PWS Attachment 26 ECI 4202.01 Health Service Support US European CC Theater Medical Entry Requirements.pdf

UNITED STATES

EUROPEAN COMMAND

INSTRUCTION

UNCLASSIFIED

ECJ4-MR ECI 4202.01

DISTRIBUTION: Contact OPR 3 July 2019

Health Service Support United States European Command (USEUCOM) Theater Medical Entry Requirements

References: See Enclosure (G)

1. Purpose. This ECI delegates responsibility to Service Component Commanders to determine unit medical readiness and fitness requirements for military and civilian personnel participating in USEUCOM missions and operations. This ECI provides a recommended template from which Component Commands can formulate their own theater medical screening requirements.

2. Cancellation. None.

3. Applicability. As determined by Service Component Commanders.

4. Policy. The USEUCOM Commander delegates responsibility to Service Component Commanders to determine unit medical readiness and fitness requirements for military and civilian personnel participating in USEUCOM missions and operations. The information in this instruction, ECI 4202.01, Enclosures (A) through (G), can be used to formulate Service-specific policy.

5. Discussion.

a. In accordance with (IAW) references (a) through (ii), and specifically DoD Instruction (DoDI) 6490.07, “Deployment-Limiting Medical Conditions for Service Members and DOD Civilian Employees,” the Combatant Commander establishes a minimum standard for theater medical entry requirements. This instruction provides an approved and standardized template from which components can form mission tailored medical screening criteria for troops deploying into the USEUCOM theater. Enclosures

(A) through (G) contain recommended Force Health Protection (FHP) standards, medical screening guidance, and waiver request procedures for deployments within the European Theater. The information is meant to synthesize and supplement DoD and Service-specific guidance in deployment health, FHP, medical policy and health

ECI 4202.01

3 July 2019

UNCLASSIFIED

guidance for military and civilian personnel deployed across the range of military operations.

b. Suggested deployment definition. IAW reference (d), DoDI 6490.07, “Deployment-Limiting Medical Conditions for Service Members and DOD Civilian Employees”, ‘deployment’ is defined as the relocation of forces and material to areas designated as operational areas. Within the USEUCOM Theater, deployment includes named operations, contingencies, and other official missions (i.e. Operation Atlantic Resolve).

c. The USEUCOM theater medical entry template is synchronized across the geographic combatant commands to ensure standardization where applicable. It is widely staffed through the Surgeons of the Components, rotational units, deployment processing sites, and thoroughly vetted by clinical and operational experts in key DoD agencies. It incorporates extensive feedback following two years of fielding.

d. The attached standards for theater entry account for the advanced standards of care available in Europe.

e. The information is proven to reduce burden on commanders, units, medical staff, and incoming personnel by identifying conditions before deployment to avoid turmoil during the mission.

f. The recommended template provides a needed reference for inexperienced providers, or providers in the civilian sector, who have never deployed.

g. Recommended clearance requirements.

(1) Medical Clearance.

(a) Information regarding the medical and mental health clearance requirements and standards (Deployment Limiting Conditions (DLCs), Pharmacy, Medical Equipment, Contact Lens, Alert Tags, Immunizations, Labs, and Health Assessments) can be found in Enclosures (A) through (D) of this document.

(b) Administrative requirements regarding pre-, during-, and post-depoyment health activities are summarized in Reference (a), DoDI 6490.03, “Deployment Health”.

(2) Waiver Request Process. According to DoDI 6490.07, a waiver process is required within the Combatant Command. Information regarding the recommended medical waiver process and authorities can be found in Enclosures (E) of this document.

(3) Theater Force Health Protection (FHP). FHP measures can be found in

Enclosure (F) of this document. Medical threat briefs will be formulated using items in

(INTENTIONALLY BLANK)

A-1 Enclosure A

Enclosure A Medical Clearance – General

1. Standards for Deployability to USEUCOM

a. Fitness for Duty. Individuals must meet Service specific standards of medical fitness.

b. Transparency to Command. An individual’s medical condition must not create undue burden on the Command.

c. Stability of Treatment. An individual’s medical condition must remain stable if treatment options become unavailable (i.e. loss of medication, malfunction of therapeutic equipment, delays in shipping, unavailability of therapist, etc.).

d. Proven Stability. Individuals must be mentally and physically stable without relapse for a minimum of 12 months following the last change of therapy or last episode of the disability (exceptions are listed within the Deployment Limiting Conditions in Enclosure (B)).

e. Successful Trial of Duty. Individuals that have completed a rehabilitative program should successfully demonstrate required fitness through a trial of duty which mimics expected conditions of deployment (i.e. environmental challenges, lifting and carrying challenges, alertness, and judgement challenges, etc.).

f. Extended Stay. An individual’s condition will remain stable if an extension of deployment duty occurs.

g. Hazardous Materials. A means to secure or properly dispose of hazardous materials (i.e. needles) is available.

h. Prescription Medications.

(1) Personnel who require medication(s) will travel with up to a 180 day supply of their maintenance medications (see paragraph 1.h.(2) below for controlled medication requirements).

(2) Controlled Medications. All FDA controlled substances (Schedule CII-CV) are limited to maximum of a 90-day supply in-theater, with only 30 days’ supply allowed on the person. All controlled substances need to be secured (i.e. to prevent diversion).

Controlled substances must be monitored using a validated quality assurance program.

(3) Prior to deploying, individuals need to arrange to obtain a sufficient supply to cover the remainder of the deployment. Where applicable, Tricare eligible personnel should have prescription refills entered into the Tricare Mail Order Pharmacy (TMOP).

A-2 Enclosure A

Individuals need to be aware certain countries (i.e. Germany) prohibit the mailing of prescription medications.

(4) See Enclosure (C), paragraph 1, for a detailed description of pharmacy requirements for entry into the USEUCOM AOR.

i. Border Clearance. Medical conditions must meet border clearance criteria of the countries in which the individual will be deployed.

j. Ability to Function During Flare-Up. Medical condition must not reach severity which completely incapacitates the individual.

k. Alert and Oriented. The individual must be alert and able to perform sensitive tasks with appropriate judgement when required (i.e. medications causing drowsiness must clear the body quickly).

l. Functional in Austerity. Individuals must be of sufficient fitness to successfully function and conduct the mission in the extremes of environmental conditions while wearing appropriate protective gear.

m. Clean Blood Supply. Individuals must be free of known blood-transmissible diseases. The expectation is to maximize the ability to serve as blood donors as part of a walking blood bank capability to assist in blood transfusions.

n. Low Risk to Command. The medical condition must not place coworkers at safety risk or at risk for mission failure.

o. Severity of medical condition. Conditions must be of sufficient simplicity to be managed by a general medical officer in facilities with limited equipment.

2. Medical Waiver Requirements. The following lists general medical waiver requirements for individuals with potential deployment limiting medical conditions:

a. Medical waiver is required.

(1) Deployment Limiting Conditions. Enclosure (B) contains a list of deployment limiting medical conditions that require a medical waiver.

(2) Specialist Required. A medical waiver is required for any individual who requires a follow-up evaluation with a specialist during the period of deployment; this includes follow-ups with behavioral health practitioners.

b. Medical waiver will not be granted.

(1) Special Storage or Handling Requirements. A medical waiver will not be granted for medications that require special handling, storage or other requirements

A-3 Enclosure A

(e.g., refrigeration, cold chain, electrical power requirements, hazardous material (HAZMAT) disposal requirements, etc.) unless the individual is deploying to an installation in the AOR with the capability to support the special handling, storage, or other requirements. See Enclosure (C), paragraph 1 for more detailed information regarding medication requirements.

(2) Required Medical Equipment. A medical waiver will not be granted for medical equipment unless the device is dual-voltage (i.e. can support 220V connections) and can be supported at the deployed location. See Enclosure (C), paragraph 2 for more detailed information regarding specifications for medical equipment.

3. Medical Fitness, Initial, and Annual Screening.

a. Exam Intervals. An examination which addresses all medical issues and requirements will remain valid for a maximum of 12 months from the date of the physical examination IAW Reference (c). Extensions may be considered by the local provider when facilities are outside reasonable access range to accommodate.

(1) Medical Treatment During Deployment. Individuals treated within the theater and cleared by the treating physician may be returned to the unit without requesting a waiver. Component Surgeons may set an additional requirement to re-process as a waiver request [Note: Individuals treated for a medical condition outside of the AOR and desiring to return to the AOR to complete an existing deployment must be cleared anew by the appropriate waiver authority].

b. Cardiovascular Screening. Service members will follow service specific guidance for cardiovascular screening requirements.

c. Dental. All personnel entering the theater require a dental examination within 12 months preceding the start of travel. Dental status must be either a Class I or II.

Individuals evaluated by a non-DoD civilian dentist should use a DD Form 2813, or equivalent, as proof of dental examination.

d. Psychoactive Medications. The use of psychoactive medications pose additional risk in the deployment environment, such as risk for heat injury, serotonin syndrome, lapses in judgment and alertness, etc. These medications are commonly used to treat depression, insomnia, drowsiness, concentration and alertness problems, mood disorders, anxiety, chronic pain, migraine headaches, seizures, etc. The following concerns will be scrutinized closely when considering waivers for psychoactive medications.

(1) Behavioral effects. Psychoactive medications affect alertness, sleep cycle, and judgment; all effects can be magnified when multiple medications are combined.

A-4 Enclosure A

(2) Suicide risk. Psychoactive medications pose additional risk for suicide based on the physiologic effects of the medications, and in their normal use by patients at higher risk for suicide.

(3) Polypharmacy concerns. Medications prescribed to counter-act the side effects of other medications are problematic, due to compounding of side effects (i.e.

treating awakeness and alertness, while also addressing insomnia) and contribution to polypharmacy.

(4) Prescribing practices to expedite grief recovery. Practices of prescribing medications early in the normal grieving process, prohibit sufficient non-medicated grief recovery time (minimum 6 months) to enable the strengthening of internal coping skills and maturation, especially in young (<25 years old) soldiers; these early prescribing practices can be problematic.

(5) Demonstrated stability. Must demonstrate clinical stability once a therapeutic dosage is established, over a minimum of 12 months, and tested by an adequate trial-of-duty under the expected stressful conditions of the deployment. Exceptions are provided in Enclosure (B).

(6) Serotonin syndrome concerns. Combinations of medications which activate the serotonergic system can increase the risk of serotonin syndrome, which can mimic heat injury. Both conditions (heat injury and serotonin syndrome) are difficult to recognize and diagnose, and require very different approaches to treatment.

(7) Antihistaminic properties. Psychoactive medications with antihistaminic properties not only cause drowsiness and alertness issues, but also increase the risk of heat injury.

e. DoD and Specialized U.S. Government Civilian Employees.

(1) General Standards. DoD Civilian employees are covered by the

Rehabilitation Act of 1973. As such, an apparently disqualifying medical condition requires an individualized assessment to determine whether the employee can perform the essential duty functions in the deployed environment, without causing undue hardship. In evaluating undue hardship, the nature of the accommodation and the limited availability of care in certain USEUCOM AOR regions 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 relevant deployed environment IAW Reference (d).

(2) Specific Standard. Specialized government civilian employees who must meet specific physical and mental standards (e.g., firefighters, security guards and police, aviators, aviation crew members and air traffic controllers, divers, marine craft operators, commercial drivers, etc.) must meet those standards without exception, in addition to being found fit for the specific deployment by a medical and dental

A-5 Enclosure A evaluation prior to travel. If fitness certifications expire while assigned within the USEUCOM AOR, it is up to the individual to plan in advance to recertify their compliance with respective fitness requirements (i.e. mid-tour leave, etc.).

(3) Screening Frequency. Government civilian employees, whose assignment 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, or request an exception to policy through the appropriate component surgeon.

f. DoD Contract Employees.

(1) General Standards. DoD contract 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 IAW their contract requirements. DoD contract employees must undergo a medical and dental evaluation, which documents fitness for duty without limitations prior to travel IAW Reference (e).

(2) Pre-Deployment. Contracting agencies will arrange provision of the pre-deployment medical and dental evaluations, and annual in-theater rescreening for the contracted employee. Medical requirements and evaluations must be completed prior to arrival at the deployment location and personnel must comply with immunization, DNA, and panograph x-ray requirements. All required immunizations are outlined in the FCG (https://www.fcg.pentagon.mil) for the countries to be visited, as well as in paragraph 5 of Enclosure (C). Travel medicine services for contracted 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.

(3) Medical Screenings. All contracting agencies are responsible for providing the appropriate level of medical screening for their contracted employees based on the job 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 contracting agency. 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.

(4) Redeployment Due to Medical Condition. A new disqualifying medical condition, as determined by an in-theater competent medical authority, will be immediately reported to the contract employee's contracting officer. The affected https://www.fcg.pentagon.mil/

A-6 Enclosure A contract employee will then be immediately redeployed and replaced at contracting agency’s expense, unless otherwise specified in the contract IAW Reference (e).

(5) Authorization of DoD Care. The guidance in this document should not be construed as authorizing use of Defense Health Program (DHP) or Military Health System (MHS) resources for such evaluations unless previously authorized. Generally, DHP and MHS resources are not authorized for the purpose of predeployment or travel medicine evaluations for contract employees IAW Reference (e). Local command legal, contracting, and resource management authorities should be consulted for questions on this matter.

g. Local National (LN) and Third Country National (TCN) employees. Minimum screening requirements for LN and TCN employees are as follows IAW Reference (e):

(1) Medical Screening. Pre-employment and annual medical screening of LN and TCN employees are normally not performed in U.S. DoD treatment facilities or by U.S. military medical personnel. Local contracting agencies must ensure screenings are conducted by a licensed medical provider (see paragraph 3.f.(3) above).

(2) Tuberculosis (TB) Screening Requirements. All LN and TCN employees in positions requiring close or frequent contact with non-LN/TCN personnel (e.g., dining facility workers, security personnel, interpreters etc.) must be screened for TB IAW service specific guidance.

(3) Food Service Employees. LNs and TCNs employed in food service, including work with water and ice production, must be screened annually for signs and symptoms of infectious diseases. Employees must be vaccinated against Typhoid and Hepatitis A. This information must be documented in the employees' medical record/screening forms.

4. Tricare Overseas Program (TOP) Requirements.

a. Enrollment Requirement. Units arriving in theater greater than 179 days for

Active Duty, and 30 days for Reserve components are required to enroll into the TOP in order to receive routine medical care from Host Nation (HN) facilities.

b. To enroll in TOP, contact the local Tricare point of contact or the Global Tricare

Service Center at: +44-20-8762-8384, option #4 (overseas) or 1-877-678-1207, option #4 (stateside)

c. Individuals with orders that do not meet the duration requirement stated in 3.a.

are only eligible for Urgent/Emergent care at HN facilities.

d. For further information on the TOP:https://intelshare.intelink.gov/sites/eucom-logistics/TRICARE%20Prime%20Remote/Forms/AllItems.aspx.

https://intelshare.intelink.gov/sites/eucom-logistics/TRICARE%20Prime%20Remote/Forms/AllItems.aspx https://intelshare.intelink.gov/sites/eucom-logistics/TRICARE%20Prime%20Remote/Forms/AllItems.aspx

B-1 Enclosure B

Enclosure B Medical Clearance – Deployment-Limiting Conditions (DLCs)

1. Remote assignments. The limited availability of DoD and host nation medical care in certain regions of the USEUCOM AOR pose challenges to individuals with chronic medical conditions. As a result, medical assessment of potentially disqualifying conditions should receive additional scrutiny to mitigate the risk of early evacuation from the theater to receive extensive medical care.

2. General waiver criteria.

a. Individuals who possess any of the following medical conditions require a medical waiver to deploy to the USEUCOM AOR unless stated otherwise.

b. Definition of “medical conditions”. "Medical conditions", as used in this context, also include those health conditions usually referred to as dental or psychological.

c. Ability to perform duties. A medical waiver must be requested if an individual possesses a medical condition that raises any doubt of whether the person can perform his/her duty in a deployed (contingency) environment (e.g. a condition that is infectious/communicable, prohibits function, degrades alertness/judgement, impairs stereoscopic vision/depth perception/color perception, impairs touch sensors, affects proprioception or impairs the ability to drive/operate heavy equipment).

d. Basic requirements. This list of Deployment-Limiting Conditions is not intended to be comprehensive; there are other conditions that may result in denial of medical clearance. Personnel with potentially disqualifying medical conditions must meet the following two criteria to be cleared for deployment: 1) Receive an evaluation by the appropriate medical provider to determine if the member can safely deploy; 2) Receive an approved medical waiver by the USEUCOM Command Surgeon or the delegated Service Component Surgeon for the potentially disqualifying medical condition(s).

e. Development of DLC while deployed. A USEUCOM waiver is not required if an individual develops a DLC while deployed and performing missions in the USEUCOM AOR. Component surgeons may set an additional requirement to re-process as a waiver request [Note: Individuals that are treated for a medical condition outside of the AOR and desiring to return to the AOR to complete an existing deployment must be cleared anew by the appropriate waiver authority].

Anaphylaxis and Allergy An established diagnosis of anaphylaxis requires a waiver for deployment. A waiver is not needed for members with anaphylaxis to an allergen that is not present in the AOR. For example – if the member had a past anaphylactic reaction to an insect not found in USEUCOM, the member does not require a waiver for deploying to the USEUCOM AOR.

Sequence # Condition Description (Waiver Required for Any of the Following, Unless Stated Otherwise)

A1 Anaphylaxis/Allergy treatment with epinephrine Clear risk that the individual will need epinephrine to treat anaphylaxis (i.e. self-treatment with an “epi-pen”)

A2 Food allergies

Food allergy to a food that would be difficult to avoid in-theater and where the symptoms of the allergic reaction are systemic and/or severe enough to the degree where it may interfere with ability to perform occupational duties

Table B-1. Anaphylaxis and Allergy DLCs

B-2 Enclosure B

Cancers Cancer for which a service member will require treatment or surveillance examination testing or imaging during the anticipated deployment.

Sequence # Condition Description (Waiver Required for Any of the Following, Unless Stated Otherwise)

B1 Remission requirements All cancers should be in complete remission for at least one year for a waiver to be considered. Exceptions will be considered on a case-by-case basis.

B2 Percutaneous lesions

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.

B3 Skin cancers (surgically removed)

No waiver required for skin cancers that have been surgically removed with clear borders demonstrated on pathological report and no evidence of spread (Exception: Melanoma does require a waiver). Must be cleared by treating physician or qualified provider.

Table B-2. Cancer DLCs

Cardiovascular Conditions Any of the following conditions (excluding C15) must include written clearance from a cardiologist or specialist appropriate to that condition for a waiver to be considered.

Sequence # Condition Description (Waiver Required for Any of the Following, Unless Stated Otherwise)

C1 Uncontrolled hypertension

1. Hypertension is worsening other significant medical problems, such as cardiovascular, cerebrovascular, renal or ophthalmological problems

2. Hypertension has not been stable (i.e. on the same medication with good blood pressure control) for > 3 months during period before deployment

3. Medication being used is producing side effects that would impair ability to function in a deployed environment.

C2 Coronary artery disease (CAD) Waiver required for all

C3 Cardiac dysrhythmias or arrhythmias

Cardiac dysrhythmias or arrhythmias which require medication, electrophysiologic manipulation, surgical ablation, or implantable cardiac device will generally not be considered for a medical waiver.

NOTE: Exceptions for consideration: History of atrial dysrhythmias, such as atrial fibrillation, premature supraventricular tachycardia (PVST), etc., without recurrence or symptoms for a minimum of 12 months and requiring no medication management.

C4 Heart failure Waiver required for all

C5 Cardiomyopathy Waiver required for all

C6 Coronary artery bypass grafting (CABG) within one year of deployment Waiver required for all

C7 Coronary artery angioplasty and/or stenting within one year of deployment Waiver required for all

C8 Carotid endarterectomy within one year of deployment Waiver required for all

C9 Aneurysm repair within one year of deployment Waiver required for all

C10 Anticoagulation therapy within one year of deployment Waiver required for all

C11 Myocardial infarction within one year of deployment Waiver required for all

C12 Elevated Framingham Risk (> 15%) Age over 40 with a Framingham 10-year Coronary Heart Disease (CHD) risk of 15% or greater requires an evaluation by cardiology.

C13 Additional cardiac disease cases that require a waiver

Clinical suspicion that cardiac disease may exist which requires further evaluation (e.g.

stress test, holter monitor, echocardiogram, cardiology consult, etc.)

C14 Specialist consultation required Requirement to see a specialist (e.g. cardiologist or internal medicine) every 3 months or less (more frequently than every 3 months)

C15 Medications (for cardiovascular conditions) Medication at higher risk for problematic side effects (e.g., Diuretics, Anticoagulants, Vasodilators, Antihypertensives)

Table B-3. Cardiovascular Conditions DLCs

B-3 Enclosure B

Dermatological Conditions Sequence # Condition Description (Waiver Required for Any of the Following, Unless Stated Otherwise)

D1 Required Specialist care Requires frequent (more often than every 3 months) specialist medical care

D2 Extensive lesions/disease Extensive lesions/disease such that, in the opinion of a dermatologist, constitutes increased risk of illness, injury, or infection in the austere setting of a deployment

D3 Interference with duty

Interferes with the satisfactory performance of duty, wearing of the uniform, or using military equipment (e.g. deployment-specific equipment/clothing or eczema worsened by conditions in the AOR)

D4 Interference with insect repellent application i.e. if unable to tolerate DEET and/or permethrin or other insect repellent or insecticide used in AOR

D5 Immunosuppressant treatment required e.g. chronic systemic steroids or immunemodulating or suppressive medications, such as Cyclosporine, Tacrolimus, etc

D6 Biologic response modifier treatment required e.g. immunomodulators or other biologic medications, such as Humira, Dupixent, etc

D7 Antineoplastic treatment required Antineoplastics (oncologic or non-oncologic use). Includes antimetabolites, such as methotrexate, hydroxyurea, mercaptopurine, etc.

D8 Skin cancer remission requirements Waiver required if condition has not been in complete remission for at least one year

D9 Skin cancers (surgically removed)

No waiver required for skin cancers that have been surgically removed with clear borders demonstrated on pathological report and no evidence of spread (Exception: Melanoma does require a waiver). Must be cleared by treating physician or qualified provider.

Table B-4. Dermatological DLCs

Endocrine-Related Disorders Any of the following conditions that require medications that have special hazardous materials (HAZMAT) require a Commander’s Endorsement letter from the first O-5/O-6 in the individual’s chain of command for a waiver to be considered (see Enclosure (E), Appendix B for example letters).

Sequence # Condition Description (Waiver Required for Any of the Following, Unless Stated Otherwise)

E1 Diabetes Mellitus

1. Insulin

2. Oral or injectable medications with a risk of hypoglycemia or severe complications

3. Poor glycemic control (hemoglobin A1C > 7)

4. Less than 90 days since last adjustment in medication regimen

5. Diabetes mellitus complications (i.e. micro or macro neuro-vascular changes, history of hypo- or hyper-glycemic urgency) in the prior 6 months

NOTE: Item 4 requires Glucagon Emergency Kit prescriptions if waiver approved

E2 Hypo/Hyperthyroid

1. New onset (within past 6 months) of either hypo- or hyper-thyroid function

2. Changes in thyroid-related symptoms during previous 3 months

3. Changes to medication or dose in preceding 3 months

4. An episode of acute thyrotoxicosis in the preceding 6 months

5. Requirements for physician follow-up within a 3 month period

E3 Replacement/adjustment therapy considerations

Condition 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.

E4 Hormonal preparation requirements

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.

E5 Injectable contraception No waiver required

Table B-5. Endocrine-Related Disorder DLCs

Environment-Related Conditions (e.g., Heat-Related Injuries)

F1 Heat stroke

1. Complicated by either acute renal failure and/or rhabdomyolysis

2. Multiple episodes of heat stroke or persistent sequelae or organ damage will not be considered for medical waiver

F2 End-organ damage from single heat illness injury i.e. renal, cardiovascular or neurological damage

Table B-6. Environment-Related DLCs

B-4 Enclosure B

Gastrointestinal Conditions

G1 Gastroesophageal Disease

Existence of associated diseases, such as esophageal stricture or Gastroesophageal Reflux Disease (GERD), that require active management or frequent (more often than every 6 months) medical care

G2 Inflammatory Bowel Disease (Crohns and Ulcerative Colitis)

1. Symptom frequency and/or severity affect ability to perform military duties

2. Symptoms not fully responsive to dietary measures available in-theatre (including fiber supplementation) and medications (e.g. anti-diarrheals; anti-spasmodics and bulk-forming laxatives)

3. Presence in-theater of triggers (e.g. irregular meals, poor sleep, loud noises, increased psychological stress) that will likely result in an exacerbation of the frequency and/or severity of the symptom pattern.

4. Chronic medication treatment with immune modulators (i.e. Mesalamine, Sulfasalazine, Lubiprostone, injectables, etc.)

Table B-7. Gastrointestinal DLCs

Genitourinary Conditions (History of Kidney Stones/Renal Colic)

H1 Kidney Stones/Renal Colic

1. History of more than three or more renal calculi

2. One or more exacerbations or urologic pain (ureteric pain or calculi) in the preceding 12 months requiring urgent care or hospitalization

3. CT Scan or intravenous pyelogram or flat plate x-rays confirms current existence of more than one calculi or a single calculi more than 5 mm in size

4. Renal/urologic intervention (e.g. lithotripsy, uretoscopic extraction, etc.) in preceding 3 months

Table B-8. Genitourinary DLCs

Infectious Diseases IAW Enclosure A, paragraph 1.m., the standard to deploy to USEUCOM is for individuals to be free of known blood transmissible diseases and possess a clean blood supply. Therefore, an individual that has a known infectious disease/infectious condition (e.g. Hepatitis A, Hepatitis C, Human Immunodeficiency Virus (HIV), etc.) that could preclude someone from being a walking blood donor requires a medical waiver to deploy. Individuals possessing any of the conditions below with measurable viral titers, positive cultures, or systemic manifestations are non-deployable. Cases with no active disease, in complete remission, and with no risk of communicability, will be considered for waiver on a case-by-case basis. Active duty must comply with status of forces agreements; civilian deployers should contact the nation's embassy for up-to-date information. All of the following infectious diseases require a Commander's Endorsement letter from the first O-5/O-6 in the individual's chain of command for a waiver to be considered because they put the member at risk of not being able to remain a blood donor (see Enclosure (E), Appendix B for example letters).

Sequence # Condition Description (Waiver Required for Any of the Following, Unless Stated Otherwise)

I1 Human Immunodeficiency Virus (HIV) Waiver requests must demonstrate lack of active disease and evidence of remission, and must include clearance from appropriate specialist

I2 Hepatitis B Waiver requests must demonstrate lack of active disease and evidence of remission, and must include clearance from appropriate specialist

I3 Hepatitis C Waiver requests must demonstrate lack of active disease and evidence of remission, and must include clearance from appropriate specialist

I4 Tuberculosis (TB) - Active or Latent

1. Any active TB case with or without therapy

2. Any recent purified protein derivative (PPD; i.e. the tuberculin intradermal test) conversion by infectious disease consultation

3. Any history of TB case with evidence of brain, kidney or bone involvement

NOTE1: Active duty servicemembers with a history of positive conversion on tuberculin skin testing, and who have documented completion of Latent Tuberculosis Infection (LTBI) evaluation and counseling for consideration of treatment and whose providers did not recommend LTBI treatment may deploy without a medical waiver as long as all service-specific requirements are met (See References f, g, and h)

NOTE2: Evaluation and treatment of TB among DoD contract employees, LN and TCN employees are normally not provided within DoD facilities

I5 Host/transit nation infectious disease consideration

A USEUCOM waiver cannot override host or transit nation infectious disease or immunization restrictions.

I6 Refusing Mandatory USEUCOM Vaccinations A waiver will not be granted for any individual that refuses mandatory USEUCOM vaccinations

Table B-9. Infectious Disease DLCs

B-5 Enclosure B

Musculoskeletal Conditions Any musculoskeletal condition that significantly impairs activities of daily living or performing of duties in a deployed environment requires a waiver.

Sequence # Condition Description (Waiver Required for Any of the Following, Unless Stated Otherwise)

J1 Chronic Low Back Pain

1. Low back pain secondary to a serious process (such as cancer, infection, cauda equina syndrome, spinal stenosis or radiculopathy, vertebral compression fracture or ankylosing spondylitis)

2. Incapacitating low back pain that occurs on average more often than once every 6 months, or that exists for more than five days in any 3 month period

3. The low back pain limits ability to perform duties during a deployment, which includes wearing of PPE, carrying full military equipment, travel in military vehicles, etc.

4. Requirement to use CII-CV medications, such as benzodiazepines, opioids, Gabapentin, or Pregablin whose side effects may limit performance of duties/occupation while deployed

5. Incomplete rehabilitation with significant functional limitations

J2 Musculoskeletal (MSK) Injuries

1. Waiver required for any musculoskeletal condition that significantly impairs activities of daily living or performance of duties/occupation while deployed (If there are concerns, an official functional capacity exam should be performed and results included with the waiver request)

2. Musculoskeletal injury or condition, including any chronic pain syndromes, results in loss of motion or function to a degree that impairs performance of duties/occupation while deployed

3. Incomplete rehabilitation with significant functional limitations

4. Requires the use of a medication which may impair the individual from performing duties/occupation while deployed

5. Diagnosed with a potentially progressive systemic or infectious disease (i.e.

osteomyelitis or autoimmune diseases such as rheumatoid arthritis, ankylosing spondylitis, and others)

6. MSK treated with controlled substances (i.e. narcotics, benzodiazepines, etc.)

Table B-10. Musculoskeletal DLCs

B-6 Enclosure B

Neurological Conditions

K1 Epilepsy and Seizure Disorder

Seizure disorder with active seizure activity within the last year or known trigger (such as sleep deprivation) that would likely be triggered in the deployed AOR (diagnosis of epilepsy with ongoing chronic risk for seizures may be considered for a medical waiver).

K2 Epilepsy and Seizure Disorder (Idiopathic) Idiopathic seizure disorder patients on a stable anticonvulsant regimen (i.e. with normal MRI, EEG and lab work-up), and is seizure-free for one year

K3 Migraines and Headaches

1. Incapacitating headaches that typically last > 2 hours and occur more often than once every 3 months

2. Any acute, urgent or emergent visits for treatment of a headache within last 3 months

3. Requirement to use a medication whose side effects would preclude carrying out duties/occupation during a deployment (e.g. narcotics)

4. Requirement for rescue medications (oral or injectable) for flare-ups greater than once a month (difficult to manage medications, i.e. ergotamines, are prohibited)

5. The presence in-theater of triggers (e.g. irregular meals, poor sleep, loud noises, increased psychological stress) will likely result in an exacerbation of the frequency and/or severity of the headache pattern

6. History of intractable migraines requiring Emergency Room care or inpatient admissions

7. Management of migraines requiring controlled substances

K4 Syncope & Loss of Consciousness (LOC)

1. An episode of syncope requiring ongoing evaluation or treatment

2. An episode of syncope that occurred < 1 year ago and was never evaluated fully by a physician to determine cause

3. More than one idiopathic syncopal or near syncopal event

4. Current restrictions or limitations of duties/occupation

K5 Traumatic Brain Injury (TBI)

1. Moderate or severe ongoing cognitive impairment precluding performance of full duties/occupation

2. Significant psychiatric or neurological comorbidity which results in an inability to perform full duties/occupation

3. History of a single mild TBI may deploy once released by a medical provider after 24-hours symptom free (See Reference i)

4. Sustainment of a second mild TBI within a 12-month period may deploy after seven days symptom free and release by a medical provider (See Reference i)

5. Three clinically diagnosed TBIs (of any severity, including mild) since last full neurological and psychological evaluation requires to such an evaluation completed prior to deployability determination (See Reference i)

K6 Cerebral Vascular Accident (CVA) History of CVA to include Transient Ischemic Attack in previous 12 months require neurologist recommendation with waiver request

Table B-11. Neurological DLCs

Obesity (BMI > 35 Or Weight Greater Than 300 Pounds) Obesity not only poses an individual health risk, but also presents challenges of mobility when injured. Morbid obesity poses difficulties for stretcher movement and field operating table stability, as well as challenges for intubation, anesthesia, and vehicle extraction.

Sequence # Condition Description (Waiver Required for Any of the Following, Unless Stated Otherwise)

L1 Body Mass Index (BMI) restrictions

1. Any individual with BMI > 35 with comorbidities (e.g., diabetes, cardiovascular disease, hypertension, sleep apnea, obesity-related cardiomyopathy, severe joint disease, etc.), will generally not be considered for a medical waiver.

2. Civilians and contract employees with BMI of 35 to 39 without serious comorbidities may be considered for a medical waiver.

3. Morbid obesity (BMI > 40) will generally not be considered for medical waiver.

NOTE1: Service members do not require a waiver if compliant with Service body fat guidelines.

NOTE2: Online BMI calculator:

https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmi-m.htm.

Table B-12. Obesity-Related DLCs

Pregnancy

M1 Currently pregnant Currently pregnant or less than 6 months post-partum will not be considered for a waiver.

M2 Becoming pregnant while deployed Decision whether to have the individual remain in theater or redeploy will be determined by the affected service component.

M3 Abortion or Miscarriage Recovery Time Requires 3 months recovery time before a medical waiver will be considered.

Table B-13. Pregnancy DLCs

B-7 Enclosure B

Psychiatry/Behavioral Health Conditions (Anxiety, Major Depressive Disorders, ADD/ADHD, Eating Disorders)

All of the following mental or behavioral health (BH) related diagnoses require that the waiver be signed by a BH specialist or a letter from a BH specialist for a waiver to be considered. All substance abuse disorders and significant BH conditions (e.g. History of suicidal ideation/attempt, severe depression/anxiety, and ongoing family/relationship problems) require a Commander’s Endorsement letter from the first O-5/O-6 in the individual’s chain of command for a waiver to be considered (see Enclosure (E), Appendix B for example letters). USEUCOM considers 12 months as the standard recovery time from BH conditions, with exceptions considered at 6 months onward (unless stated otherwise). See the contents of Tables B14 and B15 for disease specific information.

Sequence # Condition Description (Waiver Required for Any of the Following, Unless Stated Otherwise)

N1 Anxiety

1. Required regular, ongoing mental health treatment within the last six months, in order to gain stability.

2. Ongoing symptoms of any type which affects ability to perform duties/occupation effectively.

3. Lack of disease stability for < 6 months

4. Any concern about the behavioral stability (social and occupational) and the potential for deterioration or recurrence of symptoms during deployment if treatment is interrupted

5. Significant psychiatric co-morbidity

6. Any requirement for antipsychotics, benzodiazepines, or lithium

N2 Major Depressive Disorders

1. Hospitalization for psychiatric reason within last 12 months (see N10 for further guidance)

2. Any ongoing depressive symptoms (cognitive/sleep/mood/suicidal) affecting performance of duties/occupation

3. Lack of disease stability for < 6 months

4. Any requirement for antipsychotics or lithium

5. Any evidence of bipolar disorder or psychotic features

6. Reasonable concern about the behavioral stability and the potential for significant deterioration or recurrence of symptoms during deployment if treatment is interrupted

7. Ongoing requirement for psychological or mental health counseling to maintain stability and functioning

8. Any suicidal ideation/attempt in the preceding 12 months (see N9)

9. Any ongoing depressive symptoms (cognitive/sleep/mood/suicidal) affecting performance of duties/occupation will not be considered for a medical waiver.

N3.1 ADHD/ADD - prerequisites for 'no waiver required'

Waiver is not required if ALL of the following are met:

1. On stable treatment regimen with CII stimulant medications (defined as greater than 6 months on a stable dose without comorbidities) and the diagnosis has been validated by a physician or doctoral level mental health provider (Service Components may require a psychiatrist).

2. The individual does not possess duty limitations or restrictions

3. The individual is able to deploy with sufficient medications to complete deployment, or arrangements have been made for delivery of medications

4. All controlled medications, to include CII stimulants, can be maintained in a locked container, properly secured

N3.2

ADHD/ADD - Items needed to accompany waiver request (if all items in N3.1 are not met, which would necessitate a waiver).

ALL of the following are required to be included in the waiver packet submission:

1. A letter of fitness from the first O-5 in the chain of Command validating that the individual can indeed perform duties/occupation in an austere environment with a long-term irregular sleep schedule while on stimulant medication.

2. Individuals will deploy with sufficient medications to complete deployment or arrange for delivery of medications (see Enclosure A, paragraph 1.h., for further guidance on prescription medication requirements)

3. Statement from provider verifying the lack of adverse effects from stimulant medication (to include insomnia and/or hypertension) NOTE1: The USEUCOM medical supply system is not equipped to ship and/or store large amounts of controlled substances.

NOTE2: All controlled medications to include CII stimulants must be maintained in a locked container, properly secured NOTE3: Germany prohibits the delivery of medications via mail to include the military postal service (MPS) (this includes personnel in countries that receive U.S. Mail that passes through Germany).

N4

Eating Disorders (i.e. Anorexia Nervosa, Bulimia Nervosa, or other specified/unspecified feeding or eating disorder)

1. Required regular, ongoing mental health treatment within the last six months in order to maintain stability

2. Ongoing symptoms of any type which affects ability to perform duties/occupation

3. Disease stability for < 6 months

4. Any concern about the behavioral stability (social and occupational) and the potential for deterioration or recurrence of symptoms during deployment

5. Medical evaluation indicates physical health concerns related to disorder (abnormal labs, cardiac concerns, etc)

Table B-14. Psychiatric/Behavioral Health Related DLCs – Part 1

B-8 Enclosure B

Psychiatry/behavioral health conditions (Not Including Anxiety, Major Depressive, ADD/ADHD, Eating Disorders)

All of the following mental or behavioral health (BH) related diagnoses require that the waiver be signed by a BH specialist or a letter from a BH specialist for a waiver to be considered. All substance abuse disorders and significant BH conditions (e.g. History of suicidal ideation/attempt, severe depression/anxiety, and ongoing family/relationship problems) require a Commander’s Endorsement letter from the first O-5/O-6 in the individual’s chain of command for a waiver to be considered (see Enclosure (E), Appendix B for example letters). USEUCOM considers 12 months as the standard recovery time from BH conditions, with exceptions considered at 6 months onward (unless stated otherwise). See the contents of Tables B14 and B15 for disease specific information.

Sequence # Condition Description (Waiver Required for Any of the Following, Unless Stated Otherwise)

N5 Psychotic and bipolar disorders

History (within the last 12 months) of isolated brief, limited episodes which express bipolar or psychosis symptoms, now resolved.

NOTE: Bipolar disorders and psychosis are both conditions requiring a Medical Examination Board and thus are non-deployable and will not be considered for medical waiver

N6 Psychiatric disorders affecting social and/or job performance

DSM IV/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.

N7 Mental health conditions - risk of deterioration

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.

N8 Chronic insomnia

Required usage of sedative hypnotics/amnestics, benzodiazepines, and/or anti-psychotics for greater than three months will require a waiver to deploy (includes use of Zolpidem (Ambien) or similar medications for > 3 months)

N9 Psychiatric polypharmacy

Use of 3 or more psychotropics (e.g. antidepressants, anticonvulsants, antipsychotics, benzodiazepines) for stabilization, particularly if used to offset side-effects of other BH therapy, requires a waiver for deployment.

N910 Suicide ideation/attempt (including passive) Suicide ideation/attempts within the last 12 months require a waiver to deploy.

N11 Psychiatric hospitalization (excludes brief overnight stays for observation)

Psychiatric hospitalization within the last 12 months require a medical waiver submission package with a specialty evaluation prior to deployment

N12 Marital and relationship counseling Counseling required in order to gain stability; once stable, no waiver required

N13 Psychiatric disorders newly diagnosed during deployment

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

NOTE: Exceptions include diagnoses featuring bipolar, psychotic, homicidal, or suicidal features. These individuals should be redeployed at soonest opportunity via medical evacuation with appropriate escorts and per TRANSCOM guidelines.

N14 Post Traumatic Stress Disorder (PTSD)

1. Currently being evaluated for possible diagnosis of PTSD

2. Diagnosed with PTSD and currently has symptoms which interfere with ability to perform full duties/occupation

3. Diagnosed with PTSD and with symptoms controlled but period of stability is less than 6 months

4. Diagnosed with PTSD and…