PPG-TAB A: AMPLIFICATION OF THE MINIMAL STANDARDS OF FITNESS FOR DEPLOYMENT TO THE CENTCOM AOR; TO ACCOMPANY MOD 10 TO USCENTCOM INDIVIDUAL PROTECTION AND INDIVIDUAL/UNIT DEPLOYMENT POLICY
1. General. This PPG-TAB A accompanies MOD TEN, Section 15.C. and provides amplification of the minimal standards of fitness for deployment to the CENTCOM AOR, including a list of medical conditions that may be sufficient to deny medical clearance for or to disapprove deployment of a service member, civilian employee, volunteer, or contractor's employee. The list of deployment-limiting conditions is not comprehensive; there are many more conditions that could be cause to deny medical clearance for deployment. Possession of one or more of the conditions listed in this tab does not automatically mean that the individual may not deploy. Rather, it imposes the requirement to obtain a knowledgeable physician's opinion as to the deployability status of the individual. “Medical conditions” as used here also include those health conditions usually referred to as dental, oral, psychological and/or emotional. Uniformed Service Members will be evaluated for fitness according to service regulations and policies, in addition to the guidance in the parent PPG Modification (MOD). See MOD TEN REF E, F, G, H, O and HH. 2. The provider evaluating personnel for deployment must bear in mind that in addition to the individual's duties, the environmental conditions include extremes of temperature, physiologic demand (water, mineral, salt, and heat management), and poor air quality (especially particulates), while the operating conditions impose extremes of diet (to include fat, salt, and caloric levels), sleep deprivation, emotional stress, and circadian disruption. If maintaining an individual's health requires avoidance of these extremes or excursions, she/he should not deploy. 3. The rules and facts listed in paragraph 2 should assist the evaluating medical authority to make qualified judgments as to whether an individual with an existing condition is suitable for deployment. Any condition that markedly impairs an individual's daily function is grounds for disapproval. Evaluation of functional capacity to determine fitness in conditions of physiologic demand is encouraged to make a decision, such as graded exercise testing when there is coronary artery disease or significant risk thereof. The evaluating provider should pay special attention to hematologic, cardiovascular, pulmonary, orthopedic, neurological, endocrine, dermatological, psychological, visual, and auditory conditions which may present a hazard to the individual or others and/or preclude performing functional requirements in the deployed setting. Also, the amount of medications being taken and their suitability and availability in the theater environment must be considered. 4. Nothing in this guidance document should be construed as authorizing use of defense health program or military health system resources for such evaluations if it is not elsewhere previously authorized. Generally, defense health program or military health system resources are not authorized for the purpose of pre-deployment or travel medicine evaluations for contractor employees. Local command, legal, and resource management authorities should be consulted for questions on this matter. 5. Shipboard operations that are not anticipated to involve operations ashore are exempt from the deployment-limiting medical conditions listed below and will follow Service specific guidance. 6. The general guidance from MOD TEN section 15C applies to:
A. All personnel (uniformed service members, government civilian employees, volunteers, and
contractor employees) deploying to theater must be medically and psychologically fit for deployment and possess a current Periodic Health Assessment (PHA) or physical. Fitness specifically includes the ability to accomplish tasks and duties unique to a particular operation and the ability to tolerate environmental and operational conditions of the deployed location.
B. Personnel with existing conditions, other than those outlined in this document, may deploy
1) An approved medical waiver, IAW Section 15.C.3., is documented in the medical
OR 2) All of the following conditions are met:
a) The condition(s) is/are not of such a nature that an unexpected worsening or physical trauma is likely to have a medically grave outcome. b) The condition(s) is/are stable; that is, currently under medical care, and reasonably anticipated by the pre-deployment medical evaluator not to worsen during the deployment under available care in theater, in light of physical, physiological, psychological and nutritional impacts and effects of the duties, location, and limited medical capabilities at the location. c) Any required ongoing health care or medications must be available in theater within the military health system for DoD personnel or the contractor health care system for contingency contractor personnel, unless specifically authorized in the contracting officer's Letter of Authorization and the synchronized pre-deployment operational tracker database and have no special handling, storage, or other requirements (e.g., refrigeration/cold chain, electrical power, etc.). d) No need or anticipation of duty limitations that preclude performance of duty or an accommodation imposed by the medical condition. e) There is no need for routine evacuation out of theater for continuing diagnostics or other evaluations (all such evaluations must be accomplished prior to deployment). f) It is not a condition that is outlined in this document as a non-deployable condition. Such conditions require an approved waiver in order to deploy.
7. Documented medical conditions precluding medical clearance. A list of all possible diagnoses and their severity that may cause an individual to be non-deployable would be too expansive. Rather than relying solely on a specific list of medical conditions, the medical evaluator must carefully consider whether the climate, altitude, nature of available food and housing, availability of medical, behavioral health, dental, surgical, and laboratory services, or whether other environmental and operational factors may be hazardous to the deploying person's health because of a known physical or psychological condition. The following list of conditions should not be considered exhaustive. Other conditions may render an individual medically non-deployable (see paragraph 6). Medical clearance to deploy with any of the following documented medical conditions may be granted, except where otherwise noted, IAW MOD 10 Section 15.C. If an individual is found deployed with a non-deployable condition and without a waiver for that condition, a waiver request to remain deployed should be submitted to the respective component surgeon. If the waiver request is denied, the individual will be redeployed out of the CENTCOM AOR. Individuals with the following conditions should not deploy (unless a waiver is approved):
A. General Conditions / Restrictions:
1. Conditions that prevent the wear of personal protective equipment, including
protective mask, ballistic helmet, body armor, and chemical/biological protective garments, regardless of the nature of the condition that causes the inability.
2. Conditions that prohibit required theater immunizations (other than smallpox & anthrax
per current guidance) or medications (such as antimalarials, chemical and biological antidotes, and other chemoprophylactic antibiotics).
3. Any chronic medical condition that requires frequent clinical visits (more than
quarterly) or ancillary tests (more than twice/year), that fails to respond to adequate conservative treatment, necessitates significant limitation of physical activity, or constitutes increased risk of illness, injury, or infection.
4. Any unresolved acute illness or injury that would impair one's duty performance during
5. Any medical condition that requires durable medical equipment or appliances (e.g.,
CPAP, TENS, catheters, spinal cord stimulators) or that requires periodic evaluation/treatment by medical specialists not readily available in theater.
B. Specific Medical Conditions:
1. Asthma that has a Forced Expiratory Volume-1 < 50% of predicted despite
appropriate therapy, that has required hospitalization in the past 12 months, or that requires daily systemic (not inhaled) steroids.
2. Seizure disorder, either within the last year or currently on anticonvulsant medication
3. Diabetes mellitus, type 1 or 2, on pharmacotherapy or with HgA1C > 7.0. a. No waivers granted for type 1 diabetes or insulin-requiring type 2 diabetes.
b. Type 2 diabetes, on oral agents only, with HgA1C ≤ 7.0 does not require a waiver if the calculated 10-year Framingham coronary heart disease risk percentage is less than 15%. If the calculated 10-year risk is 15% or greater, further evaluation is required prior to waiver submission. See C.8. for more detailed instructions.
4. History of heat stroke. 5. Meniere's disease or other vertiginous/motion sickness disorder, unless well controlled
6. Recurrent syncope for any reason. 7. Any musculoskeletal condition that significantly impairs performance of duties in a
8. Renalithiasis, recurrent or currently symptomatic. 9. Pregnancy. No waivers granted. 10. Obstructive sleep apnea (OSA). The OSA should be documented/diagnosed with in-
laboratory polysomnography, with a minimum of 2 hours of total sleep time, that yields an apnea-hypopnea index (AHI), or respiratory disturbance index (RDI), of greater than 5 / hour. Individuals who are treated with continuous positive airway pressure (CPAP) should deploy with a machine that has rechargeable battery back-up and sufficient supplies for the duration of the deployment. Individuals deploying to a location where their sleep environment has unfiltered air will typically not be granted waivers if a waiver is required per the guidance below. Advanced modes of airway pressure (adapt-servo ventilation, BIPAP, etc.) are not permitted in theater. The following guidelines are designed to ensure that individuals with OSA are adequately treated and that their condition is not of the severity that would pose a safety risk should they be required to go without their CPAP for a significant length of time.
a. Symptomatic OSA of any severity is non-deployable. No waivers granted. b. Mild (apnea-hypopnea index, AHI, < 15/hr) OSA with or without continuous
positive airway pressure (CPAP) treatment is deployable, no waiver required.
c. Untreated moderate to severe (AHI ≥ 15/hr) OSA is non-deployable. No waivers granted.
d. Treated (CPAP or otherwise) OSA with an AHI < 30/hr does NOT require a waiver
to deploy, except to Afghanistan or Yemen.
e. Treated OSA with an AHI ≥ 30/hr requires a waiver for deployment to any location
11. History of clinically diagnosed traumatic brain injury (mTBI/TBI) of any severity,
including mild. Such history does not necessitate a waiver request, but does require pre-deployment evaluation, which may include both neurologic and psychologic components, in accordance with the Joint Theater Trauma System (JTTS) Clinical Practice Guideline (CPG). This CPG can be found at www.usaisr.amedd.army.mil/cpgs.html. Individuals who have had three clinically diagnosed TBIs (of any severity, including mild) since their last full neurologic/psychologic CPG-defined evaluation are required to have such an evaluation completed prior to
C. Cardiovascular Conditions:
1. Symptomatic coronary artery disease. Also, see C.8. 2. Myocardial infarction within one year of deployment. Also, see C.8. 3. Coronary artery bypass graft, coronary artery angioplasty, carotid endarterectomy,
other arterial stenting, or aneurysm repair within one year of deployment. Also, see C.8.
4. Cardiac dysrhythmias or arrhythmias, either symptomatic or requiring medication,
electro-physiologic control, or automatic implantable cardiac defibrillator.
5. Hypertension not controlled with medication or that requires frequent monitoring. 6. Heart failure or history of heart failure. 7. Morbid obesity (BMI > 40) in accordance with National Heart Lung and Blood Institute
guidelines. No waivers granted. Military personnel in compliance with body fat guidelines do not require a waiver.
8. Civilian personnel who are 40 years of age or older or who have a history of known
coronary heart disease (CHD) must have a Framingham 10-year CHD risk percentage calculated (online calculator available at http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof). If the individual's calculated 10-year CHD risk is 15% or greater, the individual should be referred for further cardiology work-up and evaluation, to include at least one of the following: graded exercise stress test; myocardial perfusion scintigraphy; or stress echocardiography. Results of the evaluation (physical exam, Framingham results, etc.) and testing, along with the evaluating physician's recommendation regarding deployment, should be included in a waiver request to deploy.
D. Infectious Disease:
1. Blood-borne diseases (Hepatitis B, Hepatitis C, HTLV, HIV) that may be transmitted to
others in a deployed environment. Confirmed HIV antibody positivity is disqualifying for deployment. No waivers granted for HIV.
2. Latent tuberculosis, including those who are untreated or who are currently under
treatment. Waiver requests for deployment of such individuals should include specific information regarding treatment, where they are in the treatment course, documentation of lack of adverse treatment effects, and feasibility of continued treatment in theater.
3. Active tuberculosis. No waivers granted.
E. Eye, Ear, Nose, Throat, Dental Conditions:
1. Vision loss. Best corrected visual acuity must meet job requirements to safely perform
2. Refractive eye surgery. Personnel who have had laser refractive surgery must have a
satisfactory period for post-surgical recovery before deployment. There is a large degree of patient variability which prevents establishing a set timeframe for full recovery. The attending ophthalmologist or optometrist will determine when recovery is complete.
a. Personnel are non-deployable while still using ophthalmic steroid drops post-
procedure. No waivers granted.
b. Photorefractive keratectomy (PRK). Personnel are non-deployable for three
months following uncomplicated PRK unless a waiver is granted. Related “surface ablation” procedures such as laser epithelial keratomileusis (LASEK) and epithelial LASIK are to be considered equivalent to PRK. Waiver request should include clearance from treating ophthalmologist or optometrist.
c. Laser assisted in situ keratomileusis (LASIK). Personnel are non-deployable
for one month following uncomplicated LASIK unless a waiver is granted. Waiver request should include clearance from treating ophthalmologist or optometrist.
3. Hearing loss. The requirement for use of a hearing aid does not necessarily preclude
deployment. However, the individual must have sufficient unaided hearing to perform duties safely IAW Service guidelines. If individuals meet the following criteria, no waiver is required to
a. A hearing level no greater than 30dB for either ear (the average of hearing levels at
500, 1000, and 2000 Hz), with no individual level greater than 35dB at these frequencies and no greater than 55dB at 4000 Hz; OR
b. A hearing level no greater than: 30dB at 500 Hz; 25dB at 1000 and 2000 Hz; and
4. Tracheostomy or aphonia. 5. Patients without a dental exam within the last 12 months or patients who are likely to
require dental treatment or re-evaluation for oral conditions, that are likely to result in dental emergencies, within 12 months.
a. Individuals being evaluated by a non-DoD civilian dentist should use a DD Form
2813, or equivalent, as proof of dental examination.
b. Individuals with orthodontic equipment are non-deployable without a waiver.
Waiver requests to deploy should include a current evaluation by their treating orthodontic provider and include a statement that wires with neutral force are in place.
1. Cancer for which the individual is receiving continuing treatment or requiring frequent
subspecialist examination and/or laboratory testing during the anticipated duration of the deployment.
2. Precancerous lesions that have not been treated and/or evaluated and that require
treatment/evaluation during the anticipated duration of the deployment. G. Surgery:
1. Any medical condition that requires surgery (e.g., unrepaired hernia) or for which
surgery has been performed and the patient requires ongoing treatment, rehabilitation or additional surgery to remove devices (e.g., external fixator placement).
2. Individuals who have had surgery (other than minor procedures) within the last year
who have not been cleared/released by their surgeon.
3. Individuals who have had surgery (open or laparoscopic) within 6 weeks of
deployment. H. Psychiatric Conditions:
1. Psychotic and Bipolar Disorders are disqualifying for deployment. No waivers granted. For detailed guidance on deployment-limiting psychiatric conditions or psychotropic medications, refer to Health Affairs Policy Memorandum, “Policy Guidance for Deployment- Limiting Psychiatric Conditions and Medications,” November 7, 2006.
2. Psychiatric disorders with fewer than three months of demonstrated stability from the
last change in treatment regimen (medication, either new or discontinued, or dose change). Note: Disorders that have demonstrated clinical stability for three months or greater, without change in therapy, do not require a waiver to deploy. Exceptions to this are noted elsewhere in this document and include specific diagnoses (e.g. bipolar disorder) and specific medications (e.g. antipsychotics).
3. Clinical psychiatric disorders with residual symptoms, or medication side effects, that
4. Mental health conditions that pose a substantial risk for deterioration and/or
recurrence of impairing symptoms in the deployed environment.
5. History of the following: psychiatric hospitalization; suicide attempt; substance
(medication, illicit drug, alcohol, inhalant, etc.) abuse or treatment for such abuse; and mTBI/TBI. Any such history requires evaluation by a behavioral health practitioner who is authorized to write profiles in order to make a deployability determination. Waiver requests for such individuals should include the results and recommendation from this evaluation. For mTBI/TBI, this evaluation is only required if indicated by the JTTS-CPG. See B.11.
I. Medications - although not exhaustive, use of any of the following medications (specific medication or class of medication) requires a waiver:
a. Therapeutic Anticoagulants: warfarin (Coumadin®). No waivers granted. b. Platelet Aggregation Inhibitors or Reducing Agents: clopidogrel (Plavix®),
anagrelide (Agrylin®), Note: Aspirin use in theater is to be limited to individuals who have been advised to continue use by their healthcare provider for medical reasons; such use must be documented in the medical record.
c. Hematopoietics: filgrastim (Neupogen®), sargramostim (Leukine®),
d. Antihemophilics: Factor VIII, Factor IX.
2. Antineoplastics (oncologic or non-oncologic use): e.g., antimetabolites (methotrexate,
hydroxyurea, mercaptopurine, etc.), alkylators (cyclophosphamide, melphalan, chlorambucil, etc.), antiestrogens (tamoxifen, etc.), aromatase inhibitors (anastrozole, examestane, etc.), medroxyprogesterone (except use for contraception), interferons, etoposide, bicalutamide, bexarotene, oral tretinoin (Vesanoid®).
3. Immunosuppressants: e.g., chronic systemic steroids. 4. Biologic Response Modifiers (immunomodulators) e.g., abatacept (Orencia®),
adalimumab (Humira®), anakinra (Kineret®), etanercept (Enbrel®), infliximab (Remicade®), leflunomide (Arava®), etc.
5. Antipsychotics, except quetiapine (Seroquel®) 25mg at bedtime for sleep. 6. Antimanic (bipolar) agents: e.g., lamotrigine (Lamictal®), lithium. No waivers granted.
7. Anticonvulsants, used for seizure control or psychiatric diagnoses.
a. Anticonvulsants (except those listed below) which are used for non-psychiatric
diagnoses, such as migraine, chronic pain, neuropathic pain, and post-herpetic neuralgia, are not deployment limiting as long as those conditions meet the criteria set forth in this document and accompanying MOD 10. No waiver required.
b. Valproic acid (Depakote®, Depakote ER®, Depacon®, etc.). c. Carbamazepine (Tegretol®, Tegretol XR®, etc.).
8. Varenicline (Chantix®). No waivers granted. 9. Opioids, opioid combination drugs, or tramadol (Ultram®), chronic use.
10. Insulin and exenatide (Byetta®). No waivers granted.
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