Attachment_A_-_Medical_Requirements_for_Contractors_Deploying_to_Afghanistan.docx

Attachment A: Medical Requirements for Contractors Deploying to Afghanistan

Contents

Published: March 22, 2019

Contractor Medical Deployability Requirements Applicability This policy applies to U.S. citizen and third country national (TCN) contractor employees recruited in or deploying to Afghanistan to perform work on a U.S. Department of State (DOS) contract with expected or actual time in country for a period greater than 30 days per calendar year.

Employees traveling to Afghanistan for less than 30 days in a calendar year may consider completing a pre-deployment health examination in order to document their health status and address any health concerns prior to travel to Afghanistan. This is especially relevant to those whose positions require frequent travel to Afghanistan. These employees are encouraged to complete annual pre-deployment health examinations.

General Requirements The contracting company is required to provide medically and psychologically fit contractor personnel capable of safely and satisfactorily accomplishing tasks and duties unique to a particular position while tolerating the environmental and operational conditions of Afghanistan and without posing a substantial risk of significant harm to the employee and others. The contracting company is responsible for medically vetting individual employees for deployment suitability by requiring them to undergo a comprehensive health examination and be determined medically suitable for deployment in accordance with such examinations standards. Suggested standards for this examination can be found at Tab A – Recommended Standards of Fitness for Medical Deployability to Afghanistan.

This assessment should emphasize diagnosing cardiovascular, pulmonary, orthopedic, neurologic, endocrinologic, dermatologic, psychological, visual, auditory, and other systemic disease conditions that may preclude performing the functional requirements of the contract, especially in the austere work environment encountered in Afghanistan.

At a minimum, personnel must be able to: adequately self-manage, within the austere environment and limited medical capabilities available in Afghanistan, any medical conditions discovered during the health examination in accordance with the recommended standards of fitness at Tab A; wear ballistic, respiratory, safety, chemical, and biological personal protective equipment; use required prophylactic medications; and ingress/egress in emergency situations with minimal risk to themselves or others.

Unless otherwise stated in the contract, all pre- and during-deployment health examinations are the responsibility of the contractor and U.S. government medical assets may not be used.

Specialized Contractor Personnel Specialized contractor employees (e.g., firefighters, security guards, police, aviators, aviation crew members, air traffic controllers, divers, marine craft operators, commercial drivers, etc.) who must meet specific physical standards or certifications associated with their position must also meet the requirements of this policy in addition to those standards as specified in their contract.

Infectious Disease Screening All employees must be screened for tuberculosis (tb) using an annual symptom screen. A tuberculin skin test (TST) is unreliable as a standalone screening test for TB disease in LN/TCN personnel that are from areas of high TB prevalence (as determined by the World Health Organization and/or the Centers for Disease Control), those who have been vaccinated against TB and those who have had a previous positive skin test for TB (“PPD”). A TST should not be used in these instances. For these individuals, chest radiography will be conducted for screening only if indicated by the TB screening questionnaire.

· Employees involved in food service, water, or ice production must be screened annually for signs and symptoms of infectious disease. Contractors must ensure employees receive typhoid and hepatitis A vaccinations from a reliable source and this information must be documented in the employees’ medical record/screening documentation.

· Employees involved in food service, water, or ice production who also reside in areas that are highly endemic for hepatitis A and/or hepatitis E will be screened for hepatitis E in addition to hepatitis A (if not previously immunized for hepatitis A) and upon return from any visits to that area (leave, R&R etc.).

All lab tests conducted outside of the United States must be done under the direction of a Centers for Disease Control and Prevention (CDC) approved panel physician. A copy of the results must be provided to the U.S. government’s medical contractor.

Immunizations All personnel traveling for any period of time to Afghanistan must be current with Advisory Committee on Immunization Practices (ACIP) guidelines. Personnel must comply with Centers for Disease Control (CDC) guidelines for Afghanistan.

Examination Intervals An examination with all medical issues and requirements addressed is valid for a maximum of 15 months from the date of the health examination, or 12 months following deployment, whichever is first. Contractor personnel deployed for multiple or extended tours of more than 12 months must be re-evaluated annually for fitness and should continue to meet all medical guidance to stay deployed. Unless specifically authorized by contractual arrangement neither DOS medical assets nor the U.S. government’s contracted medical provider can be used for re-evaluation to stay deployed. Periodic health surveillance requirements and prescription needs assessments should remain current through the deployment period.

Periodic health assessments in addition to the annual examination may be advised at the direction of the U.S. government’s contracted medical provider should a medical condition be identified requiring monitoring or follow-up action and are the responsibility of the employee and his/her company.

Documentation of Health Examination The examination should be documented using the Forms and Documents in Attachment B and include the evaluating medical provider’s determination of medical suitability for deployment. A copy of the examination and relevant supporting documents, in English, must be maintained by individual employee’s parent contracting company. The contracting company is responsible for submitting, with the employee’s consent, a copy of the examination record and relevant supporting documents as applicable, to the U.S. government’s medical contractor using a standard medically secure transmission or designated electronic portal.

Individual Examination Review and Determination of Medical Suitability for Deployment The U.S. government’s medical contractor will review the examination record and the evaluating medical provider’s determination of medical suitability for deployment. If the U.S. government’s medical contractor concludes that the documentation does not support a finding that the individual contractor employee is medically suitable for deployment, a recommendation will be made to the parent contracting company that the individual not deploy. However, the final deployment determination will be made by the contractor company and must be communicated to the U.S. government’s medical contractor and the contracting officer (CO).

Recommendation Not to Deploy If a contractor employee is not recommended for deployment, it will be up to the contracting company to take whatever action they deem appropriate. If the contracting company chooses to keep the employee employed under the contract, the company assumes full responsibility for the employee’s wellbeing and will reimburse the U.S. government for all costs associated with the treatment and transportation of the employee if medical evacuation becomes necessary. The employee will still remain eligible to receive medical support from the U.S. government’s contracted medical provider; however, the health service support infrastructure in Afghanistan is designed and prioritized to provide acute and emergency support and is not sized to provide support for preexisting or developed medical conditions requiring frequent professional monitoring or care.

The performance of the affected contractor employee will be monitored and if it becomes obvious that this employee requires an unusually high amount of medical support, the CO will be notified, but will not be given any specific medical information of the affected contractor employee besides the name of the individual. The CO will determine whether this impacts the performance of the contract and therefore be considered a weakness of the contracting company, which could be reflected in the annual Contractor Performance Assessment Reporting System (CPARS) report.

Medical Conditions During Deployment The U.S. government’s medical contractor will immediately notify the contracting company if a contractor employee is diagnosed with an infectious disease or a serious medical condition, and recommend that appropriate measures be taken. If the company takes no action, the contracting officer’s representative (COR) will be made aware of the situation and will notify the CO. Neither the COR or the CO will be given any specific medical information of the infected contractor employee but will contact the contracting company and take appropriate action, including the possibility of directing removal of the contractor employee from the contract/Post.

Pharmacy Contractor employees who require medication and who are deploying to Afghanistan will deploy with no less than a 180 day supply (or appropriate amount for shorter deployments) of their maintenance medications with arrangements to obtain a sufficient supply to cover the remainder of the deployment using a follow-on refill prescription. Arrangements and payment for the refill of prescriptions is the responsibility of the contractor employee and/or parent contracting company.

Permitted Medical Equipment Personnel who require minor corrective medical equipment (e.g., corrective eyewear, hearing aids) must deploy with all required items in their possession to include two pairs of eyeglasses, protective mask eyeglass inserts, ballistic eyewear inserts, and hearing aid batteries.

Medical Warning Tags Deploying personnel requiring medical warning tags (medication allergies, g6pd deficiency, diabetes, sickle cell disease, etc.) will deploy with red medical warning tags.

Defense Base Act and Medical Evacuation Insurance The contracting company is required to maintain Defense Base Act (DBA) and adequate medical evacuation insurance, including coverage for mental health emergencies. In the event it is determined that a contractor employee requires evacuation due to medical issues, it is the responsibility of the parent contracting company to make all the necessary arrangements and pay all costs for the evacuated employee. This includes all costs incurred in the event that a U.S. government aircraft is used.

Contingency plans for emergency evacuation of individuals with diagnoses that could complicate medical or mental health care following evacuation should be coordinated with the U.S. government’s medical contractor prior to the contractor employee’s deployment to Afghanistan.

Synchronized Pre-Deployment and Operational Tracker (SPOT) Registration All employees must have Primary Care selected on their letter of authorization in SPOT.

Requirements and Instructions for Access and Use of the Medical Review Web Portal

Within 15 days of award or contract modification the contractor shall provide the contracting officer contact information (name, phone number, and email address) for a singular designated “contract administrator” who will be authorized to access the U.S. government’s medical contractor web portal for the purposes of managing employment rosters, uploading examinee paperwork, and tracking medical deployment recommendations for all prime and sub-contractor employees on this contract. The contractor is responsible for ensuring the information for the individual assigned to the “contract administrator” role is always current.

The contract administrator is responsible for communicating to the web portal client administrator the establishment of sub-contract company accounts as well as changes to those accounts (e.g. termination). The contract administrator will not be allowed to grant web portal access to a sub-contract company that has not been authorized by the U.S. government’s medical contractor as affiliated with the prime contract.

The contractor’s designated “contract administrator” will determine who else within the company and at the sub-contractor level, if applicable, will have access to this system and what user rights will be delegated to these individuals. However, the prime contractor is authorized a maximum of [8] accounts and each sub-contractor is authorized a maximum of [8] accounts for this contract, unless otherwise approved by the contracting officer.

During establishment of the “contract administrator” account the identified user will have access to a dedicated help desk to answer questions regarding user rights, delegation of rights, and system training.

The contractor is required, not less than semi-annually, to review employment rosters and sub-contractor accounts in the web portal and certify in writing to the contracting officer’s representative (COR) that the employment roster(s) is current and employees no longer employed on the contract have been deactivated. If the COR or CO find after such certification has occurred that the rosters are not current the CO may note such finding in the annual CPARS report.

Tab A – Recommended Standards of Fitness for Medical Deployability to Afghanistan

Health Examinations The examination should be documented using the Forms and Documents in Attachment B.

Evaluating medical providers should consider that in addition to the individual’s assigned duties, severe environmental conditions, extremes of temperature, high physiologic demands (water, mineral, salt, and heat management), poor air quality (especially particulates), limited dietary options, sleep deprivation/disruption, and emotional stress may all impact the individual’s health. If maintaining an individual’s health requires avoidance of these extremes or conditions, they should not deploy.

Evaluation of functional capacity to determine fitness in conditions of physiologic demand is encouraged for conditions which may impair normal functionality. This includes such things as a complete cardiac evaluation, to include stress imaging, when there is coronary artery disease or an official functional capacity exam (FCE) for orthopedic issues. The evaluating provider should pay special attention to any conditions which may present a hazard to the individual or others and/or preclude performing functional requirements in the deployed setting. Also, the type, amount, suitability, and availability of medications in Afghanistan must be considered as potential limitations.

Deployability Guidelines for Individuals with Medical Conditions Regardless of underlying diagnosis, individuals with medical conditions determined to be not suitable for deployment, or who have existing conditions other than those outlined, may be considered deployable, except where otherwise noted, only if all of the following general conditions are met and the evaluating medical provider concurs:

a. The condition is not of such a nature that an unexpected worsening is likely to have a medically grave outcome or a negative impact on mission execution.

b. The condition is stable and reasonably anticipated by the pre-deployment medical evaluator not to worsen during the deployment under contractor-provided medical care in-theater in light of the physical, physiological, psychological, environmental, and nutritional effects of the duties and location. To determine stability and assess need for further care, for most conditions 90 days is considered a reasonable timeframe, subject to the examining provider’s judgment. The exception to this is noted in the section Medical Conditions Not Suitable for Deployment, paragraph a.21, Psychiatric Conditions.

c. The condition does not require frequent clinical visits (more than quarterly), ancillary tests, or significant physical limitations, and does not constitute an increased risk of illness, injury, or infection.

d. There is no need for routine out-of-theater evacuation for continuing diagnostics or other evaluations.

e. Any required, ongoing health care or medications anticipated to be needed for the duration of the deployment are available to the individual in Afghanistan. Medication must have no special handling, storage, or other requirements (e.g., refrigeration, cold chain, or electrical power requirements). Medication must be well tolerated within harsh environmental conditions (e.g. heat or cold stress, sunlight) and should not cause significant side effects in the setting of moderate dehydration.

f. The medical condition is not anticipated to significantly impair one’s duty performance during the duration of the deployment. The individual must be able to perform all essential functions of the position in the deployed environment, with or without reasonable accommodation, without causing undue hardship. In evaluating undue hardship, the nature of the accommodation and the location of the deployment must be considered. Further, the individual’s medical condition must not pose a significant risk of substantial harm to oneself or others taking into account the condition of the relevant deployed environment, with particular consideration of areas of armed conflict in Afghanistan.

g. The medical condition does not prevent the wear of ballistic, respiratory, safety, chemical, and biological personal protective equipment; use required prophylactic medications; and ingress/egress in emergency situations with minimal risk to themselves or others.

h. The medical condition does not prohibit required country immunizations or medications.

Medical Conditions Not Suitable for Deployment

a. This section is not intended to be comprehensive. A list of all possible diagnoses and their severity not suitable for deployment would be too expansive to list in this guidance. In general, individuals with the conditions in subparagraphs a.(1) through a.(22) of this section, are advised not to deploy. The medical evaluator must carefully consider whether climate; altitude; nature of available food and housing; availability of medical, behavioral health, and dental services; or other environmental and operational factors may be hazardous to the deploying person’s health because of a known physical or mental condition when determining whether the individual is medically suitable for deployment.

1. Asthma or other respiratory conditions that have a Forced Expiratory Volume-1 < 50% of predicted despite appropriate therapy, that have required hospitalization in the past 12 months, or that requires daily systemic (not inhaled) steroids. Respiratory conditions that have been well controlled for 6 months and are evaluated to pose no risk of deterioration in the deployed environment may be considered suitable for deployment.

2. Seizure disorder, either within the last year or currently on anticonvulsant medication for prior seizure disorder/activity. Persons on a stable anticonvulsant regimen, who have been seizure-free for one year, may be considered suitable for deployment.

3. Diabetes mellitus, type 1 or 2, on pharmacotherapy or with HgA1C > 7.0.

3.1. Type 1 diabetes or insulin-requiring type 2 diabetes.

3.2. Type 2 diabetes, on oral agents only, with no change in medication within the last 90 days and HgA1C ≤ 7.0 suitable for deployment if a calculated 10-year coronary heart disease risk percentage (see 16.7) is less than 15%. If the calculated 10-year risk is 15% or greater, further evaluation is recommended prior to determining if the individual is medically suitable for deployment.

3.3. Newly diagnosed diabetics will require 90 days of stability, either on oral medications or with lifestyle changes, before a medical deployability determination is made. They should also have documentation of a complete initial diabetic evaluation (eye exam, foot exam, nutrition counseling, etc.).

4. History of heat stroke. Those without multiple episodes, persistent sequelae, or organ damage, and no episode within the last 24 months, may be considered suitable for deployment.

5. Meniere’s disease or other vertiginous/motion sickness disorder, unless well controlled on medications available in Afghanistan.

6. Recurrent syncope for any reason.

7. Endocrine conditions requiring replacement or adjustment therapies must be stable, require no laboratory monitoring or specialty consultation, and require only routine follow-up which must be available in the deployed location or by specific arrangement in order to deploy. Hormonal preparations must be administered by oral or transdermal routes, be within clinically appropriate dose parameters, have no special storage requirements, and not produce side effects which interfere with the normal performance of duties or require additional medications to manage.

8. Any musculoskeletal condition that significantly impairs performance of duties in a deployed environment. If there are concerns, an official functional capacity exam (FCE) should be performed before determining whether the individual is medically suitable for deployment.

9. Migraine headache, when frequent or severe enough to disrupt normal performance of duties. The history, frequency, severity, and functional impact of headaches, as well previous and current treatment regimens should be evaluated when determining whether the individual is medically suitable for deployment. Neurology evaluation and endorsement encouraged.

10. Nephrolithiasis, recurrent or currently symptomatic.

11. Pregnancy.

12. Obstructive sleep apnea (OSA). The OSA is diagnosed with an attended, in laboratory polysomnography (PSG) with a minimum of 2 hours of total sleep time, that yields an apnea-hypopnea index (AHI), and/or respiratory disturbance index (RDI), of greater than 5 / hour. Unattended, home PSG is not acceptable for deployment purposes. For individuals previously diagnosed with OSA, updated or repeat PSG is not required unless clinically indicated (i.e. significant change in body habitus, corrective surgery or return of OSA symptoms). Individuals treated with an oral appliance require PSG documentation that OSA is controlled with its use. Individuals who are treated with automatic positive airway pressure (APAP), continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BPAP) are acceptable as long as the condition being treated is OSA and not a more complex respiratory disorder. Complex OSA, central sleep apnea or OSA that requires advanced modes of ventilation such as adaptive servo-ventilation (ASV) or average volume assured pressure support (AVAPS) is generally considered non-deployable. Individuals using PAP therapy should deploy with a machine that has rechargeable battery back-up and sufficient supplies (air filters, tubing and interfaces/masks) for the duration of the deployment. Individuals deploying with PAP therapy to a location where the sleep environment has unfiltered air generally should not deploy unless otherwise indicated under one of the provisions below (12.1-12.5). 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 PAP therapy for a significant length of time.

12.1. Symptomatic OSA (i.e. excessive daytime sleepiness) of any severity, with or without any treatment is not deployable.

12.2. Asymptomatic mild OSA (diagnostic AHI and RDI < 15/hr.): deployable with or without treatment (PAP or otherwise).

12.3. Moderate OSA (diagnostic AHI or RDI ≥15/hr and < 30/hr): deployable if successfully treated (CPAP or otherwise).

12.4. Severe OSA (AHI or RDI ≥ 30/hr): may be suitable for deployment if successfully treated (PAP or otherwise).

12.5. For moderate and severe OSA, adherence to PAP therapy must be documented prior to deployment. Adherence is defined as PAP machine data download (i.e. compliance report) that reveals the machine is being used for at least 4 hours per night for greater than 70% of nights over the previous 30-day period.

13. History of clinically diagnosed traumatic brain injury (mTBI/TBI) of any severity, including mild. Pre-deployment evaluation, which may include both neurological and psychological components, is required for:

13.1. Individuals who have a history of a single mild Traumatic Brain Injury may deploy once released by a medical provider after 24-hours symptom free.

13.2. Individuals who have sustained a second mTBI within a 12-month period, may deploy after seven days symptom free and release by a medical provider.

13.3. Individuals who have had three clinically diagnosed TBIs (of any severity, including mild) since their last full neurological and psychological evaluation are required to have such an evaluation completed prior to deployability determination.

14. BMI > 35 with or without any significant comorbidity may be considered medically suitable for deployment. Morbid obesity (BMI > 40 or weight greater than 300 pounds) is not suitable for deployment. Individuals should submit a body fat worksheet to determine medical suitability for deployment. A BMI calculator is located at http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm

15. Any medical conditions (except OSA-see 12 above) that require certain durable medical equipment or appliances (e.g., nebulizers, catheters, spinal cord stimulators) or that requires periodic evaluation/treatment by medical specialists not readily available in country.

16. Cardiovascular Conditions:

16.1. Symptomatic coronary artery disease.

16.2. Myocardial infarction within one year of deployment.

16.3. Coronary artery bypass graft, coronary artery angioplasty, carotid endarterectomy, other arterial stenting, or aneurysm repair within one year of deployment.

16.4. Cardiac dysrhythmias or arrhythmias, either symptomatic or requiring medication, electro-physiologic control, or automatic implantable cardiac defibrillator or other implantable cardiac devices.

16.5. Hypertension if controlled with medications or lifestyle regimen that has been stable for 90 days and requires no changes may be suitable for deployment. Single episode hypertension found on pre-deployment health examination should be accompanied by serial blood pressure checks (3 day BP checks) to ensure hypertension is not persistent.

16.6. Heart failure or history of heart failure.

16.7. Individuals who are 40 years of age or older must have a 10-year CHD risk percentage calculated (online calculator is available at http://tools.acc.org/ASCVD-Risk-Estimator/). 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 with a myocardial perfusion scintigraphy (SPECT scan) or stress echocardiography as determined by the evaluating cardiologist. Results of the evaluation (physical exam, Framingham results, etc.) and testing, along with the evaluating cardiologist’s recommendation regarding suitability for deployment, should be reviewed when determining whether the individual is medically suitable for deployment.

16.8. Uncontrolled hyperlipidemia. Individuals ≥35 years old should have a lipid screening profile performed prior to deployment. While hyperlipidemia should be addressed in accordance with clinical treatment guidelines, hyperlipidemia values that are outside any of the following (Total Cholesterol > 260, LDL > 190, Triglycerides > 500), either treated or untreated, should not deploy.

17. Infectious Diseases:

17.1. Blood-borne diseases (ex. Hepatitis B, Hepatitis C, HIV) that may be transmitted to others in a deployed environment. Persons testing positive for a blood borne disease should include a full test panel for the disease, including all antigens, antibodies, viral load, and appropriate tests for affected organ systems in order to determine whether the individual is medically suitable for deployment.

17.2. Latent tuberculosis (LTBI). Individuals who are newly diagnosed with LTBI by either TST or IGRA testing will be evaluated for TB disease with at least a symptom screen and chest x-ray, and will have documented LTBI evaluation and counseling for consideration of treatment. Those with untreated or incompletely treated LTBI, including those with newly diagnosed LTBI, previously diagnosed LTBI, and those currently under treatment for LTBI must be provided information regarding the risks and benefits of LTBI treatment during deployment. Individuals meeting the above criteria may be determined medically suitable for deployment.

17.3. History of active tuberculosis (TB). Must have documented completion of full treatment course prior to deployment. Those currently on treatment for active TB disease may not deploy.

17.4. Host or transit nation infectious disease or immunization restrictions may not be overridden. Individuals not meeting these requirements must not deploy. Contractor companies and/or their employees should contact the host or transit nation's embassy for up-to-date information.

18. Eye, Ear, Nose, and Throat Conditions:

18.1. Vision loss. Best corrected visual acuity which does not meet minimum occupational requirements to safely perform duties. Bilateral blindness or visual acuity that is unsafe for the austere environment per the examining provider.

18.2. 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.

18.2.1. Personnel are non-deployable while still using ophthalmic steroid drops post procedure.

18.2.2. Personnel are non-deployable for three months following uncomplicated photorefractive keratectomy (PRK) or laser epithelial keratomileusis (LASEK), or one month for laser-assisted in situ keratomileusis (LASIK).

18.2.3. Clearance from treating ophthalmologist or optometrist for conditions listed in 18.2.1. or 18.2.2. may be taken into account when determining if the individual is medically suitable for deployment.

18.3. Hearing loss. Individuals must have sufficient unaided hearing to perform duties safely, hear and wake up to emergency alarms unaided, and hear instructions in the absence of visual cues such as lip reading.

18.4. Tracheostomy or aphonia.

19. Cancer:

19.1. Cancer for which the individual is receiving continuing treatment or which requires frequent subspecialist examination and/or laboratory testing during the anticipated duration of the deployment.

19.2. Precancerous lesions that have not been treated and/or evaluated and that require treatment/evaluation during the anticipated duration of the deployment.

19.3. All cancers should be in complete remission for at least a year before determining whether an individual is medically suitable for deployment, except as noted in 19.4.

19.4. Certain slow growing cancers such as prostate cancer and certain skin cancers and myelodysplastic disorders must be stable for at least one year prior to deployment.

20. Surgery:

20.1. 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).

20.2. Individuals who have had surgery requiring follow up during the deployment period or who have not been cleared/released by their surgeon (excludes minor procedures).

20.3. Individuals who have had surgery (open or laparoscopic) within six weeks of deployment.

20.4. Cosmetic, bariatric, or gender reassignment procedures are disqualifying until fully recovered with all follow-up and revisions complete, to include adjuvant counselling, and medical treatment.

21. Psychiatric Conditions. Diagnostic criteria and treatment plans should adhere to the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and current professional standards of care. Information on applicant condition, including history and baseline symptoms of known disorders, severity of symptoms with and without treatment, and likelihood to recur or deteriorate in country if exposed to operational activity may be considered when determining if an individual is medically suitable for deployment. All conditions listed below (21.1-21.17) are non-deployable, unless otherwise noted (list is not inclusive).

21.1. Psychotic and bipolar-spectrum disorders are strictly disqualifying.

21.2. Any DSM-diagnosed psychiatric disorder with residual symptoms, or medication side effects, which impair social and/or occupational performance.

21.3. Any behavioral health condition that poses a substantial risk for deterioration and/or recurrence of impairing symptoms in the deployed environment.

21.4. Any behavioral health condition which requires periodic (beyond quarterly) counselling or therapy.

21.5. Chronic insomnia that requires regular or long-term use of sedative hypnotics, amnestics, benzodiazepines, and/or antipsychotics.

21.6. Anxiety disorders requiring use of benzodiazepines for management, or featuring symptoms of panic or phobia.

21.7. Post-Traumatic Stress Disorder, when not completely treated or when therapy includes use of benzodiazepines without additional anxiety diagnosis. If the condition is assignment- or combat- related, evaluating providers must determine the impact that return to country could have on the individual’s well-being and performance when determining if the individual is medically suitable for deployment.

21.8. Gender dysphoria, while not intrinsically disqualifying, does require underlying psychiatric, endocrine, and/or surgical issues (as applicable) to be stable and resolved. Due to complex needs, those actively undergoing gender transition are generally disqualified until the process, including all necessary follow-up and stabilization, is completed for a minimum of one year.

21.9. Bulimia and anorexia nervosa.

21.10. Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder (ADHD). Evaluation and diagnosis should be appropriate per the most current edition of DSM criteria, particularly if Class II stimulants are used for treatment. Specific clinical features or objective testing results for stimulant use may be considered when determining an individual’s medical suitability for deployment. Dosages for medications should likewise be appropriate and justified by clinical presentation.

21.11. Psychiatric hospitalization within the last 12 months.

21.12. Suicidal Ideation or Suicide Attempt with the last 12 months.

21.13. Enrollment in a substance abuse program (inpatient, specific substance abuse program or outpatient) within the last 12 months measured from time of discharge / completion of the program.

21.13.1. A post-treatment period of demonstrated stability is required, the length of which will depend on individual patient factors.

21.13.2. Substance abuse disorders (not in remission). Individuals actively enrolled in a substance abuse programs should not deploy. However, individuals enrolled in Alcoholics Anonymous or similar outpatient support groups that are available in Afghanistan or remotely may be considered suitable for deployment.

21.14. Use of antipsychotics or anticonvulsants for stabilization of DSM diagnoses.

21.15. Use of 3 or more psychotropics (e.g. antidepressants, anticonvulsants, antipsychotics, benzodiazepines) for stabilization, particularly if used to offset side-effects of other behavioral health therapy.

21.16. Psychiatric disorders with fewer than three months of demonstrated stability from the last change in treatment regimen, including discontinuation.

21.17. Psychiatric disorders newly diagnosed during deployment do not immediately disqualify an individual from deployment or redeployment. Disorders that are deemed treatable, stable, and having no impairment of performance or safety by a credentialed mental health provider may allow the individual to remain deployed in theater.

21.17.1. Exceptions include diagnoses featuring bipolar, psychotic, or suicidal features. These individuals should be medically evacuated at the soonest opportunity with appropriate escorts to ensure patient safety. If appropriate (as per the medical/psychiatric treating provider) it is the contracting company’s responsibility to safety monitor the individual prior to transport and to provide an escort(s) during medical evacuation transportation.

21.17.2. Medical conditions requiring the prescription of drugs or substances listed in The Controlled Substances Act (CSA) often are not suitable for deployment, including those described in a.(1) through a.(22) of this section. All prescriptions of CSA drugs or substances must be reviewed by the evaluating medical provider for suitability of use in the austere medical environment. Obtaining a prescription or refills of CSA drugs or substances is the sole responsibility of the individual.

22. Medications. Although not exhaustive, use of any of the following medications, or medications of the same or related classes, is disqualifying for deployment, unless otherwise noted:

22.1. Any medication which, if lost, misplaced, stolen, or destroyed, would result in significant worsening or grave outcome for the affected individual before the medication could be reasonably replaced.

22.2. Any medication which requires periodic laboratory monitoring, titrated dosing, or special handling/storage requirements, or which has documented side effects, when used alone or in combination with other required therapy, which are significantly impairing or which impose an undue risk to the individual or operational objectives.

22.3. Blood modifiers:

22.3.1. Therapeutic Anticoagulants: warfarin (Coumadin), rivaroxaban (Xarelto,) Dabigatran (Pradaxa), Apixaban (Elequis).

22.3.2. Platelet Aggregation Inhibitors or Reducing Agents: clopidogrel (Plavix), anagrelide (Agrylin), Aggrenox, Ticlid (Ticlopidine), Prasugrel (Effient), Pentoxifylline (Trental), Cilostazol (Pletal).

22.3.3. Antihemophilics: Factor VIII, Factor IX.

22.4. 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).

22.5. Immunosuppressants/modulators: e.g., chronic systemic steroids, Fingolimod (Gilenya,) Interferon, Natalizumab (Tysabri).

22.6. Biologic Response Modifiers (immunomodulators): e.g., abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), etanercept (Enbrel), infliximab (Remicade), leflunomide (Arava), etc.

22.7. Antiretrovirals used for Pre-Exposure Prophylaxis (PrEP): e.g. tenofovir disoproxil fumarate/emtricitabine (Truvada), tenofovir alafenamide (Vemlidy).

22.8. Any CSA Schedule I-V controlled substance, including but not limited to the following:

22.8.1. Benzodiazepines: lorazepam (Ativan), alprazolam (Xanax), diazepam (Valium), flurazepam (Dalmane), clonazepam (Klonopin), etc.

22.8.2. Stimulants: methylphenidate (Ritalin, Concerta), amphetamine/dextroamphetamine (Adderall), dextroamphetamine (Dexedrine), dexmethylphenidate (Focalin XR), lisdexamfetamine (Vyvanse), modafinil (Provigil), armodafinil (Nuvigil), etc.

22.8.3. Sedative Hypnotics/Amnestics: zolpidem (Ambien, Ambien CR), eszopiclone (Lunesta), zaleplon (Sonata), estazolam (Prosom), triazolam (Halcion), temazepam (Restoril), etc. Note: single pill-count issuances for operational transition do not generally require further review for deployment suitability.

22.8.4. Narcotics/narcotic combinations: oxycodone (Oxycontin, Percocet, Roxicet), hydrocodone (Lortab, Norco, Vicodin), hydromorphone (Dilaudid), meperidine (Demerol), tramadol (Ultram), etc.

22.8.5. Cannabinoids: marijuana, tetrahydrocannabinol (THC), dronabinol (Marinol), etc.

22.8.6. Anorexiants: phendimetrazine (Adipost), phentermine (Zantryl), etc.

22.8.7. Androgens and Anabolic Steroids: testosterone (Axiron, AndroGel, Fortesta, Testim), oxymetholone (Anadrol-50), methyltestosterone (Methitest), etc. Preparations used in accordance with the standards outlined in the endocrine disorders section above are acceptable. All injected preparations may disqualify an individual from deployment.

22.9. Antipsychotics, including atypical antipsychotics: haloperidol (Haldol), fluphenazine (Prolixin), quetiapine (Seroquel), aripiprazole (Abilify), Risperidone (Risperdal,) etc.

22.10. Antimanic (bipolar) agents: e.g., lithium.

22.11. Anticonvulsants, used for seizure control or psychiatric diagnoses.

22.11.1. 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 intrinsically deployment-limiting as long as treated conditions meet the criteria set forth in this document. Exceptions include:

22.11.1.1. Valproic acid (Depakote, Depakote ER, Depacon, divalproex, etc.).

22.11.1.2. Carbamazepine (Tegretol, Tegretol XR, etc.).

22.11.1.3. Lamotrigine (Lamictal)

22.12. Varenicline (Chantix).

22.13. Botulinum toxin (Botox): Current or recent use to control severe pain.

22.14. Insulin and exenatide (Byetta).

22.15. Injectable medications of any type, excluding epinephrine (Epipen).

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