Mass Prophylaxis OVERVIEW OBJECTIVES. Tab

Transcription

1 OVERVIEW When a public health emergency requires large scale clinic operations to prevent, contain, or treat disease, the Incident Commander (IC) may adapt existing clinics or establish temporary clinics for the mass distribution of medicines/vaccines (hereafter, referred to as prophylaxis). The IC dedicates clinics to prevent or contain an actual or threatened disease outbreak when: The medical system s capacity for treatment or prevention will be significantly strained. Focused screening, dispensing, and tracking becomes a necessity. OBJECTIVES Mass Prophylaxis Locate mass clinics to best attract and serve those requiring prophylaxis. Safely provide emergency prophylaxis to prevent or contain the spread of disease. Consider alternative methods of dispensing Manage and track local, regional, and federal caches of drugs, medical supplies, and staff. Promote active surveillance of disease. Document prophylaxis provided and any adverse effects. B Tab ACTIVATION The Incident Commander, in consultation with senior health department staff and other medical and government officials, determines when to implement mass prophylaxis measures. Authority for executing these measures is delegated to an assigned Incident Commander. Each clinic will be led by a Division or Group Supervisor under the Operations Section of the response organization. ADDITIONAL RESOURCES Tab A, Epi & Surveillance Tab M, Mental Health Tab Z, Logistics Tab C, Medical Care Point Tab N: Tactical Comms Tab D, Rapid Screening Point Tab Q, Security Tab E, Quarantine/Isolation Tab S, Strategic Nat l Stockpile Tab G, Risk Communication Tab T, Emergency Volunteers Tab H, Laboratory Testing Tab V, Push Partner Registry Tab J, PPE Tab W, Pandemic Influenza URLs: Avg-weight charts for children : Pediatric dosage tables for emergency use: Home Preparation instructions for Doxy for adults and children who cannot swallow pills: ucm htm Additional References: Points of Dispensing Site Specific Security Plans (on MINT and paper format) Appendices related to both Mass Medication and Vaccination Clinics: Prophy Appendix Ba Mass Clinic Organization in ICS Prophy Appendix Bb Clinic Management Structure Prophy Appendix Bc-e Mass Clinic Flow/Staffing/Tasks Prophy Appendix Bf Clinic Site Profile-Security Plan Prophy Appendix Bg - MC POD Site Summary Prophy Appendix Bh Inventory Tracking/Inventory Room Record Appendices related to Mass Medication Clinics (based on Anthrax): Med Appendix Bi-n Distrib Staffing/Admin Procedures/Forms Med Appendix Bo Mass Distrib Clinic Supply/Equipment List Appendices related to Mass Vaccination Clinics (based on smallpox): Vac Appendix Bp-q Vacc Clinic Staff/Admin Procedures Vac Appendix Br Mass Clinic Supply/Equipment List (CDC) Public Health Emergency Response Plan Tab B 1 rh

2 Checklist 1: Mass Clinic Activation, Planning, and Support TASK REFERENCE COMPLETED Conduct Preliminary Analysis. Upon report or suspicion of an outbreak, disease control investigators and epidemiologists collect and analyze information. Initial activities include: Determine disease agent: underlying medical condition(s); incubation period; period and degree of communicability; time frames between event, exposure, and notification. Define population(s) affected, using conservative estimates to account for uncertainty: number exposed (symptomatic and asymptomatic); unexposed but susceptible; number in high-risk situations (e.g., families, co-workers, medical community, first responders). Determine treatment criteria. Develop criteria to determine best and appropriate treatment and the priority populations requiring treatment for the purposes of calculating resource needs and establishing communication channels, risk communication and messages to reach target populations. Consider need for special services. The IC or designee consults with Oregon Department of Human Services (DHS) and Centers for Disease Control (CDC) regarding priority populations and need for special prophylaxis services. Determine medical/health system capacity and estimate added treatment capacity required to meet the emergency s needs. In addition to the size, geographic distribution and nature of the outbreak, consider availability of prophylaxis, personnel/staffing (base on standard module capacity of served per hour for vacc., served per hour for med.), supplies, impact on competing needs, vulnerable populations, facilities, traffic flow, etc. Establish Reasonable Objectives. Assigned IC establishes SMART (Specific, Measurable, Assignable, Reasonable, and Timed) objective(s) to treat at-risk populations (e.g., who? how many? where are they? treated with? by when?). Various treatment scenarios include: Hundreds of people may be served by existing public clinics. A thousand people may be served by existing public clinics, large ambulatory care clinics, and hospitals. Thousands of people may require special mass clinic sites at locations throughout the region. The IC locates and institutes mass clinics as well as alternative methods of dispensing in cooperation with other County and City officials, arranges contributing agency relationships, and negotiates resource ceilings with Agency Executives. Tab A Tab E, H Tabs A, G Tab A Tabs C, D, E, S, T, Z Tabs C, D Tab Z Use Risk Communication. Information Officer (IO) and Liaison Officer 2 rh

3 (LO) work with Planning Section Chief (PSC) or designee to develop and channel messages that promote the incident s objectives and operations. Use the Public Information System to develop health advisories and multiple public information announcements in populationrelevant languages that give information about: The threat. The important symptoms to watch for. Who should receive prophylaxis. The prophylactic process. The location(s) and function of mass clinics. Treatment options for the sick. Threat-specific messages tell people specific information about the disease, protective drug regimens that will be provided to protect them, and the routine they should expect when they go to the clinic. Incident-specific messages tell potentially-exposed persons where they must go for prophylactic medications if they are well and where to go if they are sick. For prophylaxis clinics, information about the drugs given should include: Reasons for using specific drugs or changing drug regimens. Why it is important to take medication. The dangers of over-medicating. Gain the support of the medical community, government jurisdictions and agencies, and other community partners by recognizing their contribution to overall objectives. Provide them with details of the disease/treatment guidelines: Syndrome/disease definitions. Reporting of cases/suspects. (To whom, frequency?) Treatment directions and contraindications. Adverse effects of prophylaxis and treatment. Follow-up guidelines. Instructions for self-care. Guidelines for isolation, quarantine, and referral for further treatment. Infection control guidelines, including use of personal protective equipment and precautions for patients. Determine Tactics and Resources. At the Tactics Meeting, the Operations Section Chief (OSC), Planning Section Chief (PSC), and Logistics Section Chief (LSC) determine the number, size, and location(s) of prophylaxis clinics, as well as the processes and resources that will be needed, based on operational period objectives and in consideration of the: Nature, size, and concentration of the outbreak. Geographic distribution and transit access of target populations. Tab G Tab A Tab E Appendices Ba, Bb Tab Z 3 rh

4 Special target population factors (age, language, ethnicity, mobility, etc.) Clinic processes required by the disease and its treatment. Resource availability. Tab A Adjust site staffing and clinic/dispensing layout to specific situation. Consider using the Head of Household model whereby a person can pick up antibiotics for his/her family. Appendix Bi Intake Form is based on the HOH model. There is no limit to the number of antibiotic regimens that an individual may pick up at a POD; POD Supervisor may impose a limit if an individual s actions are suspect. Determine number of PODs needed: TP (HPP-S) PPH = number of PODs [TP is the total population requiring prophylaxis, HPP is the number of hours to provide prophylaxis to the population, S is the amount of time needed to set up the clinic, and PPH is the number of persons per hour who are provided prophylaxis ( vacc, med.] Consider activating the Push Partner Registry (Tab V) if dispensing antibiotics and need to reach certain at-risk populations (CBO s), reduce the demand on public mass dispensing sites (large businesses) and maintain critical services (government agencies). Plan for changing levels of operations. The PSC predicts changes in the course of the disease, at-risk population(s), and resource needs, and plans accordingly. The LSC anticipates changing resource needs. An Advance Planning unit in the Planning Section may also perform these functions. Develop clinic processes and data requirements. PSC plans and customizes site layout, processes, and screening criteria to efficiently sort patients into categories (e.g., receive treatment, not eligible for treatment, send to hospital, etc.) and effectively deliver services. Determine optimal clinic layout. Design clinic flow plan that: Separates out ill persons as quickly as possible (e.g., consider strategies such as triaging in people s cars as they drive up; if there is an ill person in the car, provide directions to the nearest appropriate treatment center. This contains the contagion and keeps the family together.). Adapts to new needs arising from changes in disease Appendix Bl Tab V Mass Med Distribution: Appendices Bc, d, e, f, g, h, i, j, k, l, m, n, o Mass Vaccination: Appendices Bc, d, e, f, p, q, r 4 rh

5 transmission and/or effectiveness in service delivery. Has roamers and/or a clinic layout that allows ill or problematic patients to be quickly removed from the general flow of clients. Monitors flow to identify flow constraints and make necessary changes to meet or exceed desired throughput. Enables batching of several people at same station at the same time without excessive lines forming between clinic stations. Provides for a Family Lane capable of handling a moving unit (all of different ages and medical histories) to keep families together and help with translation or medical history issues. List staff needed to support clinic operations. At the Tactics Meeting, PSC consults with LSC to affirm or modify staffing requirements. Determine documentation guidelines. The Epidemiology Technical Specialists within the Planning Section determine what information clinics should track for use in future planning and operations (e.g., material/drug status, patient count, spread of disease, protected populations, etc). They will develop appropriate forms and processes necessary for accurate data entry and reporting. Field observers may be used to collect information and ensure that field operations are effective. Establish Badging/Identification and Credentialing Process. Planning Section ensures only authorized personnel enter restricted areas, or perform public health operations, by establishing a badging/identification and credentialing process. Badging/identification: See Tab Q: Security for badging/identification procedures Credentialing: See Tab T: Emergency Volunteers, Appendix Ta: Emergency Management Guideline for credentialing of licensed health care professionals. Coordinate Logistics. LSC arranges required facilities, equipment, supplies, staff, and overall logistics support (communication, transportation, security, food, etc.) for each operational period and clinic. Staffing If staffing shortage, consider regional mutual aid of medical and health communities, emergency management, and City, State or Federal sources. Health Reserve Corps, Red Cross, CERT teams, and other Appendices Bi, p Tab A Tab Q EMG Tab Z Appendices Bg, Bh, Bi, Bl, Bo, Bp, Br Tab T 5 rh

6 volunteer or faith-based organizations are potential volunteer resources. Health Officer may create standing orders to allow designated staff to do specified medical activities to meet response demands (e.g., pharmacists or EMS workers may be trained to assist with smallpox vaccinations). Orient lead staff on overall clinic flow and provide verbal and/or written instructions of their roles. In consultation with OSC and PSC, choose centralized (staging area) or on-site (at clinic) locations to: 1) screen for exposure and administer appropriate prophylaxis to all clinic staff before opening sites to the public; 2) issue gear (including PPE fit-testing) and 3) orient new staff to: The event. Screening protocols. Prophylaxis information and instructions. Screening and documentation requirements. Necessary consents. Follow-up requirements. Education materials to be given to patients. Staff check-in/check-out and time-keeping procedures (including wearing of staff identification at all times). Facilities Arrange access to pre-identified POD site locations using the information contained in the POD Site- Specific Security Plans, coordinated with law enforcement and site security and administrative staff. Security, traffic and crowd management Through emergency managers, seek support from law enforcement, security, and transportation organizations. See the POD Site-Specific Security Plans for the law enforcement/security plan outlined for each predesignated POD site venue. Use of Force. All law enforcement personnel should adhere to their respective agency s Use of Force policy. See Tab Q: Security for more detailed information. Have interpreters available and prepare multi-language signs, handouts, posters, and videotapes for those who do not speak English, are hearing impaired, or illiterate, that: Direct the movement of people. Keep people moving. Keep people occupied. Let people know what is happening. Tell them what they need to know about the drugs they Appendices Bc, d, e Tab Z, POD Site Specific Security Plans Tab Q POD Site Specific Security Plans Tab Q Tab G 6 rh

7 may receive. Shift hours: large-scale public health emergencies may require 12-hour shifts; shift schedules will be determined during activation Hygiene considerations Arrange for the hygiene needs of staff and public. Food and rest Arrange for food and other personnel needs such as catered food and drink, break rooms, and sleep areas. Long waits may require client support by food vendors, Red Cross, etc. Transportation Large scale operations require a transportation plan. Consult with OSC, emergency managers, and transportation services to: Transport staff to clinic sites consider pickup/drop-off locations, carpools, vans, personal vehicles. Transport POD Go-Kits and other material to the POD sites. Identify public and/or private transportation for the public and communicate through IO. Consider dispatch of mobile clinics to serve groups that may be unable to access clinic locations. Consider Receipt, Stage & Storage Center (RSS) needs for distribution (will-call) and/or delivery. Identify emergency transportation routes and resources. Decide how patients will be transported if they must go to separate treatment locations (e.g., via EMS, etc.), what to do with abandoned vehicles, etc. Communications The communications plan might include command, logistics, and several tactical radio nets that: Assign communication frequencies/lines to positions rather than individuals. Include ready access to all pertinent phone numbers and addresses. Provide necessary communications equipment at sites. Mass reproduction of printed materials Arrange for the mass reproduction of printed materials (intake forms, drug fact sheets, labels, signs, etc.) on a 24/7 basis. Sources include: City Print Shop (contract in place; 24 hour access) FedEx/Kinko s (contract in place for emergencies) Office Depot (through cooperative purchasing agreement) Several local vendors (through cooperative purchasing Tab Z Tab N The MINT Appendix Zc 7 rh

8 agreements found on MINT under Central Procurement and Contract Adminstration) Public (OPEN) POD sites have been assessed and have at least one photocopier to make copies of materials on site. Push Partner (CLOSED) POD locations have agreed to make photocopies for their recipients. Provide an initial supply of printed materials to the POD locations for further copying. Contact County EOC for further print reproduction needs Medical and Other Clinic Supplies Contact pharmacies and pharmaceutical warehouses to determine the amount and location of prophylaxis in the Portland metropolitan area (some information in Tab Z: Appendix Zc). Obtain needed supplies, pharmaceuticals, and biologics, maintaining temperature control and light sensitivity precautions as needed. Contact the Oregon Department of Human Services (DHS) through the County EOC if State s supplies, vaccines, and medications are needed. See Tab Z: Logistics for resource ordering procedures. Request DHS to notify the CDC if the federal Strategic National Stockpile (SNS) is needed. Obtain other supplies and equipment including protective personal equipment (PPE), offices supplies, information sheets, procedures, copy machines, signs, files, pens, etc. Receipt, Stage & Storage Center (RSS) Determine the need to activate the Receipt, Stage & Storage Center (RSS) (Tab Z: Logistics) to support mass prophy operations Appendix Zc Tab S, Z Tab Z 8 rh

9 Checklist 2: Mass Clinic Operations for Operations Section Chief (OSC) and Clinic Supervisor TASK REFERENCE COMPLETED Identify and brief clinic supervisors. IC and/or OSC assign clinic supervisors and conduct Operations Briefing and just-in-time training on clinic objectives, staffing, capacities, location, support, chain of command, communications, and process for changing resource levels and strategies as situation changes. Establish, monitor, and adjust clinic layout and process. OSC and each clinic supervisor adapt IC s direction (verbal or written Incident Action Plan): As unique characteristics of the site require adjusted staffing, layout, and security (e.g., actual vs. planned client load and throughput changes; more resources need to be ordered to meet needs; less resources are needed and can be released for use elsewhere, etc.). If route of disease transmission or delivery of services requires it. Manage staff. OSC, clinic supervisor, Situation Unit Leader, and field observers continuously assess staff performance relative to objectives. If the operations staff is not oriented and prepared at a central location, each clinic supervisor is responsible for orientation. Then, supervisors: Oversee lead staff on clinic process, communications, organization, hours, roles (preferably in writing), etc. Ensure that lead staff effectively manages clinic operations and orients the front-line clinic staff. Ensure resources. Monitor, anticipate, and arrange for clinic needs. Maintain sufficient resources (e.g., staff/volunteers, security, communications, equipment, supplies, etc.) to maintain predictable schedules, meet objectives/demand, and avoid critical shortages. Supervisor should first advise OSC of shortages. OSC might fill shortages from other operations having surplus resources. New orders are placed through LSC. Overall resource planning is incorporated into the planning cycle. Keep records. The PSC establishes specific documentation requirements. In general, the clinic supervisor should maintain a unit log of important clinic events, track clinic operations (staff names, hours worked), and required demographic and epidemiological information from mass clinic patients. Collect only absolutely necessary demographic and epidemiological information from mass clinic clients. Client data collection forms used in mass clinic settings are determined at the time of an event and are dependent on guidance from the CDC. For a prophylaxis clinic, drugs and drug recipients must be tracked by: Completing a NAPH (Name, address, phone number and history) form for everyone who receives prophylactic medicines; this Appendices Bc, d, e, I, p Tab Z Appendices Ba, b, c, d, e Tab S, Z Tabs A, G, H, S Appendix Bl 9 rh

10 includes those present at the clinic and those (children or family members) for whom the person in line will pick up regimens. Recording on the NAPH form, the information about the drug (drug name and lot number) that a person receives and the action associated with dispensing it to them (date, time, location, dispenser, and prescription number). Identification is not required Unaccompanied Minors: Anyone over the age of 12 years of age may pick up antibiotics at a POD. The minor must have the capacity to fill out the NAPH forms for all requested regimens. There is no limit to the number of antibiotic regimens that one individual may pick up at a POD if using the Head of Household (HOH) model (attached intake form follows the HOH model). Inventory control at mass clinic sites. Assign a Medicine Inventory and Supply Control (logistical function see Task Card) staff member to maintain and control inventory of medical supplies and pharmaceuticals Supplies are to be kept in a locked, secure closet or room. The Inventory Room Record (Appendix Bh) is used to track critical supplies. Appendix Bl Appendix Bl Tab S, Z Appendix Bh 10 rh

11 Prophy Appendix Ba: Mass Clinic Organization in the Incident Command System The diagram below illustrates where Mass Clinics fit within the Incident Command System and highlights prophylactic activities under the Operations Section Chief. Appropriate support units exist for all Section Chiefs (planning, logistics, and finance/administration) that are not represented below. This plan is based on the following assumptions: The Portland metro-area counties are working together to determine how the county incident command structures will interact within the region. Each county will establish an Incident Command (or Unified Command if appropriate) for the jurisdiction. The Incident Command will include a Safety Officer, Liaison Officer, Information Officer, Operations Section Chief, Planning Section Chief, Logistics Section Chief, Finance/Administration Section Chief and appropriate support staff for each Section Chief. Prophylaxis clinics will fall under the responsibility of county Operations Section Chief. Each prophylaxis clinic will be called a Division. Each Division will include a Security/Traffic/Facility Team, an Education/Forms Team, a Clinic Flow Team and a Clinical Task Force. The Clinical Task Force will be comprised of a Prophylaxis Crew, Symptom Assessment/Triage Crew, a Medical Screening Crew, and a Mental Health Crew. In the event that multiple Divisions are required, Divisions will be grouped geographically and managed by a Branch Director (under Operations Section Chief). Mass Clinic Branch Directors will be responsible for two to seven Divisions. 11 rh

12 Prophy Appendix Bb: Clinic Management Structure The planned capacity of staff and facility arrangement for one module is patients/hour for vaccination and patients/hour for medication dispensing. Multiply staffing and facility resource requirements for larger throughput, multiple shifts. Staffing Distribution Division Supervisor (for one clinic module) Personnel Coordinator Security/Traffic/Facility Team Leader -Security Personnel -Traffic Controllers -Facility Personnel Education/Forms Team Leader -Greeters/Educators/Registration Staff -Health Educators/Room Educators -Interpreters Clinic Flow Team Leader -Flow Monitors -Runners -Medicine inventory and supply control Clinical Task Force Leader o Symptom Assessment Crew/Triage Leader -Symptom Assessment/Triage Physician -Symptom Assessors/Triage o Medical Screening Crew Leader -Medical Screener 1 -Medical Screener 2 o Prophylaxis Crew Leader -Pharmacists/Vaccination Administrators -Dispensers/Vaccination Assistants o Mental Health Crew 11 rh

13 Prophy Appendix Bc: Mass Prophylaxis Clinic Flow Public Exit Data Collection Station Secured storage supply closet or area Mental Health Station Supply Receipt Staff Break Area First Aid Station Prophylaxis Station Prophylaxis Station Prophylaxis Station Medical Screening 2 More screening required Medical Screen 1 Intake Form Completion, Patient Education & Interpreter Stations Symptom Assess/ Triage Prophylaxis Station Express Dispensing Greeter with forms Staff Entrance Command Station Public Entrance Key: = unidirectional patient flow = off-site or in another room Notes: a) Layout will vary based on available facility. b) The number of dispensing/vaccination and medical screening stations may vary. 13

14 Prophy Appendix Bd: Instructions for Patient Movement through Mass Prophylaxis Clinic Flow Symptom Assessment/Triage Identify symptomatic patients and direct them to a hospital or designated medical care facility for treatment Direct healthy patients to enter the clinic. Forms Distribution/Education Area Provide information about what is currently known about the disease, people who may have been exposed, purpose of prophylaxis and distribution process, and nature of recommended prophylaxis. Provide information on contraindications and direction on how to complete Medical Screening Form. Answer questions. For smallpox vaccination, review forms for accuracy and completion. Medical Screening 1 (Form Review) Review Medical Screening form. If NO to all questions, direct patients to prophylaxis teams. If YES to any question, direct patients to Medical Screening 2 for more in-depth screening. Weigh as needed. Medical Screening 2 Review Medical Screening form. Identify contraindications and obtain necessary health history information. Provide medical information, answer questions, prescribe as appropriate. If patients clear screening, direct to prophylaxis station. If patients do not clear screening, direct to Clinic Exit, or refer to hospital or designated medical care facility as appropriate. Prophylaxis Station Verify patient s Medical Screening Form. Provide prophylaxis. Educate patient on post-care instruction. Validate understanding of post-care instructions. Document necessary information and collect Medical Screening form (unless Check Out station is established). Refer patient to Mental Health if necessary. Mental Health Counsel patients and answer questions. Document visit. Redirect patient into clinic flow or to Clinic Exit as appropriate. Check Out (if established) Collect Medical Screening Form (See Prophy Appendix Be for more details about clinic set-up/flow/staffing responsibilities) 14

15 Prophy Appendix Be: TASK CARDS Incident Command System Operations Section Roles/Responsibilities of Mass Clinic Staff (See next 28 pages) 15

16 TASK CARD Operations Section Division Supervisor Report to: Operations Section Chief Supervise: All clinic staff through the Team/Task Force Leaders and Personnel Coordinator Purpose: Responsible for the implementation of the incident action plan within the division. Provide oversight to overall onsite clinic operations and function as decision maker for the site. Function as onsite media contact unless PIO is present. Experience/Training: ICS, Clinic Management Check In: Obtain briefing from Operations Section Chief, Branch Director, or Incident Commander. o Identify resources (personnel, equipment, etc) assigned to the Division. o Confirm geographical boundaries or functional responsibilities of Division. o Review Division s assignments. o Confirm communications plan. Arrive at clinic at designated time with proper photo ID. Arrival time should be 1 hour before staff is expected to arrive. Sign in. Read entire Task Card. Duties: Assign tasks to subordinates and supervise the Division. Implement Incident Action Plan for Division. Ensure that Incident Communications and/or Resources Unit is/are advised of all changes in status of resources assigned to Division. Determine need for assistance on assigned work task. Coordinate activities with adjacent Divisions. Submit Situation and Resources Status information to Operations Section Chief. Ensure subordinates observe required safety precautions. Report special occurrences or events (e.g., accidents, sickness) to Operations Section Chief or Branch Director. Resolve Logistics problems within the Division. o Monitor communications and assess communications needs. o Ensure adequate food, liquids, and rehabilitation. o Ensure personnel are aware of process for medical assistance. Report status of assigned resources. Determine need for additional resources and make request through Operations Section Chief or Branch Director. Maintain Unit Log (ICS Form 214). Phone-in situation reports hourly to the Planning Unit. Serve as information point. Check Out: Debrief with Operations Section Chief or Branch Director prior to leaving shift. o Include work accomplished or left to be accomplished, operational difficulties, resource needs, etc. o Participate in the development of plans for next operational period. Brief replacement. Sign out. 16

17 TASK CARD Operations Section Personnel Coordinator Report to: Division Supervisor Supervise: None Purpose: Responsible for the registration and coordination of all staff, including volunteers Experience/training: Non-medical Check In: Arrive at clinic at designated time with proper photo ID. Arrival time should be 1 hour before staff is expected to arrive. Sign in. Receive briefing from Division Supervisor. Read entire Task Card. Duties: Establish registration station and ensure the registration of staff and volunteers. Work with Team Leaders and Crew Leaders to ensure that all staff take meal/rest breaks. Coordinate registration of volunteers. Check Out: Debrief with Division Supervisor at end of shift, brief replacement. Assist with demobilization, as directed. Sign out. 17

18 TASK CARD Operations Section Security/Traffic/Facility Team Leader Report to: Division Supervisor Supervise: Security, Traffic, and Facility staff and duties Purpose: Responsible for on-site internal and external security, facility, and traffic control/parking issues at clinic. Oversee Security, Facility, and Traffic Control Team staff and duties. Experience/Training: Security, crowd management, facility support Check In: Arrive at clinic at designated time with proper photo ID. Arrival time should 1.5 hours before staff is expected to arrive. Sign in. Read entire Task Card. Duties: Open doors early to personnel, as needed (list of names will be provided and only personnel on list who have photo ID are allowed entry to clinic; no substitutions are allowed). Receive briefing from Division Supervisor. Review staff assignments. Provide orientation and just-in-time training to security/traffic/facility staff. Oversee staff responsible for security, traffic control, and facility. Security and Traffic Control staff may be supplied by local law enforcement, professional security personnel, etc. Facility staff may be provided by facility. Standby for delivery of medications and other supplies. o Assign staff to off-load and secure medications and other supplies o Work with Clinic Flow Team Leader for inventory control and supply issues Ensure the security of staff and supplies. Continually assess/solve security needs and do routine security site duties, including: o Direct people to locations o Watch for problems and bottle-necks in traffic flow o Monitor and report number of waiting clients o Work with Clinic Flow Team Leader to adjust staffing if congestion is noted o Watch for and assist with, any disruptive behaviors o Call for back-up, alert 911 if needed Provide and manage facility support. Arrange for supplies and materials not available on-site through established ordering system. Manage media and direct to designated Public Information Officer or Division Supervisor. Use of Force: All law enforcement personnel should adhere to their respective agency s Use of Force Policy. Check Out: Debrief with Division Supervisor, Security/Traffic/Facility Team Leaders at end of shift, brief replacement. Assist with demobilization, as directed. Sign out. 18

19 TASK CARD Operations Section Security Staff Report to: Security/Traffic/Facility Team Leader Supervise: None Purpose: Responsible for on-site internal and external security, may also manage parking issues. Experience/Training: Non-medical. Security, crowd management. May be provided by supplied by local law enforcement, professional security personnel, etc. Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Security/Traffic/Facility Team Leader. Duties: Open doors to personnel, as needed (list of names will be provided and only personnel on list who have photo ID are allowed entry into clinic; no substitutions allowed). Standby for prophylaxis delivery/chain of possession. Ensure the security of staff and supplies. Continually assess/solve security needs and do routine security site duties, including: o Direct people to locations o Watch for problems and bottle-necks in traffic flow o Monitor and report number of waiting clients o Watch for and assist with, any disruptive behaviors o Call for back-up, alert 911 if needed Manage media and direct to designated Public Information Officer or Division Supervisor Manage parking issues, as directed. Use of Force: All law enforcement personnel should adhere to their respective agency s Use of Force Policy. Check Out: Debrief with Security/Traffic/Facility Team Leader and brief replacement. Assist with demobilization, as directed. Sign out. 19

20 TASK CARD Operations Section Facility Staff Report to: Security/Traffic/Facility Team Leader Supervise: None Purpose: Responsible for access to facility, maintaining facility and providing utility support Experience/Training: Non-medical. May be supplied by facility. Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Security/Traffic/Facility Team Leader. Duties: Provide access to facility to appropriate personnel. Ensure continual (24 hour) facility use. Maintain facility and provide utility support, as needed. Work with security staff to ensure safety of facility and grounds. Check Out: Debrief with Security/Traffic/Facility Team Leader and brief replacement. Assist with demobilization, as directed. Sign out 20

21 TASK CARD Operations Section Traffic Controllers Report to: Security/Traffic/Facility Team Leader Supervise: None Purpose: Responsible for directing traffic outside of clinic/parking lot and solving parking issues. Experience/Training: Non-medical. May be supplied by local law enforcement, public works, etc. Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Security/Traffic/Facility Team Leader. Duties: Set up traffic flow pattern for outside of clinic. Direct traffic and solve parking lot issues. Check Out: Debrief with Security/Traffic/Facility Team Leader and brief replacement. Assist with demobilization, as directed. Sign out 21

22 TASK CARD Operations Section Education/Forms Team Leader Report to: Division Supervisor Supervise: Greeters/educators, Health Educators, Registration Staff (vaccination only), and Interpreters Purpose: Responsible for distributing forms, health education information, and interpretation of forms. Oversee education/forms team staff and duties. Experience/Training: Non-medical. Desire Health Education background. Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Division Supervisor. Duties: Review staff assignments. Provide orientation and just-in-time training to Greeters/Educators, Health Educators, Registration Staff, and Interpreters. Ensure all forms and supplies that are needed are available. Greet and orient clients to clinic process, hand out forms, provide educational materials and information to clients, answer client questions. Assure that clients with special needs are receiving assistance from appropriate staff. Assure that non-english speaking client needs are met. Direct media inquiries to the assigned media rep. (Public Information Liaison or Division Supervisor). Alert Runners when more supplies are needed. Check Out: Debrief with Division Supervisor and brief replacement. Assist with demobilization, as directed. Sign out. 22

23 TASK CARD Operations Section Greeters/Educators Report to: Education/Forms Team Leader Supervise: None Purpose: Responsible for the distribution of forms, providing agent information, answering questions Experience/Training: Non-medical Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Education/Forms Team Leader. Duties: Assemble materials. Greet clients. Orient clients to the process so that they will expect to: o Receive information. o Be asked to complete the forms handed out. o Have their forms reviewed and, if needed, receive further counseling. o Be given prophylaxis. o Have information to take home about disease, prophylaxis and follow-up needed. o Be charged a fee, if any, and what that amount is. o Know length of process so they can plan accordingly. o Know where public restrooms are. Hand out appropriate forms (based on disease). Ask clients to fill out appropriate form(s). Direct clients to Medical Screening 1 for forms review, or to Health Education Station if in-depth education is required, or to Interpreter Station, if needed. Alert appropriate clinic staff if client has special needs. Direct media inquiries to the assigned media rep. (Public Information Liaison or Division Supervisor). Alert Runners when more supplies are needed. Check Out: Debrief with Education/Forms Team Leader and brief replacement. Assist with demobilization, as directed. Sign out. 23

24 TASK CARD Operations Section Health Educators Report to: Education/Forms Team Leader Supervise: None Purpose: Responsible for providing health education, answering client questions Experience/Training: Health Educators, bilingual a plus Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Education/Forms Team Leader. Duties: Set up educational materials. Provide educational materials/faq sheets. Answer client questions regarding agent, what they can expect. Read the intake form for individuals who are unable to read. Support understanding of health implications of the situation and intervention (vaccine, medication, assessment implications). Work with interpreters to assist non-english speaking individuals; identify appropriate language support. Direct clients to Medical Screening 1. Refer clients to Medical Screening 2 if they have more complex questions. Check Out: Debrief with Education/Forms Team Leader and brief replacement. Assist with demobilization, as directed. Sign out. 24

25 TASK CARD Operations Section Registration Staff (Vaccination only) Report to: Education/Forms Team Leader Supervise: None Purpose: Review forms to ensure accuracy and completion Experience/Training: Non-medical Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Education/Forms Team Leader. Duties: Review forms to ensure accuracy and completion. Direct clients to Medical Screening 1. Check Out: Debrief with Education/Forms Team Leader and brief replacement. Assist with demobilization, as directed. Sign out. 25

26 TASK CARD Operations Section Interpreters Report to: Education/Forms Team Leader Supervise: None Purpose: Responsible for interpretation of forms and answering client questions Experience/Training: Language interpretation Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Education/Forms Team Leader. Duties: Provide language interpretation to non-english speaking individuals. Assist with forms completion. Answer client questions. Direct clients to Medical Screening 1 or to Health Education Station if in-depth education is required. Check Out: Debrief with Education/Forms Team Leader and brief replacement. Assist with demobilization, as directed. Sign out. 26

27 TASK CARD Operations Section Clinic Flow Team Leader Report to: Division Supervisor Supervise: Flow Monitors, Runners, Medicine Inventory and Supply Control Purpose: Responsible for directing clients through clinic, clinic traffic flow, maintaining supply inventory. Oversee clinic flow team staff and duties. Experience/Training: Non-medical Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Division Supervisor. Duties: Review staff assignments. Provide orientation and just-in-time training to Flow Monitors, Runners, and Medicine Inventory and Supply Control. Ensure a smooth and efficient clinic traffic flow by identifying and solving bottleneck issues, under-used stations/positions and adjust accordingly. Direct client flow throughout clinic. Stock supplies, run errands as needed. Maintain and control inventory, report needs to Division Supervisor, or as directed. Check Out: Debrief with Division Supervisor and brief replacement. Assist with demobilization, as directed. Sign out. 27

28 TASK CARD Operations Section Flow Monitors Report to: Clinic Flow Team Leader Supervise: None Purpose: Responsible for directing clients to stations throughout the clinic Experience/Training: Non-medical Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Clinic Flow Team Leader. Duties: Direct clients to stations throughout clinic. Look out for bottlenecks and under-used stations and report these to Clinic Flow Team Leader. Escort distressed, upset, and anxious clients to Mental Health Station. Check Out: Debrief with Clinic Flow Team Leader and brief replacement. Assist with demobilization, as directed. Sign out. 28

29 TASK CARD Operations Section Runners Report to: Clinic Flow Team Leader Supervise: None Purpose: Responsible for stocking supplies, running errands as needed, and assisting with clinic flow Experience/Training: Non-medical Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Clinic Flow Team Leader. Duties: Assist Medicine Inventory and Supply Control. Stock supplies for all stations. Run errands as needed for clinic staff. This might include walking a special needs client to another station or running communications equipment out to traffic control/parking staff, for examples. Check Out: Debrief with Clinic Flow Team Leader and brief replacement. Assist with demobilization, as directed. Sign out. 29

30 TASK CARD Operations Section Medicine Inventory and Supply Control Report to: Clinic Flow Team Leader Supervise: None Purpose: Responsible for maintaining and controlling inventory of medical supplies, pharmaceuticals, and other supplies Experience/Training: Non-medical Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Clinic Flow Team Leader. Duties: Standby for delivery of medications and other supplies. Ensure that supplies are kept in a locked, secured room. This is particularly important for pharmaceutical and medical supplies. Maintain and control all supply inventory. When tracking critical pharmaceutical/medical supplies use Inventory Room Record. If not provided, track items received, issued, and balance of supply on notebook paper. Report supply inventory to Clinic Flow Team Leader regularly. Foresee and report needs to Clinic Flow Team Leader. Work with Runners to stock supplies at stations. Check Out: Debrief with Clinic Flow Team Leader and brief replacement. Assist with demobilization, as directed. Sign out. 30

31 TASK CARD Operations Section Clinical Task Force Leader Report to: Division Supervisor Supervise: Symptom Assessment/Triage Crew Leader, Medical Screening Crew Leader, Prophylaxis Crew Leader, And Mental Health Crew. Purpose: Responsible for performing tactical assignments given to their task force. Manages medication dispensing/vaccination administration, medical screening, symptom assessment/triage and mental health activities at the clinic. Reports work progress, resource status, and other important information to the Division Supervisor. Experience/Training: ICS, clinic management. Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Division Supervisor. Duties: Review staff assignments. Provide orientation and just-in-time training to Symptom Assessment/Triage Crew Leader, Medical Screening Crew Leader, Prophylaxis Crew Leader, and Mental Health Crew. Submit situation and resource status information to Division Supervisor. Report special events (e.g. sickness, accidents). Request logistics/support as needed. Report status/location changes. Maintain Unit Log (ICS Form 214). Report hourly Clinic Status Summary information to Division Supervisor. Adjust clinic flow or station assignments as needed. Oversees, trouble-shoots, and problem solves task force/clinical operations. Check Out: Debrief with Division Supervisor and brief replacement. Assist with demobilization, as directed. Sign out. 31

32 TASK CARD Operations Section Symptom Assessment/Triage Crew Leader Report to: Clinical Task Force Leader Supervise: Symptom Assessment/Triage Physician and Symptom Assessors/Triage Purpose: Responsible for assessing clients for symptoms prior to entering clinic, and instructing clients where they need to go to receive appropriate care. Oversee symptom assessment/triage crew staff and duties. Experience/Training: Medical Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Clinical Task Force Leader. Duties: Review staff assignments. Provide orientation and just-in-time training to Symptom Assessment/Triage Crew. Instruct clients, outside of clinic, that if they have symptoms, the medicine/vaccine being administered in the clinic will not help them. Instruct clients where to go to receive appropriate care (this may be a designated health care facility, hospital, or into the clinic). Observe patients in line, prior to entering the clinic, for symptoms. Evaluate as necessary, and instruct clients where to go to receive appropriate care (designated health care facility, hospital, or into the clinic). Hand out surgical facial masks to those with respiratory illness, if appropriate. It is not intended that the Symptom Assessment/Triage Crew evaluate every client. They are trying to weed out as many potentially contagious persons as possible. Check Out: Debrief with Clinical Task Force Leader and brief replacement. Assist with demobilization, as directed. Sign out. 32

33 TASK CARD Operations Section Symptom Assessment/Triage Physician Report to: Symptom Assessment/Triage Crew Leader Supervise: None Purpose: Responsible for assessing clients in line prior to entering clinic for symptoms, and providing instruction on where to go for further care (dispensing clinic or hospital) Experience/Training: MD/DO, NP Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Symptom Assessment/Triage Crew Leader. Duties: Instruct clients, outside of clinic, that if they have symptoms, the medicine/vaccine being administered in the clinic will not help them. Instruct clients where to go to receive appropriate care (this may be a designated health care facility, hospital, or into the clinic). Observe patients in line, prior to entering the clinic, for symptoms. Evaluate as necessary, and instruct clients where to go to receive appropriate care (designated health care facility, hospital, or into the clinic). Hand out surgical facial masks to those with respiratory illness, if appropriate. It is not intended that the Symptom Assessment/Triage Crew evaluate every client. They are trying to weed out as many potentially contagious persons as possible. Check Out: Debrief with Symptom Assessment/Triage Crew Leader and brief replacement. Assist with demobilization, as directed. Sign out 33

34 TASK CARD Operations Section Symptom Assessors/Triage Report to: Symptom Assessment/Triage Crew Leader Supervise: None Purpose: Responsible for assessing clients in line prior to entering clinic for symptoms, and providing instruction on where to go for further care (dispensing clinic or hospital) Experience/Training: RN, EMT, PA, NP Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Symptom Assessment/Triage Crew Leader. Duties: Instruct clients, outside of clinic, that if they have symptoms, the medicine/vaccine being administered in the clinic will not help them. Instruct clients where to go to receive appropriate care (this may be a designated health care facility, hospital, or into the clinic). Observe patients in line, prior to entering the clinic, for symptoms. Evaluate as necessary, and instruct clients where to go to receive appropriate care (designated health care facility, hospital, or into the clinic). Hand out surgical facial masks to those with respiratory illness, if appropriate. It is not intended that the Symptom Assessment/Triage Crew evaluate every client. They are trying to weed out as many potentially contagious persons as possible. Check Out: Debrief with Symptom Assessment/Triage Crew Leader and brief replacement. Assist with demobilization, as directed. Sign out 34

35 TASK CARD Operations Section Medical Screening Crew Leader Report to: Clinical Task Force Leader Supervise: Medical Screeners 1 and Medical Screeners 2 Purpose: Responsible for screening of clinic intake forms for contraindications, weighing clients if needed, and in-depth medical screening. Oversee Medical crew staff and duties Experience/Training: Medical Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Clinical Task Force Leader. Duties: Review staff assignments. Provide orientation and just-in-time training to Medical Screening 1 and Medical Screening 2 Crew. Ensure that all necessary flow charts and forms are available, including but not limited to treatment protocol flowchart, standing orders, alternative antibiotic chart, notification to patient s primary care provider. Screen clinic intake forms for contraindications and direct clients to appropriate station. Weigh clients as needed and note weight on intake form. Provide in-depth medical screening at Medical Screening 2, answer client questions, prescribe as needed. Check Out: Debrief with Clinical Task Force Leader and brief replacement. Assist with demobilization, as directed. Sign out 35

36 TASK CARD Operations Section Medical Screener 1 Report to: Medical Screening Crew Leader Supervise: None Purpose: Responsible for screening client forms for preliminary contraindications and weighing clients as needed Experience/Training: Non-medical for medication dispensing, medical for vaccination administration Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Medical Screening Crew Leader. Duties: For medication dispensing: non-medical personnel can review clinic intake forms for contraindications and direct clients to appropriate station. If no contraindications, direct clients to Prophylaxis Station. If contraindications exist or if client has complex questions, direct clients to Medical Screening 2 for more in-depth screening. For vaccination administration: medical personnel will review patient information and contraindications to determine if individual meets qualifications for vaccine/other treatment, verify vaccination status, and direct to Prophylaxis Station to receive vaccine, or direct to Medical Screening 2 for more in-depth screening. Consent forms may or may not be required. If multiple prophylaxis stations are set up (family line, express line), direct to appropriate station. Weigh children as needed and record weight on intake form. Check Out: Debrief with Medical Screening Crew Leader and brief replacement. Assist with demobilization, as directed. Sign out 36

37 TASK CARD Operations Section Medical Screener 2 Report to: Medical Screening Crew Leader Supervise: None Purpose: Responsible for screening clients in-depth for contraindications, answering questions, prescribing as needed Experience/Training: MD/DO, PA, NP, RN Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Medical Screening Crew Leader. Duties: Ensure that all necessary flowcharts, paperwork, and references are available. Clients will be directed to this station if they have complex medical questions, or if they demonstrated as having contraindications to the prescribed regimen. Answer client questions. Screen clients in-depth for contraindications and prescribe appropriate regimen. Depending upon the severity of the disease and the regimens available, clients that may be at risk for drug interactions may need to be instructed to alter their dosage of another drug. Direct clients to Prophylaxis Station if they are to receive the prescribed prophylaxis or direct clients to Exit if they are not to receive the prescribed prophylaxis. Check Out: Debrief with Medical Screening Crew Leader and brief replacement. Assist with demobilization, as directed. Sign out 37

38 TASK CARD Operations Section Prophylaxis Crew Leader Report to: Clinical Task Force Leader Supervise: Pharmacists, Dispensers, Vaccination Administrators, and Vaccination Assistants Purpose: Responsible for dispensing medication or administering vaccine. Oversee medication dispensing or vaccination crew staff and duties, answer client questions (pharmacist) Experience/Training: Medical, RPh Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Clinical Task Force Leader. Duties: Review emergency protocol/standing order. Review staff assignments. Provide orientation and just-in-time training to Pharmacists, Dispensers, Vaccination Administrators, and Vaccination Assistants. Act as a technical resource to the dispensing team. Maintain dispensing/vaccination operation efficiency and effectiveness. Ensure that all necessary paperwork is available. This might include drug information sheets, dispensing algorithms, etc. Counsel clients and answer questions as needed (pharmacist). Ensure that adequate supplies are available. Report needs to Runners. Work with Medicine Inventory and Supply Control to assess supply needs. Ensure the proper handling of pharmaceuticals and vaccine Ensure that patients are being dispensed the correct drug and strength. Monitor client flow, and recommend movement of staff to expedite flow and eliminate bottlenecks. Ensure that all forms are completed properly. Ensure that all appropriate paperwork is collected and turned in. Oversee the breakdown and repacking of pharmaceuticals/vaccines and related equipment and supplies. Check Out: Debrief with Clinical Task Force Leader and brief replacement. Assist with demobilization, as directed. Sign out 38

39 TASK CARD Operations Section Pharmacist (Medication Dispensing only) Report to: Prophylaxis Crew Leader Supervise: None Purpose: Responsible for compounding, diluting, and creating drug suspensions, if necessary, calculating dosages based on weight, dispensing medications, and counseling clients. Experience/Training: RPh Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Prophylaxis Crew Leader. Duties: Review emergency protocol/standing order. Act as a technical resource to the dispensing team. Counsel clients and answer questions as needed Set up station and ensure that all supplies are available. If required at clinic, compound, dilute, and/or create drug suspensions. Dispense appropriate medication and record medication dispensed on clinic intake form, retain form. Direct client to Prophylaxis Station or to Exit. Check Out: Debrief with Prophylaxis Crew Leader and brief replacement. Assist with demobilization, as directed. 39

40 TASK CARD Operations Section Dispensers (Medication Dispensing only) Report to: Prophylaxis Crew Leader Supervise: None Purpose: Responsible for dispensing medication Experience/Training: Pharmacist, Pharmacy Technician, RN, LPN, pharmacy student, other Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Prophylaxis Crew Leader. Duties: Review emergency protocol/standing order. Set up station and ensure that all supplies are available. Review clinic intake form for appropriate medication to be dispensed. Verify signed consent (if required). Remove lot # labels from pill bottle or label sheet. Put one label on clinic intake form and one label on patient information sheet. Fill out information on prescription label and adhere to pill bottle or to patient information sheet. Dispense appropriate medication and record medication dispensed on clinic intake form, initial intake form, and retain form. Assure client has patient information sheet. Remind client to complete the entire dosing regimen. Apply a hand stamp to those receiving medication, if directed to do so. Do not issue medication to those that already have a hand stamp. Direct client to Exit. Notify Runners if additional supplies are needed. Check Out: Debrief with Prophylaxis Crew Leader and brief replacement. Assist with demobilization, as directed. Sign out 40

41 TASK CARD Operations Section Vaccination Administrator (Vaccination only) Report to: Prophylaxis Crew Leader Supervise: None Purpose: Responsible for administering vaccine Experience/Training: LPN, RN, MD, Pharmacist Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Prophylaxis Crew Leader. Duties: Review emergency protocol/standing order. Set up station and ensure that all supplies are available. Instruct Vaccination Assistant on specific assistance required. Review questionnaire/intake form to ensure client is approved for prophylaxis, and verify signed consent. (If required.) Ensure the proper handling of vaccine. Administer vaccine according to emergency protocol/standing order. Record information on appropriate form(s). Retain clinic intake form/medical screening form. Observe client for any initial reactions and respond in an emergency situation Assure client has all appropriate forms and supplies. Direct client to Exit. Notify Runners if additional supplies are needed. Check Out: Debrief with Prophylaxis Crew Leader and brief replacement. Assist with demobilization, as directed. Sign out 41

42 TASK CARD Operations Section Vaccination Assistant (Vaccination only) Report to: Prophylaxis Crew Leader Supervise: None Purpose: Prep vaccine, verify client consent, and support vaccine administrator Experience/Training: Non-medical Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Prophylaxis Crew Leader. Duties: Review emergency protocol/standing order. Set up station and ensure that all supplies are available. Review questionnaire/intake form to ensure client is approved for prophylaxis, and verify signed consent. (If required.) Ensure the proper handling of vaccine. Prep vaccine for Vaccination Administrator. Record information on appropriate form(s). Retain clinic intake form/medical screening form. Assure client has all appropriate forms and supplies. Direct client to Exit. Notify Runners if additional supplies are needed. Check Out: Debrief with Prophylaxis Crew Leader and brief replacement. Assist with demobilization, as directed. Sign out 42

43 TASK CARD Operations Section Mental Health Crew Report to: Clinical Task Force Leader Supervise: None Purpose: Responsible for providing mental health support, counseling patients, answering questions. Experience/Training: Social Workers, Mental Health Consultants, Mental Health Counselors, Psych RN Check In: Arrive at clinic at designated time with proper photo ID. Sign in. Read entire Task Card. Receive briefing from Clinical Task Force Leader. Duties: Prepare Mental Health Station. Take steps to ease the fears and anxieties of the clients in the clinic and provide comfort. This might be done by telling clients waiting in line how long the expected wait is, by asking clients waiting in line if they have any questions. Support clients who are referred from other staff. Evaluate as necessary, and instruct clients where to go to receive appropriate care. Monitor environment and alert security staff of any concerns of potential violent situations. Check Out: Debrief with Clinical Task Force Leader and brief replacement. Assist with demobilization, as directed. Sign out. 43

44 Prophy Appendix Bf: Clinic Site Profile Security Plan (See next page) 44

45 (fill in site name here) Last Update Address: Owner: Primary Point of Contact Name/Title: Day Phone: Eve Phone: Mobil: Has access to building keys: Home Address: Location Cross Street: Major thoroughfare: Primary Phone: Alternative Point of Contact Name/Title: Day Phone: Eve Phone: Mobil: Has access to building keys: Home Address: Cell Pager Cell Pager Yes No Yes No Facility Plan Coordinated Local Public Health: Emergency Management: Law Enforcement Agency: Fire Services: Facility Representative: Plan Components Phone: Phone: Phone: Phone: Phone: Main Contact Main Contact Main Contact Main Contact Main Contact Location map Aerial map Site plan Clinic plan/orientation Needed equip list Security Plan Potential site limitations (e.g., only space available is one large room; noise and traffic flow measures will be needed to maintain order and calm in the clinic) (e.g., no hand washing facilities near proposed clinic area; will need portable sinks or large amounts of hand sanitize

46 Site Information: Primary Clinic Location Sq. ft: Clinic Needs Assessment Facility use agreement in place, Date last updated: Suitable for Inclement Weather Secondary Location: Sq. ft: Suitable for Inclement Weather Separate ingress/egress in clinic area Electricity (adequate outlets in clinic area) Backup power source Biomedical waste storage available Adequate HVAC capacity ADA access to clinic area from parking lot Break room for staff Showers Cafeteria/kitchen Site Needs Assessment Telephone availability, # of external lines/phone jacks: Clinic area: Additional rooms: ADA restrooms, # of stalls: Sewer or on-site sewage system (adequate capacity) Refrigeration, type/size: Hand washing facilities near clinic area Number of outlets/amps available under emergency power Outlets: Amps: Loading dock available Forklift on-site Adequate road access Fencing around: facility, loading area Bus loading/unloading area Alt. Transportation: Bus Route #s: Helicopter landing site: GPS locational data: Lat.: Water source: Secure (lockable) storage area near loading dock Long.: Ability to limit access only to clinic area Adequate cell phone coverage: Outside Inside PA/Intercom system Internet access: WiFi, LAN, DSL, cable Additional rooms available near clinic site Separate staff parking area, number of stalls: Parking stalls available: Available On-site Copier Fax Printer Computer Tables, #: Chairs, #: Portable cubicle walls, #: Lane roping equipment Audio/Video equip, VCR, #: DVD, #: Janitorial supplies to match expected need (I.e., toilet paper, paper towels, hand soap) Potential Facility Staff (I.e., number of facility workers who may be available to assist with the clinic operations, performing their normal jobs assignments or reassigned) Maintenance staff, #: Security staff, #: IT support, #: Bus drivers, #: Teachers (re-assigned), #: Other, #: Notes: Special opportunities or concerns around available staffing Cafeteria staff, #: Nurse, #: Law Enforcement/Security Plan

47 Address: 0 Location Cross Street: 0 0 Major thoroughfare: 0 Primary LE: Primary Fire Agency: Objective #1: Provide security to SNS assets (medication) from the point it is delivered by the State. Objective #2: Provide adequate traffic control approaching/exiting the facility and in the parking area. Objective #3: Provide crowd control and law enforcement services in and around the facility. Below are locations that have specific traffic control issues. There is a recommendation for the number of LE officers or other staff needed, but in an actual event you may need to do the best with what you have. People that may fit into the "other" ca Surrounding Area: As traffic approaches the facility provide LE, security, or signs to direct traffic # of LE Intersection Concern/possible solution Min. Op. # of other Notes/Special traffic concerns: Law Enforcement/Security Plan (cont.)

48 Below are a number of tasks and locations that need LE attention. There is a recommendation for the number of LE officers or other staff needed, but in an actual event you may need to do the best with what you have. People that may fit into the "other" Facility: Consider the security of staff, clients and medications Location/consideration Concern Parking lot(s) Outside queue Outside roving Plain clothes/concealed observers Public building entrance Staff building entrance Inside queue area Clinic entrance Clinic exit Clinic roving Medication storage Medication restock escort Arrest teams in reserve (MRT) # of LE Min. Op. # of other

49 Prophy Appendix Bg: Multnomah County POD Site Summary and Map Facility Address LE Agency MOU Barriers/Challenges Remarks (this section contains information that is not for public disclosure) 45

50 <<See next page for map of POD locations>> (the map contains information that is not for public disclosure and is not available in the web version of this document) 46

51 Start Date: End Date: ITEM: Appendix Bh: POD Inventory Tracking Street Address: INVENTORY ROOM RECORD This record is for tracking critical supplies at mass dispensing sites. UNITS OF USE: POD Site Location: Date Time Material # or Lot # Material Description Quantity Rec d Rec d From (print name) Quantity Issued Issued To (print name) Balance (left in stock) Signature 47

52 Med Appendix Bi: Mass Medication Distribution Clinic Staffing Guidelines Position #Req Station Role in Clinic Exp/Training Division Supervisor 1 Mobile Oversee all site operations and team/task force leaders ICS, clinic management Personnel Coordinator 1 Mobile/Staff Entrance Register staff, volunteers, sign-in/out, assign breaks Non-medical Security/Traffic/Facility Team Leader 1 Mobile Oversee security/traffic/facility team staff and duties Security, crowd management, facility support Security Staff TBD Entrance, exits Ensure secure environment Non-medical Facility Staff TBD Mobile Maintain facility and utility support Non-medical Traffic Controllers TBD Parking lot Direct traffic Non-medical Education/Forms Team Leader 1 Mobile Oversee education/forms team staff and duties Non-medical Greeters/Educators 8 Entrance Distribute forms, provide agent information, answer questions Non-medical Health Educators (if in-depth health TBD Entrance, education Provide education, answer questions Health Educator, bi-lingual a plus education required) room (as needed) Interpreter 6 Interpreter station or mobile Interpret forms and answer questions Language interpretation Clinic Flow Team Leader 1 Mobile Oversee clinic flow team staff and duties Non-medical Flow Monitors 8 Various stations Direct clients to stations throughout clinic Non-medical Runners 2 Mobile Stock supplies, run errands as needed Non-medical Medicine inventory and supply 1 Inventory/Supply Maintain and control inventory, report needs Non-medical control Clinical Task Force Leader 1 Mobile Oversee all clinical operations and crew leaders ICS, clinic management Symptom Assessment/Triage 1 Mobile Oversee symptom assess/triage crew staff and duties MEDICAL Crew Leader Symptom Assessment/Triage 1 Symptom Assess. Assess clients in line prior to entering clinic for symptoms, provide MEDICAL (MD/DO, NP) Physician station outside clinic instruction on where to go (disp. clinic or hospital) Symptom Assessors/Triage 5 Symptom Assess. Assess clients in line prior to entering clinic for symptoms, provide MEDICAL (RN, EMT, PA, NP) station outside clinic instruction on where to go (disp. clinic or hospital) Medical Screen. Crew Leader 1 Mobile Oversee medical crew staff and duties MEDICAL Medical Screener 1 8 Screening area Screen clients for preliminary contraindications, weigh clients as Non-medical needed Medical Screener 2 6 Screening area Screen clients in-depth for contraindications, prescribe as needed MEDICAL (RN, MD/DO, PA, NP) Prophylaxis Crew Leader 1 RPh Station/Mobile Oversee dispensing crew staff and duties, answer questions MEDICAL/RPh Pharmacist (as needed) 1 Compound station Compound, dilute, calculate dosages based on weight RPh Dispensers 16 Prophylaxis station Dispense medication MEDICAL (RN, Pharmacist, Pharm Tech, other) Mental Health Crew 2 Mental Health Station Provide mental health support, counsel patients, answer questions Soc Workers, MH Consultants, MH Counselors, Psych RN Total staff per 12hr shift 73 Data entry staff may be required. 48

53 Med Appendix Bj: Patient Movement through Mass Medication (Oral Prophy) Distribution Clinic Flow (based on Anthrax) Post-Exposure Prophylaxis Pre-Susceptibility Dispensing Algorithm START < 9 yrs old? 1 Yes No Pregnant or breast feeding? 2 Yes No Allergy to tetracyclines? 3 Yes Allergy to quinolones? 7 Yes Refer to physician 13 No No Doxycycline 2.2 mg/kg PO BID for 10 days with follow-up appointment 5 Yes < 99 lbs? 4 Taking probenecid? 8 Yes Stop probenecid temporarily 14 No No Doxycycline 100 mg PO BID for 10 days with follow-up appointment 6 Taking theophylline? 9 Yes Decrease theophylline dose 50% 15 No Kidney problems? 10 Yes < 73 lbs 16 Yes No No Ciprofloxacin 500mg PO QD with follow-up and referral to physician for dose adjustment and monitoring 17 < 73 lbs 11 Yes Ciprofloxacin mg/kg PO BID for 10 days with follow-up appointment 18 No Public Health Emergency Response Plan Ciprofloxacin 500mg PO BID for 10 days with follow-up appointment 12 Source: Mass Med Distrib Planning Guide (anthrax example); National Pharmacy Response Team, NDMS; Matthew Tarosky, PharmD, CDR, US PHS 49

54 Footnotes for Post-Exposure Prophylaxis Pre-Susceptibility Dispensing Algorithm The attached flow diagram and following footnotes describe drug selection and dosing information for patients requiring post-exposure prophylaxis or preventative treatment after exposure to Bacillus anthracis, the bacteria that causes anthrax. Reports have been published of engineered strains of tetracycline-resistant and quinolone-resistant Bacillus anthracis. 1,2 There is also a possibility for resistance to penicillins through induction of betalactamase enzymes. For these reasons, public health officials will test the antibiotic susceptibility of clinical specimens (blood, sputum, etc.), to determine drug selection. The most widely available, efficacious, and least toxic antibiotic will be dispensed for post-exposure prophylaxis based upon these susceptibility results. 1 Until antibiotic susceptibility results of the implicated strain are available, initial therapy for post-exposure prophylaxis for prevention of anthrax after intentional exposure of Bacillus anthracis is doxycycline or ciprofloxacin. 3 Since doxycycline has a more favorable safety profile, it is the drug of choice for patients without an allergy to tetracycline antibiotics. Ciprofloxacin is an alternative agent. Doxycycline and other tetracyclines are not normally recommended for children and pregnant women due to the risk of dental staining of the primary teeth, concerns about possible depressed bone growth, defective dental enamel, and rare liver toxicity. Therefore, children and pregnant and lactating women will not receive doxycycline. Ciprofloxacin and other quinolones are not normally recommended in children and pregnant women due to the risk of arthropathy (joint disease). 1,4,5 This recommendation is based on studies in animals. Data in humans have not confirmed this risk. Therefore, children and pregnant and lactating women without an allergy to quinolones will receive ciprofloxacin according to this algorithm. The risks associated with the serious and life-threatening complications from anthrax outweigh any risks from taking ciprofloxacin. The Centers for Disease Control and Prevention (CDC) recommends the use of ciprofloxacin or doxycycline as initial therapy in pregnant women, immunocompromised persons, and children for postexposure prophylaxis for prevention of anthrax after intentional exposure of Bacillus anthracis. As soon as penicillin susceptibility is confirmed, prophylactic therapy for children and pregnant women should be changed to amoxicillin. 3 The American College of Obstetricians and Gynecologists Committee on Obstetric Practice recommend the use of ciprofloxacin in pregnant or lactating women for post-exposure prophylaxis for prevention of anthrax after intentional exposure of Bacillus anthracis. 6 This algorithm does not include the use of anthrax vaccine. At the time this algorithm was developed, anthrax vaccine for post-exposure prophylaxis was an investigational new drug. It is quite possible that once the release of anthrax has been confirmed the vaccine will be made available to the affected population. All patients who have been potentially exposed should receive an initial course of drug therapy (e.g., 10 days). Public health officials will confirm the release of Bacillus anthracis and may advise people to return for follow-up in 7-10 days to obtain an additional supply (e.g., 50 days) of medication to complete a full course of therapy (e.g., 60 days). The initial course of 10 days is recommended based upon the normal twice a day regimen of ciprofloxacin and doxycycline and the availability of 20 tablets in unit-ofuse containers from the National Pharmaceutical Stockpile Program. At the follow-up visit, susceptibility data will be available and drugs may be changed. If it is determined that the strain of Bacillus anthracis is susceptible to ciprofloxacin, doxycycline, and penicillin, then the Post-Exposure Prophylaxis Post- Susceptibility Dispensing Algorithm may be used to determine drug selection and dosing for the followup visit. 50

55 The following steps and numbered paragraphs have been adapted to from the original US PHS document to support and correspond to the flow diagram entitled Post-Exposure Prophylaxis Pre-Susceptibility Dispensing Algorithm. 1. Is the patient younger than 9 years (yrs)? Due to the risk of teeth discoloration associated with tetracyclines, children without a quinolone allergy, who have not received all of their permanent teeth, should be prescribed ciprofloxacin. Since the age at which a child obtains his/her permanent teeth varies, it is possible for children under the age of 9 years to receive doxycycline. The parent or guardian of the child should be asked whether the child has a full-set of permanent teeth. 2. If the patient is female, is she pregnant or breast-feeding? The American College of Obstetricians and Gynecologists Committee on Obstetric Practice recommend the use of ciprofloxacin in pregnant or lactating women for anthrax post-exposure prophylaxis Has the patient had an allergic reaction to any medication in the tetracycline class? Allergic reactions may include: hives, redness of the skin, rash, difficulty breathing, or worsening of lupus after taking one of the following medications: demeclocycline (Declomycin); doxycycline (Adoxa, Bio-Tab, Doryx, Doxy, Monodox, Periostat, Vibra-Tabs, Vibramycin); minocycline (Arestin, Dynacin, Minocin, Vectrin); oxytetracycline (Terak, Terra-Cortril, Terramycin, Urobiotic-250); tetracycline (Achromycin V, Sumycin, Topicycline, Helidac). 7,8 Patients that are allergic to any medication in the tetracycline class should receive another form of therapy such as ciprofloxacin. 4. Does the patient weight less than 99 pounds (lbs) or 45 kilograms (kg)? 5. Patients less than 99 pounds (45 kilograms), should receive an initial supply (e.g., 10 days) of doxycycline 2.2 mg/kg (as described in the chart below) by mouth TWICE a day with a mandatory follow-up appointment within 10 days. At that time, information about the effectiveness of certain medications in preventing anthrax will be available and the drug may be changed. A minimum of 60 days of drug therapy is necessary for the full protective effect. 3 If doxycycline is unavailable, tetracycline 500 mg may be given by mouth 4 times a day. 1 Weight (lbs) Weight (kg) Dose (mg) mg PO BID mg PO BID mg PO BID mg PO BID mg PO BID mg PO BID mg PO BID mg PO BID 20mg tablet Available Dosage Forms of Doxycycline 50mg tablet or capsule 100mg tablet* or capsule 25mg/5mL 50mg/5mL suspension* syrup 2 ml 1 ml 1 4 ml 2 ml 6 ml 3 ml 2 8 ml 4 ml 1 ½ tablet 10 ml 5 ml 3 12 ml 6 ml 14 ml 7 ml 4 16 ml 8 ml 51

56 mg 18 ml 9 ml PO BID > mg PO BID ml 10 ml *Dosage Forms available through the CDC National Pharmaceutical Stockpile Program 6. Patients greater than 99 pounds should receive an initial supply (e.g., 10 days) of doxycycline 100 mg by mouth TWICE a day with a mandatory follow-up appointment within 10 days. At that time, information about the effectiveness of certain medications in preventing anthrax will be available and the drug may be changed. A minimum of 60 days of drug therapy is necessary for the full protective effect. 3 If doxycycline is unavailable, tetracycline 500 mg may be given by mouth 4 times a day Has the patient had an allergic reaction to any medication in the quinolone class? Allergic reactions may include: difficulty breathing, rash, itching, hives, yellowing of the eyes or skin, swelling of the face or neck, cardiovascular collapse, loss of consciousness, hepatic necrosis (death of liver cells), or eosinophilia (a rare skin disease) after taking one of the following medications: acrosoxacin or rosoxacin (Eradacil); cinoxacin (Cinobac); ciprofloxacin (Cipro, Ciloxan); gatafloxacin (Tequin); grepafloxacin (Raxar); levafloxacin (Levaquin, Quixin); lomefloxacin (Maxaquin); moxifloxacin (Avelox, ABC Pak); nadifloxacin (Acuatim); norfloxacin (Chibroxin, Noroxin); nalidixic acid (NegGram); ofloxacin (Floxin, Ocuflox); oxolinic acid; pefloxacin (Peflacine); rufloxacin; sparfloxacin (Zagam, Respipac); temafloxacin; trovafloxacin or alatrofloxacin (Trovan). 8 Patients that have had an allergic reaction to any medication in the quinolone class should be referred to a physician to receive another form of therapy. 8. Is the patient taking probenecid (Benemid)? Probenecid may decrease the renal excretion of ciprofloxacin, therefore increasing the risk of ciprofloxacin toxicity. Patients should be instructed to temporarily stop probenecid until they are evaluated by their primary care physician who will instruct them when to restart probenecid and whether a dosage adjustment is necessary. 9. Is the patient taking theophylline (Elixophyllin, Quibron-T, Slo-BID, Slo-Phyllin, Theo-24, Theochron, Theo-Dur, T-Phyl, Uni-Dur, Uniphyl)? Ciprofloxacin may increase the theophylline levels by inhibiting hepatic metabolism and increase the risk of theophylline toxicity. The dose of theophylline should be decreased by 50% and the patient should be referred to their primary physician regarding drug monitoring. 10. Does the patient have known kidney (or renal) problems? Patients with kidney problems include those receiving dialysis, with known kidney failure (end-stage renal disease) or who have reduced kidney function. Patients who have chronic kidney infections or kidney stones do not need an adjusted dose, unless they have been told by a health care professional that they have kidney damage. Patients with kidney problems who weigh less than 73 pounds should be referred to a physician. 11. Does the patient weigh less than 73 pounds (lbs) or 33 kilograms (kg)? If so, they should be referred to a physician for drug selection and monitoring. 12. Patients 73 pounds (33 kilograms) or greater should receive ciprofloxacin 500 mg by mouth TWICE a day for 10 days with a mandatory follow-up appointment within 10 days. At that time, information about the effectiveness of certain medications in preventing anthrax will be available and the drug may be changed. A full course of therapy (e.g., 60 days) is necessary for the full protective effect. 3 If ciprofloxacin is unavailable, one of the following regimens may be given: ofloxacin 400 mg by mouth twice a day, levofloxacin 500 mg by mouth once a day, gatifloxacin 400 mg by mouth once a day, or monifloxacin 400 mg by mouth once a day. 1 52

57 13. Give patients 73 pounds (32 kilograms) or greater with kidney problems ciprofloxacin 500 mg by mouth ONCE a day and refer them to a physician for further assessment. Use the chart 11 below to determine the dose of ciprofloxacin required for patients with kidney problems when creatinine clearance is known or can be determined. Give all patients an initial supply of medication (e.g., 10 days supply) and schedule a follow-up appointment within 10 days. At that time, information about the effectiveness of certain medications in preventing anthrax will be available and the drug may be changed. A minimum of 60 days is necessary for the full protective effect. 3 Kidney Function Creatinine Clearance >50 ml/min Creatinine Clearance = ml/min Creatinine Clearance = 5-29 ml/min Hemodialysis Ciprofloxacin Dose (milligrams=mg) 500 mg every 12 hours 250 mg every 12 hours 250 mg every 18 hours 250 mg every 24 hours 14. Patients less than 73 pounds (33 kilograms) should receive an initial supply (e.g., 10 days) of ciprofloxacin mg/kg (as described in the chart below) by mouth TWICE a day with a mandatory follow-up appointment in 7-10 days. At that time, information about the effectiveness of certain medications in preventing anthrax will be available and the drug may be changed. A minimum of 60 days of drug therapy is necessary for the full protective effect. 3 This chart purposefully reflects more than one dose for a particular weight to permit flexibility in dosing based upon the products that are available at the time of dispensing. These doses are within the recommended dosing range of ciprofloxacin mg/kg. Weight (pounds) Weight (kilogram) Dose (mg) 7-12 lbs 3-5 kg 50 mg PO BID lbs 6-10 kg 100 mg PO BID lbs 8-13 kg 125 mg PO BID lbs kg 150 mg PO BID lbs kg 200 mg PO BID lbs kg 250 mg PO BID lbs kg 375 mg PO BID >73 lbs > 33 kg 500 mg PO BID Available Dosage Forms of Ciprofloxacin 100mg tablet 250mg tablet 500mg tablet* 250mg/5mL suspension* ½ ¼ 1 ml (1 bottle) 1 2 ml (1 bottle) ½ ¼ 2.5 ml (1 bottle) 1½ 3 ml (1 bottle) 2 4 ml (1 bottle) 1 ½ 5 ml (1 bottle) 1½ ¾ 7.5 ml (2 bottles) ml (2 bottles) Dosage Forms available through the CDC National Pharmaceutical Stockpile Program. 500mg/5mL suspension 0.5 ml (1 bottle) 1 ml (1 bottle) 1.25 ml (1 bottle) 1.5 ml (1 bottle) 2 ml (1 bottle) 2.5 ml (1 bottle) 3.75 ml (1 bottle) 5 ml (1 bottle) 15. A patient may have to be referred to a physician for further assessment and drug selection. If a patient has had allergic reactions to drugs in the quinolone and tetracycline classes, other options for prophylactic (preventative) therapy include: amoxicillin/clavulanate, clindamycin, rifampin, imipenem, aminoglycosides, chloramphenicol, vancomycin, cefazolin, tetracycline, linezolid, or a macrolide (clarithromycin, erythromycin). 1,10 These other drugs are not approved by the Food and Drug Administration for preventative treatment of anthrax and require individual prescribing by a medical doctor or dispensing under an investigational new drug application. 53

58 Appendix Bk: Brochure- How to Prepare Doxycycline for Children and Adults Who Cannot Swallow Pills (See next page) 54

59 Dosing the Doxycycline and Water Mixture Mixed With Food 1. Give all of the Doxycycline and Water and food mixture in the second bowl. This is one dose. 2. Each child or adult should take 1 dose in the morning and 1 dose at night each day. Storing the Doxycycline and Water Mixture (If There Is Enough for Another Dose) If you have enough leftover doxycycline and water mixture for another dose, you can keep it for the next dose. The doxycycline and water mixture can be stored in a covered bowl or cup. Label and date. Keep the mixture in a safe place out of the reach of children. Store the Doxycycline and Water Mixture at room temperature for up to 24 hours. Throw away any unused mixture after 24 hours and make a new Doxycycline and Water Mixture before the next dose. Label and Date SUN MON TUE WED THU FRI SAT Store doxycycline and water mixture at room temperatue and throw out after 24 hours Do not take doxycycline if you have an allergy to tetracyclines Get emergency help if you have any signs of an allergic reaction including hives, difficulty breathing, or swelling of your face, lips, tongue or throat. Doxycycline may cause diarrhea, skin reaction to the sun, loss of appetite, nausea and vomiting. Birth control pills may not work as well if you take doxycycline. Report any reaction to the medication to MedWatch at or FDA-1088 In an Emergency: How to Prepare Doxycycline for Children and Adults Who Cannot Swallow Pills Mixing Doxycycline Hyclate 100mg Tablets with Food Once you have been notified by your federal, state or local authorities that you need to take doxycycline for a public health emergency, it may be necessary to prepare emergency doses of doxycycline for children and adults who cannot swallow pills. June 2008 Prepared by the U.S. Food and Drug Administration

60 Supplies You Will Need You will need these items to make doses of doxycycline for adults and children who cannot swallow pills: 1 doxycycline pill (100 mg) (Do not take doxycycline if you are allergic to tetracyclines) a metal teaspoon 2 small bowls Water one of these foods or drinks to hide the bitter taste of crushed doxycycline: - milk or chocolate milk - chocolate pudding - apple juice and sugar Adding Food to the Doxycycline and Water Mixture to Make It Taste Better 1. Weigh your child. 2. Find your child s weight on the left side of the chart below. 3. Next, look on the right side of the chart to find the amount of the Doxycycline and Water Mixture to mix with food. The chart shows you the amount to give your child for 1 dose. (For a ½ teaspoon dose, fill the metal teaspoon half way. It is better to give a little more of the medicine than not enough). 12 pounds or less 13 to 25 pounds 26 to 38 pounds 39 to 50 pounds 51 to 63 pounds ½ teaspoon 1 teaspoon 1½ teaspoons 2 teaspoons 2½ teaspoons Child s weight: Child s Weight Amount of Doxycycline and Water Mixture Teaspoons 64 to 75 pounds 3 teaspoons = 4 tsp Water after 5 minutes crush pill MIX Crushing the Pill and Mixing with Water 1. Put 1 doxycycline pill in a small bowl. 2. Add 4 full teaspoons of water to the same bowl. 3. Let the pill soak in the water for 5 minutes so it will be soft. 4. Use the back of a metal teaspoon to crush the pill in the water. Crush the pill until no visible pieces remain. 5. Stir the pill and water so it is well mixed. You have now made the Doxycycline and Water Mixture. 76 to 88 pounds 89 pounds or more and adults 3½ teaspoons Use the entire mixture 4. Add the right amount of the Doxycycline and Water Mixture from the chart above to the second bowl. For adults and children 89 pounds and more, use the entire mixture. 5. Add 3 teaspoons of milk or chocolate milk or chocolate pudding or apple juice to the second bowl. If you use apple juice, also add 4 teaspoons of sugar to the second bowl. Stir well. Doxycycline and Water Mixture = 3 tsp Food 6. Go to Step on the next page for dosing. Entire Mixture

61 Appendix Bl: Mass medication dispensing sample client intake forms (See next four pages) 1. Head of Household intake form in English 2. Head of Household intake form in Spanish 3. Anthrax Post-Exposure Assessment/Intake Form 55

62 INSTRUCTIONS: Please FILL OUT all of this form to receive medicine for you and up to 7 other people. Please PRINT Your Name: Address: Phone Number: City: Other Phone Number: Is the person ALLERGIC to any of these medicines? Is the person PREGNANT or Is the person on KIDNEY Doxycycline Ciprofloxacin BREASTFEEDING? DIALYSIS or Vibramycin Cipro have KIDNEY Tetracycline Levofloxacin DISEASE? Sumycin Levaquin Minocycline Ofloxacin Name (First and Last) Minocin Floxin 1. Yourself: Yes No Yes No Yes No Yes No 2. Yes No Yes No Yes No Yes No 3. Yes No Yes No Yes No Yes No 4. Yes No Yes No Yes No Yes No 5. Yes No Yes No Yes No Yes No 6. Yes No Yes No Yes No Yes No 7. Yes No Yes No Yes No Yes No 8. Yes No Yes No Yes No Yes No Staff Use Only: Screener, please indicate medicine to be given. Dispenser, please adhere medication label for each person. Age Weight Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Circle D C A D C A D C A D C A D C A D C A D C A D C A Affix label here D = Doxycycline; C = Ciprofloxacin; A = Amoxicillin Is the person TAKING any of these medicines? Coumadin Theophylline Glyburide Probencid Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Initial Here: Screener: Dispenser: 56

63 INSTRUCIONES: Por favor complete esta forma para que usted y otras 7 personas puedan recibir medicinas. Por favor IMPRIMA Nombre: Dirección: Número de teléfono: Ciudad: Otro teléfono: Edad (menos de 10 años) Peso (menos de 99 libras) Tiene ALERGIAS a algunos de estas medicinas? Doxycycline Vibramycin Tetracycline Sumycin Ciprofloxacin Cipro Levofloxacin Levaquin Ofloxacin Floxin Esta EMBARAZADA o DANDO PECHO? Esta recibiendo DIÁLISIS DEL RIÑON o tiene ENFERMEDAD DEL RIÑON? Primer nombre y apellido Minocycline Minocin 1. Usted: Sí No Sí No Sí No Sí No 2. Sí No Sí No Sí No Sí No 3. Sí No Sí No Sí No Sí No 4. Sí No Sí No Sí No Sí No 5. Sí No Sí No Sí No Sí No 6. Sí No Sí No Sí No Sí No 7. Sí No Sí No Sí No Sí No 8. Sí No Sí No Sí No Sí No Staff Use Only: Screener, please indicate medicine to be given. Dispenser, please adhere medication label for each person. Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Circle D C A D C A D C A D C A D C A D C A D C A D C A Affix med label here D = Doxycycline; C = Ciprofloxacin; A = Amoxicillin Esta TOMANDO algunas de estas medicinas? Coumadin Theophylline Glyburide Probencid Sí No Sí No Sí No Sí No Sí No Sí No Sí No Sí No Initial Here: Screener: Dispenser: 57

64 Anthrax Post-Exposure Assessment/Intake Form Date Completed / / YOUR INFORMATION Last Name First Name MI Employee # (if applicable) Age Date of Birth / / Sex Weight County of residence Address City Zip Home Phone ( ) Cell Phone ( ) Employer Name: Address City Zip Code Work Phone ( ) If we cannot reach you, please give the name and contact number of someone who can find you: Contact Name Contact Phone ( ) WHAT LEVEL OF DECONTAMINATION DID YOU RECEIVE? (Check one) Full shower Wash exposed skin Other (please specify) YOUR PRIMARY PHYSICIAN Physician Name Clinic Name Address City Phone YOUR MEDICAL INFORMATION Are you allergic to any medication(s) or food(s)? Yes No If yes, please list: Have you had any adverse reaction or side effects to either of the following medicines? Quinolones Ciprofloxacin (Cipro), Ofloxacin (Floxin), Levofloxacin (Levaquin) Tetracyclines Doxycycline (Vibramycin), Minocycline (Minocin), Tetracycline (Sumycin) (Achromycin) Do you have kidney disease (not including kidney stones) or are you on dialysis? Were you hospitalized in the past month for pneumonia, meningitis, or unexplained infection? Yes No Yes No Yes No Yes No Are you taking either of the following medications? Probenecid (Benemid; Used for gout) Yes No Theophylline (Used to treat breathing problems; also known as Bronkodyl, Yes No Elixophyllin, Slo-Bid, Slo-Phylline,Theo-24, Theo-Dur, Theolair, or Uniphyl) Please Continue the Assessment/Intake Form on the Reverse Side of this Page 58