A. Origin of the Issue

Nearly 700,000 American military men and women deployed to Southwest Asia at the time of the Gulf War. Since their return, some veterans have experienced persistent and unexplained illnesses possibly related to their service in the Gulf. Some veterans also have been concerned that the vaccines they received before and during this deployment may have caused or contributed to these illnesses. Other veterans have questions about which vaccines were used and why they were chosen. These concerns have focused attention on vaccine use during the Gulf War.

B. Purpose of the Paper

To better understand how vaccines were used during the Gulf War deployment, the Office of the Special Assistant to the Deputy Secretary of Defense for Gulf War Illnesses has prepared this information paper. It discusses why the military considered the need for vaccines and how they chose to use them in the Gulf War. It provides information about vaccines administered to maintain general readiness as well as information about vaccines chosen for specific use during the Gulf War deployment, including vaccines directed against biological warfare agents. The paper also discusses related issues of concern to veterans, such as adverse reactions associated with these vaccines, information about the vaccines available to servicemembers, and the use of investigational vaccines. It ends with some general observations on vaccine administration.

For veterans, this paper should provide some context in which vaccines were used and some reasonable explanations for difficulties surrounding their use. No individual health records were reviewed and this paper cannot provide detailed information on the specific vaccines that an individual servicemember may have received. In-depth discussion of such issues as investigational products, record keeping, and risk communication is also beyond the scope of this paper, but general references for these issues are provided. A listing of definitions for acronyms, abbreviations, and medical terminology used in the paper can be found in Tab A.

C. Vaccines and Vaccination [1]

Vaccines are powerful health interventions that benefit both individuals and populations. They work by stimulating the body to produce a state of immunity, or protection from disease when the individual is later exposed to an infectious agent. Some vaccines may require only one or two doses (injections or tablets) to produce this immunity; others may require several doses. Some vaccines also require extra (or booster) doses after that in order to maintain this protection.

In many cases, antibodies (protective substances) produced in vaccinated individuals can be measured as a guide to the strength of the protection. Of course, the best evidence that a vaccine has created adequate protection is for the vaccinated individual to be exposed to the infectious agent and not develop the disease, but this is not always possible. For example, some biological warfare agents occur too infrequently as natural infections, so the protection of vaccinated individuals cannot be adequately tested this way. In such cases, the effectiveness of the vaccine may be demonstrated in animals, but there are always concerns as to whether this information would apply to humans. In the United States, the Food and Drug Administration (FDA) carefully reviews research on the effectiveness of a particular vaccine (as well as its safety) before the vaccine is licensed for general use. Before this testing is complete, the vaccine is considered investigational, meaning that it is approved for more limited use in humans pending full study and approval for general use. Both licensed and investigational vaccines were used in the Gulf War.

Vaccines vary in their ability to protect and are not always successful in stimulating immunity in the individuals who receive them. As examples, tetanus toxoid will work to prevent lockjaw (tetanus) most of the time, whereas cholera vaccine may work to prevent the diarrheal disease (cholera) only half the time. Even when vaccines do not provide full protection against the disease, they may still reduce the severity of the illness. Some vaccines are more likely to cause adverse reactions (undesired side effects) than others, and nearly all vaccines can cause serious ill effects, although these are rare. Civilian and military health authorities carefully weigh advantages and disadvantages of vaccines to ensure that the benefit in protection from disease far exceeds the risk of taking a vaccine.

There are other specific countermeasures for some diseases, like antibiotics for anthrax, meningococcal disease, and typhoid fever, and injections of pre-formed antibodies, like immune globulin for hepatitis A or antitoxin for botulism. Yet whenever safe and effective vaccines are available, they offer protection that is long lasting, easily administered, and available well in advance of the expected exposures. These advantages make a strong case for vaccines in both civilian public health and military force health protection.

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