Chapter 3


1. General. This PPG-TAB A accompanies MOD ELEVEN, Section 15.C. and provides amplification of
the minimal standards of fitness for deployment to the CENTCOM AOR, including a list of medical
conditions that may be sufficient to deny medical clearance for or to disapprove deployment of a service
member, civilian employee, volunteer, or contractor's employee. The list of deployment-limiting
conditions is not comprehensive; there are many other conditions that may result in denial of medical
clearance for deployment. Possession of one or more of the conditions listed in this tab does not
automatically imply that the individual may not deploy. Rather, it imposes the requirement to obtain a
knowledgeable physician's opinion as to the deployability status of the individual. "Medical conditions" as
used here also include those health conditions usually referred to as dental, oral, psychological and/or
A. Uniformed Service Members will be evaluated for fitness according to service regulations and policies, in addition to the guidance in the parent PPG Modification (MOD). See MOD ELEVEN REF E, F, G, H, O, Q and HH. B. DoD civilian personnel with apparently disqualifying medical conditions could still possibly deploy based upon an individualized medical assessment (which shall be consistent with subparagraph 4.g.(3)(c) of DoDD 1404.10 and The Rehabilitation Act of 1973, as amended), if all of these conditions are met: 1. 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. 2. The condition is stable and reasonably anticipated by the pre-deployment medical evaluator not to worsen during the deployment in light of physical, physiological, psychological, and nutritional effects of the duties and location. 3. Any required, ongoing health care or medications anticipated to be needed for the duration of the deployment are available in theater within the Military Health System. Medication must have no special handling, storage, or other requirements (e.g., refrigeration, cold chain, or electrical power requirements). Medication must be well tolerated within harsh environmental conditions (e.g. heat or cold stress, sunlight) and should not cause significant side effects in the setting of moderate dehydration. 4. There is no need for routine evacuation out of theater for continuing diagnostics or other evaluations. (All such evaluations must be accomplished before deployment.) 5. It is determined, based upon an individualized assessment, that the employee can perform the essential functions of the position in the deployed environment, with or without a reasonable accommodation, without causing undue hardship. In evaluating undue hardship, the nature of the accommodation and the location of the deployment must be considered. Further, the employee's medical condition must not pose a significant risk of substantial harm to the employee or others taking into account the condition of the relevant deployed environment. See REF Q. 2. The provider evaluating personnel for deployment must bear in mind that in addition to the individual's duties, the environmental conditions that may impact health include extremes of temperature, physiologic demand (water, mineral, salt, and heat management), and poor air quality (especially particulates), while the operating conditions impose extremes of diet (to include fat, salt, and caloric levels), sleep deprivation, emotional stress, and sleep disturbance. If maintaining an individual's health requires avoidance of these extremes or conditions, she/he should not deploy. 3. The rules and facts listed in paragraph 2 should assist the evaluating medical authority to make qualified judgments as to whether an individual with an existing condition is suitable for deployment. Any condition that markedly impairs an individual's daily function is grounds for disapproval. Evaluation of functional capacity to determine fitness in conditions of physiologic demand is encouraged to make a decision, such as graded exercise testing when there is coronary artery disease or significant risk thereof. The evaluating provider should pay special attention to hematologic, cardiovascular, pulmonary, orthopedic, neurological, endocrine, dermatological, psychological, visual, and auditory conditions which may present a hazard to the individual or others and/or preclude performing functional requirements in the deployed setting. Also, the type and amount of medications being taken, their suitability, and availability in the theater environment must be considered as potential limitations. 4. 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 or military health system resources are not authorized for the purpose of pre-deployment or travel medicine evaluations for contractor employees. Local command, legal, and resource management authorities should be consulted for questions on this matter. 5. Shipboard operations that are not anticipated to involve operations ashore are exempt from the deployment-limiting medical conditions listed below and will follow Service specific guidance. 6. The general guidance from MOD ELEVEN section 15C applies to: A. All personnel (uniformed service members, government civilian employees, volunteers, and
DoD contractor employees) deploying to theater must be medically and psychologically fit for
deployment and possess a current Periodic Health Assessment (PHA) or physical. Fitness
specifically includes the ability to accomplish tasks and duties unique to a particular operation and
the ability to tolerate environmental and operational conditions of the deployed location.
B. The existence of a chronic medical condition may not necessarily require a waiver to deploy.
Personnel with existing conditions, other than those outlined in this document, may deploy if
1. An approved medical waiver, IAW Section 15.C.3., is documented in the medical
2. All of the following conditions are met: a) The condition(s) is/are not of such a nature that an unexpected worsening or physical trauma is likely to have a medically grave outcome. b) The condition(s) is/are stable; that is, currently under medical care, and reasonably anticipated by the pre-deployment medical evaluator not to worsen during the
deployment under available care in theater, in light of physical, physiological, psychological and
nutritional impacts and effects of the duties, location, and limited medical capabilities at the
location. For most conditions, 90 days is a reasonable timeframe to determine stability,
subject to the provider's judgment.

c) Any required ongoing health care or medications must be available in theater within the military health system for DoD personnel or the contractor health care system for contingency contractor personnel, unless specifically authorized in the contracting officer's Letter of Authorization and the synchronized pre-deployment operational tracker database and have no special handling, storage, or other requirements (e.g., refrigeration/cold chain, electrical power, etc.). d) There is no need or anticipation of duty limitations that preclude performance of duty or an accommodation imposed by the medical condition. e) There is no need for routine evacuation out of theater for continuing diagnostics or other evaluations (all such evaluations must be accomplished prior to deployment).
7. Documented medical conditions precluding medical clearance. A list of all possible diagnoses and
their severity that may cause an individual to be non-deployable would be too expansive. Rather than
relying solely on a specific list of medical conditions, the medical evaluator must carefully consider
whether the climate, altitude, nature of available food and housing, availability of medical, behavioral
health, dental, surgical, and laboratory services, or whether other environmental and operational factors
may be hazardous to the deploying person's health because of a known physical or psychological
The following list of conditions should not be considered exhaustive. Other conditions may
render an individual medically non-deployable (see paragraph 6). Medical clearance to deploy with any
of the following documented medical conditions may be granted, except where otherwise noted, IAW
MOD ELEVEN Section 15.C. If an individual is found deployed with a pre-existing non-deployable
condition and without a waiver for that condition, a waiver request to remain deployed should be
submitted to the respective component surgeon. If the waiver request is denied, the individual will be
redeployed out of the CENTCOM AOR. Individuals with the following conditions should not deploy
(unless a waiver is approved):

A. General Conditions / Restrictions:
1. Conditions that prevent the wear of personal protective equipment, including protective mask, ballistic helmet, body armor, and chemical/biological protective garments. 2. Conditions that prohibit required theater immunizations (other than smallpox & anthrax per current guidance) or medications (such as antimalarials, chemical and biological antidotes, and other chemoprophylactic antibiotics). 3. Any medical condition that requires frequent clinical visits (more than quarterly) or ancillary tests (more than twice/year), that fails to respond to adequate conservative treatment, necessitates significant limitation of physical activity, or constitutes increased risk of illness, injury, or infection. 4. Any unresolved acute illness or injury that would impair one's duty performance during the duration of the deployment. 5. Any medical condition that requires durable medical equipment or appliances (e.g., Nebulizers, TENS, catheters, spinal cord stimulators) or that requires periodic evaluation/treatment by medical specialists not readily available in theater. B. Specific Medical Conditions:
1. Asthma that has a Forced Expiratory Volume-1 < 50% of predicted despite appropriate therapy, that has required hospitalization in the past 12 months, or that requires daily systemic (not inhaled) steroids. Asthma that has been well controlled for 6 months and is evaluated to pose no risk of deterioration in the deployed environment may be considered for waiver. 2. Seizure disorder, either within the last year or currently on anticonvulsant medication for prior seizure disorder/activity. Persons on a stable anticonvulsant regimen, who have been seizure-free for 6 months, may be considered for waiver. 3. Diabetes mellitus, type 1 or 2, on pharmacotherapy or with HgA1C > 7.0. a. Type 1 diabetes or insulin-requiring type 2 diabetes. Individualized
assessment required.

b. Type 2 diabetes, on oral agents only, with no change in medication within the last 90 days and HgA1C ≤ 7.0 does not require a waiver if the calculated 10-year Framingham coronary heart disease risk percentage is less than 15%. If the calculated 10-year risk is 15% or greater, further evaluation is required prior to waiver submission. See C.8. for more detailed instructions. 4. History of heat stroke. Persons with a history of heat stroke with no multiple episodes, no persistent sequelae or organ damage and no episode within the last 24 months may be considered for waiver. 5. Meniere's disease or other vertiginous/motion sickness disorder, unless well controlled on medications available in theater. 6. Recurrent syncope for any reason. 7. Any musculoskeletal condition that significantly impairs performance of duties in a deployed environment. 8. Renalithiasis, recurrent or currently symptomatic.
9. Pregnancy. Individualized assessment required.
10. Obstructive sleep apnea (OSA). The OSA should be documented/ diagnosed with
in-laboratory polysomnography, with a minimum of 2 hours of total sleep time, that yields an apnea-hypopnea index (AHI), and/or respiratory disturbance index (RDI), of greater than 5 / hour. Individuals who are treated with continuous positive airway pressure (CPAP) should deploy with a machine that has rechargeable battery back-up and sufficient supplies for the duration of the deployment. Individuals deploying to a location where their sleep environment has unfiltered air will typically not be granted waivers if a waiver is otherwise required per the guidance below. Advanced modes of airway pressure (adapt-servo ventilation, BIPAP, etc.) are not permitted in theater. The following guidelines are designed to ensure that individuals with OSA are adequately treated and that their condition is not of the severity that would pose a safety risk should they be required to go without their CPAP for a significant length of time. a. OSA of any severity, if symptomatic despite treatment, is non-deployable.
Individualized assessment required.
b. OSA with an AHI and/or RDI ≥ 30/hr post-treatment requires a waiver for deployment to any location in the AOR. c. OSA with an AHI and/or RDI < 30/hr post-treatment does NOT require a waiver to deploy, except to Afghanistan or Yemen. d. Mild OSA ( AHI and/or RDI < 15/hr) with or without CPAP treatment is
deployable. No waiver required.
11. History of clinically diagnosed traumatic brain injury (mTBI/TBI) of any severity, including mild. Such history does not necessitate a waiver request, but does require pre-deployment evaluation, which may include both neurologic and psychologic components, in accordance with the Joint Theater Trauma System (JTTS) Clinical Practice Guideline (CPG). This CPG can be found Individuals who have had three clinically diagnosed TBIs (of any severity, including mild) since their last full neurologic/psychologic CPG-defined evaluation are required to have such an evaluation completed prior to deployability determination. 12. BMI > 35 with serious comorbidities such as diabetes, sleep apnea, obesity-related cardiomyopathy, or severe joint disease. C. Cardiovascular Conditions:
1. Symptomatic coronary artery disease. Also, see C.8. 2. Myocardial infarction within one year of deployment. Also, see C.8. 3. Coronary artery bypass graft, coronary artery angioplasty, carotid endarterectomy, other arterial stenting, or aneurysm repair within one year of deployment. Also, see C.8. 4. Cardiac dysrhythmias or arrhythmias, either symptomatic or requiring medication, electro-physiologic control, or automatic implantable cardiac defibrillator. Implantable cardiac
devices: Individualized assessment required.
5. Hypertension that is controlled with a medication regimen that has been stable for 90 days and requires no changes, does not require a waiver. Single episode hypertension found on predeployment physical should be accompanied by serial blood pressure checks to ensure hypertension is not persistent. 6. Heart failure or history of heart failure. 7. Morbid obesity (BMI > 40) in accordance with National Heart Lung and Blood Institute guidelines. Individualized assessment required. Military personnel in compliance with service
body fat guidelines do not require a waiver.
8. Civilian personnel who are 40 years of age or older must have a Framingham 10-year CHD risk percentage calculated (online calculator available at If the individual's calculated 10-year CHD risk is 15% or greater, the individual should be referred for further cardiology work-up and evaluation, to include at least one of the following: graded exercise stress test; myocardial perfusion scintigraphy; or stress echocardiography. Results of the evaluation (physical exam, Framingham results, etc.) and testing, along with the evaluating physician's recommendation regarding deployment, should be included in a waiver request to deploy. 9. Hyperlipidemia that is controlled (Total Cholesterol < 240, LDL< 160, Triglycerides< 500) with a medication regimen that has been stable for 90 days and requires no changes, does not require a waiver. D. Infectious Disease:
1. Blood-borne diseases (Hepatitis B, Hepatitis C, HTLV) that may be transmitted to others in a deployed environment. Waiver requests for persons testing positive for a blood borne disease should include a full test panel for the disease, including all antigens, antibodies and viral load. 2. Confirmed HIV infection is disqualifying for deployment, IAW References Y and Q, service specific policies, and agreements with host nations. 3. Latent tuberculosis, including those who are untreated or who are currently under treatment. Waiver requests for deployment of such individuals should include specific information regarding treatment, where they are in the treatment course, documentation of lack of adverse treatment effects, and feasibility of continued treatment in theater. Documentation should include a chest x-ray negative for active disease within 90 days of deployment, and counseling on increased risk of disease if untreated. Active duty TST convertors who have documented completion of public health nursing counseling for LTBI treatment may deploy without waiver as long as all service specific requirements are met.
4. Active tuberculosis. Individualized assessment required.

E. Eye, Ear, Nose, Throat, Dental Conditions:
1. 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.
Individualized assessment required.
2. Refractive eye surgery. Personnel who have had laser refractive surgery must have a satisfactory period for post-surgical recovery before deployment. There is a large degree of patient variability which prevents establishing a set timeframe for full recovery. The attending ophthalmologist or optometrist will determine when recovery is complete. a. Personnel are non-deployable while still using ophthalmic steroid drops post- procedure. Individualized assessment required.
b. Photorefractive keratectomy (PRK). Personnel are non-deployable for three months following uncomplicated PRK unless a waiver is granted. Related "surface ablation" procedures such as laser epithelial keratomileusis (LASEK) and epithelial LASIK are to be considered equivalent to PRK. Waiver request should include clearance from treating ophthalmologist or optometrist. c. Laser assisted in situ keratomileusis (LASIK). Personnel are non-deployable for one month following uncomplicated LASIK unless a waiver is granted. Waiver request should include clearance from treating ophthalmologist or optometrist. 3. Hearing loss. The requirement for use of a hearing aid does not necessarily preclude deployment. However, the individual must have sufficient unaided hearing to perform duties safely IAW Service guidelines. If individuals meet the following criteria, unaided, no waiver is required to deploy: a. A hearing level no greater than 30dB for either ear (the average of hearing levels at 500, 1000, and 2000 Hz), with no individual level greater than 35dB at these frequencies and no greater than 55dB at 4000 Hz; OR b. A hearing level no greater than: 30dB at 500 Hz; 25dB at 1000 and 2000 Hz; and 35dB at 4000 Hz in the better ear. c. An audiogram may not necessarily correlate with an individual's ability to perform duties as determined by an occupational health exam. Waiver requests should be accompanied by a provider's evaluation and assessment of speech recognition and ability to hear and wake up to emergency alarms and hear instructions in the absence of visual cues such as lip reading. Extreme ranges (over 75 dB either ear, at any frequency) of hearing loss should be accompanied by an audiologist's assessment of functionality and Speech Recognition In Noise Test (SPRINT). 4. Tracheostomy or aphonia. 5. Patients without a dental exam within 12 months of deployment, or those who are likely to require evaluation or treatment during the period of deployment for oral conditions that are likely to result in a dental emergency. a. Individuals being evaluated by a non-DoD civilian dentist should use a DD Form 2813, or equivalent, as proof of dental examination. b. Individuals with orthodontic equipment require a waiver to deploy. Waiver requests to deploy should include a current evaluation by their treating orthodontic provider and include a statement that wires with neutral force are in place. F. Cancer:
1. Cancer for which the individual is receiving continuing treatment or requiring frequent subspecialist examination and/or laboratory testing during the anticipated duration of the deployment. 2. Precancerous lesions that have not been treated and/or evaluated and that require treatment/evaluation during the anticipated duration of the deployment.
G. Surgery:
1. Any medical condition that requires surgery (e.g., unrepaired hernia) or for which surgery has been performed and the patient requires ongoing treatment, rehabilitation or additional surgery to remove devices (e.g., external fixator placement). 2. Individuals who have had surgery requiring follow up during the deployment period or who have not been cleared/released by their surgeon (excludes minor procedures). 3. Individuals who have had surgery (open or laparoscopic) within 6 weeks of deployment.
H. Psychiatric Conditions:
1. Psychotic and Bipolar Disorders are disqualifying for deployment. Individualized
assessment required. For detailed guidance on deployment-limiting psychiatric conditions or
psychotropic medications, refer to Health Affairs Policy Memorandum, "Policy Guidance for
Deployment-Limiting Psychiatric Conditions and Medications," November 7, 2006.
2. Clinical psychiatric disorders with residual symptoms, or medication side effects, which impair duty performance. 3. Mental health conditions that pose a substantial risk for deterioration and/or recurrence of impairing symptoms in the deployed environment. 4. History of the following: psychiatric hospitalization; suicide attempt; substance (medication, illicit drug, alcohol, inhalant, etc.) abuse or treatment for such abuse. Such history does not necessitate a waiver request, but does require a pre-deployment evaluation by a behavioral health practitioner who is authorized to write profiles in order to make a deployability determination. Waiver requests for such individuals should include the results and recommendation from this evaluation, as well as documentation of completion any formal substance-abuse classes or instruction. For mTBI/TBI, this evaluation is only required if indicated by the JTTS-CPG. See B.11. a. Substance abuse disorders (not in remission), actively enrolled in Service Specific substance abuse programs. Individualized assessment required.
5. Psychiatric disorders with fewer than three months of demonstrated stability from the last change in treatment regimen (medication, either new or discontinued, or dose change). Note: Disorders that have demonstrated clinical stability for three months or greater, without change in therapy, do not require a waiver to deploy. Exceptions to this are noted elsewhere in this document and include specific diagnoses (e.g. bipolar disorder) and specific medications (e.g. antipsychotics). a. Psychiatric disorders newly diagnosed during deployment do not immediately require a 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
waiver to remain in theater.
I. Medications – although not exhaustive, use of any of the following medications
(specific medication or class of medication) is disqualifying for deployment:

1. Blood modifiers: a. Therapeutic Anticoagulants: warfarin (Coumadin®). Individualized
assessment required.
b. Platelet Aggregation Inhibitors or Reducing Agents: clopidogrel (Plavix®), anagrelide (Agrylin®), Dabigatran (Pradaxa®), Note: Aspirin use in theater is to be limited to individuals who have been advised to continue use by their healthcare provider for medical reasons; such use must be documented in the medical record. c. Hematopoietics: filgrastim (Neupogen®), sargramostim (Leukine®), erythropoietin (Epogen®, Procrit®). d. Antihemophilics: Factor VIII, Factor IX. 2. Antineoplastics (oncologic or non-oncologic use): e.g., antimetabolites (methotrexate, hydroxyurea, mercaptopurine, etc.), alkylators (cyclophosphamide, melphalan, chlorambucil, etc.), antiestrogens (tamoxifen, etc.), aromatase inhibitors (anastrozole, examestane, etc.), medroxyprogesterone (except use for contraception), interferons, etoposide, bicalutamide, bexarotene, oral tretinoin (Vesanoid®). 3. Immunosuppressants: e.g., chronic systemic steroids. 4. Biologic Response Modifiers (immunomodulators) e.g., abatacept (Orencia®), adalimumab (Humira®), anakinra (Kineret®), etanercept (Enbrel®), infliximab (Remicade®), leflunomide (Arava®), etc. 5. Antipsychotics, except quetiapine (Seroquel®) 25mg at bedtime for sleep.
6. Antimanic (bipolar) agents: e.g., lithium. Individualized assessment required.
7. Anticonvulsants, used for seizure control or psychiatric diagnoses.
a. Anticonvulsants (except those listed below) which are used for non-psychiatric diagnoses, such as migraine, chronic pain, neuropathic pain, and post-herpetic neuralgia, are not
deployment limiting as long as those conditions meet the criteria set forth in this document and
accompanying MOD ELEVEN. No waiver required.
b. Valproic acid (Depakote®, Depakote ER®, Depacon®, etc.). c. Carbamazepine (Tegretol®, Tegretol XR®, etc.). 8. Varenicline (Chantix®). Individualized assessment required.
9. Opioids, opioid combination drugs, or tramadol (Ultram®), chronic use.
10. Insulin and exenatide (Byetta®). Individualized assessment required.



Istruzioni per l’uso Posizionamento e collegamentoReversibilità apertura porte Italiano, 1 Descrizione dell’apparecchio, 3Vista d'insieme Accessori, 4 Avvio e utilizzo, 5-6Avviare l'apparecchio Sistema di raffreddamentoUtilizzare al meglio il frigorifero Utilizzare al meglio il congelatore Manutenzione e cura, 7Escludere la corrente elettrica

N° 10 Abril 2013 Publicación de contenido científico editada por GT Laboratorio S.R.L. Necochea 3274 Rosario Método enzimático UV para la determinación cuantitativa de lactato en suero, plasma o líquido LACTATO Liquid Plus cefalorraquídeo. El nuevo método enzimático UV GT Lab para la determinación de lactato permite la cuantificación rápida y precisa, empleando un reactivo de tra-bajo único de sencilla preparación. Dicha preparación se hace por disolución de un polvo en el buffer provis-to listo para usar. El reactivo de trabajo es estable 24 horas a temperatura ambiente o 15 días refrigerado. Se resume seguidamente el documento "Lactato: utilidad clínica y reco-mendaciones para su medición", de la Sociedad Española de Química Clí-nica preparado por P. Guevara Ramírez, R. Díaz García, A. Galán Ortega, E. Guillén Campuzano, S. Malumbres, J.L. Marín Soria, M. Muñoz Pérez, X. Navarro Segarra, P. Oliver Sáez, E. Oujo, N. del Río Barcenilla y A. Buño Soto en 2010.