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Potential effects of shift work on health are probably related to the misalignment between the light-dark cycle and the human activity-rest cycle. Light exposure at night mediates these effects, including social misalignment and leads to an inversion of activity and rest, which, in turn, is linked to changes in behaviours. This article reviews the epidemiological evidence on the association between shift work and health, and possible mechanisms underlying this association. First, evidence from findings of the meta-analyses and systematic reviews published in the last 10 yr is presented. In addition, it reports the larger single-occupation studies and recent large population-based studies of the general workforce. Koch’s postulates were used to evaluate the evidence related to the development of disease as a result of exposure to shift work. Finally, we discussed limitations of the multiple pathways that link shift work with specific disorders and the methodological challenges facing shift work research. We concluded that the clearest indications of shift work being the cause of a disease are given when there is a substantial body of evidence from high quality field studies showing an association and there is good evidence from laboratory studies supporting a causal explanation of the link.

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Summary Rate of recovery of daytime performance and sleepiness following moderate and severe sleep deprivation (SD) was examined when recovery opportunity was either augmented or restricted. Thirty healthy non‐smokers, aged 18–33 years, participated in one of three conditions: moderate SD with augmented (9‐h) recovery opportunities, moderate SD with restricted (6‐h) recovery opportunities, or severe SD with augmented recovery opportunities. Each participant attended the laboratory for 8–9 consecutive nights: an adaptation and baseline night (23:00–08:00 hours), one or two night(s) of wakefulness, and five consecutive recovery sleep opportunities (23:00–08:00 hours or 02:00–08:00 hours). On each experimental day, psychomotor vigilance performance (PVT) and subjective sleepiness (SSS) were assessed at two‐hourly intervals, and MSLTs were performed at 1000h. PSG data was collected for each sleep period. For all groups, PVT performance significantly deteriorated during the period of wakefulness, and sleepiness significantly increased. Significant differences were observed between the groups during the recovery phase. Following moderate SD, response speed, lapses and SSS returned to baseline after one 9‐h sleep opportunity, while sleep latencies required two 9‐h opportunities. When the recovery opportunity was restricted to six hours, neither PVT performance nor sleepiness recovered, but stabilised at below‐baseline levels. Following severe SD, sleepiness recovered after one (SSS) or two (physiological) 9‐h sleep opportunities, however PVT performance remained significantly below baseline for the entire recovery period. These results suggest that the mechanisms underlying the recovery process may be more complicated than previously thought, and that we may have underestimated the impact of sleep loss and/or the restorative value of subsequent sleep.

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SUMMARYSubjective alertness may provide some insight into reduced performance capacity under conditions suboptimal to neurobehavioural functioning, yet the accuracy of this insight remains unclear. We therefore investigated whether subjective alertness reflects the full extent of neurobehavioural impairment during the biological night when sleep is restricted. Twenty-seven young healthy males were assigned to a standard forced desynchrony (FD) protocol (n = 13; 9.33 h in bed ⁄ 28 h day) or a sleeprestricted FD protocol (n = 14; 4.67 h in bed ⁄ 28 h day). For both protocols, subjective alertness and neurobehavioural performance were measured using a visual analogue scale (VAS) and the psychomotor vigilance task (PVT), respectively; both measures were given at various combinations of prior wake and circadian phase (biological night versus biological day). Scores on both measures were standardized within individuals against their respective baseline average and standard deviation. We found that PVT performance and VAS rating deviated from their respective baseline to a similar extent during the standard protocol, yet a greater deviation was observed for PVT performance than VAS rating during the sleep-restricted protocol. The discrepancy between the two measures during the sleep-restricted protocol was particularly prominent during the biological night compared with the biological day. Thus, subjective alertness did not reflect the full extent of performance impairment when sleep was restricted, particularly during the biological night. Given that subjective alertness is often the only available information upon which performance capacity is assessed, our results suggest that sleep-restricted individuals are likely to underestimate neurobehavioural impairment, particularly during the biological night. IN TROD UCTI ONShiftwork, in particular involving night work, disrupts the normal sleep ⁄ wake pattern in humans, causing temporary deficits in neurobehavioural performance and a heightened risk of errors and accidents (Akerstedt, 1998). Performance of safety-critical tasks could be maintained at an adequate level, and errors and accidents can be reduced, however, if necessary compensatory or preventative actions, such as mobilizing mental efforts and employing countermeasures, take place (Dinges et al., 1987;Fairclough and Graham, 1999;Purnell et al., 2002). Yet the application of such actions is guided by self-knowledge of performance capacity (Fairclough and Graham, 1999). Accurate knowledge of performance capacity, therefore, is critical for productivity and safety under conditions that are suboptimal for neurobehavioural functioning.Subjective alertness is arguably the most readily accessible information upon which performance capacity is