Allergists can guide patients through medical waivers in military enlistment

Key takeaways:

• Histories of asthma and allergy are disqualifying for military enlistment.
• Clear documentation of resolved cases can help applicants receive waivers to serve.

ANAHEIM, Calif. — Allergists can help adolescents and young adults with atopic conditions enlist in the military, according to a presentation at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.

Knowledge of the accession process and proper documentation are key to successful enlistment, Karla Adams, MD, FACAAI, associate professor of pediatrics, Uniformed Services University, said during her presentation.

“We want to ensure that individuals who are going to be considered for service are free from medical conditions that may be expected to require time lost from training due to medical treatment or hospitalization,” Adams said.

“We want to ensure that these folks are medically capable of satisfactorily completing their training, that they are adaptable to the military environment, and that they are capable of performing their duties without aggravating their medical condition,” she continued.

However, Adams said, the United States military services are struggling with recruitment.

“Only about 23% of Americans who are 17 to 24 years of age are qualified to serve without a waiver,” she said. “Of those that are disqualified, medical and physical conditions affect 7%.”

Department of Defense Instruction (DoDI) 6130.03, Volume 1, lists pre-existing medical conditions that disqualify candidates from enlisting in the military.

Allergy and asthma are among the disqualifying conditions listed in DoDI 6130.03, Adams said. But candidates with allergy and asthma can work with their allergist to provide documentation that will support a waiver, enabling them to enlist.

The process

Accession, which applies to anyone who wants to join the military as well as anyone in their first 6 months of service, is a two-step or three-step process, depending on the candidate, Adams said. It begins with a medical prescreening.

Applicants complete medical questionnaires and can submit records pertaining to whatever medical condition they may have. Next, they visit one of the military entrance processing stations (MEPS) operating across the country.

During this visit, which can last several hours, candidates have lab evaluations and get vision and hearing screenings, among other examinations, and meet with a medical provider who will review their information.

Based on the results of the visit and the medical history, the provider then determines whether the candidate meets the appropriate standards and is cleared for service or if they are permanently disqualified.

“Again, any condition that the applicant has that is included in that Department of Defense Instruction would be considered a disqualifying condition,” Adams said.

When applicants are disqualified, the provider then can determine if that condition merits a waiver and submit a package to the service review authority, which would approve or deny the waiver.

“The waiver process is designed to allow some applicants to still have a chance to join the military even if they already got disqualified based on the DoDI,” Adams said.

So, Adams said, allergists need to ensure that the medical records they provide in these cases are clear and accurate, especially because MEPS providers may request additional documentation from the applicant’s physicians.

“A lot of times, it’s our documentation of their medical condition that’s going to help, or it’s going to impact how they go through this process,” Adams said.

Adams encouraged allergists to review DoDI 6130.03, Volume 1, as they prepare these documents and quote the military’s guidelines directly when possible.

“I would be very specific and consistent. Try to avoid any statements that could be misinterpreted. You can’t say that their asthma is resolved but you should still carry albuterol,” she said.

Similarly, allergists should not say that their patients carry epinephrine autoinjectors “just in case,” Adams said, or use any other unclear language.

“I would also recommend not categorizing the food allergy,” she said. “It doesn’t matter if it’s mild, moderate or severe. It’s either there, or it’s not there.”

Adams encouraged allergists to be truthful too.

“We all want to be really helpful. But if you clear a teen or adolescent who still has symptomatic asthma, we’re just delaying the inevitable,” she said.

New recruits who cannot complete physical training will get another medical evaluation, Adams said, and those results may lead to disqualification. Additionally, recruits who make false statements about their health can be subject to court martial and less than honorable discharge.

Risks and waivers

Accurate information is important because servicemembers engage in a variety of roles in the military that subject them to varying degrees of risks, Adams explained.

For example, members of the military endure physical exertion and fatigue that may impact any allergies or asthma that they may have, she said.

“We deploy our members to austere environments, international environments, where it’s hard to sometimes identify food allergens,” she continued. “And as well, our services are enriched with young males who might represent a group at increased risk-taking behavior.”

Deployed personnel also may rely on meals ready-to-eat kits, also known as MREs, which often include common allergens.

The military processes a large number of waivers each year too, Adams said. Between fiscal years 2021 and 2022, the U.S. Army, Navy, Air Force and Marine Corps processed 54,206 waivers, approving 41,946 (77%) and denying 12,242 (23%).

Specifically, the Marine Corps approved 98%, the Navy approved 84%, the Army approved 69% and the Air Force approved 65%, as each service takes different factors into account, Adams said.

“They will look at the applicant’s aptitude testing. They’ll look at the potential job in the service. Jobs that are competitive. Think pilot. Think special forces. It’s harder to get waivers for those individuals,” Adams said, “vs. if you are trying to do a job that we need, then there is a higher likelihood that you’ll get a waiver approved.”

Example applicants

Adams also described three hypothetical applicants and what she would report if she were their allergist during this process.

First, she described an applicant aged 16 years with a history of childhood asthma who was no longer symptomatic nor on any current medications or who had any recent ED visits who wanted to join the Navy.

“They last took a short-acting bronchodilator at [age 12 years]. Their last inhaled corticosteroid was at 10 years of age,” Adams said. “I would say this patient’s asthma is probably resolved. But knowing that they want to join the Navy, that adds an extra layer of complexity.”

The DoDI document says that a history of airway hyperresponsiveness after the thirteenth birthday including symptoms suggestive of asthma would be considered disqualifying or not meeting the standard.

“In this case, I would say something along the lines of history of childhood asthma not resolved, prior to the age of 13, again not having any symptoms now, they don’t have any limitations,” Adams said.

Second, she described an applicant aged 18 years with a history of childhood peanut allergy that has since resolved. This history included recurrent cutaneous and respiratory symptoms due to peanut ingestion between ages 1 and 6 years as well as accidental ingestions without symptoms between ages 9 and 18 years. Also, this applicant carries an autoinjector.

“They submitted this information to MEPS, who unfortunately disqualified them, and now they’re coming to see you,” Adams said.

Adams said she would offer serology or skin testing to the applicant, and if the results are low or favorable, a food challenge with a serving size of peanut would follow.

“And then my documentation is really going to depend on whatever happened with the oral food challenge,” she said.

Allergists should perform the OFC with an age-appropriate dose to confirm resolution of the allergy and the need for an autoinjector, Adams continued.

“Having done multiple low-risk challenges in my clinic that have resulted in anaphylaxis, I trust, but verify,” she said.

However, Adams said, patients who are receiving oral immunotherapy for their food allergy may not get a waiver because they may not have access to these products once they are in the military. Current guidelines do not address OIT, she said.

“Unfortunately, it’s unlikely that they’re going to get in with a history of OIT,” she said.

Third, Adams described an Air Force Academy applicant aged 18 years with a history of anaphylaxis due to a yellowjacket sting at age 11 years. The reaction was moderate without any risk factors but with a normal baseline tryptase. Also, the applicant had completed 5 years of venom immunotherapy (VIT) without any adverse reactions.

The DoDI document says that venom-triggered anaphylaxis can be disqualifying without 3 years of maintenance immunotherapy.

“For this patient, they’ve done VIT for 5 years,” Adams said. “So as long as we can safely stop it and document that, they should have no issue getting a waiver.”

Resources, next steps

Adams noted that DoDI 6130.03, Volume 1, along with service-specific documents, are available to the public online and via the free Med Standards app for iOS.

“Anytime these documents get updated, the app gets updated as well,” Adams said.

Adams also encouraged allergists with questions to contact the allergy fellowships at Willford Hall Ambulatory Surgical Center in the Air Force or Walter Reed National Military Medical Center in the Army.

“One of us will get you in touch with the right person,” she said.

Further, Adams emphasized that knowledge of the military accession process is key to guiding applicants through these medical evaluations.

“You want to make it easy for whoever is reading that package to approve the waiver,” she said. “The medical documentation that you provide that’s in line with those guidelines is going to help our patients streamline that process.”