2

Current Prophylactic Agents

In the course of a career in the military, personnel are exposed to a variety of biologics, drugs, and chemicals. These include vaccines to stimulate immunologic protection against natural and biological warfare infectious disease threats, chemoprophylactic drugs against infectious diseases and chemical warfare agents, and skin repellents or uniform-impregnating agents for protection against insect vectors. Troops are also exposed occupationally to myriad environmental agents. In addition, individuals will inevitably be using a variety of prescribed and over-the-counter medications. The remainder of this chapter describes military use of preventive or prophylactic agents, those subject to direct military decision-making and provision.

The list of vaccines and other prophylactic agents used by the military is constantly changing. As new agents become available, their efficacies are determined and evidence of their disease risk is established. Preventive medicine guidelines used by the military, including medical guidelines for travel, are similar to those developed for the civilian sector (such as the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices), with modifications dictated by the peculiarities of the military environment. The military depends heavily on a group of civilian medical consultants, the Armed Forces Epidemiological Board, which has been advising the medical leadership of the U.S. Department of Defense (DoD) since World War II.



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Interactions of Drugs, Biologics, and Chemicals in U.S. Military Forces 2 Current Prophylactic Agents In the course of a career in the military, personnel are exposed to a variety of biologics, drugs, and chemicals. These include vaccines to stimulate immunologic protection against natural and biological warfare infectious disease threats, chemoprophylactic drugs against infectious diseases and chemical warfare agents, and skin repellents or uniform-impregnating agents for protection against insect vectors. Troops are also exposed occupationally to myriad environmental agents. In addition, individuals will inevitably be using a variety of prescribed and over-the-counter medications. The remainder of this chapter describes military use of preventive or prophylactic agents, those subject to direct military decision-making and provision. The list of vaccines and other prophylactic agents used by the military is constantly changing. As new agents become available, their efficacies are determined and evidence of their disease risk is established. Preventive medicine guidelines used by the military, including medical guidelines for travel, are similar to those developed for the civilian sector (such as the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices), with modifications dictated by the peculiarities of the military environment. The military depends heavily on a group of civilian medical consultants, the Armed Forces Epidemiological Board, which has been advising the medical leadership of the U.S. Department of Defense (DoD) since World War II.

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Interactions of Drugs, Biologics, and Chemicals in U.S. Military Forces BASIC PREVENTIVE SERIES In general, military recruits currently receive the following on entering active duty: poliovirus vaccine, live oral trivalent type 1, 2, and 3; measles and rubella virus vaccine live or measles, mumps, and rubella virus vaccine live; meningococcal polysaccharide vaccine (groups A, C, Y, and W-135); tetanus and diphtheria toxoids (adult), which they receive every 10 years thereafter; influenza virus vaccine, which they receive yearly thereafter; penicillin G benzathine (Bicillin) (or erythromycin for penicillin-sensitive individuals) for prophylaxis for streptococcal disease during training at several basic training camps. Some differences in policy exist between services because of different disease experiences or because of different operational requirements (Table 2-1). For example, adenovirus vaccine is given to all male Army, Navy, and Marine recruits, but it is not given to Air Force or Coast Guard recruits, because it is not considered a serious threat in the Air Force or Coast Guard. Similarly, because early overseas deployment is highly likely for Navy and Marine Corps personnel, they are given typhoid vaccine and yellow fever vaccine during recruit training and every 3 years and 10 years thereafter, respectively. Because of occupational exposure, hepatitis B virus, varicella-zoster virus, plague, or rabies virus vaccines may be added for selected individuals. Reserve component personnel usually receive oral poliovirus vaccine, diphtheria-tetanus toxoid, and influenza virus vaccines. AGENTS USED DURING DEPLOYMENTS The list of agents added to the routine preventive series described above is dependent on the deployment scenario: the climate, the state of socioeconomic development of the nation(s) to which troops will be deployed, the known or suspected natural disease threats, and the existence of biological or chemical warfare agents. The members of some alert units (ready to be deployed) receive a number of the vaccines listed below to maintain immunity, because they are at continuous risk of rapid deployment to areas of increased disease threat. The following list, which is not necessarily exhaustive, represents examples of some agents currently used (including investigational new drugs [INDs]).

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Interactions of Drugs, Biologics, and Chemicals in U.S. Military Forces Temperate Climate, Developing Country hepatitis A virus vaccine or immune globulin, hepatitis B virus vaccine (normally only Army in the Republic of Korea), typhoid vaccine (injectable or oral), tick-borne encephalitis vaccine if local threat exists (IND), and self-treatment for traveler's diarrhea, which may be prescribed (ciprofloxacin, loperamide). Tropical Climate, Developing Country hepatitis A vaccine or immune globulin, typhoid vaccine (injectable or oral), yellow fever vaccine, every 10 years, meningococcal polysaccharide vaccine (groups A, C, Y, and W-135), every 5 years, Japanese encephalitis vaccine, rabies virus vaccine (generally only Special Forces receive preexposure prophylaxis), plague vaccine (Vietnam only), mefloquine, doxycycline, or chloroquine (malaria), primaquine (relapsing malaria), doxycycline for leptospirosis or scrub typhus prophylaxis, and self-treatment for traveler's diarrhea, which may be prescribed (ciprofloxacin, loperamide). Injectable cholera vaccine is available to the military, but it is given exclusively to those personnel going to countries whose health authorities require cholera immunization for entry. See section below on IND vaccines for comments on oral cholera vaccine. Desert Climate, Developing Country hepatitis A virus vaccine or immune globulin, typhoid vaccine (injectable or oral), meningococcal polysaccharide vaccine (groups A, C, Y, W1-35), every 5 years, self-treatment for traveler's diarrhea, which may be prescribed (ciprofloxacin, loperamide), mefloquine, doxycycline, or chloroquine in oasis and riverine areas, and primaquine in oasis and riverine areas.

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Interactions of Drugs, Biologics, and Chemicals in U.S. Military Forces Some Potential Responses to Biological Warfare Threat anthrax vaccine adsorbed, ciprofloxacin self-medication (for anthrax), smallpox vaccine, plague vaccine, tularemia vaccine (IND), and botulinin toxoid (IND). Potential Response to Chemical Warfare Threat Pyridostigmine bromide (IND): 30-mg tablets are taken daily every 8 hours for a maximum of 14 days. Service members start or discontinue use on order from the commander when nerve agents, particularly soman (GD), are a threat. Agents Used in Climates Where Tick-Borne Diseases Have Been Identified DEET skin repellent and permethrin uniform impregnant.

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Interactions of Drugs, Biologics, and Chemicals in U.S. Military Forces TABLE 2-1 Vaccinations for Military Personnel Immunizing Agent Army Navy Air Force Marine Corps Coast Guard Adenovirus type 4 and 7 vaccines B B G B G Cholera vaccine E E E E E Hepatitis A virus vaccine G G C, D G G Hepatitis B virus vaccine F, G F, G F, G F, G F, G Influenza virus vaccine A, B, X A, B, R, A, B, R A, B, R B, C, G Japanese encephalitis virus vaccine D D D D G Measles virus vaccine B, F B, F B, F B, F B, G Meningococcal vaccine (groups A,C,Y, and W-135) B, D B, D B, D B, D B, G Mumps virus vaccine F, G B, F, G F, G B, F, G G Oral poliovirus vaccine B, D, R B, R B, R B, R A Plague vaccine D, F F F F F Rabies virus vaccine F F F F G Rubella vaccine B, F B, F B, F B, F B Tetanus-diphtheria toxoid A, B, R A, B, R A, B, R A, B, R A, B Typhoid vaccine C, D C, D C, D C, D D Varicella-zoster virus vaccine F, G F, G F, G G F, G Yellow fever vaccine C, D A, R C, D A, R B, C, E NOTE: A = all active-duty personnel; B = recruits; C = alert forces; D = when deploying or traveling to high-risk areas; E = only when required by host country for entry; F = high-risk occupational groups; G = as directed by applicable Surgeon General or Commandant, Coast Guard; R = reserve components; and X = reserve component personnel on active duty for 30 days or more during the influenza season. SOURCE: U.S. Army Regulation 40-562, November 1, 1995.