate values confirmed), and Category 2 by self-report and urine glucose with referral on a positive screen; assess hypoglycaemia risk including awareness with the Clarke questionnaire, end-organ effects on vision, heart, nerves and feet, sleep apnoea and cardiovascular risk, the hazards of very tight control, and the use of continuous glucose monitoring and pumps; apply the criteria and review frequencies in Tables 10 and 11 by treatment type, with an endocrinologist or diabetes physician as the appropriate specialist

What does 4.3 require?

Diabetes affects Safety Critical Work through impairment or loss of consciousness in a hypoglycaemic episode associated with treatment, which can cause collapse (critical for Category 1) and a confusional state affecting judgement (relevant to both categories), and through end-organ effects on vision, the heart, the brain, peripheral nerves and the feet; sleep apnoea is more common in type 2 diabetes, very tight control measured by HbA1c may raise incident risk, severe hyperglycaemia can alter behaviour and decisions, and continuous glucose monitors and insulin pumps can mitigate risk though their Bluetooth links to smart devices must be considered. For Category 1 workers diabetes is diagnosed on history or on the non-fasting HbA1c taken for every assessment: below 48 mmol/mol (6.5 per cent) is regarded as not diabetic with normal periodic review, 53 mmol/mol (7 per cent) or more as diabetic, and values between are confirmed, with symptomatic workers confirmed by blood glucose. Category 2 diagnosis relies on self-report and the urine glucose test, with positive screens referred to the treating doctor. Assessment attends to hypoglycaemia frequency and awareness using the Clarke questionnaire, to retinopathy and other complications, to sleep apnoea signs such as BMI above 35 or neck circumference of 40 cm or more using the STOP-Bang and Epworth tools, and to cardiovascular risk. The fitness criteria in Table 11 and the review frequencies and specialist input in Table 10 are set by treatment (diet, non-hypoglycaemic agents, sulfonylureas, insulin) and category, with the appropriate specialist being an endocrinologist or consultant physician in diabetes and annual targeted review usual for Safety Critical Workers with diabetes.