aci-420009a-signedpdf.pdf

UNCLASSIFIED

UNITED STATES AFRICA COMMAND

INSTRUCTION

J004 ACI 4200.09A

13 September 2019

FORCE HEALTH PROTECTION REQUIREMENTS AND MEDICAL GUIDANCE

FOR ENTRY INTO THE U.S. AFRICA COMMAND THEATER

References: See Enclosure I.

1. Purpose. This instruction establishes Force Health Protection (FHP) requirements, provides medical guidance, and delineates responsibilities for all travel to the U.S. Africa Command (USAFRICOM) area of responsibility (AOR).

It describes applicability, medical standards of fitness, medical waiver policy, medication and equipment requirements, immunizations, laboratory testing, deployment-related health assessment requirements, medical record requirements, and pre-travel medical training requirements.

2. Superseded. United States Africa Command Instruction 4200.09, 27 January 2017.

3. Applicability. This instruction applies to Headquarters USAFRICOM and joint activities assigned to or reporting through Headquarters USAFRICOM including Offices of Security Cooperation, Security Assistance Offices, Special Operations Command Africa (SOCAFRICA), Joint/Combined Task Forces and Service Components assigned to USAFRICOM. This instruction applies to military personnel on official or leisure travel, and Department of Defense (DoD) civilians, DoD contractors, DoD sub-contractors, and volunteers on official travel to the USAFRICOM AOR or who are currently in the USAFRICOM AOR under the auspices of the DoD. Medical requirements for Local Nationals (LN) or Third Country Nationals (TCN) and DoD contractor personnel are included to the extent provided in the applicable contracts (Reference a).

4. Policy. The National Center for Medical Intelligence designates the USAFRICOM AOR as very high risk for infectious diseases, which will adversely impact mission effectiveness unless appropriate FHP measures are implemented. Additionally, the majority of countries in Africa have underdeveloped healthcare infrastructure, making medical care generally limited.

a. Pre-Travel Training Requirements: Individuals or units traveling to the USAFRICOM AOR must understand the health threats they will encounter, ACI 4200.09A including those presented by infectious diseases (specifically those with person-to-person, point source, or arthropod-borne transmission), flora and fauna, climatic extremes, environmental contamination and pollution, physical hazards such as motor vehicle accidents, and other forms of injury. Specific medical and training requirements are found in Enclosure H.

b. Exceptions to this policy will be submitted to the USAFRICOM Command Surgeon using the waiver process identified in Enclosure D.

5. Responsibilities.

a. The USAFRICOM Command Surgeon will implement a health program, which effectively anticipates, recognizes, evaluates, controls, and mitigates health threats encountered during activities in Africa (Reference a).

b. Component and subordinate activity commanders, in coordination with their Surgeons’ offices, shall:

(1) Enforce FHP measures during the entire travel or deployment timeframe.

(2) Ensure subordinate units and activities establish processes to ensure personnel traveling to the USAFRICOM AOR are medically screened and provided health threat briefs, vaccinations, prophylactic medications, and other countermeasures, as appropriate.

c. All travelers carry the responsibility of understanding the threat and risks of disease and injury and will:

(1) Complete AC Form 42, USAFRICOM Travel Medical Screening Checklist (Enclosure C).

(2) Comply with FHP requirements throughout their travel.

(3) Complete required training.

6. Summary of Changes. This ACI has been revised extensively and must be read in its entirety. This version defines “deployment” as periods of more than 30 days; modifies pre-travel screening requirements for physical examination, laboratory, and dental; and modifies specific medical standards for diabetes, cardiac risk stratification, lipid screening, and others. It also adjusts yellow fever vaccination requirement to lifetime; updates malaria chemoprophylaxis guidance to emphasize use of atovaquone-proguanil; updates the Travel Medical Screening Checklist and Medical Waiver Request form; prescribes direct routing of medical waiver requests from requestor to waiver adjudicator;

and adjusts training requirements for medical personnel.

A-1

ENCLOSURE A

ACRONYMS, ABBREVIATIONS, AND TERMS

1. ACRONYMS/ABBREVIATIONS

ACI – Africa Command Instruction ACIP – American Committee on Immunization Practices ADD – Attention Deficit Disorder ADHD – Attention Deficit Hyperactivity Disorder AFCITA – Air Force Complete Immunization Tracking Application AFI – Air Force Instruction AMEDD – Army Medical Department AOR – Area of Responsibility APEX – Adaptive Planning and Execution (system) AR – Army Regulation ASCVD – Atherosclerotic Cardiovascular Disease BMI – Body Mass Index BUMEDINST – (US Navy) Bureau of Medicine and Surgery Instruction CJTF – Combined Joint Task Force CPAP – Continuous Positive Airway Pressure DEET – N,N-Diethyl-meta-toluamide DNA – Deoxyribonucleic Acid DoD – Department of Defense DoDD – Department of Defense Directive DoDI – Department of Defense Instruction DRHA – Deployment-Related Health Assessments DSM-5 – Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition DSN – Defense Switched Network FCG – Foreign Clearance Guide FDA – Food and Drug Administration FHP – Force Health Protection G6PD – Glucose-6-phosphate dehydrogenase GDV – Gastric Dilatation Volvulus HGB – Hemoglobin HIV – Human Immunodeficiency Virus HOA – Horn of Africa HTLV – Human T-Cell Lymphotrophic Virus IAW – In Accordance With IDA – Individual Dynamic Absorption IDC – Independent Duty Corpsman IDMT – Independent Duty Medical Technician IPV – Inactivated Polio Virus ISOS – International SOS (Medical & Travel Security Assistance Company) LDL – Low Density Lipoprotein LN – Local National

A-2

LTBI – Latent Tuberculosis Infection MEDCOM – United States Army Medical Command MTF – Medical Treatment Facility NIPR – Non-classified Internet Protocol Router NSN – National Stock Number OSA – Obstructive Sleep Apnea PHA – Periodic Health Assessment PCS – Permanent Change of Station SAMFE – Sexual Assault Medical Forensic Examiner SIPR – Secure Internet Protocol Router SPECT – Single-Photon Emission Computed Tomography TAD – Temporary Assigned Duty TB – Tuberculosis TCCC - Tactical Combat Casualty Care TCN – Third-Country National TDY – Temporary Duty TRAC2ES – U.S. Transportation Command Regulating and Command & Control Evacuation System USAFRICOM – U.S. Africa Command USPHS – U.S. Public Health Service XR – Extended Release

2. TERMS

Deployment – Any use of the word “deployment” is intended to designate any assignment greater than 30 days to support operational requirements, regardless of order type.

Travel – For the purposes of this document “travel” or “traveler” includes entry into the USAFRICOM AOR for any reason or duration (Permanent Change of Station (PCS), or individual or unit Temporary Duty (TDY)/Temporary Assigned Duty (TAD), leave, and Shipboard Personnel conducting ashore activities of any duration).

NOTE: Specific requirements exist which only apply to those traveling for 30 days or more, regardless of the use of “travel” or “deploy.”

B-1

ENCLOSURE B

MEDICAL CLEARANCE

1. All personnel (uniformed service members, government civilian employees, volunteers, DoD contractor employees) entering the theater must be medically, dentally, and psychologically fit, and possess a current Periodic Health Assessment (PHA) or physical (See paragraph 1.e. (3) of this enclosure) (Reference b). Individuals unable to comply with entry requirements will not enter or re-enter the USAFRICOM AOR, (e.g., any person who becomes medically disqualified while in leave status will not re-enter the theater) until the disqualifying condition is cleared or a waiver is approved by the appropriate USAFRICOM waiver authority. Any person who is medically evacuated from the AOR for any condition requires a medical waiver for theater re-entry.

a. Healthcare providers evaluating personnel for travel must bear in mind that in addition to the individual’s duties, the environmental conditions that may affect health include extremes of temperature, physiologic demand (water, mineral, salt, and heat management), and poor air quality (especially particulates). In addition, the operating conditions may impose extremes of diet (to include fat, salt, and caloric levels) and sleep deprivation. These conditions often result in emotional stress and sleep disturbances. If managing an individual’s health condition requires avoidance of these extremes or conditions, the individual should not travel.

b. Evaluation of functional capacity in conditions of physiologic demand is encouraged to determine fitness. This assessment should include such things as a complete cardiac evaluation to include stress imaging when there is coronary artery disease or significant risk thereof, or an official functional capacity exam as determined by the initial evaluating provider. 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 USAFRICOM AOR. Also, the type and amount of medications prescribed and their suitability and availability in the environment must also be considered as potential limitations. AC Form 42, USAFRICOM Travel Medical Screening Checklist, is to be used for medical clearance requirements (Enclosure C).

c. Fitness includes the ability to accomplish the tasks and duties unique to a particular operation/activity and the ability to tolerate the environmental and operational conditions of the duty location. Minimum standards of fitness include but are not limited to the ability to wear ballistic, respiratory, chemical and biological personal protective equipment (PPE), as required; the use of required prophylactic medications; and the ability to ingress/egress in emergency situations with minimal risk to themselves or others (Reference c).

B-2

Any condition that markedly impairs an individual’s daily function is grounds for disapproval of travel.

d. The following criteria should be utilized to evaluate each medical condition prior to travel (Reference c):

(1) The condition is stable and reasonably anticipated not to worsen during travel in the light of physical, physiological, psychological and nutritional effects of the duties and location.

(2) The condition is not of such a nature or duration that an unexpected worsening or physical trauma is likely to have a grave medical outcome or negative impact on mission execution.

(3) Ongoing healthcare or medication needed for the duration of travel is available in theater and accessible via the individual’s health plan.

(4) Medications required for the condition have no special handling, storage or other requirements (e.g., refrigeration, cold chain, or electrical power requirements).

(5) Medications are well tolerated without significant side effects.

(6) There is no requirement for evacuation out of country or theater for continued diagnostics or other evaluations.

e. Medical Fitness, Initial, and Annual Screening.

(1) DoD civilian employees are covered by the Rehabilitation Act of 1973.

It must be determined, before travel and based upon an individualized assessment, that the employee can perform the essential functions of the position in the USAFRICOM AOR, with or without a reasonable accommodation, without causing undue hardship. In evaluating undue hardship, the nature of the accommodation and the extremely limited availability of care in the USAFRICOM AOR must be considered. Further, the employee’s medical condition must not pose a substantial risk of significant harm to the employee or others when taking into account the conditions of the USAFRICOM AOR (Reference c).

(2) Specialized government employees who must meet specific physical standards (e.g., firefighters, security guards and police, aviators, aviation crew members and air traffic controllers, divers, marine craft operators, and commercial drivers) must meet those standards without exception, in addition to being found fit for the specific deployment by a medical and dental evaluation prior to travel. Certifications must remain valid throughout the duration of travel. If certifications expire while assigned within the

B-3

USAFRICOM AOR, it is up to the individual to plan for and recertify their respective requirements (i.e., mid-tour leave, etc.).

(3) Examination Intervals. An examination with all medical issues and requirements addressed will remain valid for the duration specified in DoDI

6025.19 for military members, or 12 months for all other travelers (Reference b).

(a) Individuals, whose examinations reveal changes in their medical condition, which make them ineligible to remain in theater, must submit a medical waiver request to, and receive approval from, the appropriate waiver approving authority in order to remain in theater. If further diagnostics tests or procedures are required for medical waiver adjudication and are not available locally, individuals must be redeployed to accomplish this requirement.

(b) Periodic health surveillance requirements and prescription needs assessments should be recent enough so as to remain current through the duration of assignment or travel.

(c) Government civilian employees, whose travel exceeds 12 months, must be re-evaluated annually for fitness in order to remain in a deployed status. Annual in-theater rescreening may be focused on health changes, vaccination currency and monitoring of existing conditions, but should continue to meet all medical guidance as prescribed in this document. If government civilian employees are unable to adequately complete their medical screening evaluation in the theater, they should be redeployed to accomplish this annual requirement.

(4) Dental. All travelers to the USAFRICOM AOR must be Dental Class I or II per current annual exam, which will remain current for the anticipated duration of assignment, deployment or travel. Individuals being evaluated by a non-DoD civilian dentist should use DD Form 2813, or equivalent, as proof of dental examination.

(5) DoD civilian and contractor personnel who are 40 years of age or older must have a 10-year atherosclerotic cardiovascular disease (ASCVD) risk percentage calculated. The American College of Cardiology Risk Estimator Plus calculator is available at http://tools.acc.org/ASCVD-Risk-Estimator- Plus/#!/calculate/estimate/. If the calculated 10-year risk is 15% or greater, further evaluation is required prior to medical waiver submission (see paragraph 1.e.(16(g)).

(6) DoD contractor employees must meet similar standards of fitness as other military and DoD civilian personnel, to include the ability to tolerate the environmental and operational conditions of the duty location. DoD

B-4 contractors must undergo a medical and dental evaluation, which documents their fitness for duty without limitations prior to travel (Reference d).

(a) Medical requirements and evaluations must be completed prior to arrival in the USAFRICOM AOR. Travel medicine services for contractor employees, including immunizations, evaluation of fitness, and annual re-screening are the responsibility of the contracting agency per the contractual requirements. Questions should be submitted to the supported command's contracting and medical authority.

(b) All contracting companies are responsible for providing the appropriate level of medical screening for their employees, including Local National (LN) and Third-Country National (TCN) employees, based on the jobs the employees are hired to perform. The screening must be completed by a licensed medical provider (licensed in a country with oversight and accountability of the medical profession) and an English language copy of the completed medical screening documentation must be maintained by the contractor. Such documentation may be requested by base operations center personnel prior to issuance of access badges as well as by medical personnel for compliance reviews. Installation commanders, in concert with their local medical assets and contracting representatives, may conduct quality assurance audits to verify the validity of medical screenings.

(c) Contractors will provide the pre-deployment medical and dental evaluations, and annual in-theater rescreening at contractor expense.

Redeployment is not implied in this document unless otherwise specified in the contract. These evaluations for DoD contractors shall occur prior to arrival at the deployment center/platform. All required immunizations outlined in the DoD Foreign Clearance Guide (https://www.fcg.pentagon.mil) for the countries to be visited, as well as those outlined in paragraph 1.g. of this Enclosure, will be administered at contractor expense. A new disqualifying medical condition, as determined by an in-theater competent medical authority, will be immediately reported to the appropriate contracting officer representative with a recommendation that the contractor be immediately redeployed and replaced at contractor expense. All the above expenses will be covered by the contractor unless otherwise specified in the contract (Reference d).

(d) The guidance in this document should not be construed as authorizing use of Defense Health Program or Military Health System resources for such evaluations unless previously authorized. Generally, Defense Health Program and Military Health System resources are not authorized for the purpose of pre-deployment or travel medicine evaluations for contractor employees (Reference d). Local command, legal, contracting, and resource management authorities should be consulted for questions on this matter.

B-5

(7) LN and TCN employees. Minimum screening requirements for LN and TCN employees are as follows (Reference d):

(a) Pre-employment and annual medical screening of LN and TCN employees will not be performed in military treatment facilities or by U.S.

military medical personnel. Local contracting agencies must keep documentation and ensure screenings are conducted by licensed medical providers.

(b) All LN and TCN employees whose jobs require close or frequent contact with non-LN/TCN personnel (e.g., dining facility workers, security personnel, interpreters, etc.) must be screened for tuberculosis (TB) using a chest x-ray and an annual symptom screen. Tuberculin Skin Tests and Interferon Gamma Release Assays are unreliable as stand-alone screening tests for TB in populations with high TB prevalence, and should not be used.

(c) LN and TCN employees involved in food service, including water and ice production, must be screened annually for signs and symptoms of infectious diseases. Contractors must ensure employees receive Typhoid Fever and Hepatitis A vaccinations, and this information must be documented in the employees’ medical records/screening documentation.

f. Travel-limiting conditions. The lack of DoD and host nation medical care in the USAFRICOM AOR make it likely that a member with chronic illness or medical condition will require aeromedical evacuation from the theater to receive care. As a result, medical assessment of potentially disqualifying conditions should receive additional scrutiny to mitigate the risk to the traveler as well as companion travelers. Unless otherwise noted, conditions apply to travel of any duration. Where noted, some conditions do not require waiver for TDY travel less than 30 days.

(1) This list of travel-limiting conditions is not intended to be comprehensive; there are many other conditions that may result in denial of medical clearance for travel. Possession of one or more of the conditions listed in this tab does not automatically imply that the individual may not enter the USAFRICOM AOR. Personnel with potentially disqualifying medical conditions must meet the following two criteria in order to be cleared for travel: 1) Receive an evaluation by a medical provider to determine if the member can safely travel and 2) Receive a medical waiver approved by the USAFRICOM Command Surgeon or the delegated component surgeon for the potentially disqualifying medical condition(s). “Medical conditions” as used in this context include those health conditions usually referred to as dental or psychological.

(2) Shipboard operations that are not anticipated to involve operations ashore or port calls in the USAFRICOM AOR are exempt from immunizations

B-6 requirements and the deployment-limiting medical conditions listed below and will follow service-specific guidance (Reference c).

(3) Respiratory. Asthma or other respiratory conditions with a Forced Expiratory Volume-1 (FEV-1) of less than 60% of predicted despite appropriate therapy, which have required hospitalization in the past 12 months, or which require daily systemic steroids, will not be considered for medical waiver.

Respiratory conditions with FEV-1 over 60% that have been well controlled for six months and are evaluated to pose no risk of deterioration in the deployed environment may be considered for medical waiver.

(4) Seizure disorder with active seizure activity within the last year will not be considered for medical waiver. Seizure disorder patients on a stable anticonvulsant regimen, who have been seizure-free for one year, may be considered for medical waiver.

(5) Diabetes Mellitus:

(a) Medical waiver for Diabetes Mellitus type 1 or Diabetes Mellitus type 2 requiring insulin or other injectable medications will only be considered for TDY/TAD less than 30 days. Waiver consideration will require a documented Hemoglobin A1C below 7% within 90 days of deployment and no episodes of hypoglycemia.

(b) Diabetes Mellitus type 2 either on oral medications or with lifestyle changes, requires 90 days of stability and a documented Hemoglobin A1C below 7% within 90 days of deployment, before a medical waiver will be considered. Newly diagnosed Diabetes Mellitus type 2 must have documentation of a complete initial diabetic evaluation (eye exam, foot exam, nutrition counseling, etc.).

(c) Individuals with Diabetes Mellitus must have a 10-year ASCVD risk percentage calculated (http://tools.acc.org/ASCVD-Risk-Estimator- Plus/#!/calculate/estimate/). If the calculated 10-year risk is 15% or greater, further evaluation is required prior to medical waiver submission (see paragraph 1.e.(16)(g)).

(6) History of heat stroke will be considered for a medical waiver, provided there have been no episodes within the last 12 months. A patient with multiple episodes of heat stroke, persistent sequelae, or organ damage will not be considered for medical waiver.

(7) Individuals with Meniere’s disease or other vertiginous/motion sickness disorders may be considered for medical waiver. A medical waiver will be granted only if the condition is well controlled with medications available in the USAFRICOM AOR and without any degradation in duty performance.

B-7

(8) Recurrent syncope (greater than one episode in three years) for any reason may be considered for a medical waiver. This medical waiver request must include the etiology and diagnosis of the condition.

(9) Any musculoskeletal condition that significantly impairs activities of daily living or performance of duties in a deployed environment requires a medical waiver accompanied by an official functional capacity exam.

(10) Currently symptomatic nephrolithiasis will not be considered for a medical waiver. Recurrent (two or more lifetime episodes) nephrolithiasis requires submission for a medical waiver.

(11) Pregnancy will not be considered for a medical waiver for deployment, but may be considered for medical waiver for TDY/TAD less than 30 days or leave. Pregnancy in the third trimester will not be considered for a medical waiver. See 1.l.(4), below.

(12) Obstructive sleep apnea (OSA). The following guidelines are designed to ensure that persons with OSA are adequately treated and that their condition is not of the severity that would pose a health risk should they be required to go without their Continuous Positive Airway Pressure (CPAP) for a significant length of time. While snoring is the most common complaint, the predominant symptom of concern for most individuals in the average active duty age group is excessive daytime sleepiness. Older individuals with other co-morbid severe or uncontrolled cardiovascular conditions may also have increased risk for cardiovascular events, such as myocardial infarction, symptomatic atrial fibrillation, and/or stroke.

(a) In-laboratory polysomnography is required for all personnel with the diagnosis of OSA. Home testing with portable monitors is not accepted.

For individuals previously diagnosed with OSA, updated or repeat polysomnography is not required unless clinically indicated (i.e., significant change in body habitus, corrective surgery, or return of OSA symptoms). The USAFRICOM waiver authority may request repeat polysomnography to further evaluate a specific waiver request.

(b) Asymptomatic mild OSA (with or without CPAP) does not require a medical waiver. Mild OSA is defined as the frequency of obstructive polysomnography events, apnea-hypopnea index, respiratory event index, or respiratory disturbance index of less than 15 episodes per hour.

(c) Asymptomatic, treated moderate (apnea-hypopnea index 15-30/hr) or severe (apnea-hypopnea index >30/hr) OSA requires a medical waiver for travel of greater than 30 days. Medical waivers will be reviewed dependent on travel location, comorbidities, proposed position assignment, reliability of electricity, and adherence to therapy. The submitting healthcare provider must document CPAP compliance/adherence in the Case Summary section of the

B-8

USAFRICOM Medical Waiver Request Form or provide documentation.

Adherence is defined as CPAP machine data download (i.e., compliance report) that reveals the machine is being used for at least 4 hours per night, at least five nights per week (70% of the nights) over the previous 30 day period.

(d) Personnel with OSA of any severity who have symptoms despite treatment are not eligible for a medical waiver.

(e) The traveler must know if his/her device is equipped with wireless or cellular communication capabilities and be able to disable the communication capabilities prior to departure from home station for the duration of travel to a contingency location, if so directed.

(f) Regardless of whether travel requires a waiver based on (12)(c) above, individuals using CPAP therapy must travel with sufficient supplies (air filters, tubing, interfaces/masks) and should have a device that can utilize back-up power (vendor-certified rechargeable battery system) for the duration of the travel. There is no guarantee of resupply or repair if there is a malfunction.

(g) In the case of individuals with apnea-hypopnea index greater than 60/hr, or co-morbid severe cardiovascular or neurologic (e.g., epilepsy) conditions, then a sleep specialist, pulmonologist, or neurologist (in this preferred order) should be consulted prior to the waiver submission.

(13) Traumatic Brain Injury. Individuals who have a history of a single mild traumatic brain injury/concussion may travel if they have been evaluated by a medical provider at least 24 hours after symptoms cease. Travelers who with history of potentially concussive events who have not been clinically evaluated and completed required rest periods will not be granted theater clearance; no waivers will be granted (References e and f). See also Enclosure G, 2.e.

(14) Body-Mass Index (BMI) restrictions. Service members must be in compliance with service-specific standards. Civilians and contractors with a BMI greater than 35 kg/m2 require a medical waiver for travel over 30 days, or travel less than 30 days to a forward-deployed location. In general, TDY travel less than 30 days does not require a BMI waiver. Deployers with BMI 35-39 kg/m2 without serious comorbidities (e.g., uncontrolled hypertension, diabetes mellitus, OSA, atherosclerotic cardiovascular disease, severe joint disease, etc.)

may be considered for a medical waiver. Any deployer with BMI greater than 40 kg/m2 will not be considered for a medical waiver.

(15) Any medical conditions (except OSA) that require certain durable medical equipment or appliances (e.g., nebulizers, catheters, spinal cord stimulators) or that require periodic evaluation/treatment by medical

B-9 specialists not readily available in theater will not be considered for medical waiver.

(16) Cardiovascular conditions:

(a) Symptomatic coronary artery disease will not be considered for medical waiver.

(b) Myocardial infarction within one year of travel will not be considered for a medical waiver.

(c) Coronary artery bypass graft, coronary artery angioplasty, carotid endarterectomy, other arterial stenting, or aneurysm repair within one year of travel will not be considered for a medical waiver. Once the condition has been stable for one year all waivers must include written support from the cardiovascular specialist.

(d) Cardiac dysrhythmias or arrhythmias, either symptomatic or requiring medication, electro-physiologic control, or implantable cardiac devices will not be considered for medical waiver.

(e) Hypertension that has not been controlled with medication or lifestyle changes for at least 90 days (i.e., on the same medication with good blood pressure control) requires a medical waiver. Controlled hypertension for over 90 days does not require a medical waiver. Single episode of elevated blood pressure during a travel clearance/health assessment/physical must be evaluated by a 3-day blood pressure check to ensure hypertension is not present.

(f) Heart failure or history of heart failure will not be considered for a medical waiver.

(g) Cardiac Risk Stratification. DoD civilian and contractor personnel who are 40 years of age or older must have a 10-year ASCVD risk percentage calculated (http://tools.acc.org/ASCVD-Risk-Estimator- Plus/#!/calculate/estimate/). If the individual’s calculated 10-year coronary heart disease risk is 15% or greater, the individual should be referred for further cardiac work-up and evaluation, to include at least one of the following:

Graded exercise stress test with or without a Myocardial Perfusion Scintigraphy or Stress Echocardiography, as determined by the evaluating cardiologist.

Results of the evaluation (physical exam, laboratory data, cardiac risk score, etc.) and testing, along with the evaluating physician’s recommendation regarding suitability for travel, must be included in a medical waiver request to enter the USAFRICOM AOR.

(h) Hyperlipidemia. Lipid screening must be accomplished in accordance with (IAW) Service-specific guidelines. For deployments over 30

B-10 days, all others (i.e., civilians and contractors) over 40 years of age will have a lipid screening profile performed within one year prior to travel in order to calculate the required ASCVD 10-year risk. Hyperlipidemia should be addressed in accordance with clinical treatment guidelines. Untreated values that are outside any of the following parameters require a medical waiver:

Total Cholesterol > 260 mg/dL, LDL > 190 mg/dL, Triglycerides > 500 mg/dL.

Treated hyperlipidemia with 90 days of stability and documented clinical response does not require a medical waiver. Treatment with fewer than 90 days’ stability requires a medical waiver.

(17) Infectious diseases:

(a) Blood-borne diseases (Hepatitis B, Hepatitis C, Human T-Cell Lymphotrophic Virus (HTLV)) that may be transmitted to others. Medical waiver requests for individuals testing positive for a blood-borne disease must include a full test panel for the disease, including all antigens, antibodies and viral load. Medical waiver requests for personnel with Hepatitis B or C must include a subspecialty (Gastroenterology or Infectious Disease) evaluation.

Hepatitis C patients should have been treated with direct acting antivirals with sustained virologic response in order to be eligible for waiver.

(b) Confirmed Human Immunodeficiency Virus (HIV) infection (Reference g). Medical waivers, if allowed by Service policy, will only be considered for TDY travel less than 30 days and medical waiver authority is retained by the USAFRICOM Command Surgeon.

(c) Active TB. Waivers will not be granted.

(d) U.S. Forces and DoD civilians with active TB disease will be evacuated from theater for definitive treatment. Evaluation and treatment of TB among DoD contractors, LN and TCN employees will be at contractor expense. Employees with suspected or confirmed pulmonary TB disease will be excluded from work until cleared by the USAFRICOM designated physician for return to work.

(e) Latent Tuberculosis Infection (LTBI). Individuals who are newly diagnosed with LTBI by either Tuberculin Skin Test or Interferon-Gamma Release Assays testing will be evaluated for active TB disease with at least a symptom screen and a chest x-ray, and must have documented LTBI evaluation and counseling for consideration of treatment. Active duty members who have documented completion of LTBI evaluation and counseling for consideration of treatment and whose providers did not recommend LTBI treatment may travel without a medical waiver as long as all service-specific requirements are met (References h, i, and j).

(f) A medical waiver is required for individuals at any stage of treatment or with incomplete treatment of LTBI. Those with untreated or

B-11 incompletely treated LTBI, including those with newly diagnosed LTBI, previously diagnosed LTBI, and those currently under treatment for LTBI will be provided information regarding the risks and benefits of LTBI treatment during travel.

(g) History of prior treated Active TB. Waiver is required. Must have documented completion of full treatment course prior to travel.

(18) Eye, ear, nose, throat, dental conditions:

(a) Vision Loss. Best corrected visual acuity must meet job requirements to safely perform duties. Bilateral blindness or visual acuity that is unsafe for the combat environment per the examining provider will not be considered for a medical waiver.

(b) Refractive Eye Surgery. Personnel having undergone refractive eye surgery are not cleared to travel to the USAFRICOM AOR during a satisfactory post-surgical recovery period (no waivers granted). Personnel are not cleared to travel to the USAFRICOM AOR for three months following uncomplicated Photorefractive Keratectomy, Laser Epithelial Keratomileusis and epithelial Laser Assisted in situ Keratomileusis, and one month following uncomplicated Laser in-situ Keratomileusis. Additionally, personnel are not cleared to travel while using ophthalmic steroid drops post-procedure. There is a large degree of patient variability which prevents establishing a set timeframe for full recovery. After the initial non-deployable surgery recovery period, individuals will require a medical waiver to travel to the USAFRICOM AOR for a period of one year post-procedure. A note from an attending Ophthalmologist or Optometrist must be included with the medical waiver submission. After one year post refractive eye surgery, individuals will not require a medical waiver.

(c) Hearing Loss. Travelers must have sufficient unaided hearing to perform duties safely, and medical waiver requests must reflect this. Those traveling to combat areas should have an occupationally-focused assessment of ability to wake up to emergency alarms unaided and hear instructions in the absence of visual cues such as lip reading. If there are any safety questions regarding the individual’s hearing ability, speech recognition in noise test or equivalent is a recommended adjunct (Reference c).

(d) Open Tracheostomy or Aphonia will not be considered for a medical waiver. Healed prior tracheostomies do not require a waiver if they no longer require follow-up.

(19) Dental:

(a) Absence of a dental exam within the last 12 months, or likelihood that dental treatment or reevaluation for oral conditions will result in dental

B-12 emergencies within 12 months, will not be considered for medical waiver (Reference c).

(b) Individuals with orthodontic equipment require a medical waiver to travel. Medical waiver requests to travel must include a current evaluation by the treating orthodontic provider and include a statement that wires with neutral force are in place.

(20) Cancer. Cancer for which the individual is receiving continuing treatment or requiring frequent subspecialist examination and/or laboratory testing during the anticipated duration of the travel will not be considered for medical waiver (Reference c).

(a) Precancerous lesions that have not been treated and/or evaluated and that require treatment/evaluation during the anticipated duration of the deployment will not be considered for a medical waiver.

(b) Non-melanoma skin cancers that have been surgically removed with clear borders demonstrated on pathological report, and with no required follow-up during the period of travel, do not require a medical waiver.

(c) All other cancers require a medical waiver.

(21) Surgery or surgical conditions:

(a) Any medical condition that requires surgery 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) will not be considered for a medical waiver.

(b) Individuals who have had surgery requiring follow up during the travel period or who have not been cleared/released by their surgeon will not be considered for a medical waiver.

(c) Individuals who have had abdominal or pelvic surgery (open or laparoscopic) within 6 weeks of travel require a medical waiver.

(d) Unrepaired hernias require evaluation by a surgeon and documentation indicating the hernia will not require surgery or evacuation from the deployed setting in order to be considered for a waiver.

(22) Psychiatric Conditions: Medical waiver submission is required for all mental health DSM-5 diagnoses or medication use within the past seven years. Remote history of mental health diagnosis (e.g., adjustment disorder) over seven years ago and with no treatment or medication use within the past seven years does not require medical waiver.

B-13

(a) Any current diagnosis or history of a diagnosis of a psychotic or bipolar disorder, or other disorder with associated psychotic symptoms, is considered disqualifying for deployment and will not be considered for a medical waiver (Reference r).

(b) Individuals diagnosed with mental disorders must demonstrate a pattern of stability without significant symptoms or impairment for at least 90 days prior to travel in order to be considered for a medical waiver (Reference r).

Psychiatric disorders with fewer than 90 days of demonstrated stability from the last change in treatment regimen (medication, either new or discontinued, or dose change) will not be considered for medical waiver.

(c) DSM-5 diagnosed psychiatric disorders with residual symptoms, or medication side effects which impair social and/or occupational performance will not be considered for medical waiver.

(d) Use of Lithium, antipsychotics, or anticonvulsants for stabilization of DSM-5 diagnosis will not be considered for medical waiver.

(e) Mental health conditions that pose a substantial risk for deterioration and/or recurrence of impairing symptoms in the deployed environment will not be considered for medical waiver.

(f) Chronic insomnia that requires the daily use of sedative hypnotics/amnestics, benzodiazepines, and antipsychotics for greater than three months will not be considered for medical waiver.

(g) Psychiatric hospitalization within the last 12 months requires a medical waiver submission package with a specialty evaluation prior to travel.

(h) Suicide ideation or attempt within the last 12 months will not be considered for medical waiver.

(i) Psychiatric disorders newly diagnosed during deployment do not immediately require a medical waiver or redeployment. Disorders that are deemed treatable, stable, and having no impairment of performance or safety by a credentialed mental health provider do not require a medical waiver to remain in theater.

(j) Substance abuse. Personnel who have a history of substance abuse disorders, or have been enrolled in a substance abuse program (inpatient or outpatient, to include self-referral), within the last 12 months require a medical waiver.

1 Substance abuse disorders (not in remission), actively enrolled in Service-specific substance abuse programs will not be considered for medical waiver.

B-14

2 After successful completion of a substance abuse program personnel are eligible for a waiver after 90 days of demonstrated medical stability.

3 Participation in Voluntary Alcohol-Related Behavioral Health Care that does not result in enrollment in a substance abuse program does not require medical waiver.

(23) Medications: Although not exhaustive, use of any of the following medications (specific medication or class of medication) is disqualifying for travel, unless a medical waiver is granted:

(a) Blood Modifiers:

1 Therapeutic anticoagulants (e.g., Warfarin, direct thrombin inhibitors).

2 Platelet aggregation inhibitors or reducing agents (e.g., Clopidogrel, Anagrelide, Aspirine-Dipyridamole, Ticlopidine, Prasugrel, Pentoxifylline, Cilostazol). 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.

3 Hematopoietics: e.g., Filgrastim, Sargramostim, Erythropoietin.

4 Antihemophilics: Factor VIII, Factor IX.

(b) Antineoplastics (Oncologic or non-oncologic use): e.g., Antimetabolites (Methotrexate, Hydroxyurea, Mercaptopurine, etc.), Alkylators (Cyclophosphamide, Melphalan, Chlorambucil, etc.), Antiestrogens (Tamoxifen, etc.), Aromatase Inhibitors, Medroxyprogesterone (except use for contraception), Interferons, Etoposide, Bicalutamide, Bexarotene, Oral Tretinoin.

(c) Immunosuppressants: e.g., chronic systemic steroids.

(d) Biologic Response Modifiers (Immunomodulators): e.g., Abatacept, Adalimumab, Anakinra, Etanercept, Infliximab, Leflunomide, etc.

(e) Benzodiazepines: e.g., Lorazepam, Alprazolam, Diazepam, Clonazepam, etc.

(f) Schedule II stimulants taken for treatment of Attention Deficit- Hyperactivity Disorder or Attention Deficit Disorder.

(g) Antipsychotics. Including atypical antipsychotic medication.

(h) Anticonvulsants, used for seizure control.

B-15

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 travel-limiting as long as those conditions meet the criteria set forth in this document. No medical waiver is required.

2 Valproic Acid, Carbamazepine, etc.

(i) Varenicline.

(j) Opioids, Opioid combination drugs, or Tramadol.

(k) Weight-loss medications.

(l) Stimulants used to treat narcolepsy or other sleep disorders, such as Modafinil or Armodafinil, unless prescribed solely for operational use by aircrew.

(m) Injectable medications of any type (e.g., Insulin, Exenatide, Liraglutide).

g. Pharmacy.

(1) Supply. Personnel who require medication(s) and who are traveling to the USAFRICOM AOR will travel with no less than a 180 day supply (or appropriate amount for shorter deployments or travel) of their maintenance medications with arrangements to obtain a sufficient supply to cover the remainder of the deployment using a follow-on refill prescription. Tricare-eligible personnel will have a follow-on refill prescription entered into the Tricare Mail Order Pharmacy system per the Deployment Prescription Program.

(2) Exceptions. Exceptions to the 180 day prescription quantity requirement include:

(a) Personnel requiring malaria chemoprophylactic medications (e.g.

Atovaquone/Proguanil, Doxycycline, etc.) will travel with enough medication for their entire travel period in the USAFRICOM AOR. The travel period will include an additional seven days after leaving the malaria risk area for Atovaquone/Proguanil or 28 days for Doxycycline to account for required primary prophylaxis.

(b) Psychotropic medication may be dispensed for up to a 180 day supply with no refills.

(c) Tricare Pharmacy Home Delivery. Eligible DoD beneficiaries requiring ongoing pharmacotherapy will maximize use of the local medical facility Pharmacy for refills. If the required medication is not available in the USAFRICOM AOR, personnel will use the Tricare Pharmacy home delivery

B-16 system when possible for delivery to their temporary duty/deployed location.

Those eligible for Tricare Pharmacy home delivery will complete online enrollment and registration prior to deployment to the maximum extent possible. Instructions and registration can be found at http://tricare.mil/dpp.

h. Medical Equipment.

(1) Permitted Equipment. Personnel who require medical equipment (e.g., corrective eyewear, hearing aids, etc.) must travel with all required items in their possession to include two pairs of eyeglasses, protective mask eyeglass inserts, ballistic eyewear inserts, and hearing aid batteries, as applicable (Reference c).

(2) Non-permitted Equipment. Personal durable medical equipment is not permitted (e.g., nebulizers, scooters, wheelchairs, catheters, dialysis machines, etc). Medical maintenance, logistical support and infection control protocols for personal medical equipment are not available and electricity is often unreliable. A waiver for a medical condition requiring personal durable medical equipment will also be considered applicable to the equipment. For example, if an individual is medically waived for obstructive sleep apnea requiring the use of a CPAP machine, the CPAP machine is also considered waived; a separate waiver is not required. Durable medical equipment that is not medically compulsory, but used for relief or maintenance of a medical condition will require a waiver. Maintenance and resupply of non-permitted/non-waived equipment is the responsibility of the individual.

i. Contact Lenses. Personnel requiring corrected vision will travel with two pairs of eyeglasses and a supply of contact lens maintenance items (e.g., cleansing solution) adequate for the duration of the travel (Reference b).

(1) Army, Navy, and Marine personnel will not travel to operational locations with contact lenses except IAW Service policy.

(2) Air Force personnel (non-aircrew) will not travel to operational locations with contact lenses unless written authorization is provided by the deploying unit commander. Contact lenses are life support equipment for U.S.

Air Force aircrews and are therefore exempt. Air Force aircrew personnel deploying with contact lenses must comply with the U.S. Air Force aircrew contact lens policy (Reference k).

j. Medical Alert Tags. Deploying personnel requiring medical alert tags (e.g., medication allergies, Glucose-6-phosphate Dehydrogenase (G6PD) deficiency) will travel with red medical alert tags worn in conjunction with their personal identification tags.

B-17

k. Immunizations.

(1) Administration. All immunizations will be administered IAW Reference l. Refer to the Military Health System Immunization Healthcare website at https://health.mil/vaccines. Alternatively, personnel may contact the USAFRICOM J0043 Current Operations office at USAFRICOM.stuttgart.acsg.mbx.j004-force-health-protection@mail.mil.

(2) Requirements. All personnel traveling for any period of time to the AOR will be current with Advisory Committee on Immunization Practices (ACIP), immunization guidelines, and Service individual medical readiness requirements. In addition, all personnel must comply with the DoD Foreign Clearance Guide (FCG) for the countries to which they are traveling. The FCG can be found at: https://www.fcg.pentagon.mil. The following are mandatory vaccines for DoD personnel (military, civilian, and contractors) traveling for any period of time in the AOR:

(a) Yellow Fever. Single lifetime dose is required; dose must be at least 10 days prior to arrival to Africa. Additional “booster” doses are only required if so recommended by Advisory Committee on Immunization Practices (ACIP) guidelines (Reference s). A Centers for Disease Control and Prevention Form 731 (CDC 731), International Certificate of Vaccination or Prophylaxis, (Yellow Shot Record, formerly PHS-731) that contains an official Yellow Fever certificate stamp is required for all personnel traveling or deploying on official business to the African continent. While the DD Form 2766C, vaccine administration record, is accepted by the World Health Organization, many African countries do not recognize the DD Form 2766C and may require re-vaccination or deny entry without CDC 731 containing an official Yellow Fever certificate stamp. Exception: Yellow Fever vaccination is not required for travel solely to Ascension Island (if coming directly from CONUS), Comoros, Morocco, or Tunisia.

(b) Tetanus/Diphtheria/Acellular Pertussis. Receive a one-time adult dose of Tetanus/Diphtheria/Acellular Pertussis. Receive tetanus if over 10 years since last Tetanus/Diphtheria/Acellular Pertussis or Tetanus booster.

(c) Varicella. Required documentation of one of the following: Born before 1980 (assumed immunity except for healthcare workers), documented history of disease by the provider who treated the member at that time (either by an epidemiologic link or laboratory confirmation), sufficient Varicella titer, or administration of vaccine (two lifetime doses).

(d) Measles/Mumps/Rubella. All individuals born before 1957 are considered immune and do not require the Measles/Mump/Rubella immunizations. For all personnel born in 1957 or after, documentation of

B-18 immunity by titer for each (Measles/Mumps/Rubella) or immunization records of two…