Unlike 10 years ago, the military services now accept recruits who had childhood asthma but have not been symptomatic since age 13. The relaxation of accession standards partly was necessitated by the increasing incidence of asthma in the general population. The new policy has been a success, however, with the great majority of servicemembers with waivers for childhood asthma staying in the military once they get past basic training. By Annette M. Boyle BETHESDA, MD — After 20 years of seesawing, military accession regulations regarding asthma seem to have found a workable balance. Prior to 1990, all branches accepted applicants with a history of childhood asthma who had no symptoms and required no medication after age 12. A surge in medical evacuations for asthma from the Persian Gulf wars led to a tightening of regulations that disqualified individuals ever diagnosed or treated for asthma in 1994. Now, 10 years later, new standards exclude only those who have been diagnosed or symptomatically presented with asthma, reactive airway disease, exercise-induced bronchospasm or asthmatic bronchitis after age 13.1
“In the older induction standards, any history of asthma was disqualifying. We’ve since learned that childhood asthma can be different than that which continues into adulthood and poses less risk than seen in recruits who have current asthma,” said Col. Michael R. Nelson, MD, PhD, deputy commander for education training and research, Walter Reed National Military Medical Center in Bethesda. “Emerging research and our success with those coming in with a history of just childhood asthma has supported the changed induction standards,” Nelson added. As a result of the changes in regulations, between 2007 and 2012, 3,455 applicants applied for waivers for asthma, and 1,559 were approved, accounting for 2.6% of all waivers.2 The high number of waivers reflects the increasing incidence of asthma in the general population. In 2001, just more than 7% of Americans had asthma. By 2010, that prevalence had grown 12%, to an overall rate of 8.4%. The rate was higher still in children, at 10%, according to the CDC. Still, the revised standards create some challenges for medical evaluation teams and commanders. The key to diagnosing asthma at the military entrance processing station (MEPS) is a comprehensive — and candid — medical history. “We do have some motivated applicants who have a full understanding of the restrictions and who may be disingenuous, which poses the possibility of coming into the service with conditions that would be disqualifying,” Nelson told U.S. Medicine. Because many young people with asthma have been able to participate in sports and lead very active lives, prospective recruits may not consider asthma relevant to their ability to serve and, therefore, not necessary to disclose at MEPS. For a significant number, however, asthma creates insurmountable problems once they begin basic training. Between 2007 and 2011, the services released 3,135 individuals during basic training with asthma listed as the reason for their existing-prior-to-service (EPTS) discharges. In 2011, asthma was the No. 1 reason for EPTS discharges in the Army (8.4%), Navy (11%) and Marine Corps (15.5%). More than half of servicemembers discharged for asthma during their first 180 days of service, 52.8%, report concealing the condition during the intake medical examination.3 Other applicants may have undiagnosed asthma. “The gold standard for diagnosis is a medical history with questions that could lead a screener to probe for symptoms that could indicate asthma. A single test doesn’t define it, but if anything in the history leans a screener toward a history of asthma, lung function testing may be ordered,” Nelson said. Tests that may be helpful in diagnosing asthma include spirometry and broncho-provocation with methacholine, histamine or exercise. Occasionally, chest X-rays are performed. While helpful in clarifying the risk of candidates with suspected asthma, testing makes little sense as a general screening mechanism, Nelson observed, because it lacks suitable sensitivity. “We’ve looked at lung function testing for everyone coming in, but the yield is not high enough to be fruitful. We can identify the cohort that will have problems, but we also identify some number of people who will do well in service. It simply isn’t a cost-effective screening strategy.” For now, researchers continue to seek a reliable, inexpensive and sensitive screening test. Exhaled nitric oxide (ENO) testing for ongoing lung inflammation, a marker for active asthma, holds promise as do biomarkers for the disease. In the meantime, improvements in disease identification and management have helped to limit the costs associated with asthmatic recruits. “If you look across the continuum from recruitment to active duty, the highest risk for falling off [as a result of asthma] is during initial training,” Nelson noted. A Navy study found that recruits identified during training as mild asthmatics were far more likely to be discharged than non-asthmatics (38% vs. 5%) during their first six months, but that 72% of those that graduated from recruit training remained on active duty through the study period (up to three years), compared to 83% of non-asthmatics, and 64% had no adverse consequences from asthma during that period.4 “A lot has changed in the last decade within the military regarding both who we let in and our care of active duty personnel with asthma,” Nelson noted. “The stigma and many of the challenges of managing treatment have been removed, so now people are able to treat their conditions without fear of retribution or being singled out. This has enabled patients to manage their own disease, whether developed while on duty or unearthed during service, and achieve more optimal control. As a result, we’ve prevented a lot of acute exacerbations, and the outcomes of those individuals has borne out the strategy extremely well.” 1Martin BL, Engler RJM, Nelson MR, Klote MM, With CM, Krauss M, Asthma and its Implications for Military Recruits in Recruit Medicine. Eds. Lenhart MK, Lounsbury DE, North RB., Office of the Surgeon General, Department of the Army, Washington DC, 2006;89-108. 2Gubata ME, Boivin MR, Cowan DN, et al. Attrition and Morbidity Data for 2012 Accessions. Accession Medical Standards Analysis and Research Activity 2013 Annual Report. Silver Spring, MD: Walter Reed Army Institute of Research, 2013. 3Accession Medical Standards Analysis and Research Activity 2003 Annual Report. Silver Spring, MD: Walter Reed Army Institute of Research, 2003. 4Millikan AM, Niebuhr DW, Brundage M, Powers TE, Krauss MR. Retention of mild asthmatics in the Navy (REMAIN): a low-risk approach to giving mild asthmatics an opportunity for military service. Mil Med. 2008 Apr;173(4):381-7.