Haematology guidance material (GM)

1. Applicants for a class 1 medical certificate shall be subjected to an haemoglobin test at each aero-medical examination.
2. Applicants with a haematological condition may be assessed as fit subject to satisfactory aero-medical evaluation.
3. Applicants for a class 1 medical certificate with any of the following haematological conditions shall be referred to the medical assessor of the licensing authority:
   1. abnormal haemoglobin, including, but not limited to anaemia, erythrocytosis or haemoglobinopathy;
   2. significant lymphatic enlargement;
   3. enlargement of the spleen;
   4. coagulation, haemorrhagic or thrombotic disorder;
   5. leukaemia.
4. The fitness of applicants for a class 2 medical certificate with any of the haematological conditions specified in points (4) and (5) of point (c) shall be assessed in consultation with the medical assessor of the licensing authority

CLASS 1 - AMC1 MED.B.030

(a) Abnormal haemoglobin
Applicants with abnormal haemoglobin should be investigated.

(b) Anaemia

(1) Applicants with anaemia demonstrated by a reduced haemoglobin level require investigation. Applicants with an haematocrit of less than 32 % should be assessed as unfit. A fit assessment may be considered in cases where the primary cause, such as iron or B12 deficiency, has been treated and the haemoglobin or haematocrit has stabilised at a satisfactory level.
(2) Applicants with anaemia which is unamenable to treatment should be assessed as unfit.

(c) Erythrocytosis
Applicants with erythrocytosis should be assessed as unfit. A fit assessment with an OML may be considered if investigation establishes that the condition is stable and no associated pathology is demonstrated.

(d) Haemoglobinopathy

(1) Applicants with a haemoglobinopathy should be assessed as unfit. A fit assessment may be considered where minor thalassaemia or other haemoglobinopathy is diagnosed without a history of crises and where full functional capability is demonstrated. The haemoglobin level should be satisfactory.
(2) Applicants with sickle cell disease (homozygote) should be assessed as unfit.

CLASS 2 - AMC2 MED.B.030

(a) Abnormal haemoglobin
Haemoglobin should be tested when clinically indicated.

(b) Anaemia
Applicants with anaemia demonstrated by a reduced haemoglobin level or low haematocrit may be assessed as fit once the primary cause has been treated and the haemoglobin or haematocrit has stabilised at a satisfactory level.

(c) Erythrocytosis
Applicants with erythrocytosis may be assessed as fit if the condition is stable and no associated pathology is demonstrated.

(d) Haemoglobinopathy
Applicants with a haemoglobinopathy may be assessed as fit if minor thalassaemia or other haemoglobinopathy is diagnosed without a history of crises and where full functional capability is demonstrated.

CLASS 1 - AMC1 MED.B.030

(h) Disorders of the lymphatic system

Applicants with significant localised and generalised enlargement of the lymphatic glands or haematological disease should be assessed as unfit and require investigation. A fit assessment may be considered in cases of an acute infectious process which is fully recovered or Hodgkin’s lymphoma or other lymphoid malignancy which has been treated and is in full remission.

CLASS 2 - AMC2 MED.B.030

(g) Disorders of the lymphatic system
Applicants with significant enlargement of the lymphatic glands or haematological disease may be assessed as fit if the condition is unlikely to interfere with the safe exercise of the privileges of the applicable licence(s). Applicants may be assessed as fit in cases of acute infectious process which is fully recovered or Hodgkin's lymphoma or other lymphoid malignancy which has been treated and is in full remission.

CLASS 1 - AMC1 MED.B.030

(j) Splenomegaly

Applicants with splenomegaly should be assessed as unfit and require investigation. A fit assessment may be considered when the enlargement is minimal, stable and no associated pathology is demonstrated, or if the enlargement is minimal and associated with another acceptable condition.

CLASS 2 - AMC2 MED.B.030

(i) Splenomegaly

Applicants with splenomegaly may be assessed as fit if the enlargement is minimal, stable and no associated pathology is demonstrated, or if the enlargement is minimal and associated with another acceptable condition.

CLASS 1 - AMC1 MED.B.030

(e) Coagulation disorders

(1) Applicants with a coagulation disorder should be assessed as unfit. A fit assessment may be considered if there is no history of significant bleeding episodes.
(2) Applicants with thrombocytopenia with a platelet count less than 75x109/L should be assessed as unfit. A fit assessment may be considered once the platelet count is above 75x109/L and stable.

(f) Haemorrhagic disorders

Applicants with a haemorrhagic disorder require investigation. A fit assessment with an OML may be considered if there is no history of significant bleeding.

(g) Thromboembolic disorders

(1) Applicants with a thrombotic disorder require investigation. A fit assessment may be considered when the applicant is asymptomatic and there is only minimal risk of secondary complication or recurrence.
(2) If anticoagulation is used as treatment, refer to AMC1 MED.B.010(g).
(3) Applicants with arterial embolus should be assessed as unfit. A fit assessment may be considered once recovery is complete, the applicant is asymptomatic, and there is only minimal risk of secondary complication or recurrence.

CLASS 2 - AMC2 MED.B.030

(e) Coagulation and haemorrhagic disorders

Applicants with a coagulation or haemorrhagic disorder may be assessed as fit if there is no likelihood of significant bleeding.

(f) Thromboembolic disorders

Applicants with a thrombotic disorder may be assessed as fit if there is minimal likelihood of significant clotting episodes. If anticoagulation is used as treatment, refer to AMC2 MED.B.010(g).

CLASS 1 - AMC1 MED.B.030

(i) Leukaemia

(1) Applicants with acute leukaemia should be assessed as unfit. Once in established remission, applicants may be assessed as fit.
(2) Applicants with chronic leukaemia should be assessed as unfit. After a period of demonstrated stability a fit assessment may be considered.
(3) Applicants with a history of leukaemia should have no history of central nervous system involvement and no continuing side-effects from treatment of flight safety importance. Haemoglobin and platelet levels should be satisfactory. Regular follow-up is required.

CLASS 2 - AMC2 MED.B.030

(h) Leukaemia

(1) Applicants with acute leukaemia may be assessed as fit once in established remission.
(2) Applicants with chronic leukaemia may be assessed as fit after a period of demonstrated stability.
(3) In cases (h)(1) and (h)(2), there should be no history of central nervous system involvement and no continuing side effects from treatment of flight safety importance. Haemoglobin and platelet levels should be satisfactory. Regular follow-up is required.

Class 1

Haemoglobin should be measured at every medical with appropriately maintained and calibrated testing equipment. Abnormalities on near patient testing should be confirmed with a full blood count assessed in a haematology laboratory.

Guidance Material for Applicants Considering Bone Marrow Donation (All Applicants)

Once applicants commence pre-donation treatment, (a daily injection to increase the number of stem cells in their circulating blood) they should inform their AME and be assessed as unfit.

Treatment usually starts four days prior to the donation itself. Common side-effects of the treatment are bone or muscle pain, nausea, headaches, and fatigue. Less commonly chest pain, insomnia, dizziness, and night sweats have been reported. Donation takes place on the fifth day and may need to be repeated on the sixth day if not enough cells were collected. Bone marrow is collected by one of two methods:

• Peripheral blood stem-cell donation (PBSC)

  Stem cells are collected from the circulating blood. No anaesthetic is required. If the applicant feels fully recovered after 48 hours they should contact their AME for advice on fitness to return to operational duties. If there is any doubt about fitness the AME may request a report regarding any side-effects or complications.

• Bone Marrow Aspiration

  A syringe is used to aspirate bone marrow from the hip bone and this procedure is usually performed under a general anaesthetic. The applicant may need to stay in hospital for up to 48 hours and are likely to be advised to rest at home for up to 5 days afterwards.

Once fully recovered the applicant should contact their AME for advice on fitness to return to operational duties. Assessment earlier than 5 days will require the applicant to be seen by their AME. If there is any doubt about fitness the AME may request a report regarding any side-effects or complications.

Guidance on blood donation

In order to prevent the very slight risk of post-donation faintness or syncope, donating blood or plasma should be avoided during the 24 hours before duty for holders of Class 1 and 2 medical certificates, and during the 12 hours before duty for holders of Class 3 medical certificates.

Class 1 & 2 Abnormal Haemoglobin

Refer to UK CAA Guidance on Haemoglobin test results for guidance

Iron Overload States including Haemochromatosis

An applicant with a diagnosis of Haemochromatosis or other iron overload state should be assessed as unfit.

A cardiology assessment is required to include an echocardiogram, Holter and Exercise ECG and ongoing cardiology follow-up is required.

Applicants should not fly within 48hrs of having venesection as treatment.

Applicants should have normal serum Ferritin following treatment.

Unrestricted medical certification can be considered by CAA Medical Assessor (Class 1) or AME (Class 2), once treatment is stabilised, on receipt of acceptable cardiology and haematology medical reports.

Follow up haematology reports are required on at least an annual basis.

Class 1 & 2 Haemoglobinopathy

Applicants with thalassaemia trait may be assessed as acceptable for unrestricted certification subject to the receipt of a haematology report.

Applicants with sickle cell trait may be assessed as acceptable for unrestricted certification.

Refer to Coagulation/Haemorrhagic Disorders for guidance.

Aspirin and Clopidogrel are acceptable anti-platelet medications

Anagrelide inhibits platelet formation. Applicants requiring this medication should be assessed as unfit. Medical certification for Class 1/OML can be considered by the Authority Medical Section no sooner than 2 weeks after commencing this treatment, subject to a satisfactory haematologist’s report to include comment on any side-effects. Thrombocytosis requires referral to CAA Medical

Refer to Pulmonary Embolism and Deep Vein Thrombosis for guidance.

Disorders of the lymphatic system

Guidance material currently under review.