1. Service Member Receives Vaccine NO REACTION LOCAL REACTION (Occur more often in women than men) Document. Educate. Continue to screen for exclusion criteria (e.g. steroid therapy, pregnancy). Continue series. MILD LOCAL REACTION Redness < 50 mm diameter, pain, swelling lump, itching. (LR1, LR2, LR3) Document. Educate. Offer topical corticosteroids, antihistamines, analgesics. 1,2 Continue series. Exercise as tolerated after next dose. MODERATE LOCAL REACTION Redness 50 -120 mm diameter, pain, swelling, lump, itching, numbness, tingling, (LR1, LR4, LR7) * Document. Educate. Treat within first 24 hrs with topical corticosteroids, antihistamines, +/- NSAIDS prn for pain. Consider pretreatment for next dose. 1,2,3,7 Continue series. Exercise as tolerated after next dose. LARGE LOCAL REACTION, + COMPLICATIONS Redness > 120 mm, pain, swelling to or below elbow, local rash (LR1, LR5, LR6, LR8) * Document. Educate. Take photo, if possible. Consider consultation with next level of care. Treat symptoms: Corticosteroids, antihistamines, and/or NSAIDs as needed for pain. Pretreat before next dose. 1,2,3,7 Consider temporary exemption, pending consult. Decreased reaction: Continue Worsening reaction: Reevaluate. Possible temp. exemption. Pretreatment schedule. Guidelines for Nov 1999 through Jun 2000. Version: 991115 This document provides general guidance, to adapt to individual clinical cases. Use with companion tables. Revisions to this document will be disseminated via medical command channels and posted on the AVIP website, http://www.anthrax.osd.mil. The probability of events on this chart is not uniform: some are quite common and some are rare. See cover sheet for details. Acknowledgement: This chart originated with the Allergy/Immunology Department, Walter Reed Army Medical Center. ALGORITHM FOR ADVERSE EVENTS AFTER VACCINATION Submit Form VAERS-1 as warranted. Must be submitted for hospitalization, loss of duty > 24 h, or suspected vial contamination. Other events may also be reported. Forms available at www.anthrax.osd.mil/vaers/vaers.htm. * If in yellow or red zone, avoid simultaneous administration with other vaccines.

2. OTHER SYSTEMIC DISEASE Presenting or worsening in temporal association with vaccine SYSTEMIC REACTION (Occur more often in women than men) Myalgias, arthralgias, “flu”-like symptoms temperature 100.5--102 o F, fatigue, nausea, vomiting, headaches lasting 24-72 h, syncope or near syncope, tinnitus, dizziness, focal rash, prolonged fatigue, anxiety response. Occur more often in women than men. (SE1, SE2, SE4, SE5, SE6, SE7, SE8, SE15, SE16) * Temperature >100.5  F or systemic symptoms >72 h OR temperature >102  F, recurrent headaches, generalized rashes (SE3, SE4, SE9) * ANAPHYLAXIS, Systemic allergic reaction, Serum sickness (SE11, SE12) * NEUROLOGIC DISEASE Peripheral neuropathy, Encephalopathy Guillain-Barré, Focal neurologic disease (SE13, SE14) * GENERALIZED SKIN REACTION Toxic epidermal necrolysis, Erythema multiforme, StevensJohnson syndrome, Exfoliative dermatitis (SE10) * Document. Educate. Consult as needed. Consider continuing with pre/post-treatment NSAID. Headache: acetaminophen 650-1000 mg q 4-6 h, ibuprofen, et cetera. 1,2,4 Document. Educate. Treat with antihistamines, corticosteroids. 1,2,5 Consider temp. exemption, pending consult. Treat. Document. Educate. Give temporary exemption, pending prompt consult. Treat. Document. Educate. Take photo, if possible. Give temporary exemption, pending immediate consult. Treat. Document. Educate. Consider temporary exemption, pending consult. 6 Tolerates next dose: continue. For recurrent or worsening symptoms: Consider temporary exemption, pending consult. ALGORITHM FOR ADVERSE EVENTS AFTER VACCINATION Service Member Receives Vaccine Treat acute event. Document. Educate. Give temporary exemption, pending allergy consult. 4 Discuss value of desensitization. Guidelines for Nov 1999 through Jun 2000. Version: 991115 This document provides general guidance, to adapt to individual clinical cases. Use with companion tables. Revisions to this document will be disseminated via medical command channels and posted on the AVIP website, http://www.anthrax.osd.mil. The probability of events on this chart is not uniform: some are quite common and some are rare. See cover sheet for details. Acknowledgement: This chart originated with the Allergy/Immunology Department, Walter Reed Army Medical Center. Submit Form VAERS-1 as warranted. Must be submitted for hospitalization, loss of duty > 24 h, or suspected vial contamination. Other events may also be reported. Forms available at www.anthrax.osd.mil/vaers/vaers.htm. * If in yellow or red zone, avoid simultaneous administration with other vaccines.