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An individual's resistance to a specific disease or infection depends upon the presence in the body of protective chemical substances called antibodies. When the body produces its own antibodies, it is termed active immunity. Active immunity results from having an infectious disease or from receiving an injection or inoculation of biological medication that induces an immune response. Active immunity may develop in days or weeks, but the protection received will last for relatively long periods. Another type of immunity, described as passive, is acquired. This immunity results from the body receiving serum that contains antibodies that have been preformed in humans or animals. Although this serum confers immediate protection, the immunity does not last as long. Passive immunity does not stimulate antibody formation.
Preparations administered to produce immunity are called immunizing agents. They are known as vaccines, toxoids, and antiserums. Both vaccines and toxoids cause the body to produce their own antibodies (bringing about active immunity), while antiserums produce passive immunity.
a. Vaccines. Vaccines contain either weakened or killed microorganisms (such as viruses, bacteria, or rickettsia) that are administered for the prevention, improvement, or treatment of infectious diseases. Examples are typhoid, measles, poliomyelitis, and smallpox vaccines.
b. Toxoids. Toxoids contain suspensions of modified toxins that have lost their toxicity but which have maintained the properties of combining with antitoxins, or stimulating the formation of antitoxins. Examples are diphtheria and tetanus toxoids.
c. Antiserums. Antiserums are preparations of blood serum that already contain an antibody or antibodies. They are used when there is not time to wait for the body of the exposed or infected person to produce its own antibodies. Examples are tetanus, immune globulin, and rabies.
3-3. THE ARMY IMMUNIZATION PROGRAM
a. Immunizations. The Army requires all its healthy military personnel to be actively immunized against diseases such as typhoid, tetanus, diphtheria, poliomyelitis, and influenza. Individuals traveling or assigned to certain areas may be required to be immunized against yellow fever, cholera, plague, or other diseases. Upon initial induction, recruits are also given the following vaccines--adenovirus (types 4 and 7), meningococcal (types A and C), rubella, rubeola, and TB skin hypersensitivity testing. AR 40-562 gives details of requirements, dosages, and administration. Additional information on immunizations and immunizing agents may be found in TB MED 114. Copies of these two publications governing the administration of immunization to members of the Armed Forces and their dependents must be kept readily available at all locations where immunizing agents are administered. Every medical specialist who gives immunizations must read and be very familiar with the contents of these directives.
b. Intervals. The intervals for giving immunizations are prescribed in AR 40-562. They are minimum intervals and must never be shortened. If a series is interrupted before completion, it should not be started again but should be completed by giving the remaining injections, regardless of time lapse. If a period longer than that prescribed between stimulating (booster) doses has elapsed, the initial series is not repeated. Once a basic series is completed, it need not be repeated because a stimulating dose is adequate; the single, small booster dose renews the production of antibodies to an effective immunizing level.
c. Immunization Record (SF 601). The Immunization Record (SF 601) form is prepared (in an original copy only) for all military personnel when the initial series of immunizations is given. All immunizations are recorded on this form and kept in the health record. It is the official record of an individual's immunizations and related data and the source of information for completing the Immunization Certificate.
d. Immunization Certificate. A Public Health Service Certificate (International Certificate of Vaccination, PHS Form 731) is prepared for all individuals receiving immunizations. Military personnel must carry this form when performing international travel. Nonmilitary personnel retain PHS Form 731 as their official record of immunizations received.
3-4. PROCEDURE FOR ADMINISTERING AN IMMUNIZATION
Whenever immunizations are given, a military or civilian member of the medical department must be present. This person must be trained and qualified in emergency resuscitative techniques. Follow the local SOP, AR 40-15, AR 40-562, and TB MED 114.
a. Interview Patient. The patient should bring the records mentioned above. Perform the following steps as part of the immunization procedures.
(1) Refer to the Immunization Record or Certificate to determine what immunizations are needed. (This could include a physician's order or a requirement to go overseas.)
(2) Determine whether known allergies exist. A history of reactions to previous immunizations is of great importance to alert you to possible reactions and allow you to take precautions as necessary. Allergies to eggs or fowl are important when immunization agents prepared in eggs are used, such as influenza or yellow fever. As in any type of injection procedure, allergic patients, as well as those presenting a history of suspected allergies, should be referred to the supervisor for a decision on immunizing procedure. Patients with a history of sensitivity to an immunizing agent are usually exempt from the immunizations. Ask the patient the following questions when obtaining the patient's allergy history:
(a) "Have you ever had a reaction to any previous immunization?"
(b) "Do you have a known allergy to eggs or fowl (chicken, ducks, or turkey, and so forth)?"
(c) "Do you now experience or have you ever experienced a disorder such as asthma or hay fever?"
(3) Determine whether the patient is pregnant, if appropriate. Follow local policy concerning questioning women as to whether they are pregnant or suspect they may be pregnant.
(a) Tact and discretion must be used to avoid unnecessary embarrassment.
(b) Determining pregnancy is important because of the possible effect of certain immunizing agents on the unborn child.
(c) Most immunizing clinics will not administer an immunizing agent to a pregnant woman without written authorization from her obstetrician.
NOTE: Usually, large groups of personnel are scheduled for immunizations at one time so an automatic hypodermic gun can be used and the immunization process speeded up. There may be times when you need to administer only two or three immunization injections during the day, then you would need to administer the injection with a needle and syringe. This lesson will provide the procedures to follow to administer injections with a needle and syringe. Personnel trained in the use of the hypodermic gun will instruct you on its operation and maintenance before you are required to use it.
b. Have Emergency Tray Available. An emergency tray should be present and readily accessible. An emergency tray contains materials for immediate treatment of serious reactions, including a constricting band and syringe containing a 1:1000 aqueous solution of epinephrine. A tracheostomy set should be available since the majority of fatalities reported involve asphyxiation due to laryngeal edema or swelling.
c. Perform Handwash. Perform patient care handwash.
d. Obtain Immunizing Agent. Vaccines are kept in a refrigerator or other designated storage area. The proper storage temperature of different vaccines is found on their labels and must be adhered to in order to keep them safe for administration. Some vaccines contain live organisms and must remain frozen. Since a considerable amount of variation exists between storage temperatures and potency periods for these vaccines, it is essential to review the instructions on the labels for each vaccine. Check the clinic SOP regarding proper storage of preconstituted and reconstituted vaccines. All other equipment for administering immunizations will be available in a specific location within the clinic.
e. Check Label for Expiration Date.
(1) The labels of all immunizing agents have an expiration date. The expiration date is the last date the vaccine may be used.
(2) Vaccines or other immunizing agents must not be used after the date of expiration. Expired agents must be disposed of in accordance with local policy.
(3) If vaccine is outdated, obtain new vaccine and discard or return outdated vaccine IAW local policy.
f. Examine Vial and Contents.
(1) Check the agent for unnecessary or unusual particles, clotting, discoloration, evidence of bacterial growth, or abnormal appearance.
(2) Do not use the agent if anything unusual is observed.
(3) Consult your supervisor or the pharmacy if you find any evidence of the above mentioned problems with the vaccine.
g. Draw Up Required Amount of Immunizing Agent.
(1) To determine the amount of immunizing agent required, refer to AR 40-562, check the local clinic SOP, check the supervisor's directive, or check the doctor's orders.
(2) If directed to draw the vaccine, have the supervisor check the dosage prior to administration.
(3) Use a different sterile needle and syringe for each individual.
h. Select Site Administration. Determine appropriate site and route for administration.
i. Expose and Prepare Injection Site.
(1) Ask the patient or assist the patient to remove outer garments to allow complete visualization of the selected site for injection. The deltoid area may have to be further exposed by pushing the sleeve of the T-shirt up and over the deltoid area.
(2) Prepare the site by the use of a suitable cleaning agent (either acetone, Betadine, or alcohol) and allow to dry thoroughly.
j. Administer Immunization.
(1) Whenever immunizations are given, a military or civilian member of the medical department/service will be present who is trained and qualified in emergency resuscitative technique in accordance with local SOP. See AR 40-562 for specific requirements.
(2) As indicated earlier, immunizations can also be administered by jet injection, commonly referred to as "by injection gun." Advantages include facilitating mass immunization procedures, reducing hazards of transmitting serum hepatitis, reducing requirements for large numbers of sterilized needles and syringes, and eliminating many hours expended in the care and processing of reusable syringes and needles and preparing individual dosage from vaccine vials.
k. Observe Patient. Observe for reactions.
(1) The period for observation may be determined by local SOP--usually 30 minutes. The patient should not leave the inoculation area for at least 10 minutes and should not be more than five minutes transportation time away from area during the first 30 minutes.
(2) Any dangerous, allergic reaction to any biologic agent or drug, the date, type, and severity of reaction will be recorded on the patient's appropriate immunization certificates or records. A medical warning tag should also be made.
(3) Urticaria (hives) and pruritis (itching) are common reactions. Allergic reactions vary in nature, severity, and time of onset. Hives and itching are the most common, occurring approximately 20 minutes after inoculation. Some vaccines after several hours to a day may produce general systemic reactions consisting of fever, malaise (general aches and pains), chills, and gastrointestinal upsets as well as a local reaction or swelling, redness, and tenderness at the site of injection. This type of reaction is not usually severe unless accompanied by other life-threatening symptoms.
(4) Observe the patient for progressive signs and symptoms of anaphylactic shock. Immediately treat for anaphylactic shock if signs and symptoms indicate shock.
(a) Anaphylactic shock is an immediate emergency demanding emergency intervention to prevent a patient's death.
(b) Anaphylactic shock is a life-threatening allergic reaction following exposure to a substance to which the patient is allergic. Death may occur within minutes to several hours due to respiratory failure brought on by edema or constriction of the larynx and/or spasms of the bronchus, vascular collapse, and circulatory failure, leading to coma and death.
(5) Observe for undesirable reactions. Whenever local or constitutional reactions of unexpected severity or frequency, local infections, abscess formation that is not traceable to errors in techniques of administration, or other significant manifestations occur which may be due to the use of a biologic product, further administration of the lot will be discontinued. Refer to your immediate supervisor.
l. Dispose of Equipment. Dispose of the needle and syringe in accordance with local SOP. Most areas where immunizations are administered have special plastic or cardboard devices for storing used needles and syringes. Place used needle and syringe intact into the designated container.
m. Dispose of or Store Vial.
(1) Dispose of the vaccination vials in accordance with the clinic's SOP. Containers of all living vaccines should be handled as infectious wastes. When these items are discarded, they should be burned, boiled, or autoclaved.
(2) Store unused vaccine in accordance with the manufacturer's instructions, clinic SOP, or regulations such as AR 40-562 or TB MED 114. If the vial contains more than one dose, mark the date and time opened and your initials on the label and place in refrigeration.
n. Perform a Patient Care Handwash. As always, perform a patient care handwash after treating a patient.
(1) Record the date, dose, and immunization on the patient's Public Health Service Form 731. Recording of this information should be done in accordance with AR 40-562.
(2) Record the date, dose, and immunization on the SF 601 in the patient's health record in accordance with AR 40-403.
(3) Some vaccinations may require that the patient return and be evaluated by personnel in the clinic. Such a test is the tuberculosis skin hypersensitivity test (tine test). The results of the test should be recorded in the patient's health record but there are no results listed on the "shot record," only that the patient received the vaccination.
(4) It is important to remember that entries for yellow fever must be authenticated on the PHS Form 731 by the Department of the Defense immunization stamp and the actual signature of the physician or his designated representative. Immunizations other than yellow fever may be authenticated by initialing.
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