JOB ACTION SHEET – Closed Dispensing Site COORDINATOR

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MINNESOTA CITIES READINESS INITIATIVE

Closed Dispensing Site Workbook

Mass Prophylax

100% of a Population in 48 hours

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You often plan for the unexpected — anticipating events and managing situations at hand. Local public health agencies take the same approach to protecting the health and safety of our community. In today’s post-9/11 and -Katrina world, collaboration is more important than ever in the areas of emergency preparedness and homeland security. As we build this bridge of mutual communication and alliance, we’re calling on you to help protect your organization, your employees, residents or members and our community by making your organization a Closed Dispensing Site. Taking a few small steps now to prepare for future public health emergencies will not only protect your assets, but also help prepare the entire community to respond effectively. The workbook introduces a very critical component to protecting your health and safety — providing you with the background and the “know-how” to become a Closed Dispensing Site. The workbook will answer key questions about what it takes to become a Closed Dispensing site, and empower your organization to fully develop such a program jointly with your local public health agency. This workbook is not a complete Closed Dispensing Site plan, but rather a key reference document to help you begin the planning process in conjunction with your local public health agency. This workbook will help you to develop a plan that’s just right for you. We hope that this workbook will help you and your staff develop your Closed Dispensing Site plan — one of the most effective ways to protect yourself and your organization during a public health emergency. We thank you for taking the time and effort to read this workbook.

Welcome

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Table of Contents

I. Overview 1

a. Introduction b. How it Works c. Benefits

II. Pre-Event Preparation 4 III. Event Procedures and Protocols 8

a. Activation b. Notification c. Set-up d. Getting Medications e. Operations

1. Triage 2. Screening 3. Dispensing

f. Deactivation

Appendices 14 a. Memorandum of Understanding b. Plan Template c. Job Action Sheets d. Forms, Guidance and Fact Sheets

Overview 1

Overview

INTRODUCTION In the event of a catastrophic public health emergency, large segments of the population may need to receive preventitive medication quickly. This becomes a daunting task that must be executed with great efficiency. The Cities Readiness Initiative (CRI) was created to provide direct assistance to designated cities throughout the nation to address this vulnerability. CRI is a federal program that helps metropolitan areas increase their capacity to deliver medicines and medical supplies during a large-scale public health emergency. This will build the response capacity needed to provide prophylaxis to 100 percent of their population within a 48-hour period (based on an inhalation Anthrax scenario). People will need preventive medications immediately, so the U.S. Centers for Disease Control ships pre-positioned supplies from its Strategic National Stockpile to local public health agencies.

The Strategic National Stockpile

The Strategic National Stockpile is a national supply of medications and medical supplies to be used for emergency situations such as a bioterrorism attack or natural disaster. Within 12 to 24 hours, the U.S. Centers for Disease Control and Prevention (CDC) can deploy a large shipment from the Strategic National Stockpile, known as a ‘push-pack,’ anywhere in the United States or its territories, to supplement and re-supply state and local health and medical resources. After this initial shipment, additional components such as vendor-specific products and other items from the Strategic National Stockpile may follow. State and local health agencies must have plans in place to receive shipments from the Strategic National Stockpile and distribute their contents to the community quickly and efficiently. The metro region is part of the CRI. Individual jurisdictions comprising the metro region work together under CRI as well as other programs, to ensure the goals set forth are reached. Collaboration between public health and the private sector is a crucial part of this planning effort as well. The use of Closed

Overview 2

Dispensing Sites, discussed in detail in this workbook, is just one of many dispensing methods planned to deliver medication to 100 percent of the population within 48 hours. Contact your local public health emergency planner to learn more about planning efforts currently underway in your community. (Contact information is provided in the back of the workbook.) “Mass Dispensing Sites” will be the main mechanism for the distribution of medicine and medical supplies to healthy people in the area of risk during a large-scale public health emergency. The MDSs are the responsibility of local public health departments. While MDSs will be used to reach the majority of the population, other dispensing strategies will also be brought into play. HOW IT WORKS Dispensing sites are fixed locations where medications from the Strategic National Stockpile can be given out to people in response to a public health threat or emergency.

An OPEN Dispensing Site is a location operated by a local public health department that is open to everyone who lives or works in that community. Open Dispensing Sites are meant to serve the entire public.

A CLOSED Dispensing Site is a location that is operated by a private organization for a specific target group and their families and clients. Closed Dispensing Sites are not open to the public.

Operating a Closed Dispensing Site provides your organization with extra security during a public health emergency. Essentially, you will have the means to help minimize the impact of the emergency on the community and save lives. BENEFITS As a Closed Dispensing Site, you will have a tremendous opportunity to combat the impact of a public health threat or emergency. Together with your local public health department, you will be able to address a variety of pubic health issues in a ground-breaking way. By becoming a Closed Dispensing Site, your organization will be better protected in the event of a public health emergency. You’ll receive and dispense medications and medical supplies directly to your employees and their families and the clients you serve. By

Overview 3

providing the materials and support they need, your organization will help to ensure the general health and well being of not just your employees and clients, but all of those affected by the public health emergency. Closed Dispensing Sites will play an important role in any situation where it is necessary to provide emergency medications to the entire population. Traditional medical providers, such as hospitals and medical clinics will likely be overwhelmed during a large-scale public health emergency. Open Dispensing Sites will also be highly stressed in a situation where the entire population needs to be given medications in a short time frame. Closed Dispensing Sites will help relieve some of the pressure on Open Dispensing Sites by reaching portions of the population independently. As a result, long lines and public anxiety can be reduced and resources will be used more efficiently. Closed Dispensing Sites can also help organizations ensure that their employees and clients are protected — and therefore able to continue working and/or return to work more quickly. Employees will feel secure in knowing that their organization is willing to take the ‘extra step’ to ensure that they and their families are taken care of in the event of a public health emergency. Ultimately, the need to serve the public during a public health emergency is great. Partnering with your local public health agency to become a Closed Dispensing Site is crucial in protecting the health of our citizens and enabling recovery efforts. Please complete the Closed Dispensing Site Planning Worksheet to determine whether your organization has the capabilities to function as a Closed Dispensing Site. After completing this questionnaire, you’ll have a better idea of what your business can or can’t do to dispense medication in an emergency.

Pre-Event Preparation 4

Pre-Event Preparation

Creating Your Dispensing Plan Once you sign up to be a Closed Dispensing Site (CDS) by completing the Memorandum of Understanding, you can prepare your organization to dispense medications in a large-scale infectious disease emergency by creating a dispensing plan that addresses your organization’s specific needs. Each organization is unique in the number and type of its employees and in its business operations and/or the type of services offered and clients served. All of these factors will affect how you go about dispensing medications to your employees and clients. This section will help you identify key areas in which to start developing your CDS plan. You may already have policies and procedures in place within your organization that could easily be incorporated or adapted to fit the needs of a CDS. Ultimately, it is the goal of this guide to help you plan and to describe how you will prepare your organization to dispense medications. Pre-event preparation will include the following sections:

1. Identification of key personnel for operations and getting staff ready.

2. Information regarding to whom you will dispense medications.

o Screening for and dispensing medications to employees and their families

o Screening for and dispensing medications to clients (off-site and/or on-site dispensing)

3. Communications—before, during and after an emergency. 4. Preparing to receive and dispense medications. 5. Receiving and managing inventory. 6. Returning medications when the emergency is over.

1. Identification of Key Personnel for Operations and Getting Staff Ready In this section of your dispensing plan you will identify your organization’s key personnel and provide contact information. You will also identify two backup personnel, who will be able to coordinate the project if your primary personnel are unable to do so. It is also essential to provide these personnel with descriptions of their duties and education about the operation of a CDS.

2. Information Regarding To Whom You Will Dispense Medications


In this section of your dispensing plan you will indicate to whom you will be dispensing medications (employees, employees’ family members, and clients) and provides an estimate of the numbers of employees, employee family members, and clients—both adults and children. This will enable you to determine estimates of the amount of medications you will need in an infectious disease emergency. These numbers may change over time. Please update your plan whenever there is a significant change in your organization.

3. Communications with Your Employees and Clients As a CDS, it is important to communicate with your employees and/or clients before, during, and after the event. In this section of your dispensing plan you will briefly describe how these communications will occur and who will be responsible for them. It is recommended that you share your dispensing plan with employees, especially with those who will have key roles during an emergency. Some key pieces of information to communicate to your employees and/or clients are listed below. These are only suggestions to get you started. Before the event, communicate with your employees about:

Basics of a Closed Dispensing Site and your organization’s dispensing plan.

Roles and responsibilities of employees in an emergency and where they fit in to your plans.

How they are to receive medication for themselves and their families and information they should bring when the medications are dispensed. This information will assist in screening for possible allergies and/or contraindications.

Before the event, you may communicate with your clients about:

General emergency preparedness: How they can keep informed (e.g., radio and TV). The importance of knowing/keeping a list of any drugs

they are allergic to or have been told not to take and of medicines they are taking.

How and what your organization is planning during an emergency.

During the event, communicate with your employees and clients about:

Where and when they will receive their medications. What information they should have in order to receive their

medications.


Drug information sheets for doxycyline and ciprofloxacin, including what they should do if they have a negative reaction to the antibiotic.

How they can keep informed about the emergency. For employees

Where and when to report to work. Their duties and responsibilities for the duration of the

emergency.

After the event, you may communicate with your employees and clients about:

The recommended course of medication as it pertains to the specifics of the emergency or disease.

The outcome of your organization’s dispensing effort. Any questions or concerns they may have and how to find

further information, as needed.

4. Preparing To Receive and Dispense Medications This section describes key preparation activities that should be included in your plan for a CDS. a) Activating your dispensing plan and getting medications is described in detail in Section 3 of this workbook. b) Getting materials ready involves copying enough required materials for the number of people to whom you will be dispensing medications. In this section of your dispensing plan you will indicate how you will copy and organize needed forms.

Drug Information Sheets for Doxycycline and Ciprofloxacin - You should have enough copies of the Drug Information Sheets for Doxycycline and Ciprofloxacin available for distribution to your employees and/or clients. This information will also be publicized widely on the health department website (insert your website address here) and in the media (TV, radio and newspapers).

Job Action Sheets - Designed to assist your organization and your employees in carrying out their duties responsibilities during an emergency and operation of your CDS.

CDS Final Summary Form - To be completed at the end of dispensing medications and operations of your CDS. This provides a brief summary of your efforts. This form should be returned to (insert your LPH) along with any unused medication and the antibiotic inventory tracking form.


All of the required forms should be filed with your dispensing plan in an easy-to-access location. Screening Signs are not included in this kit. You may want to create signs as needed to help direct people to the right places in the appropriate sequence. Other supplies that you may need include:

Cart Tables and chairs Vests and badges to identify staff Clipboards Pens, pencils Sandwich Board

c) Getting site(s) and vehicle(s) ready involves identifying a site(s) and the vehicle(s), (if delivering medications to clients), and determining what you will need to get them ready to dispense medications. You will need to organize copies of forms per site/vehicle and deliver them to the site(s) and vehicle(s).

5. Receiving and Managing Ongoing Inventory In this section, you will identify the person authorized to accept and sign for the medications and where you plan to store them. You will also identify whom you will assign to perform the initial inventory and to manage ongoing inventory. Authorization Letter is attached. 6. Final Report and Return of Leftover Medications When the event is over, the CDS Coordinator is responsible to call LPH for further instructions regarding final reporting and return of any medications.

Event Procedures and Protocols 8

Event Procedures and Protocols

ACTIVATION Once you have signed the Memorandum of Understanding and submitted your Closed Site Dispensing plan, you are eligible to receive medications during a public health emergency requiring mass prophylaxis. When an incident occurs, your organization will be contacted by (insert your LPH) to confirm that you are still able to participate in dispensing medications, to confirm the numbers of medications needed, and to let you know when and where your authorized employee can go to pick up medications. Your estimated numbers of employees, employees’ family members, and clients will determine how many courses of medications your organization will receive. Ideally, your estimates will be accurate and you will receive more than an adequate supply. If it is clear that demand is surpassing your supply, try to request additional medications before you run out. This way you are less likely to be in a position where you must stop operations until more medication can be picked up. If you need to request an additional medications, estimate the number of courses you will need of each type of antibiotic that was in your initial delivery and call the Local Distribution Node Manager: (insert name and number). NOTIFICATION Inform your employees and your clients that you will be dispensing medications and advise them to bring or have available a list of the medications (prescription medications and over the counter drugs, vitamins, minerals and antacids) they take and of any known drug allergies. In addition, you should advise those with small children to bring the weights of their children. Your employees should provide this information available for every member of their household for whom they will be receiving medications. Let your employees and clients know how you plan to dispense medications and your proposed schedule. It may also be helpful to e-mail the screening form to your employees and clients so they will know exactly what questions will be asked and they can come with their forms already completed, if they choose to do so. SET-UP

Employees need to get ready to perform their assigned functions, whether helping clients fill out the screening forms, answering questions, dispensing the medications, or picking up the medications from the local distribution node. If possible, there should be someone who is not dispensing medications to keep track


of the medications, the inventory and the forms (possibly the Site Coordinator). You will need to make copies of the inventory forms, antibiotic screening form and drug information sheets for doxycycline and ciprofloxacin (see attachments). To support your employees in the tasks they will be doing, make copies of the Job Action Sheets for them (see attachments). The goal is to have everything prepared so that when the medications arrive you can start dispensing right away. Make sure your employees who will be dispensing medications to others are the first to receive medications for themselves and their family members. Once employees have taken their first dose, they can then provide medications to others. GETTING MEDICATIONS An employee of your organization who has been authorized to pick up medications must go to the Local Distribution Node Site location that was communicated to you from (insert your LPH). The medications will be in unit-of-use bottles with the bottles packed into boxes. Your organization will receive one or more boxes, and in some cases partially full boxes, depending on the number of employees, employees’ family members and clients to whom you expect to dispense medications. Once the medications are picked up, the boxes of medications should be taken to a secure location (at a minimum, a locked room) and kept away from extreme heat or cold. i. Triage Triage refers to sorting symptomatic from non-symptomatic individuals at the entry to your Closed Dispensing Site. Symptomatic individuals will be referred to their health provider or the hospital and will not receive medication from your closed dispensing site. Non-symptomatic individuals will continue through the process to acquire their medications. At the time of the incident, your Closed Dispensing Site will be provided with a “Triage Client Referral Form” that will include a list of questions that will help you determine who is symptomatic.


ii. Screening One of the greatest values of a CDS is that paperwork can be completed ahead of time for the employees, their families and your clients who will receive the emergency medications. At an Open Dispensing Site, however, large numbers of people will report all at the same time, and everyone must fill out required medical evaluation and contact forms before they can receive medications. The Minnesota Department of Health requires that each person who receives medications from a CDS, fill out an antibiotic screening form. Your organization can provide the necessary forms to employees in advance and keep them on file until they are needed. Information can be updated periodically — perhaps annually — to reflect any changes in health status. When and if an emergency occurs, the forms will be on hand to simplify the dispensing process. As a CDS, you must have medical personnel available who can legally dispense medications. Regulations that identify who can legally dispense medications are determined by state law. Minnesota Statute 144.--- has been expanded to include non-professionals to dispense prophylaxis. These could include: LIST SOME HERE. Your organization may have medical personnel already on staff, or you may choose to arrange for volunteers or outside medical personnel to come into your location. Such an arrangement will require a standing agreement between your organization and the outside staff, including a clear understanding of how such an agreement will be activated at a time where their services will likely be in high demand. Employees who are picking up medications for their household members need to include information on the screening form for each household member. This is important for quality control.


Screening is critical to ensure that people get the antibiotic that is best for them. Some employees and clients may need help completing screening forms. Prepare employees to offer this assistance to people who have low vision, difficulties reading and writing, or who need interpreters. For clients who cannot fill out the form themselves and who do not have a family member to assist them, your organization should have someone ask the client the questions verbally and fill in the answers on the form. It is very important that all of the information on the form is accurate. Training on how to screen the MDH Registration form will be provided to you by your local public health agency. iii. Dispensing Once you have determined the appropriate antibiotic in the screening process, you will be giving the client a 10-day supply of medication. In addition, you will need to: a) Provide the appropriate drug information sheet for

doxycycline or ciprofloxacin with the medications. These sheets will be available on the MDH and (insert your city/county name) web site at (insert your city/county website).

b) Instruct individual to read the drug information sheet.

If after receiving the sheet and reading it over, they feel like they have received the incorrect antibiotic, they should contact their primary care providers, rather than ask you for the other drug. Note: Individuals who are picking up medications for their household need to receive only one drug information sheet for each drug. There is no need to give multiple sheets for the same drug to the same household.

(Insert your city/county name) plans are to dispense a 10-day supply of medications to each person. It is possible that (insert your city/county name) and MDH will determine that everyone needs an additional supply. As a Closed Dispensing Site, you have the option to provide additional medications to your employees, their families and your clients if it is recommended by (insert your city/county name) and MDH.



DEACTIVATION Once dispensing is complete, or you have been notified that the emergency is over, you will notify staff that operations can stop and to return all documentation and unused medication to you. Please ensure that all appropriate staff and families, in addition to clients, have received medication and that dispensing has been properly documented. You must unused medication to your local public health department as per the Memorandum of Understanding. Complete the CDS Summary Form should be returned to (insert your LPH) along with any unused medication and the antibiotic inventory tracking form. Please refer to the Agency Closing Checklist for deactivation procedures.

Appendices 14

Appendices

MEMORANDUM OF UNDERSTANDING PLAN TEMPLATE JOB ACTION SHEETS FORMS, GUIDANCE AND FACT SHEETS

Sample Memorandum of Understanding 15

Memorandum of Understanding between Local Public Health Department

And ________________________________

(Name of Entity) This Memorandum of Understanding is made and entered into between the Local Public Health Department (LPH) and _____________________ ___________ (Entity) on this the ___day of _________, 200X. WHEREAS, a local and state emergency has been declared under MN State Statute, Chapter 12, Emergency Management Act; and WHEREAS, LPH is a public agency with jurisdiction over all public health matters within City/County, State; and WHEREAS, LPH will be responsible as appropriate for prophylaxis of residents and visitors in City/County; and LPH provides needed prophylaxis to Name of Entity and, WHEREAS, Name of Entity is capable of receiving and distributing medications to their population, i.e., staff and members of their households, residents/guests, during a declared emergency, WHEREAS, persons legally authorized to dispense prophylaxis has been expanded to include non-professionals as authorized in Minnesota State Statute, Chapter 12, Emergency Health Powers Act, (Page 5, Paragraph 3) or Statute 12.34, Subdivision 1, paragraph 1; and WHEREAS, LPH will provide supervision as required by Emergency Vaccine Administration; Legend Drug, Minnesota Statute, Chapter 12, Section 144.4197. Therefore, it is mutually agreed between the parties as follows:

1. Name of Entity and LPH shall mutually support each other in planning for an emergency incident, including Name of Entity providing a contact person(s) to work with LPH and develop a plan for receiving and dispensing prophylaxis at Name of Entity’s facility including methods of notification, critical staff contact information, plan activation steps, and plans for storage and distribution of medications.

2. LPH shall provide advance training to Name of Entity staff that will function in

key positions in distributing prophylaxis. LPH will provide routine informational messages to the facility to relay to staff and their households, and facility residents/guests.

3. Name of Entity shall provide appropriate personnel to be trained in advance to

dispense prophylaxis and agrees to update staff periodically with new information provided by LPH.


4. LPH shall provide electronic and/or hard copy of all forms and information sheets to be distributed prior to and during an event. Name of Entity shall make all copies needed and provide all printed information for staff and their households and facility residents/guests.

5. LPH shall provide the proper standing orders and medical protocols as defined

by Minnesota State law at the time of the event. 6. Name of Entity shall provide to LPH the maximum potential number of staff and

households, and facility residents/guests so that an adequate supply of prophylaxis may be picked up by Name of Entity upon activation of the emergency plan.

7. Name of Entity shall provide any updates of their dispensing plan to LPH.

8. Name of Entity shall conduct pre-event screening using a form created by the

Minnesota Department of Health for all staff and their households, and residents when possible, and those assessments shall be maintained and updated at least annually.

9. Name of Entity shall provide one available staff to pick up prophylaxis and

instructions for staff and their households, and facility residents/guests.

10. Name of Entity shall dispense prophylaxis provided by LPH as per the protocol provided at time of event by the MDH and/or CDC.

11. Name of Entity shall not charge individuals a monetary fee for medications,

vaccines, or administration as provided by LPH through this agreement.

12. Name of Entity shall maintain an accurate record of the number of medications distributed by Name of Entity during an event and provide those to LPH as requested.

13. Name of Entity shall provide ongoing information to staff and their households,

and facility residents/guests as directed by LPH during an emergency.

14. Name of Entity shall provide a climate-controlled, secure room to store prophylaxis during an emergency.

15. Name of Entity shall return any unused medication or materials to LPH upon

conclusion of the emergency response as directed by LPH. 16. LPH shall provide the option to participate in periodic exercises to test plans for

dispensing of prophylaxis at the facility. It is understood that:


1. Confidentiality of all patient information will be maintained in accordance with the current Minnesota Health Insurance Portability and Accountability Act (HIPAA) by both Name of Entity and LPH.

2. Name of Entity will only provide medication or vaccine to identified staff, family,

and groups as outlined in their plan and will not provide medication or vaccine to the “general public”.

3. The participation of Name of Entity is voluntary and may not be utilized at the

time of an event. In such case, staff and identified groups of that entity would need to obtain medications or vaccine via LPH operations and will not receive preferential treatment.

Signatures By signing below, I agree to all of the above stated conditions and statements. I understand that this agreement may be modified or terminated by mutual agreement of both parties. Dated:________________________ Dated:_____________________

LPH Name of Entity

(Name) (Name)

(Title) (Title)

Approved as to Form:

Name Attorney for City/County

NOTE: THIS IS JUST A SAMPLE MOU – EACH LPH WILL NEED TO HAVE THEIR LEGAL DEPARTMENT DRAFT A JURISDICTION-SPECIFIC MOU.

Sample Authorization Letter 18

(Insert your logo here)

AUTHORIZATION LETTER For Medication Pickup

Month Date, Year Through the powers of the (City/County) Public Health Department this letter authorizes the _________________to send a representative with appropriate identification to pick up medications in the event of a declared mass prophylaxis situation. Names of Authorized Personnel: Primary Courier: Backup Courier: Backup Courier: Through self report your agency indicated that at max capacity you have:

Clients: Staff: (will be multiplied by 3 for family members) Max authorized pick up =

Please take this letter and the appropriate ID to the Local Distribution Node for pick up of medication. Appropriate identification includes State or federally issued ID (Drivers license, DMV ID card, or Passport) or Agency picture identification. Sincerely, Closed Dispensing Site Coordinator, Executive Director, Administrator or Manager Fill this section out and bring full letter with you to the Local Distribution Node. Please indicate actual numbers of clients and staff below:

Number of Staff ____________ X 3 = __________ Please provide as accurate an estimate as possible of the number of clients/residents/population to whom you will dispense meds ______________ Total meds you need today (not to exceed Max Authorized*) ______________ *If your organization has undergone major growth since this letter was created please send documented proof of expansion.

Plan Template

Closed Dispensing Site Plan Template Preparing your Organization to Dispense Medications You can fill in this template by filling in the information or use it to guide the development of your organization’s dispensing template. Use as much space as you need. Electronic copies are available from LPH. Additional guidance is provided in the Closed Dispensing Site Workbook.

1. Identification of Key Personnel for Operations

Closed Dispensing Site Coordinator

Primary Name Phone # Secondary Phone # Email Address

Secondary Name Phone # Secondary Phone # Email Address


Getting staff ready for CDS responsibilities: Based on the number of employees, families, or clients to whom you are planning to dispense medication, calculate the number of employees that will be needed, in addition to those identified above, to dispense medications in a timely manner. Employees may serve in multiple roles. You may refer to the Communications section for training and pre-event messages to communicate to employees and identified CDS personnel. Approximate total number that will receive medication via CDS (total from page 1)

Estimated number of Personnel needed to dispense medications (think about supplies, dispensing, screening, etc.)

Position Primary Name and Number Secondary Name and Number Courier

Security Officer

Information Officer

Greeter

Triage

Medication Screener

Medication Dispenser

Educator

Plan Template

2. Information Regarding to whom You will Dispense Medications

Approximate Number

Approximate Number (Adults)

Children <18 & Weigh <100lbs.

Employees

Employee Family Members

Volunteers

Volunteer Family Members

Contractors

Contractor Family Members

Clients

Client Family Members

Screening for and Dispensing Medications to Employees and their Families When you organize dispensing to employees and their family members, it will be important to dispense to those employees who will be dispensing medications to other employees first. Dispensing to Clients Not Applicable, we will only dispense to those groups as indicated above.

Our clients are: (Check as many as apply.)

Homebound Living in a Residential Facility (Please name: ___________________________) Living in a Skilled Nursing or Similar Facility (Please name: ____________________) Disabled Seniors Homeless Have behavioral health challenges Other-Please describe:___________________________________________________

We will dispense medications to clients at:

Clients’ homes Our organization’s CDS Other-Please describe:___________________________________________________

Screening for and Dispensing Medications to Clients If you have clients who cannot or are unlikely to go to a Public (Open) Mass Dispensing Site, describe how you will screen and dispense medications to your clients

Plan Template 21

3. Communications

Primary Information Officer Phone # Secondary Phone # Email Address

Secondary Information Officer Phone # Secondary Phone # Email Address

For smooth operation of your Closed Dispensing Site, it is important to think about communications and how information will be distributed to key people involved with your plan. At the time of activation, there will be a lot of information from several sources. Disseminating information to appropriate personnel ahead of time will prepare your organization to quickly and efficiently activate your Closed Dispensing Site. Your employees, clients and their family members will feel better knowing what to expect when coming, or sending their loved one, into work. Think of what works best for your organization.

Communication Materials When? To Whom? How? How Often? Basics of the CDS Plan, including when plan will be activated

Paper Electronic Verbal

Pre-Event JIT During Event Post Event

Key Personnel Employees/Volunteers/Contractors Clients CDS Personnel

Mailing In-Person Training Email Verbal (Telephone)

Roles & Responsibilities





How to receive medications





Information needed at time of medication dispensing





Importance of keeping a current list of medications and allergies





Plan Template 22

Drug information Paper Electronic Verbal




Recommendations for course of medications





General Emergency Preparedness





How to stay informed





Communication plans and guidelines





Where and when to report to work





Signs and symptoms of disease and what to do





Signs of an allergic reaction and what to do





Screening forms Paper Electronic Verbal




Plan Template 23

4. Preparing To Receive and Dispense Medications a. Activating your dispensing plan and preparing for antibiotic delivery: When an emergency has been declared, LPH will contact your CDS Coordinator and back-up coordinator to inform them: 1) if the CDS Program will be activated and 2) when and where you may go to pick up medications. At that time, you can activate your dispensing plan. Once the Local Distribution Node is open, LPH will contact you to confirm that your organization still wants to dispense medications, to confirm the numbers needed, and to confirm that you have necessary documentation required to pick-up medications. b. Getting materials ready: Estimate the number of copies you will need for each of the following:

Do you have a copier that you can use for this copying? Yes No If no, how will you get copies made? __________________________________________________________________________________________________________________________________________ c. Getting site(s) and vehicle(s) ready: The amount of site preparation will depend on the number of people you plan to dispense medications to at your organization—whether its a small number of employees, or a large number of employees, or employees, families, and clients.

How many sites will you have? Where will the site(s) be?

What will you have to do to get site(s) ready to screen for and dispense to staff/clients?

Person Responsible for Copying and Distribution to appropriate personnel

Item Number Needed

Primary Secondary

Your Dispensing Plan

Antibiotic Inventory Forms

Drug Interaction/Information Sheets Doxycycline Ciprofloxacin Amoxicillin

Job Action Sheets Checklists CDS Final Summary Form

Plan Template 24

If delivering medications (e.g., to client homes), what will you have to do to get vehicles ready to screen for and dispense to clients?

5. Receiving and Managing Inventory a. Obtaining medications: Person who will be authorized to pick up and sign for the medications: Primary Name Phone # Secondary Phone # Email Address Position?



The person who is authorized to pick-up the medications must present 1) a state or federally issued ID, 2) an organization ID or signed letter from the Director explicitly authorizing that person to pick up the medications, and 3) the medication pickup authorization letter (Attached). If brought to the facility, the medications should be stored in a secure location (at a minimum a locked room) and kept away from extreme heat or cold. b. Managing Inventory Where do you plan to store the medications?

What measures will you take to keep medications safe and secure if delivering to clients by vehicle?

Do you have an inventory system in place to track medications?

Yes-We will use this system to track the medications from the LPH department.

No-(Template available for paper tracking)

When dispensing is complete, all remaining medications must return to the secure room where medications were stored upon arrival. 6. Final Report and Return of Leftover Medications When the event is over, the CDS Coordinator is responsible to call LPH for further instructions regarding final reporting and return of any medication.

Job Action Sheets 25

Closed Dispensing Site INCIDENT COMMAND Job Action Sheet Site Coordinator

Site Coordinator

Name:_____________________________________________________________

Site: ____________________________________________________________

Job Shift(s): _______________________________________________________

You Report To: ________________________________

You Supervise: Closed Dispensing Site Dispensers

Mission: Responsible for the overall operation of the Closed Dispensing Site. Provide oversight and direction resulting in the smooth operation of the site. Function as decision-maker for the site. Act as lead contact to local health department. Coordinate the overall Closed Dispensing Site effort at your organization. Equipment: Telephone, Closed Dispensing Site Plan, Checklists, Layout Qualifications: Familiar with Closed Dispensing Site Plan, leadership and organizational skills Before Shift: Communicate the Closed Dispensing Site Plan to your employees and inform them of

their responsibilities in the effort. Read this entire Job Action Sheet and organizational chart. Review Job Action Sheets of all staff you supervise. Provide orientation to staff you supervise. Send authorized staff person to the CDS Distribution Site to pick up medications. Request status reports from staff you supervise and confirm readiness to

open/operate site. Communicate with your employees and clients that you will be dispensing

medications. Copy dispensing materials.

During Shift: Monitor functioning of site

Address issues brought forth by employees you supervise Monitor dispensing of medications on-site Ensure appropriate screening and drug dispensing Ensure distribution of drug information sheets

After Shift: Assist with clean up as necessary

Participate in scheduled debriefing sessions Check out at the Check-in/Check-out Station Ensure non-distributed medications are returned to LPH


Closed Dispensing Site LOGISTICS Job Action Sheet Courier

Courier

Site: ___________________________________________________________

Position Assigned To: ________________________________________________

Job Shift(s):_______________________________________________________

You Report To: __________________ (______________)

Mission: Responsible for picking up medications for your organization’s Closed Dispensing Site and delivering them to your site Equipment: Well-maintained vehicle, mobile phone Job Qualifications: Background Check including valid and clear driver license, willing and able to receive pretreatment if required, exercise and simulation participation Before Shift: Familiarize self with Closed Dispensing Site Plan During Shift: Pick up medications at specified location and bring to your organization After Shift: Transport unused medication back to specified location


Closed Dispensing Site INCIDENT COMMAND Job Action Sheet Security Officer

Security Officer

Site: __________________________________________________________________

Position Assigned To: ______________________________________________________

Job Shift(s): _____________________________________________________________

You Report To: _____________________ ( ______________)

You Supervise: _______________

Mission: Organize and enforce the safety and security of all staff, facilities, supplies, and clients. Equipment: Telephone, two-way radio, staffing roster, appropriate security equipment Job Qualifications: Background in security or law enforcement is preferred, but not required. Before Shift: Arrive at assigned site 2.5 hours prior to start time. Check in and receive site

orientation at the Check-in/Check-out Station. Read this entire Job Action Sheet and organizational chart on back. Review assignments and Job Action Sheets of all security staff. Attend Closed Dispensing Site Coordinator orientation meeting. Assure secure receipt and storage of on-site equipment and supplies. Obtain staffing roster from the _________, compare to all staff entering the clinic. Establish secure entry for staff and clients; secure staff rest area. Assign security staff to entrances/exits. Distribute Job Action Sheets and provide all

necessary orientation. Provide all necessary equipment, including staffing roster, to security staff. Establish ambulance entry and exit routes. Establish media area in consultation with the Public Information Officer, if needed.

During Shift: Monitor security needs, including at pedestrian/vehicular traffic control, triage,

supply storage, and all other clinic areas, as needed. Request backup from local law enforcement as necessary.

Follow up on all reports of suspicious/potentially dangerous activities, and take appropriate action.

Assist security staff with problem solving, and make any changes as necessary. Attend Closed Dispensing Site Incident Commander update sessions. Problem solve with the Closed Dispensing Site Coordinator and Information Officer Request extra security for the dispensing site as needed. Determine break coverage plan for self and security staff.

After Shift: Participate in scheduled debriefing sessions.

Make any changes to the Closed Dispensing Site security plan for the next shift, as necessary.

Contribute to summary of outcome of the site. Check out at the Check-in/Check-out Station.


Closed Dispensing Site INCIDENT COMMAND Job Action Sheet Information Officer

Information Officer

Name: ___________________________________________________ ________

Site: ____________________________________________________________

Job Shift(s): _______________________________________________________

You Report To: Closed Dispensing Site Coordinator

Mission: Disseminate information regarding the Closed Dispensing Site process.

Equipment: Communications Plan, telephone, computer with internet connectivity, pre-printed handouts/information Before Event: Basics of a Closed Dispensing Site and your organization’s dispensing plan

Roles and responsibilities of employees in an emergency, and where they fit in to your plans

How they are to receive medication for themselves and their families and information they should bring when the medications are dispensed. This information will assist in screening for possible allergies and/or contraindications

General emergency preparedness How they can keep informed

During Event: Where and when they will receive medications

What information they should have in order to receive their medications Drug information sheets for doxycycline and ciprofloxacin, including what they

should do if they have a negative reaction to the medication How they can keep informed about the emergency Advise where and when to report to work Advise duties and responsibilities for the duration of the emergency

After Event: Advise recommended course of medication as pertains to the specifics of the emergency or disease

Summarize outcome of your organization’s Closed Dispensing Site effort Answer questions or concerns as they arise


Closed Dispensing Site OPERATIONS Job Action Sheet Greeter

Greeter

Site: ____________________________________________________________


Job Shift(s): _______________________________________________________

You Report To: _____________________________________ (_______________)

Mission: Welcome clients, assure eligibility, provide forms/packets, and answer questions at the start of the dispensing process. Before Shift: Check in and receive site orientation at the Check-in/Check-out Station.

Read this entire Job Action Sheet and organizational chart. Receive orientation from the _______________. Familiarize self with Closed Dispensing Site process, forms and eligibility

requirements, if necessary. Assist with set-up of stations as needed.

During Shift: Welcome clients as they enter the site.

Direct client to appropriate station. Verify completion of antibiotic screening form and/or direct to completion of

antibiotic screening form. Answer client questions regarding the dispensing process and/or forms.

After Shift: Assist with clean-up as necessary for next shift.

Participate in scheduled debriefing sessions. Check out at the Check-in/Check-out Station.


Closed Dispensing Site OPERATIONS Job Action Sheet Triage

Triage

Site: ____________________________________________________________


Job Shift(s): _______________________________________________________

You Report To: _______________________________________ (_____________)

Mission: Assess clients for Closed Dispensing Site by sorting symptomatic from non-symptomatic clients. Before Shift: Check in and receive site orientation at the Check-in/Check-out Station.

Read this entire Job Action Sheet and organizational chart. Receive orientation from _____________. Familiarize self with triage process and site layout. Familiarize self with antibiotic screening form eligibility restrictions and disease

symptoms. Familiarize self with Triage Client Referral Form

During Shift: Determine symptomatic from non-symptomatic clients

Inform symptomatic clients that they are ineligible for prophylaxis at your Closed Dispensing Site and provide Triage Client Referral Form

Direct non-symptomatic clients to appropriate station

After Shift: Assist with clean-up as necessary for next shift. Participate in scheduled debriefing sessions. Check out at the Check-in/Check-out Station.


Closed Dispensing Site OPERATIONS Job Action Sheet Medication Screener

Medication Screener

Site: ____________________________________________________________


Job Shift(s): _______________________________________________________

You Report To: ___________________________________ (Lead Medication Screener)

Mission: Review completed antibiotic screening form. Equipment: MDH Oral Antibiotic Registration Form, Algorithm

Qualifications: EMT, Paramedic, LPN, RN, or other*

*When the governor, a mayor, county board chair, or designee has declared an emergency the commissioner of health may authorize any person licensed or otherwise to administer vaccinations or legend drugs

Before Shift: Check in and receive site orientation at the ____________________.

Read this entire Job Action Sheet and organizational chart. Receive orientation from the Lead Medication Screener. Familiarize self with antibiotic screening form.

During Shift: Review antibiotic screening form for evidence of contraindication or potential drug

interaction to first-or second-line medication. Refer clients with contraindications/interactions to first- or second-line medication

to _______________ Use medication algorithm to determine appropriate first- or second-line medication,

formulation, dosage, and amount for each client and whether any special instructions need to be given to client. Document on antibiotic screening form for each client.

Send client with antibiotic screening form to Medication Dispenser. Request supplies from the ___________________ Request break coverage from the ___________________.




Closed Dispensing Site OPERATIONS Job Action Sheet Medication Dispenser

Medication Dispenser

Site: ____________________________________________________________


Job Shift(s): _______________________________________________________

You Report To: __________________________ (________________________)

Mission: Dispense proper dosage, formulation, and amount of medications for each client.

Before Shift: Check in and receive site orientation at the Check-in/Check-out Station.

Read this entire Job Action Sheet and organizational chart. Receive orientation from the __________________. Assist in setting up dispensing station with necessary supplies. Familiarize self with dispensing and documentation process.

During Shift: Review antibiotic screening form to determine type, formulation, dosage, and

amount of medication for each client. Record lot number of medication(s) on registration form and on medication

container. Record name of client on medication container. Bag up medication containers for clients picking up for multiple people. Give medications to client. Retain registration forms for collection. Request additional supplies from the ___________________. Request break coverage from the ______________________.



IF YOU ENCOUNTER A PROBLEM WHILE DISPENSING, CONTACT YOUR CLOSED DISPENSING SITE COORDINATOR IMMEDIATELY


Closed Dispensing Site OPERATIONS Job Action Sheet Educator

Educator

Site: ____________________________________________________________


Job Shift(s): _______________________________________________________

You Report To: __________________________________________ (Lead Educator)

Mission: Educate clients about the Closed Dispensing Site process and forms, the disease and the prophylaxis agent. Assist clients in completing forms. Qualifications: Experienced Health Educator preferred; comfortable with public speaking

Before Shift: Check in and receive site orientation at the Check-in/Check-out Station.

Read this entire Job Action Sheet and organizational chart. Receive orientation from the Lead Educator. Familiarize self with Closed Dispensing Site process and forms. Review all educational materials.

During Shift: Provide information (via script or video) to clients about the mass dispensing

process and forms, the disease, and the medication/vaccination. Assist clients in completing forms. Answer questions regarding the dispensing process and/or forms. Refer those with additional questions to the Lead Educator. Request break coverage from the Lead Educator.



Checklists 34

CDS Agency Set-Up Checklist Upon activation of the agency CDS plan, Site Coordinator or designated personnel will complete the following procedures: (Please note that this is a general guide, add or remote elements to fit the needs of each CDS)

Item Procedure Completed

1

Review CDS plan and staff assignments to ensure availability of personnel to staff identified key positions, re-assign staff as needed

2 Communicate activation of CDS plan to employees/clients

3 Contact LDN/LPH liaison to confirm procedures for medication pick up and security clearance process at LDN

4 Dispatch courier to LDN for medication pick-up

5

Copy needed forms and fact sheets Inventory forms MDH screening forms Doxycycline information sheet Ciprofloxacin information sheet Amoxicillin

6 Schedule & notify relevant staff about CDS workforce briefing

7 Set up screening and dispensing area per layout design

8

When courier returns from LDN, conduct initial Inventory of medication. If not ready to start dispensing, store medication in cool, dry and secure location

9 Conduct briefing for personnel assigned to work at the CDS

10

11

12

Checklists 35

CDS Workforce Briefing Checklist This briefing will be conducted for all CDS workforce and should take no longer than 30 minutes. The Site Coordinator or a delegate is responsible for conducting the briefing. (Note that this is only a general outline, and is not all inclusive) Item Subject Completed

1

Incident Overview (Why CDS plan has been activated) Describe the incident that precipitated the response effort Include information about location, population impacted Use information from LPH/MDH to explain transmission risk,

symptoms and treatment

2

Scope of Operation (What has to be accomplished) Explain who will be served by this CDS, Discuss the anticipated duration of CDS operations Discuss tasks to be accomplished, including process to acquire

medication supplies from LDN, MDH Registration forms, distribution of medication supplies

3

Operating procedure (How this CDS will operate) Explain CDS set up and flow plan Identify leadership roles and who is filling what roles Describe process for communicating internally (among CDS

workforce) and externally (workforce to family members) Describe process for breaks and shift changes

4

Safety and Security (How CDS staff will be protected) Describe PPE requirements (if) identified by MDH/LHD Explain site security measures (eg requirement for ID badges) Identify steps CDS workforce should take if they observe

someone who does not have a badge Advise CDS workforce to report all suspicious activity to a

supervisor

5

Media & External Inquiries (Where to direct inquiries) Identify Lead Staff to whom CDS workforce should direct all

inquiries (from media and others) about CDS operations, including requests made via phone or emails

6

Job Specific Training (to explain duties in more details) Use job assignment and job action sheets to provide more

detailed description of duties Explain who CDS workers should contact if have questions while

performing duties

7 Other information determined at event

Checklists 36

CDS Agency Closing Checklist Upon notification of the Agency demobilization the Site Coordinator (or designated personnel) will complete the following procedures. (Please note that this is a general guide, add or remote elements to fit the needs of each CDS)

Item Subject Items of Importance

1

Notify CDS workforce of projected closing time

2 Instruct CDS workforce to complete all remaining operational tasks

3

Ensure all personnel and families (if appropriate) have received medication and appropriate paperwork

4

Ensure unused medical supplies are placed in secure location until they are returned to LDN/LPH.

Personnel sign in/out form

Inventory forms

5

Ensure all documentation has been completed

CDS Final Summary Form

6 Ensure clean-up of Agency work space

7

Provide workforce with final briefing Anticipated follow up issues (e.g. 2nd

dosages) Opportunities for workforce to bring up

concerns about operations, share lessons learns for future operations

8

Provide workforce with final briefing

9 Contact LDN/LPH liaison to confirm procedure for returning unused medical supplies

10

Retain/store all completed documentation until further notice

Forms, Guidance and Fact Sheets 37

ANTIBIOTIC INVENTORY TRACKING SHEET

Time Medication Lane 1 Lane 2 Lane 3 Lane 4 Totals for CDS

Doxycycline Cipro

Amoxicillin Doxycycline

Cipro Amoxicillin

Doxycycline Cipro


Cipro Amoxicillin

Doxycycline Cipro


Cipro Amoxicillin

Doxycycline Cipro


Cipro Amoxicillin

Doxycycline Cipro

Amoxicillin Cipro

Amoxicillin

Regimen Totals

Doxycycline Cipro Amoxicillin Initial Regimens

Rcv'd

Re-Supply Rcv'd

Regimens Dispensed

Amount Remaining


NOTE: At the time of an event, the most current form will be provided to you by your local health department.


CDS Final Summary Final Summary Form

To be completed at the end of dispensing medications and operations of your CDS. This form provides a brief summary of your efforts. Please fill in the appropriate information and return, with a copy of the Antibiotic Inventory Tracking Sheet, to your Local Public Health agency. Please list all personnel who acted as Site Coordinator

Name Phone Number Times of Shift

How many people were referred to a primary care provider or hospital? Have there been any reported adverse reactions to the medications? Yes No If yes, please explain. Name of person with reaction

Medication received at CDS

Date of Reaction

Actions Taken (Referred, given info, etc.)

Attach additional sheets if necessary. Name of person completing this form: ________________________________________(Please Print) Signature of person completing form: ____________________________________Date:___________


Express

*Check answer to question #5 (weight), if under 75 lbs. provide “Doxycycline Special Instructions – Children” *Dispense one 10-day regimen of doxycycline

Level 2

* For all yes answers to the questions, check those conditions or medications on the Drug Interaction Sheet * Follow Drug Interaction Sheet instructions * Check answer to question #5 (weight), if under 75 lbs. provide “Special Instructions – Children” for specific medication * Dispense medication as instructed on the Drug Interaction Sheet

Questions #2, 3, 4 - At least one answer is yes Question #1 is “no”

Look at Questions #7 and #8

Both are “no”

At least one is “yes”

Level 1 Level 2

* Check answer to question #5 (weight) * Adjust dosage for weight if needed and provide dosage sheet. * Check answer to question #6, if yes check Drug Interaction Sheet and adjust schedule accordingly. * Dispense one 10-day regimen of Ciprofloxacin

* For all yes answers, check those conditions or medications on the Drug Interaction Sheet and follow the instructions * Check answer to question #5 (weight) * Adjust dosage for weight if needed and provide “Special Instructions – Children” for specific medication * Dispense medication as instructed on the Drug Interaction Sheet

For each client, check answers 1-4 on the form

(3 initial possibilities)

Forms Reviewer and Screener Algorithm

INTERIM VERSION JUNE 2007 Use with “Client Screening – Anthrax, Plague, or Tularemia Post-Exposure

Prophylaxis (Interim Version June 2007)”

Questions #1, 2, 3, 4 - all answers are “no”

Question #1 - Answer is yes (a letter C, D, G, I, P, or T indicates a “yes” answer)

Start

Drug Interactions and Contraindications Directions for Dispensing to Level 1 and Level 2 Clients

INTERIM VERSION JUNE 2007 • Use with “Client Screening – Anthrax, Plague or Tularemia Post-Exposure Prophylaxis” • Doxycycline is the primary drug dispensed except in a U.S. Postal Service Biodetection System response. • Ciprofloxacin is the primary drug dispensed in a U.S. Postal Service Biodetection System response. • Check the instructions under “Recommended Option” column for every medication or condition in Q. 1-8

on Client Screening form. Utilize the “Alternate Option” column if the primary recommendation does not fit the client’s situation.

Med/History Recommended Option Alternate Option 1. Accutane (Isotretinoin)

• Give Ciprofloxacin. • If Ciprofloxacin is contraindicated, and Doxy is given, also provide the Health Care Provider (HCP) letter.

2. Allergic to Doxycycline and Ciprofloxacin

*For ANTHRAX ONLY. Amoxicillin is not indicated for plague or tularemia.

• Give Amoxicillin • Amoxicillin is given three times per day. • Specific Investigational New Drug (IND) forms

and protocols may be required for each patient given Amoxicillin.

• If the disease agent is not anthrax, refer to licensed provider on or off-site for alternate antibiotic.

3. Allergic to or unable to take Doxycycline, Ciprofloxacin and/or Amoxicillin

• Consult physician regarding a prescription for an alternative medication. May have to assist in finding a pharmacy to fill prescription.

• Give HCP letter and write instructions under “Other Information”.

• Consider the treatment protocols for the specific disease agent.

4. Allergic to Ciprofloxacin

• Give Doxycycline. For ANTHRAX ONLY, amoxicillin is not indicated for plague or tularemia.

• If client cannot take Doxycycline, provide Amoxicillin.

• See #3 5. Allergic to doxycycline

• Give Ciprofloxacin. • If can’t take Ciprofloxacin, refer to medical advisor.

6. Already taking: Amoxicillin Ciprofloxacin or Doxycycline

• If Doxycycline primary and on Doxycycline: • If on Doxycycline, ensure Doxycycline dose is at

least recommended dose. Instruct to take for the recommended number of days or can dispense Doxycycline and take both Tetracyclines concurrently.

• If on Ciprofloxacin, can take Doxycycline concurrently

• If on Ciprofloxacin and can’t take Doxycycline, ensure Ciprofloxacin dose is at least recommended dose, not to exceed 1500 mg/day. Instruct to take for the recommended number of days.

• If Ciprofloxacin is primary and on Ciprofloxacin: • If on Ciprofloxacin, ensure Ciprofloxacin dose is at

least recommended dose, not to exceed 1500 mg/day. Instruct to take for the recommended number of days.

• If on Amoxicillin, can take either Doxycycline or Ciprofloxacin concurrently.

• If unable to take Doxycycline or Ciprofloxacin, ensure amoxicillin (anthrax only) is at least recommended dose three times daily for recommended number of days and IND forms may be required for each patient given Amoxicillin. If Emergency Use Authorization (EUA) is activated the forms will be available by MDH via workspace.

• Use of other antibiotics is not contraindicated with Amoxicillin, Ciprofloxacin, or Doxycycline

Dispensing Directions for Level 1 or Level 2 Clients INTERIM VERSION JUNE 2007


Med/History Recommended Option Alternate Option 7. Amoxicillin, already taking. See #6 “Already taking Amoxicillin, Ciprofloxacin or Doxycycline”. 8. Ciprofloxacin, already taking. See #6 “Already taking Amoxicillin, Ciprofloxacin or Doxycycline”.

9. Coumadin (Warfarin)

• If Doxycycline is primary, give Doxycycline and give HCP letter.

• If Ciprofloxacin is primary, give Ciprofloxacin and give HCP letter.

• If can’t take Ciprofloxacin or Doxycycline and is anthrax give Amoxicillin

• If not anthrax, consider treatment protocol for the agent

10. Cyclosporine • Give Doxycycline. • If Ciprofloxacin dispensed, give HCP letter. Digoxin • If Doxycycline is primary, give Doxycycline and

give HCP letter. • If Ciprofloxacin is primary, give Ciprofloxacin

and give HCP letter.

• If can’t take Ciprofloxacin or Doxycycline and is Anthrax give Amoxicillin

• If not Anthrax, consider treatment protocol for the agent

11. Dilantin (Phenytoin)

• Give Doxycycline. • If Ciprofloxacin dispensed, give HCP letter.

12. Glyburide • Give Doxycycline. Give HCP letter. • If Ciprofloxacin dispensed, give HCP letter 13. Insulin • Give Doxycycline. Give HCP letter. • If Ciprofloxacin dispensed, give HCP letter. 14. Kidney failure, renal insufficiency or is on dialysis

• Give Doxycycline.

• If Ciprofloxacin dispensed, reduce frequency of Ciprofloxacin to recommended dose once daily and give HCP letter.

15. Lithium • Give Ciprofloxacin. • If Doxycycline dispensed, give HCP letter. 16. Methotrexate (MTX) • Give Ciprofloxacin. • If Doxycycline is dispensed, give HCP letter.

• If Amoxicillin is dispensed, complete EUA or IND forms (available on Workspace).

17. Phenobarbital • Give Ciprofloxacin. • If Doxycycline dispensed, increase dose of Doxycycline to twice recommended dose twice daily. Give two times number of bottles recommended.

• Give HCP letter. 18. Pregnant, breastfeeding, or under six months of age

• Give Ciprofloxacin. • If Doxycycline dispensed, give the HCP letter. • If Amoxicillin (anthrax only) is dispensed fill

out EUA or IND paperwork, which may be required for each patient given Amoxicillin (anthrax only). EUA or IND forms will be available by MDH via workspace .

19. Probenecid (Benemid)

• Give Doxycycline and give HCP letter. • If Ciprofloxacin dispensed, give HCP letter.

20. Rifampin • Give Ciprofloxacin. • If Doxycycline dispensed increase dose of Doxycycline to twice recommended dose twice daily. Give two times number of bottles recommended.

• Give HCP letter. 21. Ropinirole • Give Doxycycline. • If Ciprofloxacin dispensed, give HCP letter. 22. Tegretol (Carbamazepine)

• Give Ciprofloxacin.

• If Doxycycline is dispensed increase dose of Doxycycline to twice recommended dose twice daily. Give two times number of bottles recommended.

• Give HCP letter. 23.Tetracycline or Doxycycline, already taking. See #6 “Already taking Amoxicillin, Ciprofloxacin or Doxycycline.”

24. Theophylline • Give Doxycycline. • If Ciprofloxacin dispensed, reduce Theophylline dose in half, give HCP letter.

25. Tizanidine • Give Doxycycline.

• If Ciprofloxacin dispensed, give HCP letter.

Categories of Medications Referred To On Client Screening Form Generic and Brand Names - INTERIM VERSION JULY 2007

Instruction Example: “Q. 1 - Coumadin” under “Warfarin” heading means that the eight medications listed should be treated the same as “Coumadin” in Question 1 on the Client Screening form)

Use with “Client Screening – Anthrax, Plague, or Tularemia Post-Exposure Prophylaxis (Interim Version June 2007)”


Digoxin (Q. 1)

Digitek Digoxin Lanoxi-caps Lanoxin

Warfarin (Q. 1 – Coumadin)

Apo-Warfarin Athrombin-K Carfin Coumadin Jantoven Panwarfin Sofarin Warfarin

Insulin (Q. 1)

“Common Brands”

Humalin Humalog Lantus Novolin Novolog

Glyburide (Q. 1)

Apo-Glyburide Daonil DiaBeta Euglucon Gen-Glybe Glubate Glucophage Glucovance Glyburide Glynase Micronase

Probenecid (Q. 1)

Benemid Benuryl Colbenemid Probalan Probecid Proben-C Probenecid

Isotretinoin (Q. 4 - Accutane)

Accutane Amnesteem Claravis Isotretinoin Isotrex Roaccutan Sotret

Lithium (Q. 4)

Cibalith Eskalith Liskonum Lithane Lithium Lithobid Lithonate Lithotabs

Methotrexate (Q. 4)

Abitrexate Folex Folex Ifamet Ledertrexate Methotrexate Mexate MTX Rheumatrex Trexall

Phenobarbital (Q. 4)

Barbidonna Bellamine Bellergal Donnata Eskabarb Levsin PB Luminall Phenobarbital

Rifampin (Q. 4)

Rifadin Rifamate Rifampin Rifater Rifinah Rimactan Rimactane Rimactane/INH Dual Pack Rofact

Cyclosporine (Q. 7)

Cyclosporine Gengraf Neoral Restasis Sandimmune

Theophylline (Q. 7)

Aerolate Slo-Bid Theochron Theoclear Theo-Dur Theolair Theophylline Theo-SR Uniphyl

Ropinirole (Q. 7)

Repreve Requip Ropinirole

Tetracyclines (Q. 1 and 2 -Doxycycline)

Achromycin Adoxa Ak-ramycin Ak-ratabs Apo-doxy Arestin Bio-tab Bristacycline Centet-250 Cyclinex Cyclopar Declomycin Demeclocycline Doxy-cap Doxycycline Dynacin Ep-mycin Ledermycin Lemtrex Martet Minocin Minocycline Minotab Monodox Nor-tet Oxykessotetra Oxytetracycline Panmycin Periostat Retet Rexamycin Robitet Sumycin Teline Terak Terra-cortril Terramycin Terrastatin Tetrachel Tetracycline Tetracyn Tetralan Tetram Tetrex Topicycline Uri-tet Urobiotic Vectrin Vibramycin Vibratab

Quinolones (Q. 7 and 8 –

Ciprofloxacin)

Acuatim Avelox Chibroxin Ciloxan Cinobac Cinoxacin Cipro Cipro cystitis pack Cipro hc Cipro xr Ciprofloxacin Enoxacin Eradacil Floxin Gatifloxacin Grepafloxacin Levaquin Levofloxacin Lomefloxacin Maxaquin Moxifloxacin Nadifloxacin Nalidixic acid Neggram Norfloxacin Noroxin Ocuflox Ofloxacin Omniflox Oxolinic Peflacine Pefloxacin Penetrex Quixin Raxar Rosoxacin Ruflox Rufloxacin Sparfloxacin Temafloxacin Tequin Trovafloxacin Trovan Uroquina Utibid Vigamox Zagam Zymar

Carbamazepine (Q. 4 - Tegretol)

Carbamazepine Carbatrol Epitol Equetro Tegretol

Phenytoin (Q. 7 Dilantin) Dilantin Epanutin Epanutin Phenytek Phenytoin

Zanaflex (Q. 7 – Tizanidine)

Tizanidine Zanaflex

Alphabetized List of Medications Referred To On Client Screening Form Generic and Common Brand Names – INTERIM VERSION JULY 2007

Directions: If a client’s current medication is on this list, utilize the name following it in parentheses ( ) for the Client Screening form. Use with “Client Screening – Anthrax, Plague, or Tularemia Post-Exposure Prophylaxis (Interim Version June 2007)”


A Abitrexate Folex (Methotrexate) Accutane (Accutane) Achromycin (Doxycycline) Acuatim (Ciprofloxacin) Adoxa (Doxycycline) Aerolate (Theophylline) Ak-ramycin (Doxycycline) Ak-ratabs (Doxycycline) Amnesteem (Accutane) Apo-doxy (Doxycycline) Apo-Glyburide (Glyburide) Apo-Coumadin (Coumadin) Arestin (Doxycycline) Athrombin-K (Coumadin) Avelox (Ciprofloxacin)

B Barbidonna (Phenobarbital) Bellamine (Phenobarbital) Bellergal (Phenobarbital) Benemid (Probenecid) Benuryl (Probenecid) Bio-tab (Doxycycline) Bristacycline (Doxycycline)

C Carbamazepine (Tegretol) Carbatrol (Tegretol) Carfin (Coumadin) Centet-250 (Doxycycline) Chibroxin (Ciprofloxacin) Cibalith (Lithium) Ciloxan (Ciprofloxacin) Cinobac (Ciprofloxacin) Cinoxacin (Ciprofloxacin) Cipro (Ciprofloxacin) Cipro cystitis pack (Ciprofloxacin) Cipro hc or xr (Ciprofloxacin) Ciprofloxacin (Ciprofloxacin) Claravis (Accutane) Colbenemid (Probenecid) Coumadin (Coumadin) Cyclinex (Doxycycline) Cyclopar (Doxycycline) Cyclosporine (Cyclosporine)

D Daonil (Glyburide) Declomycin (Doxycycline) Demeclocycline (Doxycycline) DiaBeta (Glyburide) Digitek (Digoxin) Digoxin (Digoxin) Dilantin (Dilantin) Donnata (Phenobarbital) Doxy-cap (Doxycycline) Doxycycline (Doxycycline) Dynacin (Doxycycline)

E Enoxacin (Ciprofloxacin) Epanutin (Dilantin)

Epanutin (Dilantin) Epitol (Tegretol) Ep-mycin (Doxycycline) Equetro (Tegretol) Eradacil (Ciprofloxacin) Eskabarb (Phenobarbital) Eskalith (Lithium) Euglucon (Glyburide)

F Floxin (Ciprofloxacin) Folex (Methotrexate)

G Gatifloxacin (Ciprofloxacin) Gen-Glybe (Glyburide) Gengraf (Cyclosporine) Glubate (Glyburide) Glucophage (Glyburide) Glucovance (Glyburide) Glyburide (Glyburide) Glynase (Glyburide) Grepafloxacin (Ciprofloxacin)

H Humalin (Insulin) Humalog (Insulin)

I Ifamet (Methotrexate) Insulin (Insulin) Accutane (Accutane) Isotrex (Accutane)

J Jantoven (Coumadin)

L Lanoxi-caps (Digoxin) Lanoxin (Digoxin) Lantus (Insulin) Ledermycin (Doxycycline) Ledertrexate (Methotrexate) Lemtrex (Doxycycline) Levaquin (Ciprofloxacin) Levofloxacin (Ciprofloxacin) Levsin PB (Phenobarbital) Liskonum (Lithium) Lithane (Lithium) Lithium (Lithium) Lithobid (Lithium) Lithonate (Lithium) Lithotabs (Lithium) Lomefloxacin (Ciprofloxacin) Luminall (Phenobarbital)

M Martet (Doxycycline) Maxaquin (Ciprofloxacin) Methotrexate (Methotrexate) Mexate (Methotrexate) Micronase (Glyburide) Minocin (Doxycycline) Minocycline (Doxycycline) Minotab (Doxycycline) Monodox (Doxycycline)

Moxifloxacin (Ciprofloxacin) MTX (Methotrexate)

N Nadifloxacin (Ciprofloxacin) Nalidixic acid (Ciprofloxacin) Neggram (Ciprofloxacin) Neoral (Cyclosporine) Norfloxacin (Ciprofloxacin) Noroxin (Ciprofloxacin) Nor-tet (Doxycycline) Novolin (Insulin) Novolog (Insulin)

O Ocuflox (Ciprofloxacin) Ofloxacin (Ciprofloxacin) Omniflox (Ciprofloxacin) Oxolinic (Ciprofloxacin) Oxykessotetra (Doxycycline) OxyDoxycycline (Doxycycline)

P Panmycin (Doxycycline) Panwarfin (Coumadin) Peflacine (Ciprofloxacin) Pefloxacin (Ciprofloxacin) Penetrex (Ciprofloxacin) Periostat (Doxycycline) Phenobarbital (Phenobarbital) Phenytek (Dilantin) Phenytoin (Dilantin) Probalan (Probenecid) Probecid (Probenecid) Proben-C (Probenecid) Probenecid (Probenecid)

Q Quixin (Ciprofloxacin)

R Raxar (Ciprofloxacin) Repreve (Ropinirole) Requip (Ropinirole) Restasis (Cyclosporine) Retet (Doxycycline) Rexamycin (Doxycycline) Rheumatrex (Methotrexate) Rifadin (Rifampin) Rifamate (Rifampin) Rifampin (Rifampin) Rifater (Rifampin) Rifinah (Rifampin) Rimactan (Rifampin) Rimactane (Rifampin) Rimactane/INH Dual Pack (Rifampin) Roaccutan (Accutane) Robitet (Doxycycline) Rofact (Rifampin) Ropinirole (Ropinirole) Rosoxacin (Ciprofloxacin) Ruflox (Ciprofloxacin) Rufloxacin (Ciprofloxacin)

S Sandimmune (Cyclosporine) Slo-Bid (Theophylline) Sofarin (Coumadin) Sotret (Accutane) Sparfloxacin (Ciprofloxacin) Sumycin (Doxycycline)

T Tegretol (Tegretol) Teline (Doxycycline) Temafloxacin (Ciprofloxacin) Tequin (Ciprofloxacin) Terak (Doxycycline) Terra-cortril (Doxycycline) Terramycin (Doxycycline) Terrastatin (Doxycycline) Tetrachel (Doxycycline) Tetracycline (Doxycycline) Tetracyn (Doxycycline) Tetralan (Doxycycline) Tetram (Doxycycline) Tetrex (Doxycycline) Theochron (Theophylline) Theoclear (Theophylline) Theo-Dur (Theophylline) Theolair (Theophylline) Theophylline (Theophylline) Theo-SR (Theophylline) Tizanidine (Tizanidine) Topicycline (Doxycycline) Trexall (Methotrexate) Trovafloxacin (Ciprofloxacin) Trovan (Ciprofloxacin)

U Uniphyl (Theophylline) Uri-tet (Doxycycline) Urobiotic (Doxycycline) Uroquina (Ciprofloxacin) Utibid (Ciprofloxacin)

V Vectrin (Doxycycline) Vibramycin (Doxycycline) Vibratab (Doxycycline) Vigamox (Ciprofloxacin)

W Warfarin (Coumadin)

Z Zagam (Ciprofloxacin) Zanaflex (Tizanidine) Zymar (Ciprofloxacin)

Interim Version June 2007


Health Care Provider (HCP) Letter

Special Instructions for You and Your Clinic Regarding the Medication Dispensed in a Public Health Emergency

Client Name Date / / Information for you: This letter is a reminder of the special instructions that you or your child received regarding

medication. Please share this information with your health care provider. Questions that you have about your medication or health condition(s) should also be directed to your health care provider.

Standard directions are printed on each medication bottle; your directions may be different. Your medication directions are:

Take Doxycycline 100 mg twice/day for days (Standard adult dose and schedule)

Take according to the “Special Instructions: Children” for days

Take Ciprofloxacin mg twice/day for days

Take Ciprofloxacin mg once/day for days

Take Amoxicillin mg three times/day for days

Information for your clinic: Your patient was seen at a public health antibiotic dispensing site. The antibiotic listed above was indicated and dispensed. These special instructions are provided due to a patient condition or medication already prescribed that may need attention.

If it is determined that antibiotic use is required for longer than the number of days indicated above, there will be a public announcement.

Patient and Clinic Information: Read those below that have a

Accutane: Doxycycline could cause blurred vision and headaches. Call your clinic or go to Urgent Care if symptoms occur.

Allergic to or unable to take Doxycycline and Ciprofloxacin: dispensed.

Already taking Amoxicillin, Ciprofloxacin or Doxycycline: The dose of your current antibiotic may have been increased or the number of days for you to take it extended for adequate coverage. You could also be on your original antibiotic plus the antibiotic given to you at the Mass Dispensing Site. Call clinic to inform them if you have any gastrointestinal problems.

Coumadin (Warfarin): Doxycycline or Ciprofloxacin may enhance Coumadin’s effect, which could increase the risk of possible bleeding. Call clinic within 1 week to see if prothrombin time or INR is needed earlier than normal. Report abnormal bleeding to your clinic.

Cyclosporine: Ciprofloxacin may result in increased serum creatinine. Call your clinic within 2 days to see when they want to do a serum creatinine level and to monitor renal function.

Digoxin: Doxycycline or Ciprofloxacin may increase digoxin levels. Call your clinic within 1 week to monitor/test for digoxin toxicity.



Dilantin or Phenytoin: Ciprofloxacin may increase or decrease phenytoin levels. Call your clinic within 1 week to make an appointment to monitor the drug level.

Glyburide: Ciprofloxacin can result in sudden low blood sugars; doxycycline sometimes also causes low blood sugars. Monitor blood sugars more frequently and call your clinic to report if they are abnormal.

Insulin: Ciprofloxacin can result in sudden low blood sugars; doxycycline sometimes also causes low blood sugars. Monitor blood sugars more frequently and call your clinic to report if they are abnormal.

Kidney failure, Renal Insufficiency, on Dialysis: reduce Ciprofloxacin frequency to 1 dose per day instead of 2 per day. This is due to decreased renal clearance of the drug. Call your clinic within 2 days to monitor renal function.

Lithium: Doxycycline alters effectiveness of lithium. Call your clinic within 2 days to make an appointment to monitor lithium level.

Methotrexate: Doxycycline and amoxicillin can rapidly cause serious toxicity. Call your clinic within 24 hours to see if Methotrexate dose needs adjustment or can be temporarily discontinued during antibiotic treatment. The interaction is delayed and likely to be related to impairment of the renal excretion of the methotrexate.

Phenobarbital: Doxycycline’s effectiveness decreased, doxycycline dose is doubled twice a day.

Pregnant, Breastfeeding, or under 6 months old: doxycycline could cause dental staining of the infant’s primary teeth, possible depressed bone growth, defective dental enamel, and rare liver toxicity in pregnant women. Call your clinic within 1 week to inform them you or your child is on Doxycycline in case they want to monitor.

Probenecid (Benemid): stop the Probenecid because it will increase antibiotic serum levels of both Doxycycline and Ciprofloxacin. Call your clinic within two days to inform them that it was recommended that Probenecid be stopped until antibiotic regimen is completed. For Your Information: if Probenecid was prescribed for gout, Colchicine can be used because it doesn’t react with either Doxycycline or Ciprofloxacin. Talk with your clinic.

Rifampin: reduces Doxycycline’s effectiveness. Doxycycline dose is doubled twice a day. Call your clinic to monitor for signs of infection.

Ropinirole: Ciprofloxacin may cause toxicity. Call your clinic within three days to monitor for signs of toxicity. Report agitation, confusion, sedation, nausea and vomiting or dizziness to your clinic.

Tegretol or Carbamazepine: doxycycline half-life is reduced from 16 to 7 hours. Doxycycline dose is doubled twice a day.

Theophylline, Ciprofloxacin can alter the effectiveness of Theophylline. Reduce the Theophylline dose by half. Call your clinic to report that the Theophylline dose was reduced while taking Ciprofloxacin. Report an abnormally rapid heartbeat, an irregular heartbeat, seizures, vomiting, or a skin rash to your clinic.

Tizanidine, Ciprofloxacin can enhance the effectiveness of Tizanidine and could lower the blood pressure significantly. Call your clinic or Urgent Care immediately to report light headedness or fainting.

Other Information:



Average Weight by Age Girls and Boys

• If the weight of a child is unknown, use this chart to determine the approximate weight based on the

child’s age. • Give one bottle of pills per member of the household regardless of the weight or give the number of

bottles of suspension indicated on the “Pediatric Doses for Doxycycline & Ciprofloxacin.” • Hand out the information sheet titled “Doxycycline Special Instructions: Children or “Ciprofloxacin

Special Instructions: Children” or both, whichever is appropriate.

Girls Age Boys Average Weight Average Weight

Pounds Pounds 9 Newborn 10 15 3 months 16 20 6 months 21 23 9 months 24 25 12 months 27 27 15 months 29 28 18 months 30 31 2 years 32 37 3 years 39 44 4 years 45 50 5 years 52 56 6 years 58 65 7 years 66 80 8 years 76 90 9 years 87 104 10 years 100


NOTE: Doxycycline, Amoxicillin, and Ciprofloxacin Antibiotic - Client Instructions and Information sheets are available in English, Lao, Oromo, Hmong, Serbian, Croatian, Bosnian, Vietnamese, Khmer (Cambodian), Russian, Somali and Spanish and will be made available during the time of an event.








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www.yourwebsite.mn.us

JOB ACTION SHEET – Closed Dispensing Site COORDINATOR

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