Recruits, Military Breathe Easier with Relaxed Asthma Accession Standards

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

Recruiters and drill sergeants challenge Fond du Lac, WI, High School students to do as many push-ups as possible within 60 seconds during Pathway to Success, a fitness promotion run by the Milwaukee Recruiting Battalion. The military has changed its rules and now accepts recruits with childhood asthma who have been non-symptomatic since age 13.

Recruiters and drill sergeants challenge Fond du Lac, WI, High School students to do as many push-ups as possible within 60 seconds during Pathway to Success, a fitness promotion run by the Milwaukee Recruiting Battalion. The military has changed its rules and now accepts recruits with childhood asthma who have been non-symptomatic since age 13.

“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.” table6-6 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.

Comments (22)

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  1. Brittney Davis says:

    There are many reasonable dis-qualifiers such as, being a convicted felon, having issues with alcohol abuse, not passing the ASVAB (Armed Services Vocational Aptitude Battery), or not obeying the law. These are completely and respectfully understood. However, Asthma is different from these. A medical history with Asthma past thirteen years of age should not mean disqualification, when it comes to enlisting in the U.S. military. It is equally burdensome as the need of eye glasses. All parts of the body carry out important functions, whether it is internal or external. In case of eyes, they are mandatory for sight. In case of lungs and airways, they are required for breathing. In unfortunate cases where individuals completely do not have the ability to see, disqualification is understood. However, if there were to be only an issue with sight, such as poor vision, it could effortlessly be solved with eye glasses. It takes about 3 to 5 seconds to remove eye glasses from the case and apply them to the eyes. Asthma, too, is a simple condition that can be solved instantly. It takes a pocket-sized inhaler to seize an attack. This process takes an average of 3 to 5 seconds for inhaling a deep breath of treatment. Asthmatics that are truly determined to enlist are aware of their condition. Why should persons with need of eyeglasses be able to enlist after having their glasses past their thirteenth birthday and Asthmatic not be able to join, with their condition pass their thirteenth birthday? It is understood that if there were to be an asthma attack it could make breathing more complex. The military is for physically and mentally strong persons willing to serve their country at any cost. With that in mind, during basic training persons face plenty of complex things. There is being away from home, adjusting to time schedules, getting built physical and mentally and more. How would an individual be described, who has overcome all these barriers and has graduated basic training despite having Asthma? It is true that asthmatics could face difficulty and struggle during basic training. There are an abundance of scenarios that could happen. Individuals that comprehend their risk should be able to enlist. Risking one`s own life and putting the safety of other first is what defines a loyal soldier. The military entrance standard as of now is that a history of Asthma after the thirteenth birthday is disqualifying. The concerns regarding asthmatics are appreciated. However, each individual asthmatic who understands their risk should have the opportunity to enlist. A multitude of people can be placed under the category of being an asthmatic, but we are also different people physically capable of preforming differently.

    • Guy says:

      I completely agree… The Methacholine test is just outright unfair. I’m in the process of enlisting right now as a musician in the AF and that is the only test standing in my way. It’s quite daunting. I know I can perform the physical requirements but they want this foreign chemical inhaled into my lungs instead to test qualify me… And the fact that I already have a job lined up as a musician makes it even more ridiculous. I wish I could be an exception but I know everyone has to jump through their own hoops. I guess if I don’t get in then I can thank myself for being too honest.

    • BD says:

      I don’t agree in part. Each person needs to be deployed. If you are deployed, you rely upon your platoon, squad, boat crew, etc. Each member has a role and is relied upon to do his/her part. Losing glasses could be an issue. Not being able to breath is absolutely an issue. You do not die from losing your glasses. You can die from asthma. If you have not had it, or lived with someone who has, it is hard to understand or provide an accurate accounting. Some have light asthma. Others have medicated asthma and almost can’t function when they have an attack. They need Advair, Albuterol inhalers and a nebulizer. There is just no way, in a critical engagement, this could be allowed to be an issue when it can be prevented. Ride a desk, absolutely. Be the ship engineer, or the drone pilot, sure. But in the dirt, not a chance.

  2. Aaron Sheets says:

    This gives me hope. I have been preparing for the Army for the past four years, and when I found I might be denied, I was heart broken. This helped however, as I have not had nah restricting symptoms past 13 (I am 15). I still however, do not see a problem with asthma victims in the Army, as an inhaler takes about 3 seconds to use, and is a symptom conditioning can overcome. I understand if it may be a threat to your squad mates, but having things such as an all asthma squad would provide a common knowledge of each others conditions and an immediate contingency for scenarios involving asthma with one another.

    • Boy says:

      Having an “all asthma squad” would be a huge liability. I wouldn’t want to be a CDR or PL knowing for some reason I was given a squad of people with a potentially debilitating medical issue. And what happens when that entire SQD goes down nearly simultaneously? Now you have nine people out of the fight.

  3. Girl says:

    There has been comments that someone with asthma will not be able to help their fellow man in battle if they have an attack. I can somewhat see the understanding of that but, it does not make any sense in my opinion. If the soldier has his inhaler on him, he can use it before or during battle. It takes just about 3 seconds tops to use it and the problem is fixed. Now, take a wounded soldier for example. He cannot fix himself, but he would need someone else to help him out. That’s not one man down but two. It also takes much longer to wrap up a wound and get him to safety. These men carry a load of things on them, why can’t one be an inhaler? The logic of this new rule is preposterous and for a branch with a really great medical program, there should be a more reasonable solution. Asthma is not life-threatening if people know how to manage it, and people that enlist clearly know how to manage it if they are considering enlisting into the army or any other branch.

    • Boy says:

      Your argument makes no sense. Wounded soldiers do not enter into the combat zone already wounded. They become wounded. An asthmatic is in effect already wounded. Why would you take someone like that along?

      What happens when you lose that inhaler, run out of medication, drop it while trying to use it, etc.? You now have an SM that needs evac. Even if you successfully use it, you’ve now stopped at best an entire fire team for three seconds. And you can’t control where that three second halt happens. Very likely it’s going to be in a place you need to extricate yourself from quickly.

      Lastly, why do asthmatics need to enlist? The military is meeting their end-strength without them. Why increase liability and decrease safety and mission effectiveness with no gain?

      • Cadet says:

        Some people asthma is so little they literally only have symptoms when there sick as long as they take a pill in the morning don’t even need and pump. It’s person by person situation. They need to enlist same reasons any one else would. Some people have no other options or goals in life but army . Just like if glasses pop off some ones face and can’t see things happen not everything is planned you need to be prepared for anything

      • Zach says:

        Dude, chill. These people have been carrying their inhalers for their entire lives, they know how use them effectively. They know how to preserve medication, be frugal about when to use it at all, and how to use it without stopping what they’re doing for more than 5 seconds or so and not stop anyone around them at all. Comparing this to corrective lenses is an excellent analogy, as it causes a comparable amount of inconvenience and is just as easy to correct.

    • BD says:

      If you use an inhaler, you know that sometimes this is not enough. If you do not know this is sometimes not enough, you don’t have enough experience with all the symptoms that asthma presents. So where do you draw the line. And how do you prevent Captain America from lying to cross that line?

  4. dylan says:

    One of the big reasons is more of a liability thing to the military. I understand the glasses thing and whatnot but for example say you are out in the field and you get gassed, obviously you have to put your gas mask on and what happens if you have an attack while youve got your mask on as you are not allowed to take it off you very well could die because you cant use your inhaler. yes its an extreme example but MEPS has to look at all of the possibilities. now don’t get me wrong i had asthma back before i was 12 and im having a little bit of trouble getting into the ANG because of it but its just all in the case of life protection.

    • Mike says:

      You could fill volumes with what if’s. What if the tent burned down with my bee sting kit in it and I was stung. What if I put my mask on without my inserts and still had to shoot. My eyesight is bad enough that I might not be able to distinguish friend or foe. If a kid can pass a PT test without having to stop for his inhailer, let him in.

  5. Aaron says:

    Why not make exceptions for non-combat roles, support roles, people who are not on the front lines but they still want to serve their country. Support your fellow soldier whether you are in intelligence, communication, mechanic or a scientist.

    • proudmom says:

      I could not agree more! Our son wants to follow in the family tradition but realizes there is no point in even applying for a support role. His asthma is well-controlled with medication. I just think it is so unfair!

  6. Michael says:

    I was in the USMC and during my recruit training I had a fall and broke my arm. After that during my medical screenings and rehab they found I had asthma. I had not had a symptom in over 10 years. I was tested and promptly discharged from service. Since then I work in a high paced emergency management system as a paramedic, I have completed multiple mud runs including the Spartan race and the Tough Mudder, I swim, I work out, and I have never needed my inhaler.

    I agree that combat situations would be risky with an asthmatic, however support roles should be completed open to people with asthma. There is nothing stopping a person from working at a desk, in a hospital, in a machine shop, etc that has a condition of asthma. I dream of this becoming reality so I can reenter the military service however after the next two years I will be out of the age range.

  7. Nurseamy says:

    have an active son who has a strong desire to follow in his family’s military history. He has always been responsible with his asthma condition. When dx at 2.5yrs, the specialist said he would grow out of it with good care. Because of my proactive training and education, I have insisted on keeping inhaler on hand to be responsible as a member in society. It is less costly to society if my son has 1 rx every year for a just incase moment! He was taught to swim to expand his lungs, which also included competition to hold his breath. He was taught to drink water to keep his lungs well hydrated, it worked! He decided to attempt joining the Navy. (My dad sitting across me as I type this is 92 years old, he is a veteran of WWII and Korean Conflict as a Navy Pilot. My mother passed away 3 years ago, she served as a Navy Nurse. Both instilled a great commitment in our family to our nation and to be responsible. I am post heart surgery and was found fit for duty and hence served in the Navy as a CTO. My son’s father also served in the Navy during Desert Storm. Now because I/we have instilled in my son to be a responsible honest citizen in society. He is not eligible.) My son passed his PFT, my son has very little body fat, my son can run non-stop on the soccer field since the age of 4 and still runs 4 miles+ without getting winded (no inhaler needed), my son would hold his own against anyone physically and mentally…but he is not even worthy to have an actual physical at MEPS or a viable true review of his records or his jacket. Get real!!! As we see more children dx with this illness, I find the lack of a true viable medical review as an embarrassment from the service my father, mother, and myself served…AN EMBARRASSMENT! Thankful for this article/blog!

  8. RetiredAndAsthmatic says:

    One of the points that people forget is that every asthma attack, in and of itself, could be fatal. The fact that most people in the modern world do not die with constant medications is laudable and a credit to our system. Combat and combat conditions are not a joke. Sure it only takes 3 seconds to use an inhaler (if you didn’t run out due to a supply issue where you were stationed) but that isn’t the point. The “What If” scenarios are exactly why we have medical disqualifications. What if we are tear gassed during a mission? What if we are in a firefight and a factory catches on fire? What if we are in the desert and have bad air?

    The exclusion for asthma makes sense. The exclusion for support roles is an interesting idea and I would support it but it would have to be for non-deployable support roles only. No asthma down range. The risks to soldier and unit if something happens are just too high.

  9. Paul says:

    While I have been asthmatic since I was two, I am now 36 and still regularly suffer from symptoms. I would have gladly enlisted and followed in family footsteps even if it were for a support role in intelligence or motor pool or any other area that I was qualified. Unfortunately it is not how things are and because of something that I did not have a choice in having and was not able to enter.
    I agree with the corrective lenses analogy. What good is somebody in the battlefield that stumbles and loses their corrective lenses or glasses how are they going to see to do anything? An important detail that is being forgotten at least in my situation is what someone may lack in a physical nature more often than not make up for it the intelligence and mental areas. No war or battle is fought with people just charging in on foot with a weapon. There is intelligence collecting, planning structuring, routing and the people that do those things and behind-the-scenes people that rarely the ones on the battlefield front line.

  10. Queen Gina says:

    My son, Justin, graduated HS yesterday and he’s very motivated to follow his older brother’s footsteps and join the Navy. He met with the recruiter to complete his application, disclosed that he was diagnosed with asthma when he was 4-5 and did well on the pretest ASVAB. He was told to complete a pulmonary function test which he did and passed. I also got recommendations letters from the specialist, primary care pediatrician, and his coaches. My son was the captain for both Vollyball and Waterpolo team for PVHS and not even once had to use the inhaler in the last 4-5 years. We’re going to meet with the recruiter next week and praying that Justin is able to move forward with the application process, take ASVAB, complete physical, go to MEPS for job rating and later, swear in. Any recommendations to speed up the process will be greatly appreciated.

  11. USN MC Pulmonologist says:

    Justin should be fine. Childhood asthma that has resolved – with no sx and requiring no meds for at least three years should not be a problem. Normal PFTs are helpful.

    However;
    In general, even mild asthma is and should be a no-go for any military job. No one is going to accept a recruit with the caveat that he or she will not be deployable. Although most civilian asthma is easily controlled by compliance with inhaled medication, service members who are obligated to go into harms way often are exposed to a variety of asthma triggers that they won’t be able to protect themselves from. (Think burn pits, diesel fumes, dust-storms, jungles, MOPP gear, firefighting.) For exercise induced asthma, unlike taking a puff of albuterol 10-15 minutes before a track meet (onset of action is NOT instantaneous), the demands on service members can be immediate and unpredictable. If a Soldier, Sailor, Airman, or Marine suffers a significant exacerbation of asthma in theater, the impairment of mission from their loss and the resources expended in potential evacuation/treatment are unacceptable – particularly if a non-asthmatic recruit could have been selected just as easily.

    • RoRo says:

      Please you guys keep fighting. People are being diagnosed with asthma that never had an attack and no testing being done. Doctors hate to say there colleague was wrong. If a doctor say you have asthma asked then to show you the test that was done. My child passed the methocholine test and the PFT. Stayed on a threadmill in excess of the required time without any problems and then being told the test wasn’t definitive. Are you kidding.

  12. Lisa5433 says:

    I’m a Nurse and would like to help our service members who are injured abroad and at home. I would like to join the Nurse Corps, but have Asthma. I don’t want to do combat. I want to help treat those who are in combat or back in the states recovering from combat. I feel like my risk for an Asthma Exacerbation is minimal if I am not in a combat environment. I have so much respect for our military and the people who risk their lives to keep us safe. I just wish I could use my nursing skills to help

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