Immunization and Chemoprophylaxis
Given an order to deploy, ensure proper immunization and chemoprophylaxis IAW AR 40-562
Immunizations are administered to protect and maintain the health of the individual soldier and the population in which he lives and works. Control or elimination of disease through an effective immunization program is essential to mission accomplishment. As a medical specialist, you will have a major impact on maintaining the readiness of soldiers by maintaining immunization records and insuring all soldiers receive their immunizations.
a. All active duty personnel are subject to immunizations
b. Specific requirements
(1) Anthrax - not being administered at present
(a) Dosage schedule
1) Full immunity requires six doses. Annual boosters are required.
2) Doses of the vaccine should not be administered on a compressed or accelerated schedule (for example, shorter intervals between doses or more doses than required)
(b) Medical exemptions can only be granted by a medical officer (MD/PA)
(c) Adverse events
1) Localized injection site reactions-redness, pain
2) Serious adverse reactions are rare
(2) Cholera
(a) Cholera vaccine is not administered routinely
(b) Only administered to military personnel, upon travel or deployment to countries requiring cholera vaccination as a condition for entry
(c) Adverse events
1) Pain at injection site, mild systemic complaints, and temperature > 100.4
2) Local reaction may be accompanied by fever, malaise, and headache
3) Serious reactions, including neurologic reactions, after cholera vaccination are extremely rare
(3) Hepatitis A
(a) Use Hepatitis A vaccine and Immune Globulin (IG) according to Army Command Immunization Program (ACIP) and Service - specific guidance
(b) Dosage schedule
1) 1st dose should be given at least 4 weeks prior to deployment
2) 2nd dose given 6-12 months after initial dose
(c) Adverse events - Rare
(4) Hepatitis B
(a) Given to health care workers and soldiers PCSing to Korea
(b) Dosage schedule
1) Series of 3 injections
2) 2nd injection given 30 days after 1st shot
3) 3rd injection given 6 months after 1st shot
(c) Adverse events - Pain at injection site, mild systemic complaints, and temperature > 100.4
(5) Influenza
(a) All active duty and reserve military personnel entering active duty for periods in excess of 30 days are immunized against influenza soon after entry on active duty
(b) The vaccine is provided to all military personnel and others considered to be at high risk for influenza infection
(c) Adverse events - Local reactions, fever/malaise (common) severe allergic reactions (egg allergies), and neurological reactions (rare)
(6) Japanese B Encephalitis (JE)
(a) Specific guidance on indication for use and schedule of immunization in military populations is provided by the each service
(b) Adverse events - Fever, headache, myalgias, malaise (common). General urticaria, angioedema, respiratory distress, and anaphylaxis (rare).
(7) Measles, Mumps, and Rubella (MMR)
(a) Measles and rubella are administered to all recruits regardless of prior history
(b) Mumps or MMR vaccine is administered to persons considered to be mumps susceptible. Written documentation of physician diagnosed mumps or a documented history of prior receipt of live virus mumps vaccine or MMR vaccine is adequate evidence of immunity.
(c) Adverse events - Low grade fever, parotitis, rash, pruritis (mild), deafness (rare)
(8) Meningococcus
(a) Meningococcal vaccine is administered on a one-time basis to recruits
(b) Adverse events-rare
(9) Plague
(a) There are no requirements for routine immunization. Plague vaccine is administered to soldiers who are likely to be assigned to areas where the risk of endemic transmission or other exposure is high.
(b) The addition of antibiotic prophylaxis is recommended for such situations
(c) Adverse events - General malaise, headache, fever, mild lymphadenopathy, and/or erythema, and induration at the injection site
(d) Not currently available
(10) Polio
(a) A single dose of trivalent OPV is administered to all enlisted recruits. Officer candidates, ROTC cadets, and other Reserve Components on initial active duty for training receive a single dose of OPV unless prior booster immunization as an adult is documented.
(b) Booster doses of OPV are not routinely administered
(c) Adverse events
Paralytic poliomyelitis - more likely in immunodeficient persons, no procedure available for identifying persons at risk of paralytic disease (rare)
(d) OPV currently being phased out and being replaced with IPV
(11) Rabies
(a) Preexposure Series. Rabies vaccine is administered to personnel with a high risk of exposure (animal handlers; certain laboratory, field, and security personnel; and personnel frequently exposed to potentially rabid animals in a nonoccupational or recreational setting).
(b) Postexposure Series. Rabies vaccine and rabies immune globulin (RIG) administration will be coordinated with appropriate medical authorities following current ACIP recommendations.
(c) Adverse events - Anaphylaxis (rare)
(12) Smallpox
(a) This vaccine is administered only under the authority of the Immunization Program for Biological Warfare Defense
(b) Adverse events - Person can become infected with the smallpox virus
(13) Tetanus-Diphtheria
(a) A primary series of tetanus-diphtheria (Td) toxoid is initiated for all recruits lacking a reliable history of prior immunization. Individuals with previous history of Td immunization receive a booster dose upon entry to active duty and every 5-10 years thereafter.
(b) Adverse events
1) Local reactions (erythema, induration)
2) Nodule at injection site
3) Fever and systemic symptoms uncommon
(c) A current hold on boosters for adults due to shortage
(14) Typhoid
(a) Typhoid vaccine is administered to alert forces and personnel deploying to endemic areas. Either oral or intramuscular vaccine is used.
(b) Adverse events
1) Local reactions maybe accompanied by fever, malaise, and headache (common)
2) Nausea
3) Abdominal cramps
4) Vomiting
5) Skin rash
6) Urticaria
(c) 1st Shot of for Typhoid is .5ml is good for 2 years
(d) Pills, 4 caps-one each day for 4 days- good for 5 years, no longer available in
U.S.
(15) Yellow Fever
(a) Yellow fever immunization is required for all alert forces, active duty personnel or Reserve Components traveling to yellow fever endemic areas
(b) Adverse events
1) Mild headache, myalgia, low grade fever, other minor symptoms
2) Immediate hypersensitivity reactions: rash, urticaria, and asthma. Uncommon and occur periodically among people with a history of egg allergies.
a. Chemoprophylactic requirements - Command medical officers review indications for use and potential adverse effects of specific hemoprophylactic medications prior to use. Current ACIP (Advisory Committee on Immunization Practices) or control of communicable disease manual recommendations and consultation with the relevant preventive medicine authority are followed for the use of chemoprophylactic agents for the following diseases which have historically been shown to be of military significance
(1) Influenza
(2) Meningococcal disease
(3) Leptospirosis
(4) Plague
(5) Scrub typhus
(6) Traveler's diarrhea
b. Malaria - Comprehensive malaria prevention counseling includes mosquito avoidance and personal protective measures (clothing, repellents, bednetting, etc.). Chemoprophylaxis is provided to military and civilian personnel considered to be at risk of contracting malaria. Specific chemoprophylactic regimens are determined by each of the services based on degree and length of exposure and the prevalence of drug resistance strains of Plasmodia in the area(s) of travel.
c. Group A streptococcal disease - Each service develops policies for surveillance and prophylaxis of streptococcal disease at recruit centers
a. Medical record screening
(1) What immunizations are required for this individual?
(a) Routine immunizations are identified in AR 40-562 and local policy
(b) Additional requirements specific for deployment
1) Based on disease prevalence in specific geographic regions
2) Determined by Preventive Medicine using Federal, Department of Defense, and other relevant sources of information
(2) Current immunization status
(a) What has been given?
(b) When?
(c) Initial series completed?
NOTE: If a series has been started, and the time since the last dose is greater than the recommended interval for administration of the next dose, DO NOT RESTART THE SERIES; give the next dose and inform the patient when he must return for the remainder of the series, if additional doses are required.
(d) Are boosters current?
(3) What immunizations are needed, if any, to meet current update/deployment requirements?
(4) Does the medical record reflect any contraindications for immunization?
b. Patient screening
(1) It is YOUR responsibility to ask the patient about allergies, pregnancy, or current illness BEFORE administering the vaccine
(2) Refer patients with any risk factors to the medical officer for disposition
a. Vaccine handling
(1) Pre-immunization
(a) Check expiration date/time
CAUTION: Yellow fever vaccine must be used within one hour after reconstitution. Any yellow fever vaccine not used within this time must be discarded.
(b) Evaluate for potential mishandling or contamination
1) Proper storage temperature
a) Refrigerated vaccines - 35.6 to 46.4o F
b) Frozen vaccines - 0 to 50 F or as directed by manufacturer.
2) Evidence of bacterial growth
3) Color change/clarity of solution
NOTE: Vaccines that are expired or show signs of contamination or mishandling will be discarded IAW local SOP.
NOTE: Some facilities authorize pre-drawing of vaccines to prepare for mass immunization. It is advisable NOT to pre-draw immunizations more than four hours before administration due to risk of bacterial growth and settling out of particles in the vaccine while in the syringe. If pre-drawing is allowed, make sure filled syringes are stored within the proper temperature requirements for the specific vaccine.
(2) Post-immunization
(a) Store partially used vials at proper temperature
CAUTION: Vaccines must be maintained at required temperature, even in a field environment.
(b) All live virus vaccine containers should be handled as infectious waste and disposed in biohazard containers to be burned, boiled, or autoclaved, follow local SOP.
b. Administrative procedures
(1) Pre-immunization
(a) Screen medical record
(b) Select correct equipment (needles and syringes) for immunizations to be administered
(c) Document vaccine lot number and other identifying information as required by local SOP
(2) Post-immunization
(a) Document all vaccines given in patient medical record (SF 601) IAW local SOP
(b) Record immunizations in individual shot record (PHS 731)
(c) Record any reactions or side effects
c. Patient care procedures
(1) Pre-immunization
(a) Ask about contraindications for immunization (allergies, pregnancy, illness etc.)
(b) Implement appropriate infection control procedures
(c) Explain procedure to patient
(d) Position patient and administer required immunizations
(2) Post-immunization
(a) Inform patient when he is to return for next injection in series/booster
(b) Instruct patient to wait in facility for observation for 20 minutes (or IAW local SOP)
(c) Assure patient is evaluated during and at end of designated waiting period for signs of an adverse reaction
a. Vaccine components can cause allergic reactions in some recipients
b. Prior to the administration of any immunizing agents, determine if the individual has previously shown any adverse reactions to a specific agent or vaccine component
c. Vaccine components that can cause reactions include:
(1) Vaccine antigen (a substance that causes the formation of an antibody)
(2) Animal proteins
(3) Antibiotics (e.g., penicillin or penicillin derivatives)
(4) Preservatives (e.g., thimerosal, a mercurial compound)
(5) Stabilizers
d. The most common animal protein allergen is egg protein
CAUTION: Known pregnancy is a contraindication for all live virus vaccines.
NOTE: If a live virus vaccine is administered, counsel the individual to avoid becoming pregnant for three months and document in the health record.
e. Vaccination during pregnancy
(1) Ideally, all immunizations should precede pregnancy.
(2) Live virus vaccines are contraindicated (yellow fever, MMR, OPV)
(3) Refer pregnant soldiers to medical officer for disposition.
(4) Breast-feeding
(a) Refer soldier to the medical officer (MD, PA) for disposition
f. Vaccination with significant illness
(1) Persons should not be vaccinated if they have moderate or severe febrile illness (usually 101o F or higher, per local SOP)
(2) Persons should be vaccinated as soon as they recover from the acute phase of the illness
(3) Minor illnesses, such as diarrhea, mild upper-respiratory infection with or without low-grade fever, or other low-grade febrile illness are not contraindicated to vaccination
g. HIV positive status - due to compromised immune system, vaccines should not be administered to any patient who has tested positive for HIV, unless specifically ordered by the attending physician with knowledge of the diagnosis (See C191W039, Treat Infectious Diseases and ImmunologicalSymptoms)
h. Current use of steroids or anti-cancer drugs
I. Multiple vaccines
(1) Contraindicated combinations/cautions
(a) Do not administer cholera, plague, and/or typhoid vaccines together unless deploying immediately
(b) Multiple live virus vaccines may be given the same day. IF THEY ARE NOT GIVEN THE SAME DAY, they must be separated by 30 days. Live virus vaccines are: oral polio, yellow fever, measles, mumps, rubella, and adenovirus.
(c) Gamma globulin (immune serum globulin) and MMR must be given at least 14 days apart; if closer together, MMR may be partially or completely ineffective in protecting against disease.If closer administration is unavoidable, MMR must be repeated after three months. Gamma globulin administration does not reduce effectiveness of inactivated vaccines.
(d) A PPD TB test and live vaccines may be given the same day. IF NOT GIVEN THE SAME DAY, the TB test must be deferred for 6 weeks after the live vaccine is given, to prevent a false negative result from the TB test.
(2) No more than one vaccine should be administered in any one anatomical site.
CAUTION: If the soldier is receiving immediate predeployment immunizations, local policy may authorize administration of a greater number of vaccines than routinely permitted, or combinations of vaccines that create increased risk of undesirable side effects. This should be the EXCEPTION, however, and not simply done for convenience.
a. DHHS Form PHS 731 is prepared for each member of the Armed Forces and for nonmilitary personnel.
(1) Valid certificates of immunization for international travel and quarantine purposes.
(2) Remains in the custody of the individual who is responsible for its safekeeping and for keeping it in his or her possession when performing international travel.
(3) Entries based on prior official records have the following statement added - "Transcribed from official U.S. Department of Defense records."
(4) Obtained through normal publication supply channels. The DOD immunization stamp is available through medical supply channels.
b. National vaccine injury compensation program
(1) Information is recorded on PHS Form 731, medical record and on the clinic log or equivalent computer data base. Information includes, name, sponsor's SSN, date of administration, type of vaccine, manufacturer, lot number, and the name, address, and title of person administering the vaccine.
(2) In addition, all health care providers who administer any vaccine containing diphtheria, tetanus, pertussis, measles, mumps, rubella, or polio to either children or adults must provide a copy of the most recent relevant vaccine information materials provided by the DHHS
c. Issuance of DHHS Form PHS 731 to Military Personnel
(1) At the time of initial immunization of a person entering military services, DHHS Form PH 731 and SF 601, Health Records-Immunization Records, are initiated as outlined below. Written statements from civilian physicians attesting to immunization with approved vaccines, and providing dates and dosages, are accepted as evidence of immunization. Such information is transcribed to official records. Immunizations are recorded on the cited forms, and the forms are maintained as follows.
(2) Army, Navy, and Marine Corps. SF 601 is prepared in accordance with AR 40-66, Medical Records and Quality Assurance Administration, And Chapter 16, NAVMED P-107, Manual of the Medical Department, U.S. Navy. When prepared, SF 601 and DHHS Form 731 contain the SSN as identifying data
d. Issuance of DHHS Form PHS 731 to Nonmilitary Personnel - At the time of initial immunization of nonmilitary personnel, entries are made on DHHS Form PHS 731, which is retained by the individual. All subsequent immunizations are recorded on this form which can be presented as an official record of immunizations received. In addition to DHHS Form PHS 731, SF 601 (Army, Navy and Marine Corps) or SF 600 (Air Force) is prepared and permanently maintained for each individual. Individuals preparing the DHHS Form PHS 731 and SF 601(600) ensure appropriate entries are recorded on both forms and both forms are current and agree with one another.
SUMMARY
Administration of immunizations to active duty soldiers is a responsibility you may often be given during your career as a medic. It can become so routine that you may forget that a severe, life-threatening reaction can occur, EVEN IF YOU DO EVERYTHING RIGHT. Don’t take this responsibility lightly. Cutting corners because it’s easier or to save time is tempting, especially when you have a lot of immunizations to give. The result of taking short-cuts can range from a slightly uncomfortable local reaction to infection with a preventable disease, or even death of the patient. Anaphylaxis or fetal deformity resulting from improper medication administration are unacceptable risks of failure to follow correct procedures. Make sure that you always follow the steps outlined in this class and you will assure the best care for a fellow soldier and other health care beneficiaries.