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General public Not recommended Recommended Special populations in the general public Pregnant women Not recommended Recommended Breastfeeding women Not recommended Recommended Children (aged <18 yrs) Not recommended Determined on an event-by-event basis Medical professionals Not recommended Recommended Populations at risk for occupational exposure Persons who handle animals or animal products Not routinely recommendedΔ Recommended Persons who perform certain types of laboratory work Recommended◊ Based on pre-event vaccination status Persons who work in postal facilities Not recommended Recommended Military personnel As recommended by the Department of Defense As recommended by the Department of Defense Persons involved in environmental investigations or remediation efforts Recommended Based on pre-event vaccination status Persons involved in emergency response activities§ Not routinely recommended; may be offered on a voluntary basis under the direction of a comprehensive occupational health and safety program Recommended * Five 0.5-mL doses administered intramuscularly at 0 wks, 4 wks, 6 mos, 12 mos, and 18 mos; annual boosters are required to maintain immunity. • Three 0.5-mL doses administered subcutaneously at 0, 2, and 4 wks after exposure to aerosolized Bacillus anthracis spores for persons who have not completed the pre-event vaccination schedule. Δ Recommended only if handling potentially infected animals in research settings or in areas with a high incidence of enzootic anthrax or when standards and restrictions are insufficient to prevent exposure to B. anthracis spores. ◊ Laboratorians who work 1) with pure cultures of B. anthracis or preparations of B. anthracis spores, 2) with environmental samples associated with anthrax investigations, or 3) in spore-contaminated areas or other settings with exposure to aerosolized B. anthracis spores. Laboratorians who do not work in these settings are not recommended for pre-event vaccine. § Persons involved in emergency response activities might include persons who work in police departments, fire departments, hazardous material units, and the National Guard, as well as other government responders. These persons might perform site investigations, respond to suspicious substance reports (also known as white powder incidents), and perform other related activities, such as evacuation procedures or other activities critical to the maintenance of infrastructure.

* Five 0.5-mL doses administered intramuscularly at 0 wks, 4 wks, 6 mos, 12 mos, and 18 mos; annual boosters are required to maintain immunity. • Three 0.5-mL doses administered subcutaneously at 0, 2, and 4 wks after exposure to aerosolized Bacillus anthracis spores for persons who have not completed the pre-event vaccination schedule. Δ Recommended only if handling potentially infected animals in research settings or in areas with a high incidence of enzootic anthrax or when standards and restrictions are insufficient to prevent exposure to B. anthracis spores. ◊ Laboratorians who work 1) with pure cultures of B. anthracis or preparations of B. anthracis spores, 2) with environmental samples associated with anthrax investigations, or 3) in spore-contaminated areas or other settings with exposure to aerosolized B. anthracis spores. Laboratorians who do not work in these settings are not recommended for pre-event vaccine. § Persons involved in emergency response activities might include persons who work in police departments, fire departments, hazardous material units, and the National Guard, as well as other government responders. These persons might perform site investigations, respond to suspicious substance reports (also known as white powder incidents), and perform other related activities, such as evacuation procedures or other activities critical to the maintenance of infrastructure. Modified from: Use of Anthrax Vaccine in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR Recomm Rep 2010; 59(RR-6):1-36.