Part 1

Peter Clemens MD, Denis FitzGerald MD, Joshua Vayer BA*+

Introduction

Tactical operators on law enforcement special operations teams labor in unique, often harsh surroundings with exposure to many pathogens. Through working in these various environments with diverse groups of people, there is often exposure to and possible transmission of vaccine-preventable disease via contact, airborne droplets or percutaneous exposure to blood or body fluids. In addition, operators may be utilized as first responders in situations to assist with medical care of encountered individuals or their team members in, at times, frenzied environments thus increasing their risk of exposure. With this context in mind, it is important to create a blueprint for basic preventable disease vaccination of the tactical operator.

The Centers for Disease Control and Prevention(CDC) framework of vaccinations for healthcare workers (HCW) provides the minimal initial template that may be examined for application to the law enforcement tactical community.¹ CDC recommendations for administration of vaccines and other immunobiologic agents to HCW can be organized in three categories:

1. Immunization is strongly recommended because of special risk (i.e., Hepatitis B, influenza, measles, mumps, rubella, and varicella);
2. Immunization may be indicated in certain circumstances (i.e. tuberculosis, meningococcal disease, hepatitis A, smallpox, anthrax) but vaccinations are not routinely recommended for these entities;
3. Immunization of all adults is recommended (i.e., tetanus).

Using this format, these recommendations can then be investigated for pertinence to tactical operators in the law enforcement setting. PART 1 presents those immunizations strongly recommended for tactical operators because of special risk. PART 2 identifies the remaining immunizations, some additional considerations and some conclusions regarding vaccination of tactical operators. A detailed bibliography is also included.

Immunization Is Strongly Recommended

Operators take part in dignitary protection details, hostage rescues, barricades, civil disorder situations and other law enforcement activities. All of these involve direct person-to-person contact, but some events place the operator at even higher risk through their possible exposure to blood and body fluids via physical contact with subjects, contaminated missiles used by assailants or accidental exposure (i.e. discarded needles, glass, or other paraphernalia). Operators can be considered at significant risk for acquiring Hepatitis B, influenza, measles, mumps, rubella, and varicella. All of these conditions are vaccine-preventable.

1. Hepatitis B

Hepatitis B virus (HBV) is the causative agent of Hepatitis B. HBV is transmitted when a person who is not immune is exposed to blood or body fluids from an infected person. Occupational exposure is defined as "...skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties."² 

Symptoms of HBV can include loss of appetite, nausea/vomiting, joint pain, jaundice, fatigue and abdominal pain. About 30% of infected persons have no signs or symptoms. 6% of infected adults will develop chronic HBV infection and are thus at risk of chronic liver disease. 15-25% of chronically infected persons die from the disease.⁵ An estimated 100-200 health-care personnel die annually secondary to chronic HBV infection. (CDC, unpublished data)

Most operators are often exposed to contact with blood, blood-contaminated body fluids, or sharps and are at significant risk. For HCW, the risks for percutaneous and permucosal exposures are often highest during the professional training period. This finding can be extrapolated to the new tactical operator who is at risk for exposure during training because of the nature of the training activities. Therefore, vaccination should be completed before or during initial operator training.

Studies demonstrate that, despite the gradual decline of vaccine-induced antibody levels over time, the vaccine continues to prevent clinical disease or detectable HBV infection.³ As such, initial vaccination is thought to provide lifelong immunity. Boosters are not considered necessary, though data is continually being collected by the CDC.

2. Influenza

Influenza (commonly called "the flu") is a contagious respiratory illness caused by multiple influenza viruses. An average of 114,000 people are hospitalized for flu-related complications and 36,000 Americans die each year from complications of flu. Influenza is rarely life threatening in the healthy, active operator, but a flu outbreak can significantly impair the response capability of a tactical team. Some of the complications caused by flu include bacterial pneumonia, dehydration, and worsening of chronic medical conditions. ⁶

Flu symptoms consist of high fever, fatigue, headache, dry cough, sore throat, runny/stuffy nose, and muscle aches. The viruses are spread in respiratory droplets of coughs and sneezes. The viruses also can be spread by fomites (when a person touches respiratory droplets on another person or an object and then touches their own mouth or nose before washing their hands).

The single best way to prevent the flu is to get vaccinated each year before flu season. The most likely strain(s) of the virus for that year are predicted by vaccine manufacturers, and vaccine is prepared prior to the start of the flu season. While the predictions of which strain(s) will predominate during a given season are sometimes inaccurate, vaccination still imparts some protection and should be given. Newer antiviral medications (amantadine, rimantadine, and oseltamivir) are approved and commercially available. Unfortunately they have not been shown to eliminate or "cure" the flu. The medications have been shown to decrease the length of the illness by approximately one day if taken within the first two days of the illness.

Influenza can be considered a public health problem faced by the medical community during peak onset. Operators, unlike HCW, have only a minor role in limiting epidemic spread of influenza. Therefore, the CDC recommendation for mandatory yearly vaccination of HCW cannot be rigidly extrapolated to the tactical community. However, operators are valuable assets and the loss of even one member of a team to illness could be critical to mission timing and success. In addition, operators often find themselves in close quarters contact for long periods of time on their missions, which significantly increases the risk of spreading illness. To reduce such risk, flu vaccinations should be strongly encouraged each year.

3. Measles, Mumps, and Rubella

a. Measles
Measles, also known as Rubeola, is a rare but extremely contagious respiratory disease caused by the measles virus. It is spread from person to person through coughs, sneezes, and contact with fomites. There were 116 cases reported in the United States in 2001, and the disease is much more prevalent outside the country. Globally, over 30 million cases of measles occur annually.

Symptoms include cough, runny/stuffy nose, fatigue, red eyes, rash and a fever up to 105 degrees. Pink or bright red spots that are not itchy usually characterize the measles rash, which begins at the head and then spreads downward. ⁷ At the same time or just before the measles rash, small gray spots can develop in the mouth.

In susceptible adults, measles tends to be more severe than in children. About 3 percent of adults with measles develop symptoms of pneumonia severe enough to require hospital treatment. In one of every 1,000 cases, measles produces encephalitis (brain infection), with risk of seizures, coma and death, as well as long-term risk of mental retardation and epilepsy. In unusual cases, measles also can directly attack the digestive organs (including the liver), the heart muscle or the kidneys. Death from measles complications such as pneumonia or encephalitis occurs in 1-2 of every 1,000 cases. Most healthy operators should be expected to recover completely from measles.

Although birth before 1957 is generally considered acceptable evidence of measles immunity, 27% of all measles cases among HCWs during 1985-1992 occurred in persons born before 1957. (CDC, unpublished data). There is no specific treatment for measles. It can be prevented with the measles vaccine.

b. Mumps
Mumps is caused by infection with the mumps virus. Mumps is spreads from person to person through coughs, sneezes, saliva, as well as fomites. Since introduction of the mumps vaccine, the number of annual cases has decreased to one in 1 million people in the United States.

Symptoms can include fever, headache, sore throat, muscle aches, poor appetite and fatigue.⁸ In about 15-20 percent of patients, mumps does not cause any symptoms. The virus causes pain and swelling of the glands in front of each ear, and can cause inflammation and swelling of the testes or ovaries. Mumps can also cause abdominal pain through inflammation of the pancreas. Most seriously, it can travel to the brain where it may cause inflammation and infection of membranes covering of the brain (meningitis), or the brain itself (encephalitis), although this occurs in less than 1 in 1,000 patients with mumps.

Mumps transmission in medical settings has been reported nationwide. (CDC, unpublished data). There is no cure for mumps and the treatment is generally supportive. Most operators can be expected to recover completely from mumps. In males, there is a small risk of sterility if the infection affects both testicles, but this is unusual. Mumps can be prevented through administration of the mumps vaccine.

c. Rubella
Rubella, also called German measles, is caused by the rubella virus. It is spread from person to person through coughs or sneezes, as well as fomites. Vaccination has decreased the overall risk for rubella transmission in all age groups in the United States by greater than or equal to 95%, but 10%-15% of young adults are still susceptible. During 2000, 87% of all reported cases of rubella occurred among people 15-39 years of age.⁹

Symptoms of rubella may include a rash, slight fever, aching joints, lymph node swelling, headaches, discomfort, runny nose and reddened eyes. Approximately 20-50% of infected individuals may be asymptomatic. The rash first appears on the face and spreads from head to toe. Only about half of the people who have the disease get a rash. If a pregnant woman gets rubella during the first 3 months of pregnancy, her baby has a good chance of having serious birth defects. There is no cure for rubella and treatment is generally supportive. The vaccine to prevent rubella is safe and effective.

d. MMR (Measles, Mumps, Rubella) Vaccine
Operators born in 1957 or later can be considered immune to measles, mumps, or rubella if they have documentation of a) physician-diagnosed measles or mumps disease; or b) laboratory evidence of measles, mumps, or rubella immunity; or c) appropriate record of vaccination against measles, mumps, and rubella (i.e., administration on or after the first birthday of two doses of live measles vaccine separated by greater than or equal to 28 days, at least one dose of live mumps vaccine, and at least one dose of live rubella vaccine).

Although birth before 1957 generally is considered acceptable evidence of measles and rubella immunity, encouragement is given for a single dose of MMR vaccine to unvaccinated operators born before 1957 who are in either of the following categories: a) those who do not have a history of measles disease or laboratory evidence of measles immunity, and b) those who lack laboratory evidence of rubella immunity. Rubella vaccination or laboratory evidence of rubella immunity is particularly important for female HCWs born before 1957 who can become pregnant.¹

4. Varicella

Varicella-zoster virus (VZV) is the causative agent in varicella (chickenpox). VZV is a member of the herpes virus family. Transmission of varicella zoster virus (VZV) is documented via contact and even airborne transmission from persons who had varicella to susceptible persons who had no direct contact. There are about 4 million cases of varicella, mostly in children, occurring annually in the United States. Every year there are approximately 5,000-9,000 hospitalizations and 100 deaths from chickenpox. About 5 percent of the American adult population is susceptible to varicella.¹¹

The rash may be the first sign of illness, sometimes coupled with fever, loss of appetite and general malaise that is usually more severe in adults. The characteristic itchy rash then forms blisters that dry and become scabs in 4-5 days. An infected person may have anywhere from only a few lesions to more than 500 lesions on their body during an attack (average 300-400).

Adults are more likely to have a serious case of chickenpox with a higher rate of complications and death. The complications of varicella are estimated to be 25 times more severe in adults than in children. Complications include bacterial superinfections, encephalitis, pneumonia, and severe birth defects in 2 percent of offspring whose mothers have varicella in pregnancy.

Varicella vaccine is now a part of regularly scheduled childhood vaccination series. The vaccine is also approved for use in all susceptible adults (i.e., no evidence of having had chickenpox in the past). A history of chickenpox is considered adequate evidence of immunity. Operators who do not have a history of varicella or whose history is uncertain can be considered susceptible, or tested to determine their immune status.

Varicella virus vaccine protects approximately 70%-90% of recipients against infection, and 95% of recipients against severe disease for at least 7-10 years after vaccination and probably longer. Boosters are not considered required at this time as significant protection appears long-lasting.

This area will require further study as children now receive childhood varicella vaccination. This creates the possibility of waning individual immune titers, creating an adult population at risk for the more serious complications when exposed to varicella.

Part 2

Peter Clemens MD, Denis FitzGerald MD, Joshua Vayer BA*+

Introduction

In PART 1, a blueprint for basic preventable disease vaccination of the tactical operator was presented. The Centers for Disease Control (CDC) framework for immunization of healthcare workers (HCW) was presented with a focus on its applicability to law enforcement special operations teams. The first category, immunizations strongly recommended because of special risk, was discussed in detail. In PART 2, the remaining two vaccination categories, immunizations indicated in certain circumstances and immunizations recommended for all adults, are reviewed with additional significant considerations for vaccination.

Immunization May Be Indicated

The Advisory Committee on Immunization Practices (ACIP) does not recommend any of the following immunizations as routine for HCWs, and they are not specifically necessary for routine use in tactical operators. These targeted diseases include tuberculosis, hepatitis A, meningococcal disease, anthrax and smallpox. However, immunoprophylaxis for these diseases may be indicated for operators in certain circumstances. These circumstances include, but are not limited to, isolated exposures (tuberculosis/meningitis), community outbreaks or travel to areas where endemic disease exists (hepatitis A), and overt or credible risk of biologic agent exposure (anthrax, smallpox). Of note, many of these diseases can be treated on a post-exposure basis with significantly reduced morbidity and mortality by using appropriate antibiotics. As a result, these immunizations should be provided on a selective basis.

1. Tuberculosis (Bacille-Calmette-Guerin) Vaccination

Tuberculosis (TB) is a disease that is spread from person to person through the air. TB usually affects the lungs, but it can also affect other parts of the body, including the brain, kidneys, and spine. People with TB infection do not initially feel sick and do not have any symptoms. However, they may develop TB disease at some time in the future. The general symptoms of acute TB disease include feeling sick or weak, weight loss, fever, and night sweats. The symptoms of TB of the lungs include coughing, chest pain, and coughing up blood. Other symptoms depend on the part of the body that is affected.¹²

In the United States, Bacille-Calmette-Guerin (BCG) vaccine has not been recommended for general use among HCW as the risk for infection with Mycobacterium tuberculosis is low and the efficacy of BCG vaccine uncertain. The immune response to BCG vaccine also interferes with use of the tuberculin skin test to detect M. tuberculosis exposure. ⁷ In the United States, the tuberculin skin test is used to screen whether a person has been exposed to TB. It is a yearly recommendation for HCWs.

For the reasons of questionable efficacy and need, BCG vaccination is not recommended as routine for most tactical operators. However, secondary to the high percentage of TB in certain populations (i.e. correctional institutions), some operators may find themselves at even higher risk than most HCWs for TB exposure. Yearly tuberculin skin testing would be considered the bare minimum in this setting. BCG vaccination may be considered for the operator whose assignment requires extended work in prison environments or prisoner transfer details.

2. Meningococcal Disease

Meningococcal disease is caused by the Neisseria meningitidis bacteria. It occurs worldwide but devastating epidemics continue to occur mostly in Africa. During 1996-1997, 213,658 cases with 21,830 deaths were reported in West African countries. Fully 10%-15% of cases are fatal. Of patients who recover, 10%-15% have serious health consequences. Transmission generally occurs through direct contact with respiratory secretions from a nasopharyngeal carrier. Symptoms include fever, headache, neck stiffness, rash and sepsis.¹⁵

In rare instances, direct contact with respiratory secretions of infected persons (e.g., during mouth-to-mouth resuscitation) has resulted in transmission from patients with meningococcemia or meningococcal meningitis to HCWs. Post-exposure prophylaxis (antibiotics) is advised for persons who have had intensive, unprotected contact (i.e., without wearing a mask) with infected persons.¹⁶ Antibiotics can eradicate carriage of N. meningitidis and prevent infections in persons who have had such unprotected exposure to patients with meningococcal infections.¹⁷ Consequently, with the exceptions of extended team deployment under close contact situations and deployment to endemic areas, there is no need for routine pre-exposure meningococcal vaccination in the tactical operator.

3. Hepatitis A

Hepatitis A is caused by the Hepatitis A Virus (HAV). During epidemic years, the number of reported cases has reached as many as 35,000. Symptoms include jaundice, fatigue, abdominal pain, loss of appetite, nausea, diarrhea, and fever. Adults will have signs and symptoms more often than children. Unlike the more serious Hepatitis B virus, there is no chronic (long-term) infection with Hepatitis A.

HAV is spread from fecal-oral transmission (person to person by putting something in the mouth that has been contaminated with the stool of a person with hepatitis A, easily occurring with poor handwashing). Operators at increased risk include those whose travel takes them to countries where Hepatitis A is common. Such areas include most of Mexico, Africa, the Middle East and lower Asia. Otherwise, when proper infection control practices are followed, transmission is rare.

Routine pre-exposure Hepatitis A vaccination of tactical operators working domestically in the United States is not required, but strongly recommended. Hepatitis A infection is rarely life threatening to the healthy operator.¹⁴ However, an outbreak of Hepatitis A can be very incapacitating to a tactical team, particularly in deployed or field settings. Routine Hepatitis A vaccination should be administered in those select tactical teams involved with foreign travel or frequent extended operations under field conditions where sanitary conditions may not be optimal. In all situations, sound hygienic practices regarding direct contact with potentially infective materials (e.g., hand washing) should be emphasized, particularly with food preparation and handling during extended operations or public events. Data indicate that the duration of clinical protection conferred by Hepatitis A vaccine is a minimum of 3-4 years, and may last up to 20 years.

4. Anthrax

Anthrax is a disease caused by Bacillus anthracis bacteria. Anthrax usually affects one of three systems: the skin (cutaneous), lungs (inhalation), or digestive (gastrointestinal). Most commonly, humans become infected with anthrax by handling products from infected animals or by breathing in anthrax spores from infected animal products (like wool, for example). More importantly to the tactical community, anthrax also can be used as a weapon. As seen in the United States in 2001, anthrax was deliberately spread through the postal system by sending letters with powder containing the agent. This attack resulted in 22 cases of anthrax infection.¹⁸

The symptoms of anthrax are different depending on the type of the disease. In cutaneous disease, the first symptom is a small sore that develops into a blister. The blister then develops into a skin ulcer with a black area in the center. The sore, blister and ulcer do not hurt. In inhalation, the first symptoms are like cold or flu symptoms and can include sore throat, mild fever and muscle aches. Later symptoms include cough, chest discomfort, shortness of breath, tiredness and muscle aches. Shock and death may result.

In a suspected or confirmed exposure, antibiotics are combined with the anthrax vaccine to prevent anthrax infection. The vaccine is available currently for U.S Armed Forces because of the potential use of anthrax as a weapon. In addition, anyone who may be exposed to anthrax, laboratory workers, and workers who may enter or re-enter contaminated areas, may get the vaccine.¹⁹ 

In the setting of a biological weapon attack involving anthrax, antibiotic stores may be rapidly depleted and operator access to these drugs cannot be assured. Furthermore, mortality will be relatively high in people who do not start antibiotics until after symptoms occur, so early detection of possible exposures is critical, although difficult. In planning for such contingencies, vaccination for anthrax may not be necessary or cost effective for the whole operator community on the local level. However, if the team's duties include response to, or investigation of, a possible bioterror event, then immunization is appropriate. On a regional basis, a select group of individuals in either federal or state and local law enforcement could be selected and vaccinated against anthrax as a designated response team. This approach would help assure appropriate response by protected individuals in case of a biologic threat in that area.

5. Smallpox

Smallpox is caused by the Variola virus. It is very contagious, and often fatal with mortality rates historically up to 30%. Smallpox outbreaks have occurred from time to time for thousands of years, but the disease is now eradicated after a successful worldwide vaccination program. Except for laboratory stockpiles, the variola virus has been eliminated. However, of concern to the tactical community, there is heightened anxiety that the variola virus might be used as an agent of bioterrorism.

Face-to-face contact is required to spread smallpox from one person to another. Smallpox also can be spread through direct contact with infected bodily fluids or fomites. Humans are the only natural hosts of variola. The first symptoms of smallpox include fever, malaise, head and body aches, and sometimes vomiting. The fever is usually high, in the range of 101 to 104 degrees Fahrenheit. At this time, people are usually too sick to carry on their normal activities.

A rash emerges first as small red spots on the tongue and in the mouth. These spots develop into sores that break open and spread large amounts of the virus into the mouth and throat. Around the time the sores in the mouth break down, a macular rash appears on the skin, starting on the face and spreading to the arms and legs and then to the hands and feet. Usually the rash spreads to all parts of the body within 24 hours. By the third day of the rash, the macules and papules become vesicles. By the fourth day, the bumps fill with a thick, opaque fluid and become pustules with a depression in the center. (This is a major distinguishing characteristic of smallpox). ²⁰

Although risk assessment is varied, the potential for smallpox as a weapon of mass destruction is sobering, and the only prevention of smallpox is vaccination. Unlike with anthrax, there is no post-exposure antibiotic treatment available for smallpox. While smallpox vaccine does exist and stockpiles are being expanded, availability is limited, side effects are significant and efficacy remains a question. As with anthrax, routine vaccination for smallpox may not be necessary, cost effective, or worth the vaccination risk for the tactical operator on the local level. However, if the team's duties include response to, or investigation of, a possible bioterror event, then immunization is appropriate, after careful suitability screening by a medical provider, since there are some significant potential side effects of the vaccine. A select group of individuals in either the federal or state system could be selected and vaccinated against smallpox to ensure tactical response capability in the event of an incident. As the vaccine becomes more available and efficacy studies are continued, the recommendation for smallpox vaccination in all tactical operators might then be appropriate.

Immunization of All Adults is Recommended

In the CDC immunization framework, certain immunizations are recommended for all adults regardless of occupation. HCWs are not considered at higher risk than the general adult population for acquiring diphtheria, pneumococcal disease, or tetanus. However, tactical operators can be assumed to be at an increased risk for acquiring tetanus in particular because of the environments where they work. Few tactical officers do not sustain at least one tetanus-prone wound each year.

Tetanus

Tetanus is caused by the bacterium Clostridium tetani. C. tetani spores (the dormant form of the organism) are found in soil and in animal and human feces. Tetanus is an acute, often fatal disease that is characterized by generalized increased rigidity and convulsive spasms of skeletal muscles. During the period 1996-2000, a total of 202 cases were reported in the United States²² with death in about 11% of cases, especially people over age 60.

The spores enter the body through breaks in the skin. Puncture wounds and wounds with a significant amount of tissue injury are more likely to promote infection. The organisms excrete a toxin in the bloodstream. The toxin then reaches the nervous system, causing the classic symptoms. Tetanus may present as painful and often violent muscular contractions, lockjaw, neck stiffness, rigidity of the abdomen and difficulty swallowing. Later symptoms include fever, elevated blood pressure and severe muscle spasms.

Primary vaccination of previously unvaccinated adults consists of three doses of adult tetanus-diphtheria toxoid (Td): 4-6 weeks should separate the first and second doses; the third dose should be administered 6-12 months after the second.²³ After primary vaccination, a tetanus-diphtheria (Td) booster is recommended for all persons routinely every 10 years or every 5 years for high risk, dirty wounds. As the nature of tactical operations provides ample opportunities for breaks in the skin, often via dirty sources, the majority of wounds sustained by operators fall into this latter category. As such, it is recommended that operators have recorded tetanus vaccine boosters every five years to assure immunity.

OTHER CONSIDERATIONS

Immunization Records

Immunization records should be maintained for all operators tracking documented disease and vaccination histories, as well as immunizing agents administered. The record should be carefully updated and maintained by the individual.

Foreign Travel

Operators undertaking missions in foreign countries may be at increased risk for acquiring other diseases for which pre-exposure vaccination may be helpful (e.g. poliomyelitis, Japanese encephalitis, plague, rabies, typhoid, or yellow fever).²⁴ Elevated risks for acquiring these diseases may stem from exposure to patients in first responder setting. The risks may also arise from circumstances unrelated to patient care - such as high endemic presence (rabies) or likely exposure to arthropod disease vectors (yellow fever). During the planning stages of missions abroad, the medical support staff should address such considerations in the Medical Threat Assessment brief to the team specifically tailored to that area of the country. Sources of such information are widely available, for example through the CDC's website recommendations for foreign travelers.²⁵

Administration of Concurrent Vaccines

Situations occasionally arise that require administration of vaccines simultaneously in a short period of time. This approach should not raise concerns in the vast majority of cases about vaccine interaction. The ACIP provides this guidance:²⁷ 

In the absence of specific data indicating interference, following the ACIP general
recommendations for immunization is prudent. Inactivated vaccines do not interfere with the immune response to other inactivated vaccines or to live vaccines. An inactivated vaccine can be administered either simultaneously or at any time before or after LAIV (live attenuated influenza vaccine). Two live vaccines not administered on the same day should be administered >= 4 weeks apart when possible.

Conclusion

Through adaptation of the CDC recommendations for HCWs, a template for vaccination of tactical operators in law enforcement special operations can be formulated. The nature of tactical missions, the occupational environment, and the use of operators as first responders to selected medical events provide a basis for this comparison. In reviewing this vaccination blueprint, all tactical operators should assure immunity to Hepatitis B, Measles, Mumps, Rubella, Varicella, as well a tetanus booster every 5 years. In addition, strong consideration should be given to yearly Influenza vaccination. Vaccination for TB, Meningococcemia, Hepatitis A are not routinely recommended but should be considered in select circumstances. Vaccination for anthrax and smallpox are recommended for specialized groups of individuals who have bioterror response in their specific mission profile. Vaccination for smallpox may become a future recommendation in the tactical community secondary to the increasing risk of bioterrorism and the lack of definitive treatment options. As the tactical operator often works in multiple environments, even outside the country, the Medical Threat Assessment must incorporate recommendations for vaccination tailored to the particular mission.

* The views presented herein are those of the individual authors and do not necessarily reflect the policies or views of the Department of Defense, the US Army, the Uniformed Services University, the Department of Homeland Security or the Federal Protective Service.

+ From the Department of US Department Of Homeland Security, Federal Protective Service, Office of Protective Medicine, 4301 Jones Bridge Road, Bethesda, MD 20814-4799

References

1. Morbidity and Mortality Weekly Report- December 26, 1997 / 46(RR-18);1-42 Centers for Disease Control and Prevention. Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices and the Hospital Infection Control Practices Advisory Committee.
2. Department of Labor. Bloodborne pathogens: the standard. Federal Register 1991;60:64175-82.
3. Hadler SC, Margolis HS. Hepatitis B immunization: vaccine types, efficacy, and indications for immunization. In Remington JS, Swartz MN: Current topics in infectious diseases. Boston: Blackwell Scientific, 1992:282-308.
4. Davis RM, Orenstein WA, Frank Jr, JA, et al. Transmission of measles in medical settings, 1980 through 1984. JAMA 1986;255:1295-8
5. http://www.cdc.gov/ncidod/diseases/hepatitis/b/fact.htm 
6. http://www.cdc.gov/flu/keyfacts.htm 
7. http://www.intelihealth.com/IH/ihtIH/WSIHW000/9339/18658.html 
8. http://www.intelihealth.com/IH/ihtIH/WSIHW000/18664/11194.html 
9. http://www.nfid.org/pdf/factsheets/rubellaadult.pdf 
10. http://www.cdc.gov/od/oc/media/fact/chickenp.htm
11. http://www.nfid.org/_old/factsheets/varicellaadult.html 
12. http://www.cdc.gov/nchstp/tb/pubs/tbfactsheets/250010.htm 
13. CDC. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1996:45(No. RR-15:1-30.
14. http://www.cdc.gov/ncidod/diseases/hepatitis/a/fact.htm 
15. http://www.cdc.gov/ncidod/dbmd/diseaseinfo/meningococcal_t.htm 
16. CDC. Guidelines for infection control in health care personnel, 1997: recommendations of the Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1998.
17. CDC. Control and prevention of meningococcal disease and control and prevention of serogroup C meningococcal disease: evaluation and management of suspected outbreaks: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46(No.RR-5):1-21
18. http://www.bt.cdc.gov/agent/anthrax/needtoknow.asp 
19. http://www.bt.cdc.gov/agent/anthrax/anthrax-hcp-factsheet.asp 
20. http://www.bt.cdc.gov/agent/smallpox/overview/disease-facts.asp 
21. VPD Surveillance Manual, 3 rd Edition, 2002,Chapter 13, Tetanus: 13 - 1 Tippavan Nagachinta, MD, DrPH; Margaret Mary Cortese, MD; Marty H. Roper, MD, MPH; F. Brian Pascual, MPH; Trudy Murphy, MD
22. Bardenheier B, Prevots DR, Khetsuriani N, et al. Tetanus surveillance United States, 1995-1997. Mor Mortal Wkly Rep CDC Surveill Summ. 1998;47:1-13.
23. CDC. Diptheria, tetanus, and pertussis: recommendations for the use and other preventative measures: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1991;40(No. RR-10):1-28
24. CDC. Health information for international travel, 1996-1997. Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention, 1997.
25. http://www.cdc.gov/travel/vaccinat.htm 
26. http://books.nap.edu/books/0309055938/html/9.html: Interactions of Drugs, Biologics, and Chemicals in U.S. Military Forces (1996)
    Institute of Medicine (IOM)
27. http://www.cdc.gov/flu/professionals/vaccination/live.htm (2004)