New Jersey Mass Prophylaxis Manual

Transcription

1 New Jersey Mass Prophylaxis Manual New Jersey Department of Health and Senior Services Communicable Disease Service Bioterrorism Unit January 2005

2 Acknowledgements The New Jersey Department of Health and Senior Services would like to thank the following LINCS Bioterrorism Nurses for their input in the development of the manual: Christine Cooper, Atlantic County Health Department Nancy Gerrity, Camden County Department of Health Jennifer Horner, Burlington County Health Department Mary Pat Hastings, Cape May County Health Department Gladys Nay, Hunterdon County Department of Health NJDHSS also extends sincere appreciation to the following external reviewers for their time and valuable feedback. Kate Bond, Paterson Division of Health Sharen Clugston, Hamilton Township Division of Health Dot Harth, Warren County Health Department John Middleton, MD, Raritan Bay Medical Center Ronald Nahass, MD, Infectious Disease Associates Joy Spellman, Gloucester County Department of Health NJDHSS - January

3 Mass Prophylaxis Clinic Guidelines Table of Contents Chapter Page 1. Introduction Clinic Operations and Management Clinic Flow Plan (Appendix A) ICS Organizational Chart (Appendix B) Mass Clinic Command Structure (Appendix C) 3. Personnel Duties and Responsibilities..20 Staffing Recommendations (Appendix D) Staffing Numbers (Appendix E) 4. Equipment and Supplies Personal Protective Equipment Medications and Standing Orders Communication Education and Training Special Populations Evaluation NJDHSS - January

4 Mass Prophylaxis Clinic Manual Glossary ADA BDS CDC EOC EOP FAQ HERC ICS JIC LINCS MAIN Line MOA MOU NJDHSS OEM PEP PIO POD PPE RESS SNS USPS American s with Disabilities Act Biological Detection System Centers for Disease Control and Prevention Emergency Operations Center Emergency Operations Plan Frequently Asked Questions Health Educator/Risk Communicator Incident Command Center Joint Information Center Local Information Network Communication System More Assessment and Information Needed (MAIN) Line Memorandum of Agreement Memorandum of Understanding New Jersey Department of Health and Senior Services Office of Emergency Management Post Exposure Prophylaxis Public Information Officer Point of Dispensing Personal Protective Equipment Registration, Education and Self-Screening Strategic National Stockpile United States Postal Service NJDHSS - January

5 Chapter 1: Introduction Purpose: The New Jersey Department of Health and Senior Services (NJDHSS) has developed this manual, based on guidelines from the Centers for Disease Control and Prevention (CDC) and our experience with anthrax post-exposure prophylaxis and smallpox preparedness efforts, to define the roles, resources, and materials needed to plan and conduct a mass prophylaxis clinic. Revised following the functional exercises of October 2004, this manual identifies logistical and staffing issues for the clinic planning team to consider when establishing a structure to provide medication to specifically defined populations during a public health emergency. Clinic planning teams in all jurisdictions should adopt the principles outlined here as closely as possible. This will assure uniformity of operations across the state, and facilitate statewide allocation of resources. Assumptions: A mass prophylaxis clinic can exist only within the context of an overall community emergency operations plan based on guidelines issued by the New Jersey Office of Emergency Management (OEM). Issues such as security, transportation, site selection and public information are integral to the success of the clinic; however, these issues will not be discussed in detail in this manual. The focus of this manual is the set-up and operation of the actual clinic (also known as Point of Dispensing, POD), and assumes that other related issues are addressed at the county level, in the formal emergency response plan. The contents of this manual assume a throughput (number of patients seen per unit time) of 1,000 participants per hour to distribute pills, 500 per hour to immunize against influenza, and 250 per hour to vaccinate for anthrax or smallpox. NJDHSS - January

6 Other assumptions made in the development of this manual are: 1. Prophylaxis refers to any intervention aimed at prevention or amelioration of disease among well individuals; it can also be called preventive treatment. 2. Mass prophylaxis clinics will be conducted at the most local level, coordinated by the LINCS agency, under the direction and guidance of state and federal authorities as outlined in the New Jersey Emergency Operations Plan. 3. Anytime a mass prophylaxis clinic is opened, the State Emergency Management System is activated. 4. The purpose of a mass prophylaxis clinic is to rapidly distribute/administer medication regimens to identified populations, and educate recipients about the risks/benefits of the regimen. 5. While patient throughput is an important consideration, a precautionary approach (i.e., appropriate medical screening for contraindications) is the paramount requirement of the clinic. 6. The standard model of patient care (i.e., a one-on-one dialog that includes history-taking, assessment, education and feedback) is modified in the New Jersey mass prophylaxis model. Patient selfscreening of health issues and self-declaration of education are heavily relied upon to judge suitability to receive medication. This adapted care model may feel uncomfortable to licensed health professionals accustomed to practice in normal clinical settings. Nevertheless, it is required to process very large numbers of people in an efficient and timely manner. 7. While patient privacy and confidentiality are normally important considerations, high patient throughput is unquestionably more important in a mass prophylaxis model. 8. Decisions about the types of medication/vaccination supplies and populations to be treated will be made at the federal and/or state level at the time of the event. 9. Medication/vaccination provisions will be supplied using state channels specified in the state Strategic National Stockpile Plan, and as warranted by the incident/situation. NJDHSS - January

7 10. The choice to be vaccinated/medicated rests with each participant. Individuals who choose not to participate, or have a contraindication to the proposed treatment, are subject to isolation or quarantine. 11. Non-clinical activities in support of the mass prophylaxis clinic operations (e.g., law enforcement, traffic control, site security) shall be accomplished as outlined in the jurisdiction s Emergency Operations Plan (EOP). 12. Medication regimens described in this manual are deemed medically appropriate as of July 2004 and may be updated as knowledge changes. 13. Patients must be provided with information regarding how to deal with medication side effects/adverse events and a means to relay concerns about medication regimens. 14. A participant s City/County/State of residence (e.g., a California resident presenting in Cape May, or a Monmouth County resident presenting in Middlesex County), native language, and physical disabilities are NOT valid reasons to deny admittance to a mass prophylaxis clinic. NJDHSS has made every effort to incorporate practical approaches to mass prophylaxis in this manual. The goal is to provide a sound template for planning and implementing mass clinics in a coordinated and consistent manner throughout the state. NJDHSS - January

8 Lessons Learned from Past Prophylaxis/Vaccination Clinics in New Jersey ( ) The New Jersey public health system has planned for and/or implemented: 1. Anthrax post-exposure prophylaxis (PEP) clinics in 2001, 2. Distribution of potassium iodide pills to residents and workers of counties within 10 miles of the nuclear power plants in the state in 2002, 3. Twenty-three (23) smallpox preparedness vaccination clinics at nine sites throughout the state in 2003, and 4. Possible anthrax post-exposure prophylaxis for the United States Postal Service (USPS) as a result of a confirmed test in the Biohazard Detection System (BDS) at major USPS Processing and Distribution Centers in These efforts enabled the New Jersey public health system to learn valuable lessons that will aid all members of the preparedness planning teams, both at the state and local level, arrange for efficient mass prophylaxis clinics/pods. Many of the assumptions discussed previously were derived from these past experiences, as well as New Jersey s emergency response to natural disasters. POD managers must not lose sight of the fact that the planning for and opening of a Mass Prophylaxis Clinic/POD must be done in context with the jurisdiction s EOP. This will save a tremendous amount of time that can be devoted to more appropriate public health issues and needs of clinic operations. A jurisdiction s Emergency Operations Center (EOC) already has plans to handle security requirements and traffic control related to disaster management centers. These plans are easily applied to the Mass Clinic Operations Model. NJDHSS - January

9 Other important lessons learned from those four prophylaxis/vaccination dispensing experiences/models are: The mass prophylaxis effort must be tied in with a corresponding public education effort. In each of New Jersey s prophylaxis efforts, specific, targeted and sometimes elaborate educational materials (e.g., fact sheets, Q & A s, press releases, posters, videos) were developed to reach and communicate with the various targeted and non-targeted populations. Inter-agency cooperation and coordination are vital to the success of a mass prophylaxis event. Prior to 2001, NJDHSS did not have plans for operating a mass prophylaxis clinic. However, with the support of CDC, USPS, and hospital partners, NJDHSS was able to organize and operate a clinic within 24 hours of the decision to provide PEP. For each smallpox preparedness vaccination clinic, staffing was dependent upon strong working relationships among the numerous area public health and healthcare agencies. No one organization or institution could have operated any of these centers on its own. A mass prophylaxis effort requires many types of workers. General staffing for clinics included a medical/nursing component, a pharmacy component, an administrative/support component, a counseling component and general operations component (which included security). Flexibility in staffing PEP centers is crucial. Some members of the public will attend the clinic based on their own needs and beliefs, regardless of public information messages. At the St. Francis Center where PEP was offered to business visitors to the non-public areas of the (Hamilton) post facility, and at the preparedness smallpox clinics, a NJDHSS - January

10 significant number of individuals expected did not attend, and a number of eligible individuals who did come, deferred receiving medication. In most cases, only exposed people, and not the general public, will be receiving prophylaxis. Articulating clear eligibility criteria and verifying these at Triage helps maintain order at the front door and ensures that targeted individuals receive PEP in a timely and thorough manner. For example, a brief triage form was used at the anthrax PEP clinics to assess exposure criteria of individuals who came to the clinic. Those who did not fit these criteria (the worried well ) were offered background materials and the opportunity to talk to a crisis counselor. Mass prophylaxis operations draw a great deal of public interest and media attention. Hospital switchboards, local and state health department emergency numbers, the USPS and numerous local physicians received huge volumes of calls about who should get treated, and how, and why. Information sheets were prepared for individuals handling the phones, and were also used for individuals entering the clinic sites. NJDHSS - January

11 Chapter 2: Clinic Operations and Management Intentional release of a weaponized infectious agent could result in a mass casualty incident with many exposed individuals. The large-scale prophylaxis effort required by such an event could quickly overcome the present public health system that is so effective in containing small natural outbreaks. Therefore, a streamlined model of care is necessary to dispense/administer medication to large groups of people in a short period of time. The mass prophylaxis model is unlike any of the customary clinical settings in which healthcare professionals usually practice. In it, the normal one-on-one dialog between patient and healthcare provider is largely replaced by patient self-assessment and self-declaration of medical or educational concerns. The clinical professional accepts the statements made on the form by the patient, and bases medication dispensing on them. Individualized assessment and teaching are greatly reduced or eliminated. Considerations such as privacy, normally an essential part of patient care, will have to be sacrificed to manage large numbers of people quickly and efficiently. Nevertheless, certain fundamental aspects of care must be maintained. These elements will be detailed in this chapter. This manual is constructed using the clinic flow outlined in Appendix A, found at the end of this chapter. Note that this diagram illustrates the various paths through which a participant might pass; it is NOT meant to be a floor plan for the clinic. Each individual prophylaxed at the POD will pass through either the MAIN line or the Fast Track, depending on how they answer the questions on their POD form. Depending on community needs and resources, a jurisdiction may operate multiple sites for mass prophylaxis clinics based on varied target populations. For example, one clinic may handle contacts and exposed populations, and another be devoted to medical personnel, public health workers and first responders. Depending on the circumstances and level of exposure, special populations may be provided prophylactic care at a location that is not a POD. For instance, residents of group homes or incarcerated individuals may have NJDHSS - January

12 clinic services brought to them. In an extreme emergency requiring prophylaxis for the entire population, a combination of pulling participants to a POD, and pushing medications to participants in home or work settings will be needed. The mass prophylaxis model adapted by NJDHSS has four separate but interdependent parts. Each is vital to the overall function of the clinic, and a problem in one will have a negative impact on all of the others. The four parts of clinic operations are as follows: Public information campaign Pre-POD area POD area Support functions Public Information Campaign The purpose of the public information campaign is to educate the public about the disease, its prevention, and what to do if they believe that they have been exposed. Through the campaign, public health professionals will clearly define the population at risk and provide them with specific instructions. Equally as important, the populations NOT at risk will be defined, and will receive general information on what to do to remain safe. The campaign should begin as soon as an event is suspected, and be updated frequently. In conjunction with the campaign, an emergency call center that can be reached through an 800 number should be opened. A properly run public information campaign can do much to prevent panic and make POD operations run more smoothly. First, it will cut down on crowds by encouraging non-eligible persons to stay at home. Additionally, the campaign will make POD registration forms available online and in newspapers, and in such public places as libraries, places of worship and malls. In this way, POD participants can arrive at the clinic with registration forms already filled out. The NJDHSS - January

13 NJDHSS POD model allows one individual to bring forms and pick up medications for the entire household. Pre-POD Area The Pre-POD area is a free-standing unit that receives and attends to all members of the public who believe themselves to be in need of treatment. Its main function is to prevent sick and non-eligible individuals from entering the actual dispensing clinic. Depending on the incident, the Pre-POD area may have to deal with 3-10 times more people than actually enter the POD and receive medication. Some members of the public may ignore or disbelieve the messages of the public information campaign; others may not even hear them. In any case, all people who come to the Pre-POD area will need to be triaged, and they may receive counseling, health education, or transportation services. Because the Pre-POD area will be dealing with larger numbers of people than the POD itself, it is vital that it be fully staffed with clinical, mental health, and health education professionals. In addition, a full security and law enforcement component must be on duty at all times. All individuals who enter the POD to receive medication must be screened and cleared through the Pre-POD area. They should be identified with a wrist bracelet, hand stamp, or other means that quickly identifies them to security staff at the POD entrance. Those persons who are sick or do not meet criteria for entrance to the POD must be provided with education and crisis counseling as appropriate, or with transportation to acute care facilities and/or treatment centers. The Pre- POD area must be physically separated from the POD site so that participants who have not been cleared will be unable to access the POD area. It may be set-up near the entrance to the POD in a weather-protected temporary structure, for example, or it may be set up on one floor of a building where the POD is on another floor. Another option is to set up the Pre-POD at an off-site location with bus transport to the POD. This is preferable since it NJDHSS - January

14 offers greater control of access to the POD. In some jurisdictions, multiple Pre- POD areas might be set-up in several locations, each feeding to a single POD. POD Area Participants who meet eligibility criteria and are not sick will receive prophylaxis at the POD by passing through a specified series of workstations. Security and law enforcement staff must control the POD entrance, and only allow access to persons who have been identified as eligible by Pre- POD staff. After being admitted to the POD, individuals will be sent through one of three paths: Fast Track MAIN Line POD Sick Bay Participants who self-identify as having no medical contraindications or questions about medications are directed through the Fast Track where they receive medication without stopping at the medical screening or education stations. It is expected that about 80% of persons admitted to the POD will be processed through the Fast Track. Participants who self-identify with medical or educational issues are directed through the More Assessment & Information Needed path, the MAIN Line. Here participants stop at the medical screening, health education, or medical consultation workstations where they can have questions answered and the proper medication can be determined, according to predetermined parameters. The terms Fast Track and MAIN Line will be used throughout this manual to denote these paths, but should be considered for internal use only. Within the actual POD, these paths should be identified by names that are more neutral. (e.g., the green path and the yellow path.) NJDHSS - January

15 Participants who are ill should have been excluded at the Pre-POD area. Some may develop symptoms while in the POD, however. They should be sent to the POD Sick Bay where transport to an acute care facility or treatment center can be arranged. The POD Sick Bay must be physically separated from other areas of the POD to decrease risk of spread of disease. Persons who become overly anxious or disruptive but who are not physically ill should NOT be directed to the POD Sick Bay. They should be assessed and attended to by professional or security staff, as appropriate, at a workstation or a designated mental health area. Support Functions Services not provided at workstations are referred to as support functions. These include monitors, mental health professionals, security staff, housekeeping and hospitality staff. Monitors are positioned between workstations to assure smooth flow of traffic between workstations, assist with courier and communication support, and act as trouble spotters. Mental health professionals explain eligibility criteria to non-eligible individuals at the Pre-POD area, and provide counseling to assist participants and staff to cope with stress or anxiety in the POD and Pre-POD areas. Security professionals work cooperatively with law enforcement officials to secure access to the POD and medication supplies, and to maintain order within the POD and Pre-POD areas. Housekeeping and hospitality staff are responsible for maintaining a clean, tidy environment, and comfortable, wellstocked break rooms. During the smallpox preparedness vaccination initiative of 2003 and the anthrax PEP of 2001, well-defined lines of authority and responsibilities helped ensure success. It is especially important that lines of responsibility be clarified and understood by all staff. NJDHSS strongly recommends that there be 2 lines of management within the POD: a POD manager and a clinical manager. The NJDHSS - January

16 POD manager is responsible for overall POD operations. The clinical manager, a public health nurse or physician, is responsible for all clinical aspects of the POD. This management structure is outlined in Appendix B, located at the end of this chapter. Specific management responsibilities will be discussed in detail in Chapter 3. The management structure described in this manual is based on the Incident Command System (ICS) model. ICS is a flexible organization management system that is currently applied in a wide variety of emergency incidents. NJDHSS has adopted the ICS system to enable the public health system to work collaboratively within the emergency management system. Principles and Features of ICS, Module 2 of the Incident Command System National Training Curriculum, states that there are five principal ICS management functions: Command: Responsibilities for all event activity. Operations: Responsibilities for tasks and functions needed to meet incident objective. Planning: Responsibilities for the collection, evaluation and display of incident information, maintaining status of resources and preparing the incident related documentation. Logistics: Responsibilities for providing adequate services and support to meet all event needs. Finance/Administration: Responsibilities for tracking incident- related costs, personnel and equipment records and administering contracts associated with the event. The POD falls under the operations function of ICS. Appendix C, at the end of this chapter, illustrates the organization of a mass prophylaxis clinic and how it fits within the larger ICS structure. It must be recognized that the POD is only one aspect of the overall incident response. NJDHSS - January

17 Mass Prophylaxis Clinic Flow Plan Appendix A OUT Pre-POD Sick Bay Triage Pre-POD Debriefing Counseling & Education (Non-Targeted Population) OUT Triage Reception (Targeted Population) OUT POD Sick Bay POD Debriefing MAIN Line Registration Education Fast Track RESS Registration Education Self-Screening Medical Consultation Medical Screening LEGEND Rose: Yellow: Green: Blue: Pre-POD Area MAIN Line Fast Track Inside Sick Bay Dispensing Dispensing DOTTED LINES INDICATE OPTIONAL PATHS. Aftercare (Smallpox only) Aftercare (Smallpox only) NJDHSS - January 2005 OUT 17

18 Mass Prophylaxis Organizational Chart and Reporting Structure Appendix B POD Manager Medical Director Security Liaison Facility Liaison Clinical Manager Clinic Communication Officer Inventory Controller Administrative Area Leader Pre-POD Area Leader Medical Area Leader MAIN Line Area Leader Fast Track Area Leader Check-in Hospitality Translators Housekeeping Staff Trainers Communication NJDHSS-January 2005 Triage Translators Pre-POD Debriefing Pre-POD Sick Bay Pre-POD Monitors Pre-POD Check-in Pre-POD Hospitality Pre-POD Runner POD Debriefing POD Sick Bay Medical Consultant Registration Education (roving & station) Medical Screening MAIN Line Dispensing MAIN Line Aftercare Reception RESS (Registration, Education and Self-screening) Fast Track Dispensing Fast Track Aftercare POD Monitor POD Runner 18

19 Mass Clinic Command Structure Appendix C Incident Commander Health & Safety Officer Liaison Officer Public Information Officer Note: The operations branch is responsible for other activities such as epidemiological investigations. Only the POD activity is illustrated in this chart. Financial/Admin. Planning Logistics Operations Data entry Resources Supply/Inventory Clinic Operations Procurement Demobilization Clinic Set-up POD Manager Cost Time Transportation Pre-POD Area Leader Admin. Area Leader Clinical Manager Security Clinic Comm. Officer Inventory Controller Fast track Area Leader Facility Liaison MAIN Line Area Leader Medical Area Leader NJDHSS - January

20 Chapter 3: Personnel Duties and Responsibilities The number and types of individuals required to staff a mass prophylaxis clinic are dependent on the size of the population being prophylaxed and the medication being offered. The contents of this manual assume a throughput of 1,000 participants per hour to distribute pills, 500 participants per hour to immunize against influenza and 250 participants per hour to vaccinate for anthrax or smallpox. These numbers can only be achieved by adapting the standard model of patient care to the unique version represented in the POD model where individualized patient assessment and teaching are greatly reduced or eliminated. Staffing patterns should be arranged so that the clinic can run for at least 16 hours, with time allowed for breaks and overlap at shift change. Some jurisdictions may want to operate PODs 24 hours. While 24-hour operations increase the number of individuals prophylaxed, the 24-hour model raises concerns such as adequate staffing and re-stocking supplies. Crowd control may become an issue if participants travel to a 24-hour POD when the POD closest to them closes. It is for this reason that NJDHSS strongly recommends all PODs maintain consistent hours of operation at 16 hours per day. Staffing recommendations for positions at the POD can be found in Appendix D; Appendix E contains recommendations for the number of persons needed to staff the POD. These appendices may be found at the end of this chapter. Activities at the POD occur in various settings. Most patient-centered activities (e.g., dispensing) are done at workstations, while rovers who move between workstations accomplish other activities (e.g., crisis counseling). Still other activities occur throughout the POD (e.g., housekeeping). This chapter will describe the process for accomplishing the work of the POD by outlining staffing requirements and describing job duties. NJDHSS January

21 The POD itself refers to the workstations, roving positions and support activities within the clinic itself. The Pre-POD area refers to the workstations, roving positions and support activities that occur outside of the POD, whether nearby or in remote locations. Each job title is presented separately in a job description page that includes the job s purpose, the type of staff needed to fill the position, and the process for performing the duties of the position. A job action sheet follows each job description page. This sheet contains the position s name, location and role, and the duties to be performed before, during and after the work shift. Job action sheets can be distributed to workers at the POD, and used as an orientation tool. Management positions are listed first, followed by Pre-POD positions, then POD positions; support positions are listed last. NJDHSS - January

22 Appendix D Position Staffing Recommendations POD Manager Emergency management or other professional with planning experience Health/Public Health Professionals Clinical Manager Registered Nurse or Physician with experience planning and operating clinics Clinic Communications Officer Health Educator/Risk Communicator Communications professional with training in risk communication Area Leaders Health/Public Health Professionals Facility Liaison Site Owner/Manager Inventory Controller Administrative professional with excellent organizational skills Medical Director Physician Reception Health/Public Health Professionals Registered Nurses Outside/Inside Debriefing Mental Health professionals Crisis Counselors Licensed Practical or Registered Nurses Health Educators Social Workers Others with special training in counseling Outside/Inside Sick Bay EMT/Paramedics Physician Assistants (must have Physician on site) Registered Nurses Licensed Practical Nurses Outside/Inside Monitors Administrative and/or clerical personnel with experience working with the public Triage Individuals must demonstrate sound and quick assessment and decision making skills Health/Public Health professionals Physician Assistants (must have Physician on site) EMT/Paramedics Registered Nurses Registration/Education/Self- Screening (RESS) Individuals must demonstrate sound and quick assessment and decision making skills Health/Public Health professionals Administrative or Clerical staff NJDHSS - January

23 Medication Dispensing Registered Nurses Advanced Practice Nurses Physicians Pharmacists (depending on training and type of prophylaxis) Pharmacy Technicians (depending on training and type of prophylaxis) Licensed Practical Nurses (depending on training and type of prophylaxis) Medical Screening Registered Nurses Advanced Practice Nurses Physicians After Care/Observation Registered Nurses EMT/Paramedics Physician Assistants (must have Physician on site) Licensed Practical Nurse Registration Administrative professionals Clerical staff Education Health Educators Registered Nurses Health/Public Health professionals Medical Consultation Physicians Advanced Practice Nurses Physician Assistants (must have Physician on site) Check-in Administrative professionals Clerical staff Staff Trainer Area leaders Security Liaison Law enforcement Security personnel Military personnel Security Staff Law enforcement Security personnel Military personnel Translators Multi-lingual staff Hospitality Administrative professionals Clerical staff Housekeeping Housekeeping personnel Communications Technician Equipment technician IT technical specialist NJDHSS - January

24 Appendix E Position Recommended number of staff per POD for an 8 hour shift* Oral Medication Flu Vaccine Smallpox/Anthrax Vaccine POD Manager Clinical Manager Clinic Communications Officer Area Leaders Facility Liaison Inventory Controller Medical Director Triage Pre-POD Debriefing Counselor Pre-POD Debriefing Educator Pre-POD Sick Bay Pre-POD Monitor Pre-POD Runner Reception Fast-track RESS Fast-track Dispensing MAIN line Registration Education Medical Screening Medical Consultation MAIN line Dispensing Aftercare POD Counselor POD Sick Bay POD Monitors POD Runner Translators Housekeeping Communication Technician Staff Trainer Check-in Hospitality Security Liaison Security Staff TOTAL *=This table provides guidance for recommended staffing numbers based on the CDC s Maxi- Vac software program, the Weil-Cornell Model, the State of California Mass Prophylaxis Model, the 2003 City of San Francisco Smallpox Exercise, NJDHSS anthrax post-exposure prophylaxis clinics and New Jersey s 2004 SNS TED exercise. NJDHSS - January

25 Table of Contents for Job Descriptions & Job Action Sheets Position Page After Care/Observation Fast Track 63 MAIN Line 73 Area Leaders Administrative.. 41 Fast Track 35 MAIN Line 37 Medical. 39 Pre-POD.. 33 Check-in. 83 Clinic Communications Officer 31 Clinical Manager 29 Communication Technician. 97 Debriefing Pre-POD 51 POD. 75 Education 67 Facility Liaison 43 Hospitality 93 Housekeeping. 95 Inventory Controller 45 Medical Consultation. 77 Medical Director. 47 Medical Screening. 69 Medication Dispensing Fast Track. 61 MAIN Line. 71 Monitor Pre-POD 55 POD POD Manager 27 Reception Staff.. 49 Registration 65 Registration/Education/Self-Screening (RESS) 59 Runner. 99 Security Liaison.. 87 Security Staff.. 89 NJDHSS- January

26 Position Page Sick Bay Pre-POD 53 POD Staff Trainer 85 Translators.. 91 Triage.. 57 Workstation Communication Contact NJDHSS - January

27 POD Manager Purpose: Staff: Process: Responsible for administrative oversight of the entire POD. A public health professional with strong supervisory and decision making skills. Identify a clinical manager. Ensure staffing requirements are met, both clinical and nonclinical. Make appropriate assignments using the mass prophylaxis organization chart described in Appendix C, Chapter 2. Ensure orientation of non-clinical staff. Supervise non-clinical staff through area leaders. Communicate with NJDHSS, clinical manager, area leaders and staff as needed. Ensure security of clinic site and medications, through security staff. Ensure clinic setup, operation and tear down through supervisory staff. Serve as trouble-shooter and resource person during clinic operation, or clearly communicate designee. Facilitate staff debriefing at shift change and/or at the close of the clinic. NJDHSS - January

28 JOB ACTION SHEET Position: Location: Role: POD Manager On-site Responsible for administrative oversight of the entire POD Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Brief staff, as needed Ensure site is physically set-up and ready for operations Hold clinic walk through with clinical manager During your shift: Wear appropriate PPE, as needed Supervise all administrative aspects of the clinic Ensure staffing requirements are met, both clinical and non-clinical Make appropriate job assignments using the NJDHSS POD operations organizational chart Ensure clinic operation through supervisory staff Orient and supervise non-clinical staff through area leaders Ensure security of clinic site and medication through security liaison Communicate with NJDHSS, clinical manager and other staff, as needed Act as spokesperson to communicate with media, as needed Serve as trouble-shooter and resource person during clinic operation After your shift: Ensure tear down and clean up of clinic Facilitate staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming POD manager NJDHSS - January

29 Clinical Manager Purpose: Staff: Process: Responsible for clinical operations at the POD. A public health nurse or physician with experience in planning and operating clinics. Coordinate with the POD manager concerning clinical issues. Communicate regularly with POD manager to ensure sufficient clinical supplies. Ensure staff follows universal precautions and practices appropriate infection control. Ensure reordering of clinical supplies. Assign/reassign clinical staff to meet needs throughout shift. Ensure orientation of clinical staff through area leaders. Supervise clinical staff through area leaders. Communicate with staff. Oversee medication receipt, reconstitution, storage and use. Oversee clinic setup, operation and take down, focusing on clinical issues. Serve as trouble-shooter and resource person for clinical operations, or clearly communicate designee. Report issues or problems to POD manager. NJDHSS - January

30 JOB ACTION SHEET Position: Location: Role: Clinical Manager On-site Responsible for clinical operations at the POD Before your shift: Register at check-in Clearly display ID badge Receive briefing from outgoing clinical manager Familiarize self with location of all clinic areas Brief staff, as needed During your shift: Wear appropriate PPE, as needed Ensure staff practices universal precautions and appropriate infection control Coordinate with POD manager concerning clinical issues Communicate with POD manager to ensure sufficient clinical supplies Attend clinic walk-thru with POD manager Ensure reordering of equipment and clinical supplies Assign/reassign clinical staff through area leaders Ensure orientation of clinical staff through area leaders Supervise clinical staff through area leaders Communicate with clinical staff Oversee medication reconstitution, reception, storage and use Oversee clinic set-up and operations with POD manager Serve as trouble-shooter and resource person for clinical operations Report problems or issues to POD manager After your shift: Assist with tear down and clean up of clinic Facilitate staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming clinical manager NJDHSS - January

31 Clinic Communication Officer Purpose: Responsible for coordinating communications at the clinic. Staff: An individual with experience developing messages who is trained in risk communication, such as a health educator/risk communication specialist (HERC) or other communication professional. Process: Inform POD manager of communication updates, as needed. Create and disseminate risk communication messages in coordination with NJDHSS Office of Communications and PIO, as needed. Act as or prepare a spokesperson to interact with media. Update messages in collaboration with NJDHSS and PIO, as needed. Participate in debriefing at shift change or close of clinic. Report issues or problems to POD manager. Notify security to handle disruptive individuals, as needed. NJDHSS - January

32 JOB ACTION SHEET Position: Location: Role: Clinic Communication Officer On-site Responsible for coordinating communications at the clinic Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation Receive briefing from out-going clinic communication officer During your shift: Wear appropriate PPE, as needed Inform POD manager of communication updates, as needed Field media calls and requests, as needed Act as or prepare spokesperson to interact with media Create and disseminate risk communication messages, in consultation with NJDHSS Update messages in collaboration with NJDHSS, as needed Monitor outside communication Report issues or problems to POD manager Notify security to handle disruptive individuals, as needed After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming clinic communication officer NJDHSS - January

33 Pre-POD Area Leader Purpose: Staff: Supervises staff and acts as trouble-shooter for all activities in the Pre-POD area (e.g., Triage, Translators, Pre-POD Debriefing, Pre- POD Sick Bay, Pre-POD monitors, and Pre-POD runners). A clinical or mental health professional with strong supervisory and decision making skills. Process: In coordination with POD manager: Make appropriate staff assignments. Ensure orientation and supervision of all Pre-POD staff. Assign/reassign staff to meet needs throughout shift. Ensure reordering of supplies. Oversee Pre-POD area setup, operation and tear down. Serve as trouble-shooter and resource person, or clearly communicate designee. Ensure security of the Pre-POD area, through security staff. Report issues or problems to POD manager. NJDHSS - January

34 JOB ACTION SHEET Position: Location: Role: Pre-POD Area Leader On-site Supervise activities in the Pre-POD Area Before your shift: Register at check-in Clearly display ID badge Receive briefing from outgoing area leader Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Make appropriate staff assignments Ensure orientation of all Pre-POD staff Assign/reassign staff to meet needs throughout shift Ensure reordering of supplies Oversee Pre-POD area setup, operation and take down Serve as trouble-shooter and resource person, or clearly communicate designee Ensure security of the Pre-POD area, through security staff Report issues or problems to POD manager After your shift: Assist with tear down and clean up of Pre-POD area Attend staff debriefing at shift change and/or close of Pre-POD area Prepare area for next day operations, as needed Brief in-coming Pre-POD area leader NJDHSS - January

35 Fast Track Area Leader Purpose: Staff: Supervise staff and act as trouble-shooter for activities in assigned areas at the POD (e.g., Reception, RESS, Fast Track dispensing, Fast Track aftercare, POD runners and POD monitors.) A clinical health professional Process: In coordination with clinical manager: Make appropriate staff assignments. Ensure orientation and supervision of all area staff. Assign/reassign staff to meet needs throughout shift. Ensure reordering supplies. Oversee area setup, operation and tear down. Serve as trouble-shooter and resource person, or clearly communicate designee. Ensure security of areas, through security staff. Report issues or problems to clinical manager. NJDHSS - January

36 JOB ACTION SHEET Position: Location: Role: Fast Track Area Leader On-site Supervise staff and act as trouble-shooter for activities in assigned areas at the POD (e.g., reception, RESS, Fast Track dispensing, Fast Track aftercare, POD runners and POD monitors.) Before your shift: Register at check-in Clearly display ID badge Receive briefing from outgoing area leader Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Serve as resource person and administrative liaison for Fast Track workstations: triage, RESS, Fast Track dispensing and aftercare/observation, and inside monitors Report issues or problems to clinical manager After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming Fast Track area leader NJDHSS - January

37 MAIN Line Area Leader Purpose: Supervise staff and act as trouble-shooter for activities in assigned areas at the POD (i.e., registration, station & roving education, medical screening, MAIN Line dispensing, and MAIN Line aftercare.) Staff: Process: A clinical health professional In coordination with clinical manager: Make appropriate staff assignments. Ensure orientation and supervision of all area staff. Assign/reassign staff to meet needs throughout shift. Ensure reordering supplies. Oversee area setup, operation and tear down. Serve as trouble-shooter and resource person, or clearly communicate designee. Ensure security of areas, through security staff. Report issues or problems to clinical manager. NJDHSS - January

38 JOB ACTION SHEET Position: Location: Role: MAIN Line Area Leader On-site Supervise staff and act as trouble-shooter for activities in assigned areas at the POD (i.e., registration, stationed & roving education, medical screening, MAIN Line dispensing, and MAIN Line aftercare.) Before your shift: Register at check-in Clearly display ID badge Receive briefing from outgoing area leader Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Make appropriate staff assignments Ensure orientation and supervision of all area staff Assign/reassign staff to meet needs throughout shift Ensure reordering supplies Oversee area setup, operation and tear down Serve as trouble-shooter and resource person, or clearly communicate designee Ensure security of areas, through security staff Report issues or problems to clinical manager After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming MAIN Line area leader NJDHSS - January

39 Medical Area Leader Purpose: Supervises staff and acts as trouble-shooter for assigned areas at the POD (i.e., POD Sick Bay, medical consultation, translators, POD debriefing and mental health rovers.) Staff: A clinical health professional Process: In coordination with clinical manager: Make appropriate staff assignments. Ensure orientation and supervision of all area staff. Assign/reassign staff to meet needs throughout shift. Ensure reordering supplies. Oversee area setup, operation and tear down. Serve as trouble-shooter and resource person, or clearly communicate designee. Ensure security of areas, through security staff. Report issues or problems to clinical manager. NJDHSS - January

40 JOB ACTION SHEET Position: Location: Role: Medical Area Leader On-site Supervise staff and act as trouble-shooter for activities in assigned areas at the POD (i.e., POD Sick Bay, medical consultation, translators, and POD debriefing/mental health rovers.) Before your shift: Register at check-in Clearly display ID badge Receive briefing from outgoing medical area leader Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Make appropriate staff assignments Ensure orientation and supervision of all area staff Assign/reassign staff to meet needs throughout shift Ensure reordering supplies Oversee area setup, operation and tear down Serve as trouble-shooter and resource person, or clearly communicate designee Ensure security of areas, through security staff Report issues or problems to clinical manager After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming medical area leader NJDHSS - January

41 Administrative Area Leader Purpose: Staff: Process: Supervises staff and acts as trouble-shooter for administrative activities at the POD. A public health professional with strong supervisory and decision making skills. In coordination with POD manager: Make appropriate staff assignments. Ensure orientation of all area staff. Assign/reassign staff to meet needs throughout shift. Ensure reordering of food, drink and supplies. Oversee area setup, operation and tear down. Serve as trouble-shooter and resource person, or clearly communicate designee. Ensure security of areas, through security staff. Report issues or problems to POD manager. NJDHSS - January

42 JOB ACTION SHEET Position: Location: Role: Administrative Area Leader On-site Supervise staff and act as trouble-shooter for administrative elements of the POD (i.e., check-in, hospitality, translators, housekeeping, staff trainers, and communication technician). Before your shift: Register at check-in Clearly display ID badge Attend clinic orientation Receive briefing from outgoing area leader Familiarize self with location of all clinic areas During your shift: Wear appropriate PPE, as needed Make appropriate staff assignments Ensure orientation and supervision of all area staff Assign/reassign staff to meet needs throughout shift Ensure reordering of food, drink and supplies Oversee area setup, operation and tear down Serve as trouble-shooter and resource person, or clearly communicate designee Ensure security of areas, through security staff Report issues or problems to POD manager After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming administrative area leader NJDHSS - January

43 Facility Liaison Purpose: Ensure facility is in working order for clinic operations. Staff: Process: Owner/Operator of facility or site. Maintain site for use during clinic. Communicate with POD manager regarding facility issues. Ensure facility utilities (i.e., heat, air conditioning, water, lighting, refrigeration) are operational and functioning properly. Ensure accessibility to facility (i.e., doors unlocked, snow removed from entrances and parking lots, lawn mowed, etc.). Coordinate initial delivery of clinical and non-clinical supplies and equipment with POD manager. Report problems to POD manager. Notify security, as needed. NJDHSS - January

44 JOB ACTION SHEET Position: Location: Role: Facility Liaison On-site Ensure facility is in working order for clinic operations Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Maintain site for use during clinic Communicate with POD manager regarding facility issues Ensure facility utilities (i.e., heat, air conditioning, water, lighting, refrigeration) are operational and functioning properly Ensure accessibility to facility (i.e., doors unlocked, snow removed from entrances and parking lots, lawn mowed, etc.) Coordinate initial delivery of clinical and non-clinical supplies and equipment with POD manager Notify security to handle disruptive individuals, as needed Report issues or problems to POD manager After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief incoming facility liaison NJDHSS - January

45 Inventory Controller Purpose: Oversee inventory management and reordering of supplies. Staff: Administrative professional with experience and excellent organizational skills. Process: Communicate with area leaders regarding clinical and non-clinical supplies and equipment needs. Maintain appropriate clinical and non-clinical inventory. Communicate with area leaders to facilitate re-stocking of clinical and non-clinical supplies and equipment. Coordinate with NJ OEM to order additional clinical and nonclinical supplies and equipment. Replenish clinical and non-clinical supplies and equipment for next day, as needed. Report issues or problems to POD manager. Notify security to handle disruptive individuals, as needed. NJDHSS - January

46 JOB ACTION SHEET Position: Location: Role: Inventory Controller On-site Responsible for inventory management and restocking of equipment, clinical and non-clinical supplies for the clinic Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Communicate with area leaders regarding supplies and equipment needs Maintain appropriate clinical and non-clinical inventory Communicate with area leaders to facilitate re-stocking of clinical and nonclinical supplies and equipment Coordinate with NJ OEM to order additional supplies Report issues or problems to POD manager Replenish clinical and non-clinical supplies and equipment for next day, as needed Notify security to handle disruptive individuals, as needed After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming inventory controller NJDHSS - January

47 Medical Director Purpose: Staff: Process: Provide medical guidance at the POD. Physician with a valid New Jersey medical license. Sign standing orders for POD. Oversee clinical operations at the POD, through the clinical manager. Ensure epidemiological guidance and follow up if individual is deferred or refuses prophylaxis. Report issues or problems to POD manager. NJDHSS - January

48 JOB ACTION SHEET Position: Location: Role: Medical Director On-site Provide medical guidance at the POD Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Sign standing orders, as needed Oversee clinical operations at the POD, through the clinical manager Report issues or problems to POD manager After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming medical screening staff NJDHSS - January

49 Reception Staff Purpose: Staff: Process: Reconfirm participant eligibility and sort to MAIN line or Fast track path. Clinical health professionals and public health professionals with excellent communication, decision-making and assessment skills; trained administrative professionals, as needed. Wear appropriate PPE. Confirm that participant has been cleared through reception by observing wristband. Re-confirm that the participant meets eligibility criteria: o If they do not, have security escort the participant to the debriefing area or out of the clinic area. Confirm registration form is complete; if the registration form is incomplete, defer participant until form is complete. If the participant is an eligible adult and has no additional questions or medical concerns, direct to the Fast Track line. If the participant is an eligible adult and has any questions or medical concerns, direct to the Main Line. If one individual is picking up medication for several household members: o Direct to the RESS workstation if all forms are complete and there are no additional questions or medical concerns. o Direct to the registration workstation if there are any questions or medical concerns to the Main Line. If the participant is an eligible child (under 18 years of age), the above must be completed, as well as the line requesting the child s weight. A parent or guardian must accompany minors. If the participant is noticeably ill, direct to the Inside Sick Bay. Sick individuals will not be prophylaxed at the mass clinic. NJDHSS - January

50 JOB ACTION SHEET Position: Location: Role: Reception Staff Reception Workstation Sort eligible individuals to MAIN Line or Fast Track line Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation Put on appropriate PPE During your shift: Wear appropriate PPE, as needed Confirm registration form is completed Confirm that individual has wristband and is eligible to receive prophylaxis Sort eligible individuals to one of three areas: Main Line, Fast Track or Inside Sick Bay Direct individuals with completed forms who have no additional questions or medical concerns to the RESS workstation Direct individuals who have any questions or medical concerns to the Main Line registration workstation Direct individuals who appear ill to Inside Sick Bay Refer individuals to mental health, as needed Refer individuals with language barriers to translator Report issues or problems to Fast Track area leader Notify security to handle disruptive individuals, as needed After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming reception staff NJDHSS - January

51 Pre-POD Debriefing Purpose: Staff: Process: Provide education and mental health services to non-eligible individuals. Mental health professionals, crisis counselors, health educators, licensed practical or registered nurses, social workers and others with special training in counseling. Explain eligibility criteria to non-eligible individuals. Provide education regarding disease and prophylaxis. Provide mental health/crisis counseling as needed. Answer general questions as needed. Notify security to handle disruptive individuals. Report issues or problems to Pre-POD area leader. NJDHSS - January

52 JOB ACTION SHEET Position: Location: Role: Debriefing Staff Pre-POD Debriefing Workstation Provide education and mental health services to non-eligible individuals Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Explain eligibility criteria to non-eligible individuals Provide mental health counseling to ineligible individuals Provide disease education and non medical prophylaxis information Assist individuals with questions, concerns or fears Notify security to handle disruptive individuals, as needed Direct individuals out of the clinic area Report issues or problems to Pre-POD area leader After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming debriefing staff NJDHSS - January

53 Pre-POD Sick Bay Purpose: Staff: Process: Attend to visibly ill individuals and coordinate transportation to acute care facilities or treatment centers. Emergency medical technicians, licensed practical or registered nurses, physician assistants or paramedics. Wear appropriate PPE. Greet and comfort referred individuals. Provide individual with chair or cot. Contact EMS provider to transport to acute care facility or treatment center. Call security to handle disruptive individuals, as needed. Report issues or problems to Pre-POD area leader. NJDHSS - January

54 JOB ACTION SHEET Position: Location: Role: Pre-POD Sick Bay Attendant Pre-POD Sick Bay Attends to visibly ill individuals and coordinates transportation to acute care facilities and treatment centers Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE Greet and comfort referred individuals Provide individual with chair or cot Contact EMS provider to transport to acute care facility or treatment center Notify security to handle disruptive individuals, as needed Report issues or problems to Pre-POD area leader After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming Pre-POD Sick Bay staff NJDHSS - January

55 Pre-POD Monitor Purpose: Staff: Process: Assist with traffic flow outside of POD. Administrative and/or clerical personnel with experience working with the public. Ensure smooth flow of traffic between workstations. Answer general questions about clinic, as needed, using published materials. Give directions, as needed (restrooms, break rooms, public telephones). Observe workers and participants for signs of fatigue, stress or anxiety and refer to debriefing staff. Report problems to Pre-POD area leader. Notify security to handle disruptive individuals, as needed. NJDHSS - January

56 JOB ACTION SHEET Position: Location: Role: Pre-POD Monitor Roving Assist with clinic flow Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Direct participants to appropriate lines Call security to handle disruptive individuals, as needed Give directions, as needed (i.e., restrooms, public telephones, etc.) Refer individuals to mental health, as needed Refer individuals with language barriers to translator Report issues or problems to Pre-POD area leader After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming Pre-POD monitors NJDHSS - January

57 Triage Purpose: Staff: Process: Sort participants into three groups based on criteria developed by the state and federal authorities, and direct them to the appropriate area. The three groups are: ill persons, non-eligible persons, and eligible persons. Clinical health professionals and public health professionals with good decision-making skills. Wear appropriate PPE. Sort participants according to eligibility criteria. Identify individuals who meet target criteria and are well by placing a wristband on them. Direct individuals who meet target criteria and are well to the reception workstation at the POD or transportation holding area. Direct sick participants to Pre-POD Sick Bay, regardless of eligibility status. They may have symptoms of the illness to be prophylaxed, or another illness. Direct persons who do not meet eligibility criteria to the Pre-POD debriefing area. Distribute clinic information and answer questions/concerns as appropriate. Refer overly anxious and disruptive individuals to the Pre-POD debriefing area. Encourage form completion. When possible, work in pairs: one clinician and one non-clinician. Report issues or problems to the Pre-POD area leader. NJDHSS - January

58 JOB ACTION SHEET Position: Location: Role: Triage Staff Triage Workstation Sort individuals based on pre-determined criteria and direct to appropriate area Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Verify eligibility criteria on registration form to receive medication Sort eligible, non-eligible and visibly ill individuals Place a wristband on eligible participants for admittance to the POD Direct eligible individuals to the POD registration workstation or transportation holding area Direct non-eligible individuals to the Pre-POD debriefing area Refer visibly ill individuals to the Pre-POD Sick Bay Answer general questions, as needed Report issues or problems to Pre-POD area leader After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming triage staff NJDHSS - January

59 Registration/Education/Self-Screening (RESS) Fast Track Purpose: Staff: Process: Review contents of registration forms and direct participants to the appropriate workstation. Health, public health or administrative professionals, or clerical staff with good decision making skills. Verify eligibility for Fast Track medication dispensing by checking registration form(s). Direct participants who have indicated no education concerns or medical contraindications to Fast Track medication dispensing workstation. Refer participants who have indicated education concerns to the MAIN Line education station. Call monitor to escort referred participant(s) to MAIN Line. Refer participants who have indicated medical contraindications to the MAIN Line education station. Call monitor to escort referred participant(s) to MAIN Line. Notify security to handle disruptive individuals, as needed. NJDHSS - January

60 JOB ACTION SHEET Position: Location: Role: RESS Staff Fast Track RESS Workstation Review registration forms and direct participants to appropriate workstation Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Verify eligibility for Fast Track medication dispensing by checking registration form(s) Direct participants who have indicated no education concerns or medical contraindications to Fast Track medication dispensing workstation Refer participants who have indicated education concerns to the MAIN Line education station. Call monitor to escort referred participant(s) to MAIN Line Refer participants who have indicated medical contraindications to the MAIN Line education station. Call monitor to escort referred participant(s) to MAIN Line Notify security to handle disruptive individuals, as needed Report issues or problems to Fast Track area leader After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming RESS staff NJDHSS - January

61 Fast Track Medication Dispensing Purpose: Staff: Process: Dispense appropriate prophylactic treatment. Registered and advanced practice nurses, physicians, pharmacists (depending on training and type of prophylaxis), pharmacy technicians. Individuals administering smallpox vaccine must be vaccinated. Review registration form to confirm eligibility status and medication to be dispensed. Confirm consent signature(s). Household representative may sign consent on all forms for entire household. Apply patient identification label to medication container(s). Dispense/administer medication. Distribute educational/informational materials. Direct individual to exit, if dispensing non-injection prophylaxis. Dress injection site and direct individual to aftercare/observation workstation, if dispensing injection prophylaxis. Notify security to handle disruptive individuals, as needed. NJDHSS - January

62 JOB ACTION SHEET Position: Location: Role: Fast Track Dispenser Fast Track Medication Dispensing Workstation Dispense appropriate prophylactic treatment Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Practice appropriate infection control measures Ensure proper reconstitution, use and storage of medication Following clinic protocols, dispense prophylaxis Attach patient identification label to container, if oral prophylaxis Provide patient education materials Direct individual to exit, if dispensing non-injection prophylaxis Dress injection site and direct individual to aftercare/observation workstation, if dispensing injection prophylaxis Report issues or problems to Fast Track area leader Notify security to handle disruptive individuals, as needed After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming Fast Track medication dispensing staff NJDHSS - January

63 Fast Track After Care & Observation (Injections only) Purpose: Staff: Process: Observe participants for negative reactions to vaccine or other injectable medication. Smallpox clinics are required to have this station. Registered and licensed practical nurses, EMTs, paramedics, physician assistants (must have physician on site). Monitor for untoward or adverse reaction(s) to injection. Assure that participants remain at this workstation for at least 20 minutes. If no negative reactions are observed, direct to exit. If observe untoward reaction(s), provide first aid and/or arrange transportation as needed. Distribute and review packet of aftercare information. Following smallpox vaccination: teach site care, take reading, and follow-up. Report issues or problems to Fast Track area leader. Notify security to handle disruptive individuals, as needed. NJDHSS - January

64 JOB ACTION SHEET Position: Location: Role: Fast Track Aftercare & Observation Fast Track Aftercare & Observation Workstation Explain post-vaccination follow-up and monitor for untoward affects Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Distribute and review packet of aftercare information Counsel individuals about proper vaccination site care Counsel individuals about take reading (smallpox only) Educate individuals about self-identification of Adverse Events Distribute list of hospitals designated to treat Adverse Events Observe individual for 20 minutes following vaccination If no negative reactions observed, direct to exit Report issues or problems to Fast Track area leader After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming aftercare/observer staff NJDHSS - January

65 Registration (MAIN Line) MAIN Line stands for More Assessment or Information Needed Line. This line is for those who have additional education or clinical questions. Participants who require extra assistance should be directed to this station. The registration workstation is the first station within the MAIN Line. Purpose: Staff: Process: Ensure form completion and process the participant to the appropriate next station. Trained administrative and clerical personnel. Review completed form. All participants must have form completed by the time they reach this workstation. Verify registration form is complete and direct participant to the next workstation as follows: o If the participant requires education refer to the education workstation. o If the participant has completed the Education Self-Screening section appropriately but has concerns or medical questions, refer to the medical screening workstation. Keep all family members together as they move through the clinic. If one requires education or medical screening, they all must attend that workstation together. NJDHSS - January

66 JOB ACTION SHEET Position: Location: Role: MAIN Line Registrar Registration Workstation Confirm completeness of registration form(s) and direct participants to the appropriate workstations. Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Confirm registration form is completed Direct individuals who have education questions to education workstation Direct individuals who have medical questions to medical screening workstation Refer individuals to mental health, as needed Refer individuals with language barriers to translator Report issues or problems to MAIN Line area leader After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming MAIN Line registration staff NJDHSS - January

67 Education Purpose: Staff: Process: Provide information and answer questions. Clinical health professionals and/or health educators. At least one clinical person must be available to address clinical questions from participants. Disseminate education materials regarding disease and prophylaxis. Answer general questions regarding the disease and prophylaxis. Direct individuals to the appropriate workstation (i.e., medical screening, medical consultation, POD Sick Bay or inside debriefing or MAIN Line medication dispensing). Notify translator(s) to assist individuals with language barriers. Notify security to handle disruptive individuals, as needed. NJDHSS - January

68 JOB ACTION SHEET Position: Location: Role: Educator Education Workstation or Roving Provide information and answer questions Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Disseminate education materials regarding the disease and prophylaxis Answer general questions regarding the disease and prophylaxis Direct individuals with medical issues flagged on the registration form to the medical screening workstation Direct individuals who have no medical issues flagged on their form to the medication dispensing workstation Refer individuals to mental health, as needed Refer individuals with language barriers to translator Report issues or problems to MAIN Line area leader After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming education staff NJDHSS - January

69 Medical Screening Purpose: Staff: Assess participant for contraindications to prophylaxis. Registered and advanced practice nurses, physician s assistants or physicians with valid licenses to practice in New Jersey. Process: Evaluate the medical history portion of the registration form and indicate appropriate PEP, following POD protocols. Evaluate the medical history portion of the registration form of pediatric participants and indicate appropriate PEP and dosage, following POD protocols. Refer participants to medical consultation for further clinical evaluation, as needed. Refer anxious or overly worried individuals to the inside debriefing workstation. Refer participants who have completed medical screening to the medication dispensing workstation in the MAIN Line. NJDHSS - January

70 JOB ACTION SHEET Position: Location: Role: Medical Screener Medical Screening Workstation Clears or defers for prophylactic treatment Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Review registration form to assess for contraindications Following clinic protocols, clear or defer for prophylaxis Following clinic protocols, determine proper medication regimen Indicate appropriate medication regimen on registration form Direct individual to medication dispensing workstation Refer individuals to medical consultation, as needed Refer individuals to mental health, as needed Report issues or problems to MAIN Line area leader Notify security to handle disruptive individuals, as needed After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming medical screening staff NJDHSS - January

71 MAIN Line Medication Dispensing Purpose: Staff: Process: Dispense appropriate prophylactic treatment. Registered and advanced practice nurses, physicians, pharmacists (depending on training and type of prophylaxis), pharmacy technicians. Individuals administering smallpox vaccine must be vaccinated. Review registration form to confirm eligibility status and medication to be dispensed. Confirm consent signature(s). Household representative may sign consent on all forms for entire household. Apply patient identification label to medication container(s). Dispense/administer medication. Distribute educational/informational materials. Direct individual to exit, if dispensing non-injection prophylaxis. Dress injection site and direct individual to aftercare/observation workstation, if dispensing injection prophylaxis. Notify security to handle disruptive individuals, as needed. NJDHSS - January

72 JOB ACTION SHEET Position: Location: Role: MAIN Line Dispenser MAIN Line Medication Dispensing Workstation Disseminate appropriate prophylactic treatment Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE and practice infection control measures Ensure proper reconstitution, use and storage of medication Following clinic protocols, dispense prophylaxis Attach patient identification label to container, if oral prophylaxis Provide patient education materials Direct individual to exit, if dispensing non-injection prophylaxis Dress injection site and direct individual to aftercare/observation workstation, if dispensing injection prophylaxis Report issues or problems to MAIN Line are leader After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming MAIN Line medication dispensing staff NJDHSS - January

73 MAIN Line After Care & Observation (smallpox only) Purpose: Staff: Process: Observe participants for negative reactions to vaccine or other injectable medication. Smallpox clinics are required to have this station. Registered and licensed practical nurses, EMTs, paramedics, physician assistants (must have physician on site). Monitor for untoward or adverse reaction(s) to injection. Assure that participants remain at this workstation for at least 20 minutes. If no negative reactions are observed, direct to exit. If observe untoward reaction(s), provide first aid and/or arrange transportation as needed. Distribute and review packet of aftercare information. Following smallpox vaccination: teach site care, take reading, and follow-up. Report issues or problems to MAIN Line area leader. Notify security to handle disruptive individuals, as needed. NJDHSS - January

74 JOB ACTION SHEET Position: Location: Role: MAIN Line Aftercare & Observation Aftercare & Observation Workstation Monitor individuals for negative reactions from vaccination and discuss injection site care Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Distribute and review packet of aftercare information Counsel individuals about proper vaccination site care Counsel individuals about take reading (smallpox only) Educate individuals about self-identification of Adverse Events Distribute list of hospitals designated to treat Adverse Events Observe individual for 20 minutes following vaccination If no negative reactions observed, direct to exit Report issues or problems to MAIN Line area leader After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming MAIN Line aftercare/observation staff NJDHSS - January

75 POD Debriefing Purpose: Staff: Process: Provide mental health and crisis counseling services to clinic participants and workers. Mental health professionals, crisis counselors, social workers, physicians and others with special training in counseling. Provide mental health services at the inside debriefing workstation or anywhere in the POD by roving. Monitor workers and participants for signs of fatigue or stress. Rotate inside debriefing workstation duties with roving duties. Escort anxious participants to inside debriefing workstation, as needed. When individual has calmed down, they must be escorted to appropriate workstation. Notify security to handle disruptive individuals, as needed. NJDHSS - January

76 JOB ACTION SHEET Position: Location: Role: Mental Health/Crisis Counselor POD Debriefing Area and Roving Provide mental health and crisis counseling services to clinic participants and workers Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Monitor workers and individuals for signs of fatigue or stress Provide mental health services at inside debriefing workstation and throughout POD Rotate between inside debriefing workstation and roving debriefing Escort anxious individuals to inside debriefing workstation, as needed Escort calmed individual to appropriate workstation, as needed Notify security, as needed Report issues or problems to medical area leader After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming mental health/crisis counselors NJDHSS - January

77 Medical Consultation Purpose: Staff: Process: Assist and evaluate those participants who have been referred from other stations because they have medical questions. Physicians or advanced practice nurses who are licensed to practice in New Jersey and physician assistants (under supervision of a physician) may staff this station. Review medical history, contraindications and other concerns. Provide medical health assessment/referral/services, as needed. Make appropriate recommendation regarding PEP to be used. Make appropriate recommendation to defer prophylaxis and/or quarantine. Ensure epidemiological guidance and follow-up if individual is deferred or refuses prophylaxis. Direct participants to medication dispensing, as appropriate. Refer to Inside Sick Bay/debriefing, as needed. Notify security to handle disruptive individuals, as needed. NJDHSS - January

78 JOB ACTION SHEET Position: Location: Role: Medical Consultant Medical Consultation Workstation Assess participants for contraindications to prophylactic treatment or other medical issues Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Review medical history, contraindications and other concerns Provide medical health assessment/referral/services, as needed Make appropriate recommendation regarding medical regimen to be used Make appropriate recommendation to defer prophylaxis and/or quarantine, as needed Ensure epidemiological guidance and follow-up if individual is deferred or refuses prophylaxis Refer to dispensing, as needed Refer to Inside Sick Bay, as needed Report issues or problems to medical area leader Notify security to handle disruptive individuals, as needed After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming medical consulting staff NJDHSS - January

79 POD Sick Bay Purpose: Attend to visibly ill individuals and coordinate transportation to acute care facilities or treatment centers. Staff: Process: Emergency medical technicians, licensed practical or registered nurses, physician assistants or paramedics. Wear appropriate PPE. Greet and comfort referred individuals. Provide individual with chair or cot. Contact EMS provider to transport to acute care facility or treatment center. Refer to medical consultation, as needed. Call security to handle disruptive individuals, as needed. Report issues or problems to medical area leader. NJDHSS - January

80 JOB ACTION SHEET Position: Location: Role: Sick Bay Attendant POD Sick Bay Attends to visibly ill individuals and coordinates transportation to acute care facilities Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Practice appropriate infection control measures Provide individual with chair or cot Contact EMS provider to transport to acute care facility Call security to handle disruptive individuals, as needed Refer to medical consult, as needed Report issues or problems to medical area leader After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming Inside Sick Bay staff NJDHSS - January

81 POD Monitor Purpose: Staff: Process: Assist with traffic flow inside the POD. Administrative and/or clerical personnel with experience working with the public. Ensure smooth flow of traffic between workstations. Answer general questions about clinic, as needed, using published materials. Give directions, as needed (restrooms, break rooms, public telephones). Observe workers and participants for signs of fatigue, stress or anxiety and refer to debriefing staff. Report problems to RESS area leader. Notify security to handle disruptive individuals, as needed. NJDHSS - January

82 JOB ACTION SHEET Position: Location: Role: POD Monitor Various locations in the POD Assist with clinic flow Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Direct participants to appropriate lines Call security to handle disruptive individuals, as needed Give directions, as needed (i.e., restrooms, public telephones, etc.) Refer individuals to mental health, as needed Refer individuals with language barriers to translator Report issues or problems to Fast Track area leader After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming inside monitor staff NJDHSS - January

83 Check-in Purpose: Staff: Process: Register workers and verify clinical credentials. Administrative professionals or trained clerical personnel and volunteers are recommended to staff this station. Register all staff and volunteers as they report. Check photo identification of all clinic workers and volunteers. Check licenses of clinical staff. Direct workers to area leaders for job assignments. Provide workers with their job description. Inform workers of time and location of staff training session. Notify clinic communication officer if/when media arrive; prevent unescorted access to clinic areas. Report issues or problems to administrative area leader. Notify security to handle disruptive individuals, as needed. NJDHSS - January

84 JOB ACTION SHEET Position: Location: Role: Check-in Clerk Check-in Workstation Register workers and verify clinical credentials Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Examine licenses of clinical workers for validity Confirm photo ID of workers and volunteers Provide workers and volunteers with POD ID badge Inform workers of time and location of staff training session Direct workers to area leaders for job assignments Report issues or problems to administrative area leader Notify security to handle disruptive individuals, as needed After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming check-in staff NJDHSS - January

85 Staff Trainer Purpose: Staff: Process: Provide orientation to clinic workers. Clinical area leaders should orient clinical workers; administrative area leaders to orient non-clinical workers. Provide orientation for all workers. Provide information packets and job responsibilities to all workers. Convene clinic walk-through for all workers. Ensure all workers are oriented. Notify security to handle disruptive individuals, as needed. Report problems to administrative area leader. NJDHSS - January

86 JOB ACTION SHEET Position: Location: Role: Staff Trainer On-site Provide orientation to clinic workers Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Orient staff regarding clinic functions Provide information packets and job responsibilities to all workers Convene clinic walk-through for all workers Ensure all workers are oriented Report issues or problems to administrative area leader Notify security to handle disruptive individuals, as needed After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming staff trainer NJDHSS - January

87 Security Liaison Purpose: Staff: Process: Assure security and order in the Pre-POD area and inside the POD. Law enforcement, security personnel or military personnel. Deter public disturbances. Protect staff and participants. Safeguard medication and supplies. Maintain organized and appropriate traffic control. Report need for reinforcements to the POD Manager. NJDHSS - January

88 JOB ACTION SHEET Position: Location: Role: Security Liaison On-site Ensure security and order Before your shift: Register at check-in Clearly display ID badge Receive briefing from outgoing security staff Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Ensure security of clinic site and medication Ensure security staffing requirements are met Make appropriate job assignments Orient and supervise security staff Communicate with POD manager and security staff, as needed Communicate with law enforcement as needed Serve as trouble-shooter and resource person during clinic operation Report issues or problems to POD manager After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming security liaison NJDHSS - January

89 Security Staff Purpose: Staff: Process: Ensure security and order in assigned area. Law enforcement, security personnel or military personnel. Deter public disturbances. Protect staff and participants. Safeguard medication and/or supplies. Maintain organized and appropriate crowd/traffic control. Respond to request(s) for assistance by clinic staff. Report need for reinforcements to security liaison. NJDHSS - January

90 JOB ACTION SHEET Position: Location: Role: Security Staff On-site Maintain order within assigned area; keep security liaison informed about conditions Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Provide crowd control Assist roving staff as needed Communicate with and assist law enforcement as needed Communicate with area leader as needed Respond to request(s) for assistance from clinic staff Report issues or problems to security liaison After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming security liaison NJDHSS - January

91 Translator Purpose: Staff: Process: Provide translation services to individuals who do not speak English. Multi-lingual staff. Provide translation services at the Pre-POD areas or inside the POD. Assist clinic workers and clinic participants with translation services to facilitate prophylaxis. Refer anxious participants to the debriefing area. Notify security to handle disruptive individuals, as needed. Report problems to appropriate area leader: Outside translators report to Pre-POD area leader. Inside translators report to the administrative area leader. NJDHSS - January

92 JOB ACTION SHEET Position: Location: Role: Translator Roving Provide translation services for individuals who do not speak English Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Provide assistance translating registration form Provide translation services for participants at workstations Provide translation assistance throughout POD, as needed Report issues or problems to appropriate area leader: Outside translators report to Pre-POD are leader Inside translators report to administrative are leader Notify security to handle disruptive individuals, as needed After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming translators NJDHSS - January

93 Hospitality Purpose: Staff: Process: Provide support services to clinic workers. Administrative and/or clerical staff. Refer workers to debriefing staff, as needed. Maintain adequate supplies of food and drink. Report issues or problems to appropriate area leader: o Outside hospitality reports to Pre-POD area leader. o Inside hospitality reports to administrative area leader. Maintain a clean and comfortable break area. Assist in others duties as assigned. NJDHSS - January

94 JOB ACTION SHEET Position: Location: Role: Hospitality Staff Hospitality Area Responsible for break area for workers Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Maintain a clean and comfortable break area Refer workers to debriefing staff as needed Maintain adequate supplies of food and drink Report issues or problems to appropriate area leader: Outside hospitality reports to the Pre-POD area leader Inside hospitality reports to the administrative area leader After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming hospitality staff NJDHSS - January

95 Housekeeping Purpose: Staff: Process: Maintain clean and tidy public areas and workstations in the Pre- POD areas or inside of the POD. Housekeeping Personnel Empty trash and medical waste from workstations. Dispose of waste from public areas. Replenish bathroom supplies. Maintain clean and dry public areas. Notify security to handle disruptive individuals, as needed Report problems to appropriate area leader: ο Outside housekeeping reports to the Pre-POD area leader. ο Inside housekeeping reports to administrative are leader. NJDHSS - January

96 JOB ACTION SHEET Position: Location: Role: Housekeeping Staff On-site Responsible for housekeeping activities inside the POD or the Pre-POD areas Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Empty trash and medical waste Properly dispose of trash and medical waste Replenish bathroom supplies, in both public areas and in hospitality workstation(s) Maintain clean and dry public and clinic area (i.e., sweeping, mopping) Report issues or problems to appropriate area leader Outside housekeeping reports to Pre-POD area leader Inside housekeeping reports to administrative area leader Notify security to handle disruptive individuals, as needed After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming housekeeping staff NJDHSS - January

97 Communications Technician Purpose: Staff: Process: Oversee technology needs at the POD. Professional or administrative staff with computer and/or portable communication device experience. Assist with set-up of audiovisual and other equipment. Maintain technology needs during clinic. Ensure equipment is functional and in working order. Notify security to handle disruptive individuals, as needed. Report problems to administrative area leader. NJDHSS - January

98 JOB ACTION SHEET Position: Location: Role: Communications Technician On-site Assist clinic staff with technology needs Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Assist with set-up of audiovisual and equipment Ensure equipment is functional and in working order Maintain technology needs during clinic Report issues or problems to administrative area leader Notify security to handle disruptive individuals, as needed After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming communications technician NJDHSS - January

99 Runner Purpose: Staff: Process: Assisting staff at the POD workstations Energetic individual with experience working with the public Locate and acquire items and services for participants as requested by workers. Hand carry messages and other communication to workstations. Give directions, as needed (e.g., restrooms, public telephones). Report issues or problems to Fast Track area leader. Notify security to handle disruptive individuals, as needed. NJDHSS - January

100 JOB ACTION SHEET Position: Location: Role: Runner On-site Assisting staff at the POD workstations Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Locate and acquire items for participants at the request of workers (e.g., wheelchair) Locate and acquire service provider for participants at the request of workers (e.g., translation services, mental health counseling) Hand carry communications to various workstations Assist staff with various duties, as needed Call security to handle disruptive individuals, as needed Give directions, as needed (e.g., restrooms, public telephones) Report issues or problems to Fast Track area leader After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming Runner NJDHSS - January

101 Workstation Communication Contact Purpose: Staff: Process: Communicating with staff at the workstation. Designated staff person at each workstation. Act as point person to receive messages from clinic administration and other communication contacts. Disseminate messages from clinic administration and other communication contacts to workstation staff. Respond to communication requests and issues from clinic administration and staff, as needed. Use communication equipment or interpersonal communication strategies to relay messages to workstation staff. Report issues or problems to area leader. NJDHSS - January

102 JOB ACTION SHEET Position: Location: Role: Workstation Communication Contact At each workstation Communicate with workers and clinic administration at the workstation Before your shift: Register at check-in Clearly display ID badge Familiarize self with location of all clinic areas Attend clinic orientation During your shift: Wear appropriate PPE, as needed Act as point person to receive messages from clinic administration and communication contacts Act as point person to disseminate messages from clinic administration and communication contacts to workstation staff Ensure that staff at workstation is kept informed of clinic updates Respond to communication requests from clinic staff, as needed Use communication equipment or effective interpersonal strategies to relay information to workstation staff Call security to handle disruptive individuals, as needed Report issues or problems to area leader After your shift: Assist with tear down and clean up of clinic Attend staff debriefing at shift change and/or at the close of clinic Prepare clinic for next day operations, as needed Brief in-coming workstation communication contact NJDHSS - January

103 Chapter 4: Equipment and Supplies While each county/jurisdiction differs in terms of population size and number of individuals to be prophylaxed, having adequate supplies is essential to smooth clinic operations. Arrangements for equipment and supplies to be delivered to and picked up from, the clinic site(s) should be detailed. Refer to your county s community emergency response plan and Strategic National Stockpile (SNS) plan for specific details. Consideration must be given regarding arrangements for disposal of medical waste. Needles used to administer immunizations and used vaccine vials must be placed in a sharps container; all other materials from the vaccination station (gloves, gauze, table protectors, etc.) must be placed in biohazard bags and disposed of appropriately. The POD manager and clinical manager should determine who will regularly inventory existing supplies and place orders to re-stock supplies, and establish ordering and receiving procedures in advance. Estimating the inventory that will be needed to run and maintain the clinic will vary from site to site. POD managers and clinical managers must work together to ensure that the inventory is monitored regularly and maintained to accommodate clinic needs. It is strongly recommended that the Clinic Planner and Clinical Manager develop an internal communication plan to assess the need to replenish supplies and address other logistical clinic issues. When placing an order to restock supplies, it is necessary to take into consideration traffic delays, delivery and packaging issues. To alleviate confusion and traffic congestion at the clinic, it is strongly recommended that supplies not be delivered to the same door where clinic participants enter. NJDHSS - January

104 The checklists below are provided as guidance for implementing a mass prophylaxis clinic within 12 hours of an event. Much will depend on the actual layout/floor plan of the facility and the situation surrounding the clinic. These lists are meant to be inclusive of the minimum equipment and supplies that should be incorporated in a mass clinic setting. NJDHSS - January

105 Equipment Non-clinical Supplies Clinical Supplies Blankets 8 ½ X 11 paper for Broom printer/fax/copier Adhesive tape Bucket Cleaning materials Alcohol/Alcohol wipes Computer networking Clipboards Band-aids device(s) Disposable paper Biohazard (red) bags Computers with ware/cutlery for Cotton balls Internet access refreshments or meals Disposable gloves Cots (for staff) (latex/non-latex in variety Duct tape Food and beverages for of sizes) Dustpan staff Emergency/first aid kit Extension cord(s) Markers Eye protection glasses Megaphone or public Paper towels and tissues Gowns address system Patient education video(s) Hand sanitizer Pillows and materials Hospital grade disinfectant Portable copier Patient information N-95 masks Portable fax machine materials Sandwich-size baggies Portable printer Pencils Sharps containers Power strip(s) Pens Spray bottles Privacy Receptacles for regular Sterile and non-sterile screens/partitions paper and food waste gauze (2x2) Refrigeration or cold Registration forms Syringes/bifurcated storage for vaccine Tape (duct and scotch) needles Scale Toner and ink cartridges Thermometer Signage for printer/fax/copier Waterproof table Stanchions (inside) Waste receptacle coverings for each Tables and chairs bags/liners vaccination station Traffic cones (outside) Wet spill absorbent VCR with TV or projector(s) Vests/smocks/security badges Walkie-talkies or other internal communication devices Waste receptacles Wheelchairs Yellow Caution ribbon NJDHSS - January

106 Equipment Inventory Item Quantity Available On-site Date of Order (month/day/year Time of Order (specify AM/PM) Initials Blankets Broom Bucket Chairs Computers with Internet access Computer networking device(s) Cots Duct tape Dustpan Extension cord(s) Megaphone or public address system Pillows Privacy screens/partitions Portable copier Portable fax machine Portable printer Power strip(s) Refrigeration for cold storage for vaccine Scale Signage Stanchions (inside) Tables Traffic cones (outside) VCR with TV or projectors Vests/smocks/security badges Walkie-talkies or other internal communication Waste receptacles Wheelchairs Yellow Caution ribbon NJDHSS - January

107 Non-Clinical Supplies Inventory Form Item 8 ½ X 11 paper Bleach Cleaning materials Clipboards Disposable paperware/cutlery Food and beverages for staff Magic markers Paper towels and tissues Patient education video(s) Patient information materials Pencils Pens Receptacles for paper and food waste Registration forms Tape (duct and scotch) Toner and ink cartridges Waste receptacle bags/liners Quantity Available On-site Date of Receipt (month/day/year) Time of Receipt (specify AM/PM) Initials NJDHSS - January

108 Clinical Supplies Inventory Form Item Adhesive tape Alcohol and/or alcohol wipes Ambulance(s) Band-aids Biohazard (red) bags Cotton balls Hospital grade disinfectant Disposable gloves (latex and non-latex in a variety of sizes) Eye protection glasses First aid kit Gowns Hand sanitizer N-95 masks Sharps containers Spray bottles for bleach solution Sterile and non-sterile gauze (2X2) Syringes/bifurcated needles Thermometer Waterproof table coverings Ziploc baggies (sandwich size) Quantity Available On-site Date Received (month/day/year) Time of Receipt (specify AM/PM) Initials NJDHSS - January

109 Equipment Order Form Item Blankets Broom Bucket Chairs Computers with Internet access Computer networking device(s) Cots Duct tape Dustpan Extension cord(s) Megaphone or public address system Pillows Privacy screens/partitions Portable copier Portable fax machine Portable printer Power strip(s) Refrigeration for cold storage for vaccine Scale Signage Stanchions (inside) Tables Traffic cones (outside) VCR with TV or projectors Vests/smocks/security badges Walkie-talkies or other internal communication Waste receptacles Wheelchairs Yellow Caution ribbon Amount Requested Date of Order (month/day/year) Time of Order (specify AM/PM) Initials NJDHSS - January

110 Non-Clinical Supply Order Form Item 8 ½ X 11 paper Amount Requested Date of Order (month/day/year) Time of Order (specify AM/PM) Initials Cleaning materials Clipboards Disposable paperware/cutlery Food and beverages for staff Magic markers Paper towels and tissues Patient education video(s) Patient information materials Pencils Pens Receptacles for paper and food waste Registration forms Tape (duct and scotch) Toner and ink cartridges Waste receptacle bags/liners NJDHSS - January

111 Clinical Supply Order Form Adhesive tape Item Amount Requested Date of Order (month/day/year) Time of Order (specify AM/PM) Initials Alcohol and/or alcohol wipes Ambulance(s) Band-aids Biohazard (red) bags Cotton balls Hospital grade disinfectant Disposable gloves (latex and non-latex in a variety of sizes) Eye protection glasses First aid kit Gowns Hand sanitizer N-95 masks Sharps containers Spray bottles for bleach solution Sterile and non-sterile gauze (2X2) Syringes/bifurcated needles Thermometer Waterproof table coverings Ziploc baggies (sandwich size) NJDHSS - January

112 Chapter 5: Personal Protective Equipment The CDC recognizes six Class A Biologic Agents: Anthrax, Botulism, Plague, Smallpox, Tularemia and Viral Hemorrhagic Fevers. The mode of transmission for these agents is varied, and therefore each requires different types of personal protection. It is vital for the mass prophylaxis clinic staff to be familiar with transmission mechanisms in order to protect themselves against infection. This chapter provides an overview of personal protective equipment (PPE) and recommendations of the appropriate PPE to be used in a mass prophylaxis clinic setting. Four levels of infection control precautions have been developed to reduce the transmission of microorganisms in health care settings where direct patient care is provided. These are Standard, Contact, Droplet, and Airborne Precautions. Each of these categories defines the personal protective equipment (PPE) and procedures to be used by care-givers to safeguard against disease transmission. Detailed information about them may be found on the CDC web site at: or the Association of Professionals in Infection Control (APIC) website at: m/apic_btwg_btrsugg.pdf. Recommendations for use of PPE at the Pre-POD and POD have been abstracted from these guidelines. Decisions about the use of PPE are based on the type of patient interaction that is expected. Most staff working at a POD operation will NOT need to use PPE because they will NOT be exposed to infectious materials. Routine use of PPE by ALL staff working at the POD is not recommended. It is unlikely that large numbers of infectious individuals will present at the POD site for the following reasons: NJDHSS - January

113 Only individuals who have the disease can transmit it person-to-person; those who have merely been exposed do not transmit disease. The public information campaign that precedes the opening of the POD will instruct persons who are symptomatic to seek treatment at a healthcare facility and not to present to the POD. The campaign will stress that prophylaxis is meant only for patients who are exposed and asymptomatic. Screening performed at the pre-pod will identify those individuals who are symptomatic. Complete evaluation at the pre-pod site is not possible; therefore, persons who are symptomatic will be excluded from the POD and sent for assessment to an emergency department or other treatment center. Staff at the Pre-POD and Sick Bay area in the POD may be exposed to potentially infectious patients. In these areas, the NJDHSS recommends that ALL staff wear the PPE outlined in the chart located in this chapter. In addition, the NJDHSS strongly encourages ALL staff working in these areas to perform routine hand washing. If a symptomatic patient should escape prior detection and enter the POD, the staff should use PPE based on the disease and type of contact anticipated. NJDHSS - January

114 SUMMARY OF INDICATED PERSONAL PROTECTIVE EQUIPMENT FOR POD OPERATIONS AGENT PERSON-TO-PERSOM TRANSMISSION PRE-POD PPE POD PPE SICK BAY PPE Cutaneous Anthrax Yes, direct contact with skin lesions but extremely unlikely NONE NONE Gloves- only needed for direct contact with nonintact skin Inhalational Anthrax NONE NONE NONE NONE Botulism NONE NONE NONE NONE Pneumonic Plague Yes, large respiratory droplet transmission For Suspect Cases: Surgical mask - only needed when within 3 feet of infected patient NONE For Suspect Cases: Surgical mask - only needed when within 3 feet of infected patient Smallpox Yes, droplet and airborne* transmission and direct contact with skin lesions or items soiled with drainage from lesion For Suspect Cases: Particulate respirator meeting NIOSH requirements NONE For Suspect Cases: Gloves- only needed for direct contact with nonintact skin & items soiled with drainage from lesions Particulate respirator meeting NIOSH requirements. *Airborne transmission is rare NJDHSS - January

115 SUMMARY OF INDICATED PERSONAL PROTECTIVE EQUIPMENT FOR POD OPERATIONS - Continued AGENT TRANSMISSION PRE-POD PPE POD PPE SICK BAY PPE Tularemia NONE NONE NONE NONE Viral Hemorrhagic Fevers Yes, direct contact, droplet and airborne* exposure For Suspect Cases: Particulate respirator meeting NIOSH requirements NONE For Suspect Cases: Gloves- only needed for direct contact with nonintact skin Particulate respirator meeting NIOSH requirements *Limited animal studies have shown that airborne transmission can be engineered using a fine aerosol Further recommendations regarding these agents and precautions can be found at: NJDHSS - January

116 Chapter 6: Medications and Standing Orders Antibiotics and vaccines used for prophylaxis are prescription medications. Unlike over-the-counter medications, such as aspirin and cough syrup, they are not available to the general public without a specific recommendation for their use by a licensed health professional with prescriptive practice. Under normal circumstances, a prescription medication would be dispensed or administered only after the prescriber evaluates the person and then judges the medication to be appropriate. In a mass prophylaxis clinic, the need to process large numbers of people quickly and efficiently makes such individualized prescribing impractical. Instead, the means to provide prescription medications to large populations is through use of standing orders. The New Jersey POD model makes use of standing orders and greatly reduces or eliminates individualized patient assessment and teaching by substituting patient self-assessment. Standing orders authorize registered nurses and, in some cases, registered pharmacists to administer vaccinations or distribute medication regimens according to a physician-approved protocol without a physician's exam. They have been used for years in such settings as managed-care organizations, pediatrician offices, assisted living facilities, correctional institutions and workplaces, to vaccinate patient, resident, and employee populations for influenza. More recently, standing orders were used successfully during the smallpox preparedness vaccination initiatives of The standing order documents a plan for service delivery at the mass prophylaxis clinic. It must contain protocols for the following procedures: The standing order s start and expiration date. Identification of persons eligible for medication based on specific criteria. A detailed description of the primary and alternate medication regimens including dosage, route of administration, and duration of therapy. A means of provision of information to participants or their guardians regarding the risks for, and benefits of, the medical regimen. Medical contraindications to the medical regimens. Recording of informed consent or refusal. NJDHSS - January

117 Recording of vaccine administration or medication regimen. Recording of untoward effects and treatment. Provision of counseling to assure participant is aware of follow-up services. Since mass prophylaxis clinics must stand ready to be made operational within 12 hours of the decision to initiate prophylaxis, a basic format for standing orders and their protocols should be prepared at the local level well in advance of need. In an actual event, decisions about types of medication regimens and populations to be treated will almost surely be made at the federal and/or state level. Nevertheless, community preparedness and response plans should specifically describe the lines of authority within the clinic site, identify a medical director, and specify who will sign the standing order. Examples of formats for standing orders are shown in the following pages. Standing orders provide authorization to medicate a specific population based on predetermined criteria. Before they can be carried out, two functions must be fulfilled. First, the individual must be educated about the medication, and screened to confirm medical eligibility. Second, the individual must give his or her informed consent to be medicated. Obtaining a very focused medical history will accomplish screening for medical eligibility. Providing the participant with educational materials and the opportunity to ask questions will facilitate informed consent. In the New Jersey POD model, declaration of self-education and self-screening are acceptable. The history, confirmation that there are no contraindications to the medicine or vaccine, evidence of education, and documentation of informed consent can be combined with the participant s contact information on a single form. This registration form would then be maintained by the clinic to serve as the participant s medical record. All medical records at the POD should be kept on paper. For ease of retrieval, information may be transferred to a computer database after the POD has closed. NJDHSS - January

118 Several samples of standing orders and registration forms may be found at the end of this chapter, along with the CDC s post-exposure prophylaxis recommendations for anthrax, plague and tularemia. Examples of medication information sheets for patients are also included at the end of this chapter. These sheets, available in many languages, were created by the CDC, and are downloadable from the SNS Extranet. NJDHSS - January

119 Anthrax NJDHSS - January

120 Post-Exposure Prophylaxis for Bacilius Anthracis Patient Category Initial Therapy Duration* Adults (including Ciprofloxacin, 500 mg PO twice daily Or 60 days immunocompromised patients) Doxycycline, 100 mg PO twice daily Pregnant women and breastfeeding mothers Ciprofloxacin, 500 mg PO twice daily or 60 days Doxycycline, 100 mg PO twice daily (Amoxicillin, 500 mg orally three times daily, may be used if isolate involved in exposure is determined to be susceptible to Children (including Immunocompromised patients) penicillin**,***,**** Ciprofloxacin, mg/kg PO every 12 hr. not to exceed 1 gm/day or Doxycycline: >8 yr and >45 kg: 100 mg PO twice daily >8yr and <45 kg: 2.2 mg/kg PO twice daily <8yr: 2.2 mg/kg PO twice daily 60 days Abbreviations: PO orally. (Amoxicillin, 80 mg/kg/day divided every 8 hr. not to exceed 500 mg/dose, may be used if the isolate involved in exposure is determined to be susceptible to penicillin***) *Additional recommendations were made for those exposed to high levels of anthrax, see comments below. **See comments below from American College of Obstetricians and Gynecologist regarding use of amoxicillin. ***Amoxicillin is not approved by the FDA for post exposure prophylaxis or treatment of anthrax; however, CDC indicated that it could be used for pregnant women or children for post exposure prophylaxis if the isolate is determined to be susceptible (CDD: Interim recommendations for antimicrobial prophylaxis for children and breastfeeding mothers and treatment of children with anthrax ( CDC: Updated recommendations for antimicrobial prophylaxis among asymptomatic pregnant women after exposure to Bacillus anthracis. MMWR 2001;50(43):960. ****American Academy of Pediatrics considers ciprofloxacin and tetracyclines to usually be compatible with breastfeeding because the amount of either drug absorbed by infants is small, but little is known about the safety of long-term use. Therefore, amoxicillin may be considered an alternative for breastfeeding mothers if the isolate causing exposure is known to be susceptible to penicillin. Alternatively, mothers could consider expressing and discarding breast milk during therapy with ciprofloxacin or doxycycline and resuming breastfeeding after therapy is complete. Adapted from CDC. Update: Investigation of bioterrorism-related anthrax and interim guidelines for exposure management and antimicrobial therapy, October 19, MMWR 2001;50(41): NJDHSS - January

121 Standing Orders for Anthrax Post Exposure Prophylaxis Purpose: Reduce morbidity and mortality from anthrax by providing antibiotic medication as prophylaxis. Policy: Under these standing orders, registered nurses and pharmacists may dispense antibiotic regimens to persons who have been found to meet criteria established by the New Jersey Department of Health and Senior Services (NJDHSS) and the Centers for Disease Control and Prevention (CDC). Procedure: 1. Confirm that participant is eligible to receive post exposure prophylaxis, and has been educated about its risks and benefits. Declaration of self-education is acceptable. 2. Screen all participants for contraindications and precautions to antibiotic therapy with ciprofloxacin or doxycycline. Declaration of self-screening is acceptable. 3. Dispense an antibiotic post exposure prophylaxis regimen as follows: Adults and children over 55 pounds with no contraindications/precautions to ciprofloxacin: Ciprofloxacin, 500 mg PO twice daily for 10 days Children 55 pounds with no contraindications/precautions to ciprofloxacin: Ciprofloxacin, mg/kg PO twice daily for 10 days (maximum daily dose, 1 gm) Adults and children over 99 pounds with contraindications/precautions to ciprofloxacin and no contraindications/precautions to doxycycline: Doxycycline, 100 mg PO twice daily for 10 days Children 99 pounds with contraindications/precautions to ciprofloxacin and no contraindications/precautions to doxycycline: Doxycycline, 2.2 mg/kg PO twice daily for 10 days Adults and children with contraindications/precautions to ciprofloxacin and doxycycline: Refer to medical consultation workstation 4. Provide all participants with a patient information sheet that includes: name and dose of drug, instructions on how to take the drug, drug/food interactions, warnings, side effects, and 24- hour telephone number for questions or problems. 5. Document each participant s medication information in the following places: a) Medical Chart: Record the date the drug was dispensed, the manufacturer and lot number, and the name and title of the person distributing the medication. b) Personal Information Sheet: Record the date of dispensing and the name/location of the POD. This policy and associated procedures shall remain in effect until rescinded or until (date). Medical Director s signature: Effective date: NJDHSS - January

122 Decision-Making Guidelines for Medical Screeners Post Exposure Prophylaxis for Anthrax Medical Screeners should use these guidelines to determine proper recommendations for antibiotics when patients have yes answers in the medical self-screening section of the registration form. When in doubt, screeners should refer patients to medical consultation. See page 2 of this form for decision-making rationale. Yes Question Action Reactions or problems after taking antibiotics Hives or breathing problems after Refer to Medical Consult Workstation antibiotics Allergy Ciprofloxacin Give Doxycycline Doxycycline Give Ciprofloxacin Ciprofloxacin and doxycycline Refer to Medical Consult Workstation Pregnant or trying to become 1 st choice Give Ciprofloxacin and refer patient to her obstetrician/pcp for follow-up 2 nd choice (if allergic to Ciprofloxacin) Give Doxycycline and refer patient to her obstetrician/pcp for follow-up Kidney Hemodialysis Give ½ dose Ciprofloxacin Peritoneal dialysis Give ¾ dose Ciprofloxacin Kidney damage Give Doxycycline Taking following medications Theophylline (asthma) Give Doxycycline Dilantin (seizures) Give Doxycycline Tegretol (seizures) Give Ciprofloxacin Phenobarbital (seizures) Give Ciprofloxacin Oral hypoglycemics (diabetes) Give Doxycycline Coumadin (blood thinner) Give Ciprofloxacin and refer to PCP for coumadin dose adjustment/monitoring Probenicid (gout) Give Doxycycline Cyclosporine (immunosuppressant) Give Doxycycline Not Sure of Medication(s) taken Attempt to determine medication(s) through interview. If unable, refer to Medical Consult Workstation Children Weight 55 lbs. to receive Ciprofloxacin See dosing chart Weight 99 lbs. to receive Doxycycline NJDHSS - January

123 Yes Question Hives or breathing problems after taking antibiotics Allergy Ciprofloxacin Doxycycline Ciprofloxacin and Doxycycline Pregnant or trying to become Decision-Making Guidelines Issues and Rationale See page 1 of this form for medication recommendations. Issues to Consider Possible anaphylaxis Ciprofloxacin and doxycycline are both preferred choices. Normal side effects (nausea, diarrhea, etc.) can be confused with true allergy (hives, respiratory distress, throat swelling.) Determine if true allergy. IF YES: refer to medical consult. IF NO: Give Ciprofloxacin. Ciprofloxacin Ciprofloxacin has not been adequately studied for use in pregnant women, but an expert review of published data on experience with Ciprofloxacin use during pregnancy concluded that Ciprofloxacin is unlikely to pose substantial risk. Doxycycline Doxycycline use during tooth development (2 nd & 3 rd trimester) can cause staining of teeth in the fetus, and liver problems in the mother. Ciprofloxacin is the drug of choice, unless allergic. Kidney Disease Hemodialysis Patients on dialysis clear Ciprofloxacin more slowly than normal. They Peritoneal dialysis will need reduced a reduced Ciprofloxacin dose, or Doxycycline. Kidney disease Ciprofloxacin is not recommended for patients with inadequate creatinine clearance. They should be given Doxycycline. Taking following medications Theophylline Ciprofloxacin can inhibit hepatic metabolism of theophylline, thus increasing risk of theophylline toxicity. Serious and fatal reactions have been reported. Dilantin Altered serum levels of dilantin (increased and decreased) have been reported in patients receiving concomitant ciprofloxacin. Tegretol Tegretol decreases the half-life of doxycycline. Phenobarbital Barbiturates decrease the half-life of doxycycline. Oral hypoglycemics Concomitant use of Ciprofloxacin can cause severe hypoglycemia. Coumadin Both Ciprofloxacin and Doxycycline can enhance the effects of coumadin. Ciprofloxacin is the preferred therapy; prothrombin times should be closely monitored. Probenicid Probenicid may decrease the renal excretion of ciprofloxacin, therefore increasing the risk of ciprofloxacin toxicity. Cyclosporine Concomitant use of ciprofloxacin may result in increased serum creatinine. Children under 18 years old Ciprofloxacin Ciprofloxacin has not been fully studied for routine use in children, but is approved for post-exposure prophylaxis. Doxycycline Doxycycline in children under 8 years old can cause staining of teeth and joint problems. Ciprofloxacin is the drug of choice, unless allergic. NJDHSS - January

124 Pediatric Dosing Chart Children under 18 years or weighing less than 55 pounds Ciprofloxacin Suspension, 250 mg per 5 ml Anthrax PEP Recommendation: mg per kilogram of body weight, BID Weight (lbs) Weight (kg) Dose (mg) BID Amount of Suspension per Dose Under 5 Under 2 Refer to Medical Consultation ml ml ml ml ml ml ml ml ml ml ml 55 or 25 or over Adult Dose N/A NJDHSS - January

125 Pediatric Dosing Chart Children under 18 years or weighing less than 99 pounds Doxycycline Sus pension, 25 mg per 5 ml Anthrax PEP Recommendation: 2.2 mg doxycycline per kilogram of body weight, BID Weight (lbs) Weight (kg) Dose (mg) Amount of Suspension per Dose Under 5 Under 2 Refer to Medical Consultation mg 2 ml mg 4 ml mg 6 ml mg 8 ml mg 10 ml mg 12 ml mg 14 ml mg 16 ml mg 18 ml Over 99 Over 45 Adult Dose N/A NJDHSS - January

126 Información para el Paciente: DOXYCYCLINE 100 MG TABLETA ORAL Organización Estatal de Salud Pública: Número de Teléfono para Obtener Información 24 Horas al Día: Este fármaco se emplea para el tratamiento de infecciones. Pertenece a los grupos antibióticos de las tetraciclinas (tetracycline). Esta droga le ha sido administrada a Ud. para su protección contra la posible exposición a bacterias que causan infecciones. Este fármaco se emplea para el tratamiento de: Ántrax Usted ha sido provisto con una cantidad limitada de medicamento. Los profesionales locales de la salud para casos de emergencia o su proveedor del cuidado de la salud le informarán si Ud. necesitara más medicina después que este abastecimiento haya sido agotado. Si así ocurriera, durante su próxima consulta, Ud. será informado de cómo conseguir más medicina. Usted también será informado si no tuviera necesidad de tomar más medicina. Tome esta medicina según las indicaciones: una tableta, por vía oral, dos veces al día. Si Ud. tuviera niños de 8 años de edad o menores, recibirá instrucciones especiales con respecto a las dosis para niños. No deje de tomar la medicina aunque se sienta bien. Deje de tomar esta medicina únicamente si su médico o profesional de la salud así lo indicara. Si Ud. dejara de tomar esta medicina prematuramente, podría ser infectado o su infección podría reaparecer. Esta medicina puede ser ingerida con o sin alimento o leche, pero es posible que comer o tomar leche ayudará a evitar molestias estomacales. Si dejara de tomar una dosis, tómela tan pronto como sea posible. Si fuera ya casi hora de tomar su próxima dosis regular, tome esa próxima dosis y olvídese de la que dejó de tomar. Nunca tome una dosis doble. DROGAS Y ALIMENTOS QUE SE DEBEN EVITAR: No tome las siguientes medicinas hasta pasadas las 2 horas después de tomar DOXYCYCLINE: antiácidos tales como Maalox o Mylanta, suplementos de calcio o de hierro, cholestyramine (Questran) o colestipol (Colestid). Es posible que, mientras esté tomando esta medicina, las pastillas anticonceptivas no surjan completo efecto. Le recomendamos que utilice otro método anticonceptivo. ADVERTENCIA: Si padeciera de enfermedades hepáticas o si estuviera, o existiera la posibilidad de que estuviera embarazada, o si estuviera amamantando, infórmelo a los profesionales de la salud para casos de emergencia, antes de comenzar a tomar la medicina. El uso de esta medicina aumenta la posibilidad de susceptibilidad a las quemaduras de sol; asegúrese de proteger su piel utilizando productos con protección contra el sol. No tome esta medicina si Ud. hubiera tenido una reacción alérgica a los antibióticos de las tetraciclinas (tetracycline). Es posible que esta medicina induzca la infección vaginal por levadura, en algunas mujeres. EFECTOS SECUNDARIOS: Llame a su médico o procure atención médica inmediata, si sufriera de cualquiera de los siguientes efectos secundarios: salpullido, urticaria o picazón; jadeo o dificultad para respirar; hinchazón de la cara, los labios o de garganta. Los efectos secundarios de menor gravedad incluyen: diarrea, malestar estomacal, náuseas, dolor de garganta o en la boca, sensibilidad a la luz del sol y picazón de la boca o de la vagina que dure más de 2 días. Hable con su médico si sufriera de cualquiera de estos efectos secundarios. Spanish - Doxycycline 100mg - Anthrax.doc NJDHSS - January

127 Patient Information: DOXYCYCLINE 100 MG ORAL TABLET State Public Health Organization: 24-hour Information Telephone Number: This drug treats infections. It belongs to a class of drugs called tetracycline antibiotics. You have been given this drug for protection against possible exposure to an infectioncausing bacteria. This drug treats: Anthrax You have been provided a limited supply of medicine. Local emergency health workers or your healthcare provider will inform you if you need more medicine after you finish this supply. If so, upon your follow-up visit, you will be told how to get more medicine. You will also be told if no more medicine is needed. Take this medicine as prescribed. one tablet by mouth, two times a day. You will be provided special dosing instructions if you have a child under 8 years of age. Keep taking your medicine, even if you feel okay, unless your healthcare provider tells you to stop. If you stop taking this medicine too soon, you may become infected, or your infection may come back. You may take your medicine with or without food or milk, but food or milk may help you avoid upset stomach. If you miss a dose, take the missed dose as soon as possible. If it is almost time for your next regular dose, wait until then to take your medicine, and skip the missed dose. Do not take two doses at the same time. DRUGS AND FOODS TO AVOID: Do not take the following medicines within 2 hours of taking DOXYCYCLINE: antacids such as Maalox or Mylanta, calcium or iron supplements, cholestyramine (Questran) or colestipol (Colestid). While you are taking this medicine, birth control pills may not work as well; make sure to use another form of birth control. WARNINGS: If you have liver disease, or if you are or might be pregnant, or if you are breastfeeding, tell emergency healthcare workers before you start taking this medicine. This medicine increases the chance of sunburn; make sure to use sunscreen to protect your skin. Do not take this medicine if you have had an allergic reaction to any tetracycline antibiotics. Women may have vaginal yeast infections from taking this medicine. SIDE EFFECTS: Call your doctor or seek medical attention right away if you are having any of these side effects: skin rash, hives, or itching; wheezing or trouble breathing; swelling of the face, lips, or throat. Less serious side effects include diarrhea, upset stomach, nausea, sore mouth or throat, sensitivity to sunlight, or itching of the mouth or vagina lasting more than 2 days. Talk with your doctor if you have problems with these side effects. Doxycycline 100mg - Anthrax.doc NJDHSS - January

128 Información para el Paciente: CIPRO (ciprofloxacin) TABLETA ORAL 500 mg Organización Estatal de Salud Pública: Número de Teléfono para Obtener Información 24 Horas al Día: Este fármaco se emplea para el tratamiento de infecciones. Pertenece a los grupos antibióticos de las quinolonas (quinolone). Esta droga le ha sido administrada a Ud. para su protección contra la posible exposición a bacterias que causan infecciones. Este fármaco se emplea para el tratamiento de: Ántrax Usted ha sido provisto con una cantidad limitada de medicamento. Los profesionales locales de la salud para casos de emergencia o su proveedor del cuidado de la salud le informarán si Ud. necesitara más medicina después que este abastecimiento haya sido agotado. Si así ocurriera, durante su próxima consulta Ud. será informado de cómo conseguir más medicina. Usted también será informado si no tuviera necesidad de tomar más medicina. Tome esta medicina según las indicaciones: una tableta, por vía oral, dos veces al día. Si Ud. tuviera hijos menores, recibirá instrucciones especiales con respecto a las dosis para niños. No deje de tomar la medicina, aunque se sienta bien. Deje de tomar esta medicina únicamente si su médico así lo indicara. Si Ud. dejara de tomar esta medicina prematuramente, podría ser infectado o su infección podría reaparecer. Esta medicina debe ser ingerida con un vaso lleno de agua. Tome varios vasos de agua por día, mientras se encuentre tomando esta medicina. Lo mejor es tomar esta medicina dos horas después de las comidas. Si le produjera malestar estomacal podría tomarla con la comida, pero no debe tomarla con leche, yogur o queso. Si dejara de tomar una dosis, tómela tan pronto como sea posible. Si fuera ya casi hora de tomar su próxima dosis regular, tome esa próxima dosis y olvídese de la que dejó de tomar. Nunca tome una dosis doble. DROGAS Y ALIMENTOS QUE SE DEBEN EVITAR: No tome las siguientes drogas hasta pasadas las 2 horas después de tomar CIPRO: antiácidos tales como Maalox o Mylanta, vitaminas o suplementos de hierro, suplementos de zinc, o sucralfate (Carafate). Puede tomarlas dos horas después o seis horas antes de tomar el CIPRO. Asegúrese también que su médico sepa que Ud. está tomando medicinas para el asma, tal como theophylline, medicinas para la gota, tales como probenecid (Benemida), o adelgazadores de sangre, tal como Coumadin. Evite tomar más de una (1) ó dos (2) tazas de bebidas con cafeína (café, té, refrescos con cafeína) por día. Evite tomar esta medicina con alimentos que contengan un gran porcentaje de calcio, tales como la leche, el yogur o queso. ADVERTENCIA: Si Ud. sufriera de epilepsia o padeciera de los riñones, o si estuviera o existiera la posibilidad de que estuviera embarazada, o si estuviera amamantando, infórmelo a los profesionales de la salud para casos de emergencia, antes de comenzar a tomar la medicina. No tome esta medicina si Ud. hubiera tenido una reacción alérgica a ciprofloxacin u otras medicinas de la quinolona (quinolone), tales como norfloxacin (Noroxin), ofloxacin (Floxin), o nalidixic acid (NegGram). Esta medicina puede provocar mareos. Evite conducir un automóvil u operar cualquier tipo de maquinaria hasta que sepa cómo habrá de afectarle la medicina. El uso de esta medicina aumenta la posibilidad de susceptibilidad a las quemaduras de sol; asegúrese de proteger su piel utilizando productos con protección contra el sol. EFECTOS SECUNDARIOS: Llame a su médico o procure atención médica inmediata, si sufriera de cualquiera de los siguientes efectos secundarios: salpullido, urticaria o picazón; hinchazón de la cara, los labios o de garganta; jadeo o dificultad para respirar, convulsiones o diarrea aguda. Los efectos secundarios de menor gravedad incluyen: náuseas, diarrea benigna, dolor estomacal, mareos y dolores de cabeza. Hable con su médico si sufriera de cualquiera de estos efectos secundarios. Spanish - Cipro 500mg - Anthrax.doc NJDHSS - January

129 State Public Health Organization: 24-hour Information Telephone Number: You have been provided a limited supply of medicine. Local emergency health workers or your healthcare provider will inform you if you need more medicine after you finish this supply. If so upon your follow-up visit, you will be told how to get more medicine. You will also be told if no more medicine is needed. Take this medicine as prescribed. one tablet by mouth, two times a day. You will be provided special dosing instructions for children. Anthrax Keep taking your medicine, even if you feel okay, unless your doctor tells you to stop. If you stop taking this medicine too soon, you may become infected, or your infection may come back. You should take this medicine with a full glass of water. Drink several glasses of water each day while you are taking this medicine. It is best to take this medicine 2 hours after a meal. If it upsets your stomach, you may take it with food, but do not take it with milk, yogurt, or cheese. If you miss a dose, take the missed dose as soon as possible. If it is almost time for your next regular dose, wait until then to take your medicine, and skip the missed dose. Do not take two doses at the same time. DRUGS AND FOODS TO A VOID: Do not take the following drugs within 2 hours oftaking CIPRO: antacids such as Maalox or Mylanta, vitamins, iron supplements, zinc supplements, or sucralfate (Carafate). You may take them 2 hours after or 6 hours before CIPRO. Also, make sure your doctor knows if you are taking asthma medicine like theophylline, gout medicine like probenecid (Benemid), or a blood thinner such as Coumadin. Avoid drinking more than one or two caffeinated beverages (coffee, tea, soft drinks) per day. Avoid taking this medicine with foods containing large amounts of calcium, like milk, yogurt, or cheese. WARNINGS: If you have epilepsy or kidney disease, or if you are pregnant, become pregnant, or are breastfeeding, tell emergency healthcare workers before you start taking this medicine. Do not take this medicine if you have had an allergic reaction to ciprofloxacin or other quinolone medicines such as norfloxacin (Noroxin), ofloxacin (Floxin) or nalidixic acid (NegGram). This medicine may make you dizzy or lightheaded. Avoid driving or using machinery until you know how it will affect you. This medicine increases the chance of sunburn; make sure to use sunscreen to protect your skin. SIDE EFFECTS: Call your doctor or seek medical advice right away if you are having any ofthese side effects: rash or hives; swelling of face, throat, or lips; shortness of breath or trouble breathing; seizures; or severe diarrhea. Less serious side effects include nausea, mild diarrhea, stomach pain, dizziness, and headache. Talk with your doctor if you have problems with these side effects. ~ Cipro 500mg - Plague. doc NJDHSS - January

130 Anthrax Post Exposure Prophylaxis Participant Screening and Consent Form Date Participant Identification Number Participant s Name Birth Date Sex: M Address Street & House Number City State Zip Code Telephone ( ) Form Filled Out By: SELF or OTHER When completing this form for a household member, answer all questions as if you were that person. Were you or a close contact present at (site) on (date) at (time)? Yes No Have you been in contact with materials from (site)? Yes No Education Self-Screening: Have you received or viewed education about anthrax? Yes No Have you received or viewed education about medicine to prevent anthrax? Yes No Do you understand the benefits and risks of taking medicine to prevent anthrax? Yes No Have your questions about receiving medicine to prevent anthrax been answered? Yes No Signature to Acknowledge Education I am informed about why medicine to prevent anthrax is being made available. I understand the risks and benefits associated with taking medicine to prevent anthrax. There are no questions about anthrax or taking medicine to prevent anthrax that I would like to have answered. Participant Signature Date F Medical Self-Screening: Have you ever had hives or trouble breathing after taking antibiotics? Yes No Are you allergic to Doxycycline, Ciprofloxacin or Amoxicillin? Yes No Are you pregnant now or trying to become pregnant? Yes No Do you have kidney disease or need renal dialysis? Yes No For Children Only: What is your weight? Do you take any of the following medications? Yes No Theophylline, seizure medicine, oral diabetes medicine, blood thinners, Not Sure medicine for gout, or immunosuppressants Informed Consent Signature to Receive Medication: There is no condition that stops me (or my household member) from using medicine to prevent anthrax. I have decided to receive medicine to prevent anthrax today for myself or for my household member. Participant Signature Date Informed Refusal Signature to Decline Medication: I am informed about why medicine to prevent anthrax is being made available. I understand the risks and benefits associated with taking medicine to prevent anthrax. There are no questions about anthrax or taking medicine to prevent anthrax that I would like to have answered. I have decided not to receive medicine to prevent anthrax today for myself or for my household member,. Participant Signature Date 130

131 FOR CLINIC USE ONLY Medication Regimen to Be Used: Adult: Ciprofloxacin Doxycycline Amoxicillin Child: weight Ciprofloxacin mg Doxycycline mg Amoxicillin mg Screener s Signature Medication Dispensed: Adult: Ciprofloxacin 500 mg PO twice a day for days Doxycycline 100 mg PO twice a day for days Amoxicillin 500 mg PO 3 times daily for days LOT NUMBER LOT NUMBER LOT NUMBER Child: Ciprofloxacin mg PO every 12 hours for days Doxycycline mg PO twice a day for days Amoxicillin mg PO 3 times daily for days LOT NUMBER LOT NUMBER LOT NUMBER Dispenser s Signature Date Revised

132 Influenza NJDHSS - January

133 CDC Recommendations for Influenza Prevention December 16, 2003 Vaccination Emphasis should be placed on targeting trivalent inactivated vaccine to persons at high risk for complications from influenza: children aged 6 23 months, adults aged > 65 years, pregnant women in their second or third trimester during influenza season, and persons aged > 2 years with underlying chronic conditions. Persons at high risk should be encouraged to search locally for vaccine if their usual health-care provider no longer has vaccine available. All children at high risk, including those aged 6 23 months, who report for vaccination should be vaccinated with a first or second dose, depending on vaccination status. Doses should not be held in reserve to ensure that two doses will be available. Next priority should be given to vaccinating those persons at greatest risk for transmission of disease to persons at high risk, including household contacts and health-care workers. Healthy persons aged 5 49 years should be encouraged to be vaccinated with intranasally administered live, attenuated influenza vaccine. Decisions about vaccinating healthy persons, including adults aged years, with inactivated influenza vaccine should be made on a case-by-case basis, depending on local disease activity, vaccine coverage, feasibility, and supply. NJDHSS - January

134 NJDHSS - January

135 Standing Orders for Administering Influenza Vaccine to Adults Purpose: To reduce morbidity and mortality from influenza by vaccinating all patients who meet the criteria established by the Centers for Disease Control and Prevention s Advisory Committee on Immunization Practices. Policy: Under these standing orders, eligible nurses may vaccinate patients who meet the criteria below. Procedure: 1. Identify adult in need of influenza vaccination based on the following criteria: a) Age 50 years or older b) Age less than 50 years with any of the following conditions: chronic disorder of the pulmonary or cardiovascular system, including asthma chronic metabolic disease (e.g., diabetes mellitus), renal dysfunction, hemoglobinopathy, or immunosuppression (e.g., caused by medications, HIV) that has required regular medical follow-up or hospitalization during the preceding year will be in the second or third trimester of pregnancy during the influenza season c) Residence in a nursing home or other chronic-care facility that houses persons of any age who have chronic medical conditions. d) In an occupation or living situation that puts one in proximity to persons at high risk, including: a health care worker, caregiver, or household member in contact with person(s) at high risk of developing complications from influenza a household contact or out-of-home caretaker of a child 0-23 months of age e) Wish to reduce the likelihood of becoming ill with influenza 2. Screen all patients for contraindications and precautions to influenza vaccine: a) Contraindications: serious reaction (e.g., anaphylaxis) after ingesting eggs or after receiving a previous dose of influenza vaccine or an influenza vaccine component. For a list of vaccine components, go to Do not give live attenuated influenza vaccine (LAIV) to pregnant or immunosuppressed persons. Use of inactivated influenza is preferred over LAIV for close contacts of immunosuppressed persons (e.g., healthcare workers or household contacts). b) Precautions: moderate or severe acute illness with or without fever 3. Provide all patients with a copy of the most current federal Vaccine Information Statement (VIS). Although not required by federal law, it is prudent to document in the patient s medical record or office log, the publication date of the VIS and the date is was given to the patient. Provide non-english speakers with a VIS in their native language if available; these can be found at 4. Administer 0.5 ml inactivated influenza vaccine IM (22-25g, 1-1 1/2 needle) in the deltoid muscle. Alternatively, healthy persons 5-49 years of age without contraindications may be given 0.5 ml of LAIV; 0.25 ml is sprayed into each nostril while the patient is in an upright position. 5. Document each patient s vaccine administration information and follow up in the following places: a) Medical chart: Record the date the vaccine was administered, the manufacturer and lot number, the vaccination site and route, and the name of the title of the person administering the vaccine. If vaccine was not given, record the reason(s) for non-receipt of the vaccine (e.g., medical contraindication, patient refusal). c) Personal immunization record card: Record the date of vaccination and the name/location of the administering clinic. 6. Be prepared for management of a medical emergency related to the administration of vaccine by having a written emergency medical protocol available, as well as equipment and medications. 7. Report all adverse reactions to influenza vaccine federal Vaccine Adverse Event Reporting System (VAERS) at or (800) VAERS report forms are available at This policy and procedures shall remain in effect for all patients of (the name of practice or clinic) until rescinded or until (date). Medical Director s signature: Effective date: NJDHSS - January

136 Influenza Prophylaxis Participant Screening and Consent Form Date Participant Identification Number Participant s Name Birth Date Sex: M Address Street & House Number City State Zip Code Telephone ( ) Form Filled Out By: SELF or OTHER When completing this form for a household member, answer all questions as if you were that person. Are you over 50 years of age Yes No Are you at least 6 months of age? Yes No Do you have any of the following: A chronic condition of the heart, lungs or kidneys; diabetes; a blood disorder, or a weakened immune system? Yes No Are you in an occupational or other priority group? Yes No Education Self-Screening: Have you received or viewed education about influenza? Yes No Have you received or viewed education about medicine to prevent influenza? Yes No Do you understand the benefits and risks of taking medicine to prevent influenza? Yes No Have your questions about receiving medicine to prevent influenza been answered? Yes No Signature to Acknowledge Education I am informed about why medicine to prevent influenza is being made available. I understand the risks and benefits associated with taking medicine to prevent influenza. There are no questions about influenza or taking medicine to prevent influenza that I would like to have answered. Participant Signature Date F Medical Self-Screening: Have you ever had hives or trouble breathing after a previous flu shot? Yes No Are you allergic to eggs or mercury? Yes No Are you pregnant now or trying to become pregnant? Yes No For Children Only: Are you less than 3 years old? Yes No Informed Consent Signature to Receive Medication: There is no condition that stops me (or my household member) from taking vaccine to prevent influenza. I have decided to receive vaccine to prevent influenza today for myself or for my household member. Participant Signature Date Informed Refusal Signature to Decline Medication: I am informed about why vaccine to prevent influenza is being made available. I understand the risks and benefits associated with taking vaccine to prevent influenza. There are no questions about influenza or taking vaccine to prevent influenza that I would like to have answered. I have decided not to receive vaccine to prevent influenza today for myself or for my household member,. Participant Signature Date 136

137 FOR CLINIC USE ONLY Medication To Be Administered Adult: influenza vaccine NONE Child: age 0.25 ml 0.50 ml Medication Administered: Adult: 0.5 ml influenza vaccine IM in the deltoid muscle LOT NUMBER Child: 0.25 ml influenza vaccine IM in the muscle 0.5 ml influenza vaccine IM in the muscle LOT NUMBER LOT NUMBER Health Care Worker s Signature Date Revised

138 FACT SHEET Key Facts About Flu Vaccine Preventing the Flu: Get a Flu Vaccine The single best way to prevent the flu is to get a flu vaccine each fall. There are two types of vaccines: The flu shot an inactivated vaccine (containing killed virus) that is given with a needle, usually in the arm. The flu shot is approved for use in people older than 6 months, including healthy people and people with chronic medical conditions. About 58 million flu shots will be available in the United States this season. The nasal-spray flu vaccine a vaccine made with live, weakened flu viruses that do not cause the flu (sometimes called LAIV for Live Attenuated Influenza Vaccine ). LAIV is approved for use in healthy people 5 years to 49 years of age who are not pregnant. About 3 million doses of LAIV will be available in the United States this season. Each vaccine contains three influenza viruses one A (H3N2) virus, one A (H1N1) virus, and one B virus. The viruses in the vaccine change each year based on international surveillance and scientists predictions about which types and strains of viruses will circulate in a given year. About two weeks after vaccination, antibodies that provide protection against influenza virus infection develop in the body. When to Get Vaccinated October or November is the best time to get vaccinated, but you can still get vaccinated in December and later. Flu season can begin as early as October and last as late as May. Who Should Get Vaccinated Because of a shortfall in flu shot production for this season, CDC is recommending that certain people be given priority for getting the flu shot. People in the following groups should seek vaccination this season: all children aged 6 23 months; adults aged 65 years and older; persons aged 2 64 years with underlying chronic medical conditions; all women who will be pregnant during the influenza season; residents of nursing homes and long-term care facilities; children aged 6 months 18 years on chronic aspirin therapy; health-care workers involved in direct patient care; and out-of-home caregivers and household contacts of children aged <6 months. These are people who are at high risk for serious flu complications or are in contact with people at high risk for serious flu complications. If available, vaccination with LAIV is an option for healthy persons aged 5-49 years who are caregivers of children less than 6 months of age and for health-care workers. If a health-care worker receives LAIV, October 7,

139 Key Facts About Flu Vaccine (continued from previous page) that worker should refrain from contact with severely immunosuppressed patients requiring care in a protected environment for 7 days after vaccination. People who are not included in one of the priority groups listed above are asked to forego or defer vaccination because of the vaccine supply situation. Vaccine Effectiveness The ability of flu vaccine to protect a person depends on the age and health status of the person getting the vaccine, and the similarity or "match" between the virus strains in the vaccine and those in circulation. Testing has shown that both vaccines are effective at preventing the flu. Vaccine Side Effects (What to Expect) Different side effects can be associated with the flu shot and LAIV. The flu shot: The viruses in the flu shot are killed (inactivated), so you cannot get the flu from a flu shot. Some minor side effects that could occur are: Soreness, redness, or swelling where the shot was given Fever (low grade) Aches If these problems occur, they begin soon after the shot and usually last one to two days. Almost all people who get influenza vaccine have no serious problems from it. However, a vaccine may rarely cause serious problems, such as severe allergic reactions. LAIV: The viruses in the nasal-spray vaccine are weakened and will not cause severe symptoms often associated with influenza illness. (In clinical studies, transmission of vaccine viruses to close contacts has occurred only rarely.) In children, side effects can include: runny nose headache vomiting muscle aches fever In adults, side effects can include: runny nose headache sore throat cough For more information, visit or call the CDC Flu Information Line at (800) CDC-INFO. October 7,

140 HOJA INFORMATIVA Datos importantes sobre la vacuna contra la gripe (o flu) Prevención de la gripe: la forma más eficaz de protegerse contra la gripe es vacunándose cada otoño. Existen dos tipos de vacunas: La vacuna contra la gripe inyectable, una vacuna inactivada (elaborada con virus muertos) que se administra mediante inyección en el brazo. Este tipo de vacuna es recomendada para personas de más de 6 meses de edad, tanto las sanas como aquellas con afecciones médicas crónicas. En esta temporada habrá disponible aproximadamente 58 millones de vacunas contra la gripe inyectables en los Estados Unidos. La vacuna contra la gripe de aplicación mediante atomizador nasal, elaborada con virus vivos debilitados que no causan gripe (algunas veces denominada vacuna viva atenuada o LAIV, por sus siglas en inglés). El uso de la LAIV está aprobado para personas sanas de edades comprendidas entre los 5 y 49 años, no embarazadas. En esta temporada habrá disponibles aproximadamente un 3 millón de dosis de vacuna LAIV en los Estados Unidos. Cada vacuna contiene tres virus de la gripe: un virus A (H3N2), un virus A (H1N1) y un virus B. Los virus que se utilizan en la elaboración de la vacuna cambian todos los años según los hallazgos de las actividades de vigilancia internacional y las predicciones de los científicos sobre qué tipos y cepas de virus circularán en un determinado año. Aproximadamente 2 semanas después de la aplicación de la vacuna, el organismo comienza a producir anticuerpos que lo protegen contra la infección por el virus de la gripe. Período de vacunación El mes de octubre o noviembre es el mejor momento para vacunarse, pero también puede hacerlo en diciembre o más tarde. La temporada de la gripe puede comenzar en octubre y durar hasta finales de mayo. Quién debe vacunarse Debido a una reducción en la producción de vacunas contra la gripe disponibles para esta temporada, los CDC recomiendan que se dé prioridad a ciertas personas. Las personas que están en los siguientes grupos deben vacunarse esta temporada: todos los niños de 6 a 23 meses de edad; adultos de 65 años en adelante; personas de 2 a 64 años de edad con algún tipo de afección médica crónica subyacente; todas las mujeres que estarán embarazadas durante la temporada de la gripe; residentes de asilos para ancianos y de otras instalaciones de cuidado a largo plazo; niños de 6 meses a 18 años de edad que estén siguiendo una terapia crónica con aspirina; empleados en el área de salud que trabajen directamente en el cuidado de pacientes; y encargados del cuidado a domicilio y personas que vivan con niños menores de 6 meses de edad. Éstas son personas que están expuestas a un alto riesgo de complicaciones serias relacionadas con la gripe o que están en contacto con personas que están expuestas a un alto riesgo de sufrir este tipo de complicaciones. 6 de octubre de

141 Datos importantes sobre la vacuna contra la gripe (o flu) (continuación de la página anterior) Si está disponible, la administración de la LAIV es una opción para personas saludables de 5 a 49 años de edad que están encargadas del cuidado de niños menores de 6 meses de edad y para personas que trabajan en el área de cuidado de la salud. Si un empleado del área de salud recibe la LAIV, ese trabajador debe evitar, durante los 7 días posteriores a la vacunación, el contacto con pacientes seriamente inmunodeprimidos que necesitan cuidados de salud en un ambiente protegido. Se les pide a las personas que no están incluidas en uno de los grupos de prioridad mencionados anteriormente que no se vacunen o que retrasen su vacunación debido a la problemática en el abastecimiento de vacunas. Eficacia de la vacuna La habilidad de la vacuna contra la gripe de proteger a una persona depende de la edad y el estado de salud de la persona que la recibe, junto con la similitud o "correspondencia" de las cepas del virus que contiene la vacuna y aquellas que están en circulación. Las pruebas han demostrado que tanto la vacuna contra la gripe inyectable como la vacuna de aplicación mediante atomizador nasal son eficaces para prevenir la gripe. Efectos secundarios de la vacuna (lo que puede pasar) Pueden ocurrir diferentes efectos secundarios que pueden asociarse a la vacuna contra la gripe inyectable y la LAIV. La vacuna contra la gripe inyectable. La vacuna inyectable contiene virus muertos (inactivados), por consiguiente, usted no puede contraer la gripe al aplicarse esta vacuna. Algunos efectos secundarios leves que podrían ocurrir son: sentirse adolorido, piel enrojecida o inflamación del sitio donde se puso la vacuna sentirse afiebrado dolores musculares Si se presentan estos problemas, comienzan inmediatamente después de la aplicación de la vacuna y usualmente duran 1 ó 2 días. Casi todas las personas que reciben la vacuna contra la gripe no sienten molestias graves a causa de la misma. Sin embargo, en raras ocasiones, la vacuna contra la gripe puede causar problemas serios, como por ejemplo reacciones alérgicas graves. LAIV. Los virus que contiene la vacuna contra la gripe de aplicación mediante atomizador nasal son virus debilitados y no causan los síntomas graves frecuentemente asociados con esta enfermedad. (En estudios clínicos, solo muy raramente se ha observado la transmisión de los virus de la vacuna entre personas en estrecho contacto.) En los niños, los efectos secundarios pueden ser los siguientes: secreción nasal (moqueo) dolor de cabeza vómito dolores musculares fiebre En los adultos, los efectos secundarios pueden ser los siguientes: secreción nasal (moqueo) dolor de cabeza dolor de garganta tos Para más información, visite o llame a la National Immunization Hotline (Línea de Vacunación contra la Gripe) al (800) (español), (800) (inglés), ó (800) (TTY). 6 de octubre de

142 INFLUENZAVACCINE INACTIVATED W H A T YO U N E E D T O K N O W Why get vaccinated? Influenza ( flu ) is a serious disease. It is caused by a virus that spreads from infected persons to the nose or throat of others. Influenza can cause: fever sore throat chills cough headache muscle aches Anyone can get influenza. Most people are ill with influenza for only a few days, but some get much sicker and may need to be hospitalized. Influenza causes an average of 36,000 deaths each year in the U.S., mostly among the elderly. Influenza vaccine can prevent influenza. 2 Influenza vaccine Two types of influenza vaccine are now available. Inactivated (killed) influenza vaccine, given as a shot, has been used in the United States for many years. A live, weakened vaccine was licensed in It is sprayed into the nostrils. Influenza viruses change often. Therefore, influenza vaccine is updated every year. Protection develops about 2 weeks after getting the shot and may last up to a year. Some people who get flu vaccine may still get flu, but they will usually get a milder case than those who did not get the shot. Flu vaccine may be given at the same time as other vaccines, including pneumococcal vaccine. Some inactivated flu vaccine contains thimerosal, a form of mercury, as a preservative. Some contains only a trace of thimerosal. There is no scientific evidence that thimerosal in vaccines is harmful, and the known benefits of the vaccine outweigh any potential risk from thimerosal. If you have questions about thimerosal or reduced-thimerosal flu vaccine, ask your doctor. 3 Who should get inactivated influenza vaccine? People 6 months of age and older at risk for getting a serious case of influenza or influenza complications, and people in close contact with them (including all household members) should get the vaccine. An annual flu shot is recommended for: All children 6-23 months of age. Household contacts and out-of-home caretakers of infants from 0-23 months of age. People 50 years of age or older. Residents of long-term care facilities housing persons with chronic medical conditions. People who have long-term health problems with: - heart disease - kidney disease - lung disease - metabolic disease, such as diabetes - asthma - anemia, and other blood disorders People with a weakened immune system due to: - HIV/AIDS or another disease that affects the immune system - long-term treatment with drugs such as steroids - cancer treatment with x-rays or drugs People 6 months to 18 years of age on long-term aspirin treatment (these people could develop Reye Syndrome if they got the flu). Women who will be pregnant during influenza season. Physicians, nurses, family members, or anyone else coming in close contact with people at risk of serious influenza. Anyone else who wants to reduce their chance of catching influenza. An annual flu shot should be considered for: Inactivated Influenza Vaccine 5/24/04 People who provide essential community services. People at high risk for flu complications who travel to the Southern hemisphere between April and September, or who travel to the tropics or in organized tourist groups at any time. People living in dormitories or under other crowded conditions, to prevent outbreaks. 142

143 4 When should I get influenza vaccine? The best time to get a flu shot is in October or November. Some people should get their flu shot in October or earlier. This includes: - people 50 years of age and older, - younger people at high risk from flu and its complications (including children 6 through 23 months of age), - household contacts of persons at high risk, - health care workers, and - children under 9 years of age getting the flu shot for the first time. The flu season can peak anywhere from December through March, but most often it peaks in February. So getting the vaccine in December, or even later, can be beneficial in most years. Most people need only one flu shot each year to prevent influenza. Children under 9 years old getting flu vaccine for the first time should get 2 doses. With the inactivated vaccine, these doses are given one month apart. Children in this age group who got one dose the previous year, even if it was the first time they got the vaccine, need only one dose this year. 5 Some people should talk with a doctor before getting influenza vaccine Talk with a doctor before getting a flu shot if you: 1) ever had a serious allergic reaction to eggs or to a previous dose of influenza vaccine, or 2) have a history of Guillain-Barré Syndrome (GBS). If you have a fever or are severely ill at the time the shot is scheduled, you should probably wait until you recover before getting influenza vaccine. Talk to your doctor or nurse about whether to reschedule the vaccination. 6 What are the risks from inactivated influenza vaccine? Severe problems: Life-threatening allergic reactions from vaccines are very rare. If they do occur, it is within a few minutes to a few hours after the shot. In 1976, swine flu vaccine was associated with a severe paralytic illness called Guillain-Barré Syndrome (GBS). Influenza vaccines since then have not been clearly linked to GBS. However, if there is a risk of GBS from current influenza vaccines, it is estimated at 1 or 2 cases per million persons vaccinated... much less than the risk of severe influenza, which can be prevented by vaccination. 7 What if there is a moderate or severe reaction? What should I look for? Any unusual condition, such as a high fever or behavior changes. Signs of a serious allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heart beat or dizziness. What should I do? Call a doctor, or get the person to a doctor right away. Tell your doctor what happened, the date and time it happened, and when the vaccination was given. Ask your doctor, nurse, or health department to report the reaction by filing a Vaccine Adverse Event Reporting System (VAERS) form. Or you can file this report through the VAERS web site at or by calling VAERS does not provide medical advice. 8 How can I learn more? Ask your doctor or nurse. They can give you the vaccine package insert or suggest other sources of information. Call your local or state health department. Contact the Centers for Disease Control and Prevention (CDC): - Call (English) - Call (Español) - Visit CDC s website at A vaccine, like any medicine, could possibly cause serious problems, such as severe allergic reactions. The risk of a vaccine causing serious harm, or death, is extremely small. Serious problems from inactivated flu vaccine are very rare. The viruses in inactivated influenza vaccine have been killed, so you cannot get influenza from the vaccine. Mild problems: soreness, redness, or swelling where the shot was given fever aches If these problems occur, they usually begin soon after the shot and last 1-2 days. department of health and human services Centers for Disease Control and Prevention National Immunization Program Inactivated Influenza Vaccine (5/24/04) Vaccine Information Statement 143

144 Plague NJDHSS - January

145 Post Exposure Prophylaxis for Plague Recommendations from the Working Group on Civilian Biodefense for Antibiotic Postexposure Prophylaxis During an Outbreak of Pneumonic Plague Following a Bioterrorism Event Choices by Patient Category Adults: Preferred choices Therapy Recommendations* Doxycycline, 100 mg PO twice daily for 7 days **,*** or Ciprofloxacin, 500 mg PO twice daily for 7 days***, **** Adults: Alternative choice Chloramphenicol, 25 mg/kg PO 4 times daily for 7 days****** Children: Preferred choices Doxycycline: if>45 kg give adult dosage; if <45 kg, give 2.2 mg/kg PO twice daily for 7 days** Or Ciprofloxacin, 20 mg/kg PO twice daily for 7 days (maximum daily dose, 1 gm)***** Children: Alternative choice Chloramphenicol, 25 mg/kg PO 4 times daily for 7 days (maximum daily dose, 4 gm)******,***** Abbreviation: PO orally. *Recommendations were reached by consensus of the Working Group on Civilian Biodefense and may not necessarily be approved by the Food and Drug Administration. Although these recommendations are intended for postexposure prophylaxis, they also can be used for treatment of plague cases in the mass casualty setting where the number of patients is too great for all patients to receive intravenous antibiotics and oral antibiotics must be substituted (except that treatment should be continued for 10 days instead of 7 days as for prophylaxis) **Tetracycline can be substituted for doxycycline at a dose of mg/kg/day divided into 2-4 doses. *** Acceptable for pregnant women. Although fetal toxicity may occur with doxycycline use and toxic effects on the liver in pregnancy have been noted with the tetracycline class, the Working Group recommended doxycycline or ciprofloxacin for postexposure prophylaxis of pregnant women or for treatment of infection in the mass casualty setting. ****Other fluoroquinolones may be substituted at dosages appropriate for age. *****Trimethoprim-sulfamethoxazole (40 mg sulfa/kg/day administered orally in 2 divided doses for 7 days) has been recommended for postexposure prophylaxis in children younger than 8 years old and pregnant women (AAP, Plague, In: Pickering LK, ed Red book: report of the Committee on Infectious Diseases, Ed 25, Elk Grove Village, Ill: American Academy of Pediatrics, 2000:450-2; McGovern, Plague, In: Zajtchuk R, Bellamy RF, eds. Textbook of military medicine: medical aspects of chemical and biological warfare, Washington, DC: Office of the Surgeon General, Borden Institute, Walter Reed Army Medical Center, 1997 ( ******Concentration should be maintained between 5 and 20 ug/ml; concentrations >25 ug/ml can cause reversible bone marrow suppression. The oral formulation is available only outside the United States. *******According to the Working Group, children younger than 2 years of age should not receive chloramphenicol. Adapted from Inglesby TV et al. Plague as a biological weapon: medical and public health management, JAMA 2000:283(17): ( NJDHSS - January

146 Standing Orders for Plague Post Exposure Prophylaxis Purpose: Reduce morbidity and mortality from plague by providing antibiotic medication as prophylaxis. Policy: Under these standing orders, registered nurses and pharmacists may dispense antibiotic regimens to persons who have been found to meet criteria established by the New Jersey Department of Health and Senior Services (NJDHSS) and the Centers for Disease Control and Prevention (CDC). Procedure: 1. Confirm that participant is eligible to receive post exposure prophylaxis, and has been educated about its risks and benefits. Declaration of self-education is acceptable. 2. Screen all participants for contraindications and precautions to antibiotic therapy with ciprofloxacin or doxycycline. Declaration of self-screening is acceptable. 3 Dispense an antibiotic post exposure prophylaxis regimen as follows: Adults and children over 55 pounds with no contraindications/precautions to ciprofloxacin: Ciprofloxacin, 500 mg PO twice daily for 7 days Children 55 pounds with no contraindications/precautions to ciprofloxacin: Ciprofloxacin, 20 mg/kg PO twice daily for 7 days (maximum daily dose, 1 gm) Adults and children over 99 pounds with contraindications/precautions to ciprofloxacin and no contraindications/precautions to doxycycline: Doxycycline, 100 mg PO twice daily for 7 days Children 99 pounds with contraindications/precautions to ciprofloxacin and no contraindications/precautions to doxycycline: Doxycycline, 2.2 mg/kg PO twice daily for 7 days Adults and children with contraindications/precautions to ciprofloxacin and doxycycline: Refer to medical consultation workstation 4. Provide all participants with a patient information sheet that includes: name and dose of drug, instructions on how to take the drug, drug/food interactions, warnings, side effects, and 24-hour telephone number for questions or problems. 5. Document each participant s medication information in the following places: d) Medical chart: Record the date the drug was dispensed, the manufacturer and lot number, and the name and title of the person distributing the medication. e) Personal information sheet: Record the date of dispensing and the name/location of the POD. This policy and associated procedures shall remain in effect until rescinded or until (date). Medical Director s signature: Effective date: NJDHSS - January

147 Decision-Making Guidelines for Medical Screeners Post Exposure Prophylaxis for Plague Medical Screeners should use these guidelines to determine proper recommendations for antibiotics when patients have yes answers in the medical self-screening section of the registration form. When in doubt, screeners should refer patients to medical consultation. See page 2 of this form for decision-making rationale. Yes Question Action Reactions or problems after taking antibiotics Hives or breathing problems after Refer to Medical Consult Workstation antibiotics Allergy Ciprofloxacin Give Doxycycline Doxycycline Give Ciprofloxacin Ciprofloxacin and doxycycline Refer to Medical Consult Workstation Pregnant or trying to become 1 st choice Give Ciprofloxacin and refer patient to her obstetrician/pcp for follow-up 2 nd choice (if allergic to Ciprofloxacin) Give Doxycycline and refer patient to her obstetrician/pcp for follow-up Kidney Hemodialysis Give ½ dose Ciprofloxacin Peritoneal dialysis Give ¾ dose Ciprofloxacin Kidney damage Give Doxycycline Taking following medications Theophylline (asthma) Give Doxycycline Dilantin (seizures) Give Doxycycline Tegretol (seizures) Give Ciprofloxacin Phenobarbital (seizures) Give Ciprofloxacin Oral hypoglycemics (diabetes) Give Doxycycline Coumadin (blood thinner) Give Ciprofloxacin and refer to PCP for coumadin dose adjustment/monitoring Probenicid (gout) Give Doxycycline Cyclosporine (immunosuppressant) Give Doxycycline Not Sure of Medication(s) taken Attempt to determine medication(s) through interview. If unable, refer to Medical Consult Workstation Children Weight 55 lbs. to receive Ciprofloxacin See dosing chart Weight 99 lbs. to receive Doxycycline NJDHSS - January

148 Yes Question Hives or breathing problems after taking antibiotics Allergy Ciprofloxacin Doxycycline Ciprofloxacin and Doxycycline Pregnant or trying to become Decision-Making Guidelines Issues and Rationale See page 1 of this form for medication recommendations. Issues to Consider Possible anaphylaxis Ciprofloxacin and doxycycline are both preferred choices. Normal side effects (nausea, diarrhea, etc.) can be confused with true allergy (hives, respiratory distress, throat swelling.) Determine if true allergy. IF YES: refer to medical consult. IF NO: Give Ciprofloxacin. Ciprofloxacin Ciprofloxacin has not been adequately studied for use in pregnant women, but an expert review of published data on experience with Ciprofloxacin use during pregnancy concluded that Ciprofloxacin is unlikely to pose substantial risk. Doxycycline Doxycycline use during tooth development (2 nd & 3 rd trimester) can cause staining of teeth in the fetus, and liver problems in the mother. Ciprofloxacin is the drug of choice, unless allergic. Kidney Disease Hemodialysis Patients on dialysis clear Ciprofloxacin more slowly than normal. They will Peritoneal dialysis need reduced a reduced Ciprofloxacin dose, or Doxycycline. Kidney disease Ciprofloxacin is not recommended for patients with inadequate creatinine clearance. They should be given Doxycycline. Taking following medications Theophylline Ciprofloxacin can inhibit hepatic metabolism of theophylline, thus increasing risk of theophylline toxicity. Serious and fatal reactions have been reported. Dilantin Altered serum levels of dilantin (increased and decreased) have been reported in patients receiving concomitant ciprofloxacin. Tegretol Tegretol decreases the half-life of doxycycline. Phenobarbital Barbiturates decrease the half-life of doxycycline. Oral hypoglycemics Concomitant use of Ciprofloxacin can cause severe hypoglycemia. Coumadin Both Ciprofloxacin and Doxycycline can enhance the effects of coumadin. Ciprofloxacin is the preferred therapy; prothrombin times should be closely monitored. Probenicid Probenicid may decrease the renal excretion of ciprofloxacin, therefore increasing the risk of ciprofloxacin toxicity. Cyclosporine Concomitant use of ciprofloxacin may result in increased serum creatinine. Children under 18 years old Ciprofloxacin Ciprofloxacin has not been fully studied for routine use in children, but is approved for post-exposure prophylaxis. Doxycycline Doxycycline in children under 8 years old can cause staining of teeth and joint problems. Ciprofloxacin is the drug of choice, unless allergic. NJDHSS - January

149 Pediatric Dosing Chart Children under 18 years or weighing less than 55 pounds Ciprofloxacin Suspension, 250 mg per 5 ml Plague PEP Recomm endation: 20 mg per kilogram of body weight, BID Weight (lbs) Weight (kg) Dose (mg) BID Amount of Suspension per Dose Under 5 Under 2 Refer to Medical Consu ltation ml ml ml ml ml ml ml ml ml ml ml 55 or 25 or over Adult Dose N/A NJDHSS - January

150 Pediatric Dosing Chart Children under 18 years or weighing less than 99 pounds Doxycycline Suspension, 25 mg per 5 ml Plague PEP Recommendation: 2.2 mg doxycycline per kilogram of body weight, BID Weight (lbs) Weight (kg) Dose (mg) Amount of Suspension per Dose Under 5 Under 2 Refer to Medical Consultation mg 2 ml mg 4 ml mg 6 ml mg 8 ml mg 10 ml mg 12 ml mg 14 ml mg 16 ml mg 18 ml Over 99 Over 45 Adult Dose N/A NJDHSS - January

151 Plague Post Exposure Prophylaxis Participant Screening and Consent Form Date Participant Identification Number Participant s Name Birth Date Sex: M Address Street & House Number City State Zip Code Telephone ( ) Form Filled Out By: SELF or OTHER When completing this form for a household member, answer all questions as if you were that person. Were you or a close contact present at (site) on (date) at (time)? Yes No Have you been in contact with materials from (site)? Yes No Education Self-Screening: Have you received or viewed education about plague? Yes No Have you received or viewed education about medicine to prevent plague? Yes No Do you understand the benefits and risks of taking medicine to prevent plague? Yes No Have your questions about taking medicine to prevent plague been answered? Yes No Signature to Acknowledge Education I am informed about why medicine to prevent plague is being made available. I understand the risks and benefits associated with taking medicine to prevent plague. There are no questions about plague or taking medicine to prevent plague that I would like to have answered. Participant Signature Date F Medical Self-Screening: Have you ever had hives or trouble breathing after taking antibiotics? Yes No Are you allergic to Doxycycline or Ciprofloxacin? Yes No Are you pregnant now or trying to become pregnant? Yes No Do you have kidney disease or need renal dialysis? Yes No For Children Only: What is your weight? Do you take any of the following medications? Yes No Theophylline, seizure medicine, oral diabetes medicine, blood thinners, Not Sure medicine for gout, or immunosuppressants Informed Consent Signature to Receive Medication: There is no condition that stops me (or my household member) from using medicine to prevent plague. I have decided to receive medicine to prevent plague today for myself or for my household member. Participant Signature Date Informed Refusal Signature to Decline Medication: I am informed about why medicine to prevent plague is being made available. I understand the risks and benefits associated with taking medicine to prevent plague. There are no questions about plague or taking medicine to prevent plague that I would like to have answered. I have decided not to receive medicine to prevent plague today for myself or for my household member,. Participant Signature Date 151

152 FOR CLINIC USE ONLY Medication Regimen to Be Used: Adult: Ciprofloxacin Doxycycline Child: weight Ciprofloxacin mg Doxycycline mg Screener s Signature Medication Dispensed: Adult: Ciprofloxacin 500 mg PO twice a day for days Doxycycline 100 mg PO twice a day for days LOT NUMBER LOT NUMBER LOT NUMBER Child: Ciprofloxacin mg PO every 12 hours for days Doxycycline mg PO twice a day for days LOT NUMBER LOT NUMBER LOT NUMBER Dispenser s Signature Date Revised

153 State Public Health Organization: 24-hour Information Telephone Number: You have been provided a limited supply of medicine. Local emergency health workers or your healthcare provider will inform you if you need more medicine after you finish this supply. If so upon your follow-up visit, you will be told how to get more medicine. You will also be told if no more medicine is needed. Take this medicine as prescribed. one tablet by mouth, two times a day. You will be provided special dosing instructions for children. Keep taking your medicine, even if you feel okay, unless your doctor tells you to stop. If you stop taking this medicine too soon, you may become infected, or your infection may come back. You should take this medicine with a full glass of water. Drink several glasses of water each day while you are taking this medicine. It is best to take this medicine 2 hours after a meal. If it upsets your stomach, you may take it with food, but do not take it with milk, yogurt, or cheese. If you miss a dose, take the missed dose as soon as possible. If it is almost time for your next regular dose, wait until then to take your medicine, and skip the missed dose. Do not take two doses at the same time. DRUGS AND FOODS TO A VOID: Do not take the following drugs within 2 hours oftaking CIPRO: antacids such as Maalox or Mylanta, vitamins, iron supplements, zinc supplements, or sucralfate (Carafate). You may take them 2 hours after or 6 hours before CIPRO. Also, make sure your doctor knows if you are taking asthma medicine like theophylline, gout medicine like probenecid (Benemid), or a blood thinner such as Coumadin. Avoid drinking more than one or two caffeinated beverages (coffee, tea, soft drinks) per day. Avoid taking this medicine with foods containing large amounts of calcium, like milk, yogurt, or cheese. WARNINGS: If you have epilepsy or kidney disease, or if you are pregnant, become pregnant, or are breastfeeding, tell emergency healthcare workers before you start taking this medicine. Do not take this medicine if you have had an allergic reaction to ciprofloxacin or other quinolone medicines such as norfloxacin (Noroxin), ofloxacin (Floxin) or nalidixic acid (NegGram). This medicine may make you dizzy or lightheaded. Avoid driving or using machinery until you know how it will affect you. This medicine increases the chance of sunburn; make sure to use sunscreen to protect your skin. SIDE EFFECTS: Call your doctor or seek medical advice right away if you are having any ofthese side effects: rash or hives; swelling of face, throat, or lips; shortness of breath or trouble breathing; seizures; or severe diarrhea. Less serious side effects include nausea, mild diarrhea, stomach pain, dizziness, and headache. Talk with your doctor if you have problems with these side effects. NJDHSS - January ~ Cipro 500mg - Plague. doc

154 Información para el Paciente: CIPRO (ciprofloxacin) TABLETA ORAL 500 mg Organización Estatal de Salud Pública: Número de Teléfono para Obtener Información 24 Horas al Día: Este fármaco se emplea para el tratamiento de infecciones. Pertenece a los grupos antibióticos de las quinolonas (quinolone). Esta droga le ha sido administrada a Ud. para su protección contra la posible exposición a bacterias que causan infecciones. Este fármaco se emplea para el tratamiento de: Peste Usted ha sido provisto con una cantidad limitada de medicamento. Los profesionales locales de la salud para casos de emergencia o su proveedor del cuidado de la salud le informarán si Ud. necesitara más medicina después que este abastecimiento haya sido agotado. Si así ocurriera, durante su próxima consulta Ud. será informado de cómo conseguir más medicina. Usted también será informado si no tuviera necesidad de tomar más medicina. Tome esta medicina según las indicaciones: una tableta, por vía oral, dos veces al día. Si Ud. tuviera hijos menores, recibirá instrucciones especiales con respecto a las dosis para niños. No deje de tomar la medicina, aunque se sienta bien. Deje de tomar esta medicina únicamente si su médico así lo indicara. Si Ud. dejara de tomar esta medicina prematuramente, podría ser infectado o su infección podría reaparecer. Esta medicina debe ser ingerida con un vaso lleno de agua. Tome varios vasos de agua por día, mientras se encuentre tomando esta medicina. Lo mejor es tomar esta medicina dos horas después de las comidas. Si le produjera malestar estomacal podría tomarla con la comida, pero no debe tomarla con leche, yogur o queso. Si dejara de tomar una dosis, tómela tan pronto como sea posible. Si fuera ya casi hora de tomar su próxima dosis regular, tome esa próxima dosis y olvídese de la que dejó de tomar. Nunca tome una dosis doble. DROGAS Y ALIMENTOS QUE SE DEBEN EVITAR: No tome las siguientes drogas hasta pasadas las 2 horas después de tomar CIPRO: antiácidos tales como Maalox o Mylanta, vitaminas o suplementos de hierro, suplementos de zinc, o sucralfate (Carafate). Puede tomarlas dos horas después o seis horas antes de tomar el CIPRO. Asegúrese también que su médico sepa que Ud. está tomando medicinas para el asma, tal como theophylline, medicinas para la gota, tales como probenecid (Benemida), o adelgazadores de sangre, tal como Coumadin. Evite tomar más de una (1) ó dos (2) tazas de bebidas con cafeína (café, té, refrescos con cafeína) por día. Evite tomar esta medicina con alimentos que contengan un gran porcentaje de calcio, tales como la leche, el yogur o queso. ADVERTENCIA: Si Ud. sufriera de epilepsia o padeciera de los riñones, o si estuviera o existiera la posibilidad de que estuviera embarazada, o si estuviera amamantando, infórmelo a los profesionales de la salud para casos de emergencia, antes de comenzar a tomar la medicina. No tome esta medicina si Ud. hubiera tenido una reacción alérgica a ciprofloxacin u otras medicinas de la quinolona (quinolone), tales como norfloxacin (Noroxin), ofloxacin (Floxin), o nalidixic acid (NegGram). Esta medicina puede provocar mareos. Evite conducir un automóvil u operar cualquier tipo de maquinaria hasta que sepa cómo habrá de afectarle la medicina. El uso de esta medicina aumenta la posibilidad de susceptibilidad a las quemaduras de sol; asegúrese de proteger su piel utilizando productos con protección contra el sol. EFECTOS SECUNDARIOS: Llame a su médico o procure atención médica inmediata, si sufriera de cualquiera de los siguientes efectos secundarios: salpullido, urticaria o picazón; hinchazón de la cara, los labios o de garganta; jadeo o dificultad para respirar, convulsiones o diarrea aguda. Los efectos secundarios de menor gravedad incluyen: náuseas, diarrea benigna, dolor estomacal, mareos y dolores de cabeza. Hable con su médico si sufriera de cualquiera de estos efectos secundarios. Spanish - Cipro 500mg - Peste.doc NJDHSS January

155 Patient Information: DOXYCYCLINE 100 MG ORAL TABLET State Public Health Organization: 24-hour Information Telephone Number: This drug treats infections. It belongs to a class of drugs called tetracycline antibiotics. You have been given this drug for protection against possible exposure to an infection-causing bacteria. This drug treats: Plague You have been provided a limited supply of medicine. Local emergency health workers or your healthcare provider will inform you if you need more medicine after you finish this supply. If so, upon your follow-up visit, you will be told how to get more medicine. You will also be told if no more medicine is needed. Take this medicine as prescribed. one tablet by mouth, two times a day. You will be provided special dosing instructions if you have a child under 8 years of age. Keep taking your medicine, even if you feel okay, unless your healthcare provider tells you to stop. If you stop taking this medicine too soon, you may become infected, or your infection may come back. You may take your medicine with or without food or milk, but food or milk may help you avoid upset stomach. If you miss a dose, take the missed dose as soon as possible. If it is almost time for your next regular dose, wait until then to take your medicine, and skip the missed dose. Do not take two doses at the same time. DRUGS AND FOODS TO AVOID: Do not take the following medicines within 2 hours of taking DOXYCYCLINE: antacids such as Maalox or Mylanta, calcium or iron supplements, cholestyramine (Questran) or colestipol (Colestid). While you are taking this medicine, birth control pills may not work as well; make sure to use another form of birth control. WARNINGS: If you have liver disease, or if you are or might be pregnant, or if you are breastfeeding, tell emergency healthcare workers before you start taking this medicine. This medicine increases the chance of sunburn; make sure to use sunscreen to protect your skin. Do not take this medicine if you have had an allergic reaction to any tetracycline antibiotics. Women may have vaginal yeast infections from taking this medicine. SIDE EFFECTS: Call your doctor or seek medical attention right away if you are having any of these side effects: skin rash, hives, or itching; wheezing or trouble breathing; swelling of the face, lips, or throat. Less serious side effects include diarrhea, upset stomach, nausea, sore mouth or throat, sensitivity to sunlight, or itching of the mouth or vagina lasting more than 2 days. Talk with your doctor if you have problems with these side effects. Doxycycline 100mg - Plague.doc NJDHSS January

156 Información para el Paciente: DOXYCYCLINE 100 MG TABLETA ORAL Organización Estatal de Salud Pública: Número de Teléfono para Obtener Información 24 Horas al Día: Este fármaco se emplea para el tratamiento de infecciones. Pertenece a los grupos antibióticos de las tetraciclinas (tetracycline). Esta droga le ha sido administrada a Ud. para su protección contra la posible exposición a bacterias que causan infecciones. Este fármaco se emplea para el tratamiento de: Peste Usted ha sido provisto con una cantidad limitada de medicamento. Los profesionales locales de la salud para casos de emergencia o su proveedor del cuidado de la salud, le informarán si Ud. necesitara más medicina después que este abastecimiento haya sido agotado. Si así ocurriera, durante su próxima consulta Ud. será informado de cómo conseguir más medicina. Usted también será informado si no tuviera necesidad de tomar más medicina. Tome esta medicina según las indicaciones: una tableta, por vía oral, dos veces al día. Si Ud. tuviera niños de 8 años de edad o menores, recibirá instrucciones especiales con respecto a las dosis para niños. No deje de tomar la medicina aunque se sienta bien. Deje de tomar esta medicina únicamente si su médico o profesional de la salud así lo indicara. Si Ud. dejara de tomar esta medicina prematuramente, podría ser infectado, o su infección podría reaparecer. Esta medicina puede ser ingerida con o sin alimento o leche, pero es posible que comer o tomar leche ayudará a evitar molestias estomacales. Si dejara de tomar una dosis, tómela tan pronto como sea posible. Si fuera ya casi hora de tomar su próxima dosis regular, tome esa próxima dosis y olvídese de la que dejó de tomar. Nunca tome una dosis doble. DROGAS Y ALIMENTOS QUE SE DEBEN EVITAR: No tome las siguientes medicinas hasta pasadas las 2 horas después de tomar DOXYCYCLINE: antiácidos tales como Maalox o Mylanta, suplementos de calcio o de hierro, cholestyramine (Questran) o colestipol (Colestid). Es posible que mientras esté tomando esta medicina, las pastillas anticonceptivas no surjan completo efecto. Le recomendamos que utilice otro método de anticonceptivo. ADVERTENCIA: Si padeciera de enfermedades hepáticas o si estuviera o existiera la posibilidad de que estuviera embarazada, o si estuviera amamantando, infórmelo a los profesionales de la salud para casos de emergencia, antes de comenzar a tomar la medicina. El uso de esta medicina aumenta la posibilidad de susceptibilidad a las quemaduras de sol; asegúrese de proteger su piel utilizando productos con protección contra el sol. No tome esta medicina si Ud. hubiera tenido una reacción alérgica a los antibióticos de las tetraciclinas (tetracycline). Es posible que esta medicina induzca infección vaginal por levadura, en algunas mujeres. EFECTOS SECUNDARIOS: Llame a su médico o procure atención médica inmediata, si sufriera de cualquiera de los siguientes efectos secundarios: salpullido, urticaria o picazón; jadeo o dificultad para respirar; hinchazón de la cara, los labios o de garganta. Efectos secundarios de menor gravedad incluyen: diarrea, malestar estomacal, náuseas, dolor de garganta o en la boca, sensibilidad a la luz del sol y picazón de la boca o de la vagina que dure más de 2 días. Hable con su médico si sufriera de cualquiera de estos efectos secundarios. Spanish - Doxycycline 100mg - Plague.doc NJDHSS January

157 Smallpox NJDHSS - January

158 Indications for Vaccination during a Smallpox Emergency Abstracted from CDC Guidelines for Large Scale Vaccination Clinics Revised Feb. 27, In a smallpox outbreak, the following high-risk groups should be prioritized for vaccination: Persons who were exposed to the initial release of the virus. Persons who had face-to-face, household, or close-proximity contact (< 2 meters = 6.5 feet) with a confirmed or suspected smallpox patient after the patient developed fever and until all scabs have separated (no longer infectious). Healthcare personnel, public health personnel, first responders, law enforcement personnel, and others whose jobs put them at increased risk of exposure to smallpox. Laboratory personnel involved in the collection or processing of clinical specimens from confirmed or suspected smallpox cases. Other persons with increased likelihood of contact with infectious materials from a smallpox patient, such as laundry or medical waste handlers for a facility where smallpox patients are admitted. Other groups whose unhindered function is deemed essential to maintaining basic community needs (e.g., transportation, pharmacy, etc), response activities, and who are not otherwise involved in patient-care activities but who have a reasonable probability of contact with smallpox patients or infectious materials (e.g., law enforcement, emergency response, or military personnel). 2. Persons with contraindications for vaccination, but not in a situation likely to encounter a smallpox case: In general, the risk of developing smallpox for face-to-face contacts with smallpox cases outweighs the risk of developing vaccine complications for those smallpox case contacts with contraindications. In general, individuals with the below conditions should not be vaccinated unless they have been exposed to smallpox virus. When there is uncertainty as to the level of exposure to the virus, the risks versus benefits of vaccination must be evaluated. NJDHSS - January

159 Persons who have ever been diagnosed with eczema or atopic dermatitis, even if the condition is mild or not presently active. Persons with other acute, chronic, or exfoliative skin conditions such as, burns, impetigo, shingles, herpes, severe acne, severe diaper rash or psoriasis should not be vaccinated until the condition resolves. Additionally, persons with Darier s disease should not be vaccinated. Persons with diseases or conditions which cause immunodeficiency, such as HIV/AIDS, leukemia, lymphoma, generalized malignancy, agammaglobulinemia, or therapy with alkylating agents, antimetabolites, radiation, immunosuppressive medications, or large doses of corticosteroids (i.e., > 2mg/kg body weight or 20 mg/day of prednisone for >2 weeks). Persons with immunosuppression also include hematopoietic stem cell transplant recipients who are <24 months post transplant, and hematopoietic stem cell transplant recipients who are 24 months post transplant, but have graft-versus-host disease or disease relapse. It is also reported that some patients with severe clinical manifestations of some autoimmune diseases (e.g., systemic lupus erythematosis) may have some degree of immunocompromise as a component of the disease. While there are no data to indicate that an individual is at risk from live virus vaccines due to severe autoimmune disease in the absence of immunosuppressive therapy, individuals with immunodeficiency as a clinical component of their autoimmune disease should not receive the smallpox vaccine. Persons with inflammatory eye disease being treatment with steroids. Women who are pregnant or breast-feeding. Persons < 1 year of age. Persons with serious, life-threatening allergies to the antibiotics polymyxin B, streptomycin, tetracycline, or neomycin (risk of anaphylactic reaction to vaccine component, but otherwise no increased risk from the live vaccinia virus unless requires suppressive doses of steroids to control allergic reaction). Household members of smallpox contacts who have contraindications to vaccination should consider housing themselves separately from vaccinated contacts, to avoid potential exposure to smallpox or inadvertent inoculation with vaccine virus, until their vaccination sites have healed. NJDHSS - January

160 Standing Order to Registered Nurses For the Administration of Vaccinia Live Virus Smallpox Vaccine This standing order shall serve as a directive to Registered Nurses (R.N.s) to execute a medial regimen, to perform such tasks, as may be directed by the below signed licensed physician, from (date) through (date), or until rescinded, to: 1. Assess those individuals who present for smallpox vaccination to determine whether they are suitable candidates, consistent with the New Jersey Department of Health and Senior Services Plan and current recommendations of the Centers for Disease Control and Prevention (CDC). 2. Administer Smallpox Vaccine, dried calf lymph type, Wyeth Dryvax, dried smallpox vaccine live-virus preparation of vaccinia virus. The vaccination program is entirely voluntary. Vaccination is not to be performed until and unless vaccination risks, benefits, and alternative options have been explained and informed consent has been signed. Insert a pre-sterilized bifurcated needle vertically into the vaccine vial, causing a small droplet of vaccine (approximately ml) to adhere between the prongs of the needle. Visually confirm the presence of the droplet, which contains the recommended dosage of the vaccine, within the prongs of the bifurcated needle. Deposit the droplet of vaccine onto clean, dry skin over the insertion of the deltoid muscle on the upper arm or over the posterior aspect of the arm over the triceps muscle. Using the multiplepuncture technique, holding the bifurcated needle perpendicular to the skin, make punctures in an area approximately 5 mm in diameter with strokes vigorous enough to allow traces of blood to appear after seconds. Three (3) punctures are to be performed for primary vaccinations and, if no traces of blood appear, three (3) additional punctures are to be performed. Fifteen (15) punctures are to be performed for revaccination. Vaccination is to be performed only once per individual, with the exception that a repeat vaccination may be performed after one week for those individuals only who demonstrate failure of vaccine take (no signs of vaccine effect). 3. Ensure that a record of the vaccination is appropriately made and maintained. 4. Provide such counseling to assure that the recipient is made aware of the location of follow-up services, in the event of untoward effects. John Smith, M.D. Medical Director Date NJDHSS - January

161 NJDHSS January

162 NJDHSS January

163 VACCINE INFORMATION STATEMENT (VIS) SMALLPOX VACCINE W H A T Y O U N E E D T O K N O W 1 WHAT IS SMALLPOX? Smallpox is a serious disease that can kill up to 3 out of 10 people who get it. Smallpox can also cause a severe rash, which can leave scars when healed. high fever. tiredness. severe headaches and backache. blindness. Smallpox is caused by a virus called "variola," which spreads from person to person. Usually, face-to-face contact lasting 3 or more hours is needed to spread smallpox from one person to another. Smallpox can also be spread through direct contact with infected body fluids or objects such as bedding or clothing that have smallpox virus on them. Smallpox killed millions of people over the centuries. Smallpox vaccination was developed in As a result, the last outbreak of smallpox in the United States was in 1949.The world's last case of naturally occurring smallpox was in Routine vaccination of the American public against smallpox ended in WHAT IS THE SMALLPOX VACCINE? Smallpox vaccine is made from a living virus called "vaccinia." Vaccinia virus is like smallpox virus, but less harmful. The smallpox vaccine can NOT give you smallpox. The vaccine is not a shot like other vaccines.the needle is pricked into the skin a number of times in a few seconds (usually in the upper arm).the pricking is not deep, but will cause one or two small drops of blood to form.the place on the skin where the vaccine is given is called the "vaccination site." Getting the vaccine before exposure will protect most people from smallpox (the vaccine is about 95% effective). up to 3 days after exposure can prevent the disease or at least make it less severe. 4-7 days after exposure can still make the disease less severe and decrease the chance of death. Smallpox vaccine protects people from getting smallpox for 3 to 5 years. Protection from severe illness and death can last 10 years or more. 3 WHY GET VACCINATED NOW? Smallpox vaccine protects people from smallpox. Some people should get the vaccine because they work with smallpox or related viruses in laboratories. Others are being offered the vaccine so they can assist in responding to a smallpox outbreak. Smallpox virus is kept in two approved laboratories in the United States and Russia.There is concern that terrorists may have obtained the smallpox virus and could use it as a weapon. If this happened, many people could become ill and many could die. The U.S. needs teams of health care providers and others to be vaccinated so they can respond quickly if a smallpox attack happens.these teams will do many things to help control a smallpox outbreak, including quickly vaccinating people who have been exposed to the disease. Smallpox VIS 11/15/03 Page 1 of 6 Version 1I 163

164 4 When There is NO Smallpox Outbreak You should get the smallpox vaccine if you Are a lab worker who works with smallpox or viruses like it. Are a member of a smallpox response team. When There IS a Smallpox Outbreak You should get the smallpox vaccine if you Are directly exposed to smallpox virus. If there is a smallpox outbreak, public health experts will say who else should get the vaccine. Vaccinated persons may need to get the vaccine again at least every 3-10 years, depending on their risk of exposure to smallpox or related viruses. 5 WHO SHOULD GET SMALLPOX VACCINE AND WHEN? WHO SHOULD NOT GET THE SMALLPOX VACCINE, OR SHOULD WAIT? When There is NO Smallpox Outbreak You should NOT get the smallpox vaccine if you Have Skin Problems People with skin problems are at risk of developing rashes which can be severe if they get the smallpox vaccine. Anyone who has atopic dermatitis (often called eczema) or had it in the past, should not get the smallpox vaccine. Anyone who has Darier's disease (a skin disease that usually begins in childhood) should not get the smallpox vaccine. Anyone who has a skin problem that has made many breaks in the skin (such as an allergic rash, bad burn, impetigo, psoriasis, pityriasis rosea, poison oak, poison ivy, chickenpox, shingles, herpes, or very bad acne) should not get the vaccine now.they should wait until the skin heals before getting the smallpox vaccine. Have Immune System Problems Rarely, when a person with a weakened immune system gets the smallpox vaccine, their vaccination site does not heal. Instead, it spreads to other parts of the body.this reaction can be life-threatening. Anyone with a weakened immune system should NOT get the smallpox vaccine, including anyone who: Has HIV/AIDS, primary immune deficiency disorders, humoral (antibody) immunity problems (such as agammaglobulinemia or lack of normal antibodies), or other diseases that affect the immune system. Has lupus or another severe autoimmune disease that weakens the immune system. Has leukemia, lymphoma, or most other cancers. Is taking cancer treatment with radiation or drugs, or has taken such treatment in the past 3 months. Is taking, or has recently taken, drugs that affect the immune system.these include high-dose steroids (for 2 weeks or longer within the past month), some drugs for autoimmune disease, or drugs taken for an organ or bone marrow transplant. Have Heart Problems Smallpox vaccination may cause heart inflammation that can be mild to life-threatening. It is not known who is at risk for this problem.as a precaution, anyone who has been told by a doctor that they have a heart condition should NOT get the smallpox vaccine, even if they feel well.this includes anyone who has: Known heart disease, such as past heart attack or angina (chest pain caused by lack of blood to the heart). Congestive heart failure Cardiomyopathy (heart muscle becomes enlarged and does not work as well as it should) Stroke or transient ischemic attack (a "mini-stroke" that causes stroke-like symptoms, but no lasting damage) Chest pain or shortness of breath with activity (such as walking up stairs) Other heart conditions that require the care of a doctor Smallpox VIS 11/15/03 Page 2 of 6 Version II 164

165 In addition, anyone with 3 or more of the following risk factors should NOT get the smallpox vaccine: Have been told by a doctor that you have high blood pressure. Have been told by a doctor that you have high blood cholesterol. Have been told by a doctor that you have diabetes or high blood sugar. Have a first degree relative (for example, mother, father, sister or brother) who had a heart condition before the age of 50. Smoke cigarettes now Are Pregnant or Breastfeeding Babies of mothers who have been vaccinated while pregnant or during the month before they become pregnant can get a very rare but serious infection from the vaccine. Do NOT get the smallpox vaccine if you are pregnant, think there is a chance you are pregnant, or think you might become pregnant within 4 weeks after vaccination. Sexually active women are encouraged to take a pregnancy test before getting the vaccine.the test should be done the day their vaccination is scheduled. But be aware that even the best tests may not detect early pregnancies (those less than 2 weeks). Take steps to prevent pregnancy during the month before and the month after vaccination: Do not have sex, or Use effective birth control every time you have sex. Effective birth control methods include male or female sterilization, hormonal methods (such as birth control pills, implants, patches or injections) and intrauterine devices (IUDs). Condoms and the use of spermicide with diaphragms, sponges, or cervical caps are also acceptable methods, although they are less effective. Do NOT rely solely on the rhythm or natural family planning method. Do NOT get the smallpox vaccine if you are breastfeeding. Follow this advice even if you are pumping and then bottle-feeding breast milk. It is not known if smallpox vaccine virus or antibodies can be passed to babies through breast milk. Other Reasons Do NOT Get the Smallpox Vaccine if You Are very allergic to polymyxin B, streptomycin, chlortetracycline, neomycin, or latex. Had a bad reaction the last time you got the smallpox vaccine. Are using steroid drops in your eyes. Are moderately or severely ill the day of your vaccination appointment.wait until you are better before getting the smallpox vaccine. You should NOT get the smallpox vaccine if you live with or have close physical contact with anyone (such as a sex partner) who Has any of the skin problems listed above. Has any of the immune system problems listed above. Is pregnant or may become pregnant within 4 weeks of your vaccination. The smallpox vaccine may pose a similar risk to them. Smallpox vaccine is not routinely recommended for anyone under 18 years of age or for older people. People age 65 or older who do not have any of the conditions listed above should talk to their health care provider before getting the vaccine. If There IS a Smallpox Outbreak These restrictions may not apply. Public health experts will say who should get the vaccine at that time. Smallpox VIS 11/15/03 Page 3 of 6 Version II 165

166 6 WHAT SHOULD YOU EXPECT AFTER VACCINATION? Normal Reactions Week 1: Three or 4 days after vaccination, a red, itchy bump will form at the vaccination site". Most times, this spot is about the size of a dime. It can be larger than 3 inches. The bump becomes a blister. It will fill with pus and then start to drain. A health care provider should check your vaccination site 6 8 days after you get the vaccine to make sure the vaccination worked and everything is o.k. Week 2: The blister will dry up and a scab will form. Week 3: The scab will fall off. It will leave a small scar. ½ inch ½ inch To Help Prevent Spread of the Virus: Cover the area loosely with a gauze bandage held in place with first aid tape.while at work, health care workers should also cover the gauze with a semi-permeable bandage (this type of bandage allows air to flow through but not fluids). Change the bandage often (at least every 3 days). Try not to touch your vaccination site. Do not let others touch the site or items that have touched it such as bandages, clothes, sheets, or towels. Always wash your hands with soap and water or alcohol-based hand wash if you touch the site or if you touch bandages, clothes, sheets, or towels that have touched the site. Keep the vaccination site dry. If the gauze bandage gets wet, change it right away. Cover your vaccination site with a waterproof bandage while bathing. Day 4 ½ inch Day 7 ½ inch Don't scratch or put ointment on the vaccination site. Don't touch your eyes, any part of your body, or another person after changing the bandage or touching the vaccination site until you have washed your hands. Day 14 Day 21 The lymph nodes under your arm may swell and be sore.the vaccination site may itch.you may also feel tired, have a mild fever, headache, or muscle aches. You may not get a blister if the vaccine did not work properly or if you are already immune to smallpox. In this case, you will need to get the vaccine again. If you still do not get a blister after getting the vaccine a second or third time, a health care provider will tell you if you are, or are not, considered immune. What You Will Need to Do The virus in the vaccine is alive. It can be spread from the vaccination site to other parts of your body or to other people through close physical contact. This can happen until the scab falls off. In the past, the vaccine virus was spread from vaccinated people to others about 2 to 6 times out of every 100,000 people vaccinated for the first time (this usually happened between people who lived together). Wear a shirt that covers the vaccination site and bandage.this helps protect those you have close contact with such as young children or the person you share a bed with. Don't share towels. Do your own laundry. Use a separate laundry hamper for clothes, towels, sheets, and other items that may come into contact with your vaccination site or pus from the site. Machine wash items that have touched the vaccination site in hot water with detergent and/or bleach. Put used bandages in plastic zip bags, then throw them away in the regular trash. After the scab falls off, put it in a plastic zip bag and throw it away. If you do not feel like you can follow these instructions, do not get vaccinated. Smallpox VIS 11/15/03 Page 4 of 6 Version II 166

167 7 WHAT ARE THE RISKS FROM THE SMALLPOX VACCINE? A vaccine, like any medicine, can cause serious problems.there is a very small risk of smallpox vaccine causing serious harm, or death. The following information is about known reactions to smallpox vaccine.there may be other unknown side effects. People who did not get the vaccine can also have the side effects described below if they touch someone's vaccination site or items that have touched the site (like bandages, clothes, sheets, or towels). Following instructions on how to care for the vaccination site (such as covering the site and washing hands) can help prevent spread of the vaccine virus to others. MILD TO MODERATE PROBLEMS Feel sick enough to miss work Fever of over 100ºF Mild rash that gets better without medicine Blisters on other parts of the body MODERATE TO SEVERE PROBLEMS CALL OR VISIT A HEALTH CARE PROVIDER HOW OFTEN DID IT HAPPEN IN THE PAST? About 1 out of 10 to 20 people vaccinated About 1 out of 10 people vaccinated About 1 out of 12 people vaccinated About 1 out of 10,000 people vaccinated HOW OFTEN DID IT HAPPEN IN THE PAST? Eye infection from touching your eye if you have vaccine virus on your hand.this can lead to a loss of vision in the infected eye. Rash on entire body which usually goes away without problems Inflamed heart (can be mild to life-threatening) SEVERE OR LIFE-THREATENING PROBLEMS GET TO A HEALTH CARE PROVIDER IMMEDIATELY Severe rash on people with eczema or atopic dermatitis, which can lead to scarring or death. Encephalitis (severe brain swelling), which can lead to permanent brain damage or death. Skin and tissue destruction starting at the vaccination site and spreading to the rest of the body, which can lead to scarring or death (usually happens in people with very weakened immune systems). Vaccinia virus infection in unborn child that can lead to premature delivery, skin rash with scarring, stillbirth, or death of the child after delivery About 1 out of 45,000 people vaccinated About 1 per 15,000 people vaccinated About 1 out of 10,000 people vaccinated for the first time HOW OFTEN DID IT HAPPEN IN THE PAST? About 1 out of 26,000 people vaccinated About 1 out of 83,000 people vaccinated About 1 out of 667,000 people vaccinated Very rare, less than 50 cases have been reported throughout the world in the last 100 years For every million people vaccinated in the past, up to 52 people had a life-threatening reaction to smallpox vaccine and up to 2 people died. The numbers provided above for severe or life-threatening problems are from studies done in the 1960 s when the smallpox vaccine was still routinely used in the U.S.The numbers reflect how often the problems occurred in infants, children, and adults. The numbers provided for all other problems are from recent studies and experiences vaccinating members of response teams and the military. Smallpox VIS 11/15/03 Page 5 of 6 Version II 167

168 8 WHAT IF SOMEONE HAS A MODERATE, SEVERE OR LIFE-THREATENING PROBLEM? Within a Few Minutes to a Few Hours of Getting the Vaccination, Watch For Trouble breathing, hoarseness or wheezing. Hives, pale skin, weakness, a fast heart beat, or dizziness. These could be signs that you are having an allergic reaction to the vaccine. For the Next 3 to 4 Weeks, Keep Watching For A vaccination site that is not healing. A rash or sore on other parts of your body. An eye infection. A lasting headache or fever. Confusion, seizures, or trouble staying awake. Chest pain, shortness of breath, rapid or unusual heartbeat or unusual fatigue. Any unexpected health problem. What Should You Do? If you or a close contact have any of these problems, or if you are concerned about any health problem that you have after vaccination Call or go to a health care provider right away. Tell the health care provider that you received the smallpox vaccine and when. Ask your doctor or nurse to file a Vaccine Adverse Event Report (VAERS form) and contact the health department.you can also file a report yourself by visiting the VAERS website at or by calling Treating Serious Problems There are two drugs that may help people who have certain serious side effects from the vaccine:vaccinia Immune Globulin (VIG) and cidofovir.these drugs are not licensed for this purpose, and may also cause side effects. Cost of Treating Serious Problems In the rare event that you have a serious reaction to the smallpox vaccine, a federal program has been created to help pay for related costs of medical care and lost wages.this program was created to compensate certain people, such as health care workers and emergency responders, injured by the vaccine. It will also cover certain people injured as the direct result of exposure to vaccinia through contact with certain people who received the smallpox vaccine (or with the contacts of such vaccine recipients).the program covers related costs of medical care and lost wages (usually starting after the first five days of missed work) after other available coverage, such as workers compensation or health insurance, has been used. The Department of Health and Human Services will make more information about this program available soon, including how to request benefits and/or compensation. For more information contact Paul T. Clark, Director, Smallpox Vaccine Injury Compensation Program, Office of Special Programs, or go to 9 HOW CAN YOU LEARN MORE? Ask your health care provider.they can give you more information, show you the vaccine package insert or suggest other sources of information. Call your local or state health department. Visit the Centers for Disease Control and Prevention (CDC) smallpox website at Contact the (CDC): Call (English) Call (Español) Call (TTY) If you decide to get the smallpox vaccine, please KEEP THIS DOCUMENT for one month following vaccination. Smallpox VIS 11/15/03 Page 6 of 6 Version II 168

169 Tularemia NJDHSS - January

170 Post-Exposure Prophylaxis Recommendations for Antibiotic Postexposure Prophylaxis During an Outbreak of Tularemia Following a Bioterrorism Event * Patient Category Adults (including pregnant Women) Children Abbreviation: PO orally Therapy Recommendations** Doxycycline, 100 mg PO twice daily for 14 days*** Or Ciprofloxacin, 500 mg PO twice daily for 14 days*** Doxycycline >45 kg. Give adult dosage <45 kg. Give 2.2 mg/kg PO twice daily for 14 days or Ciprofloxacin, 15 mg/kg/po twice daily for 14 days (maximum daily dose; 1 gm) *In the mass casualty setting where the medical care delivery system is not able to meet the demands for patient care, oral antibiotics may need to be substituted for intravenous antibiotics for treatment of patients with tularemia. In such a situation, the recommendations in this table should be followed for treatment as well as for prophylaxis. **Recommendations were reached by consensus of the Working Group on civilian Biodefense and may not necessarily approved by the Food and Drug Administration. ***Although fetal toxicity may occur with doxycycline use, the Working Group recommended doxycycline or ciprofloxacin for postexposure prophylaxis of pregnant women or for treatment of infection of pregnant women in the mass casualty setting. Adapted from Dennis DT, Inglesby TV, Heanderson DA et al for the Working Group on Civilian Biodefense. Tularemia as a biological weapon medical and public health management JAMA NJDHSS - January

171 Standing Orders for Tularemia Post Exposure Prophylaxis Purpose: Reduce morbidity and mortality from tularemia by providing antibiotic medication as prophylaxis. Policy: Under these standing orders, registered nurses and pharmacists may dispense antibiotic regimens to persons who have been found to meet criteria established by the New Jersey Department of Health and Senior Services (NJDHSS) and the Centers for Disease Control and Prevention (CDC.) Procedure: 1. Confirm that participant is eligible to receive post exposure prophylaxis, and has been educated about its risks and benefits. Declaration of self-education is acceptable. 2. Screen all participants for contraindications and precautions to antibiotic therapy with Ciprofloxacin or Doxycycline. Declaration of self-screening is acceptable. 3. Dispense an antibiotic post exposure prophylaxis regimen as follows: Adults and children over 55 pounds with no contraindications/precautions to ciprofloxacin: Ciprofloxacin, 500 mg PO twice daily for 7 days Children 55 pounds with no contraindications/precautions to ciprofloxacin: Ciprofloxacin, 15 mg/kg PO twice daily for 7 days (maximum daily dose, 1 gm) Adults and children over 99 pounds with contraindications/precautions to ciprofloxacin and no contraindications/precautions to doxycycline: Doxycycline, 100 mg PO twice daily for 7 days Children 99 pounds with contraindications/precautions to ciprofloxacin and no contraindications/precautions to doxycycline: Doxycycline, 2.2 mg/kg PO twice daily for 7 days Adults and children with contraindications/precautions to ciprofloxacin and doxycycline: Refer to medical consultation workstation 4. Provide all participants with a patient information sheet that includes: name and dose of drug, instructions on how to take the drug, drug/food interactions, warnings, side effects, and 24-hour telephone number for questions or problems. 5. Document each participant s medication information in the following places: f) Medical Chart: Record the date the drug was dispensed, the manufacturer and lot number, and the name of the title of the person administering the vaccine. g) Personal information Sheet: Record the date of dispensing and the name/location of the POD. This policy and associated procedures shall remain in effect until rescinded or until (date). Medical Director s signature: Effective date: NJDHSS - January

172 Decision-Making Guidelines for Medical Screeners Post Exposure Prophylaxis for Tularemia Medical Screeners should use these guidelines to determine proper recommendations for antibiotics when patients have yes answers in the medical self-screening section of the registration form. When in doubt, screeners should refer patients to medical consultation. See page 2 of this form for decision-making rationale. Yes Question Action Reactions or problems after taking antibiotics Hives or breathing problems after Refer to Medical Consult Workstation antibiotics Allergy Ciprofloxacin Give Doxycycline Doxycycline Give Ciprofloxacin Ciprofloxacin and doxycycline Refer to Medical Consult Workstation Pregnant or trying to become 1 st choice Give Ciprofloxacin and refer patient to her obstetrician/pcp for follow-up 2 nd choice (if allergic to Ciprofloxacin) Give Doxycycline and refer patient to her obstetrician/pcp for follow-up Kidney Hemodialysis Give ½ dose Ciprofloxacin Peritoneal dialysis Give ¾ dose Ciprofloxacin Kidney damage Give Doxycycline Taking following medications Theophylline (asthma) Give Doxycycline Dilantin (seizures) Give Doxycycline Tegretol (seizures) Give Ciprofloxacin Phenobarbital (seizures) Give Ciprofloxacin Oral hypoglycemics (diabetes) Give Doxycycline Coumadin (blood thinner) Give Ciprofloxacin and refer to PCP for coumadin dose adjustment/monitoring Probenicid (gout) Give Doxycycline Cyclosporine (immunosuppressant) Give Doxycycline Not Sure of Medication(s) taken Attempt to determine medication(s) through interview. If unable, refer to Medical Consult Workstation Children Weight 55 lbs. to receive Ciprofloxacin See dosing chart Weight 99 lbs. to receive Doxycycline NJDHSS - January

173 Yes Question Hives or breathing problems after taking antibiotics Allergy Ciprofloxacin Doxycycline Ciprofloxacin and Doxycycline Pregnant or trying to become Decision-Making Guidelines Issues and Rationale See page 1 of this form for medication recommendations. Issues to Consider Possible anaphylaxis Ciprofloxacin and doxycycline are both preferred choices. Normal side effects (nausea, diarrhea, etc.) can be confused with true allergy (hives, respiratory distress, throat swelling.) Determine if true allergy. IF YES: refer to medical consult. IF NO: Give Ciprofloxacin. Ciprofloxacin Ciprofloxacin has not been adequately studied for use in pregnant women, but an expert review of published data on experience with Ciprofloxacin use during pregnancy concluded that Ciprofloxacin is unlikely to pose substantial risk. Doxycycline Doxycycline use during tooth development (2 nd & 3 rd trimester) can cause staining of teeth in the fetus, and liver problems in the mother. Ciprofloxacin is the drug of choice, unless allergic. Kidney Disease Hemodialysis Patients on dialysis clear Ciprofloxacin more slowly than normal. They will Peritoneal dialysis need reduced a reduced Ciprofloxacin dose, or Doxycycline. Kidney disease Ciprofloxacin is not recommended for patients with inadequate creatinine clearance. They should be given Doxycycline. Taking following medications Theophylline Ciprofloxacin can inhibit hepatic metabolism of theophylline, thus increasing risk of theophylline toxicity. Serious and fatal reactions have been reported. Dilantin Altered serum levels of dilantin (increased and decreased) have been reported in patients receiving concomitant ciprofloxacin. Tegretol Tegretol decreases the half-life of doxycycline. Phenobarbital Barbiturates decrease the half-life of doxycycline. Oral hypoglycemics Concomitant use of Ciprofloxacin can cause severe hypoglycemia. Coumadin Both Ciprofloxacin and Doxycycline can enhance the effects of coumadin. Ciprofloxacin is the preferred therapy; prothrombin times should be closely monitored. Probenicid Probenicid may decrease the renal excretion of ciprofloxacin, therefore increasing the risk of ciprofloxacin toxicity. Cyclosporine Concomitant use of ciprofloxacin may result in increased serum creatinine. Children under 18 years old Ciprofloxacin Ciprofloxacin has not been fully studied for routine use in children, but is approved for post-exposure prophylaxis. Doxycycline Doxycycline in children under 8 years old can cause staining of teeth and joint problems. Ciprofloxacin is the drug of choice, unless allergic. NJDHSS - January

174 Pediatric Dosing Chart Children under 18 years or weighing less than 55 pounds Ciprofloxacin Suspension, 250 mg per 5 ml Tularemia PEP Recommendation: 15 mg per kilogram of body weight, BID Weight (lbs) Weight (kg) Dose (mg) BID Amount of Suspension per Dose Under 5 Under 2 Refer to Medical Consultation ml ml ml ml ml ml ml ml ml ml ml 55 or 25 or over Adult Dose N/A NJDHSS - January

175 Pediatric Dosing Chart Children under 18 years or weighing less than 99 pounds Doxycline Suspension, 25 mg per 5 ml Tularemia PEP Recommendation: 2.2 mg doxycycline per kilogram of body weight, BID Weight (lbs) Weight (kg) Dose (mg) Amount of Suspension per Dose Under 5 Under 2 Refer to Medical Consu ltation mg 2 ml mg 4 ml mg 6 ml mg 8 ml mg 10 ml mg 12 ml mg 14 ml mg 16 ml mg 18 ml Over 99 Over 45 Adult Dose N/A NJDHSS - January

176 Tularemia Post Exposure Prophylaxis Participant Screening and Consent Form Date Participant Identification Number Participant s Name Birth Date Sex: M Address Street & House Number City State Zip Code Telephone ( ) Form Filled Out By: SELF or OTHER When completing this form for a household member, answer all questions as if you were that person. Were you or a close contact present at (site) on (date) at (time)? Yes No Have you been in contact with materials from (site)? Yes No Education Self-Screening: Have you received or viewed education about tularemia? Yes No Have you received or viewed education about medicine to prevent tularemia? Yes No Do you understand the benefits and risks of taking medicine to prevent tularemia? Yes No Have your questions about receiving medicine to prevent tularemia been answered? Yes No Signature to Acknowledge Education I am informed about why medicine to prevent tularemia is being made available. I understand the risks and benefits associated with taking medicine to prevent tularemia. There are no questions about tularemia or taking medicine to prevent tularemia that I would like to have answered. Participant Signature Date F Medical Self-Screening: Have you ever had hives or trouble breathing after taking antibiotics? Yes No Are you allergic to Doxycycline or Ciprofloxacin? Yes No Are you pregnant now or trying to become pregnant? Yes No Do you have kidney disease or need renal dialysis? Yes No For Children Only: What is your weight? Do you take any of the following medications? Yes No Theophylline, seizure medicine, oral diabetes medicine, blood thinners, Not Sure medicine for gout, or immunosuppressants Informed Consent Signature to Receive Medication: There is no condition that stops me (or my household member) from using medicine to prevent tularemia. I have decided to receive medicine to prevent anthrax today for myself or for my household member. Participant Signature Date Informed Refusal Signature to Decline Medication: I am informed about why medicine to prevent tularemia is being made available. I understand the risks and benefits associated with taking medicine to prevent tularemia. There are no questions about tularemia or taking medicine to prevent tularemia that I would like to have answered. I have decided not to receive medicine to prevent tularemia today for myself or for my household member,. Participant Signature Date 176

177 FOR CLINIC USE ONLY Medication Regimen to Be Used: Adult: Ciprofloxacin Doxycycline Child: weight Ciprofloxacin mg Doxycycline mg mg Screener s Signature Medication Dispensed: Adult: Ciprofloxacin 500 mg PO twice a day for days Doxycycline 100 mg PO twice a day for days LOT NUMBER LOT NUMBER LOT NUMBER Child: Ciprofloxacin mg PO every 12 hours for days Doxycycline mg PO twice a day for days LOT NUMBER LOT NUMBER LOT NUMBER Dispenser s Signature Date Revised

178 Patient Information: CIPRO (ciprofloxacin) ORAL TABLET 500mg State Public Health Organization: 24-hour Information Telephone Number: This drug treats infections. It belongs to a class of drugs called quinolone antibiotics. You have been given this drug for protection against possible exposure to an infectioncausing bacteria. This drug treats: Tularemia You have been provided a limited supply of medicine. Local emergency health workers or your healthcare provider will inform you if you need more medicine after you finish this supply. If so upon your follow-up visit, you will be told how to get more medicine. You will also be told if no more medicine is needed. Take this medicine as prescribed. one tablet by mouth, two times a day. You will be provided special dosing instructions for children. Keep taking your medicine, even if you feel okay, unless your healthcare provider tells you to stop. If you stop taking this medicine too soon, you may become infected, or your infection may come back. You should take this medicine with a full glass of water. Drink several glasses of water each day while you are taking this medicine. It is best to take this medicine 2 hours after a meal. If it upsets your stomach, you may take it with food, but do not take it with milk, yogurt, or cheese. If you miss a dose, take the missed dose as soon as possible. If it is almost time for your next regular dose, wait until then to take your medicine, and skip the missed dose. Do not take two doses at the same time. DRUGS AND FOODS TO AVOID: Do not take the following drugs within 2 hours of taking CIPRO: antacids such as Maalox or Mylanta, vitamins, iron supplements, zinc supplements, or sucralfate (Carafate). You may take them 2 hours after or 6 hours before CIPRO. Also, make sure your doctor knows if you are taking asthma medicine like theophylline, gout medicine like probenecid (Benemid), or a blood thinner such as Coumadin. Avoid drinking more than one or two caffeinated beverages (coffee, tea, soft drinks) per day. Avoid taking this medicine with foods containing large amounts of calcium, like milk, yogurt, or cheese. WARNINGS: If you have epilepsy or kidney disease, or if you are pregnant, become pregnant, or are breastfeeding, tell emergency healthcare workers before you start taking this medicine. Do not take this medicine if you have had an allergic reaction to ciprofloxacin or other quinolone medicines such as norfloxacin (Noroxin), ofloxacin, (Floxin) or nalidixic acid (NegGram). This medicine may make you dizzy or lightheaded. Avoid driving or using machinery until you know how it will affect you. This medicine increases the chance of sunburn; make sure to use sunscreen to protect your skin. SIDE EFFECTS: Call your doctor or seek medical advice right away if you are having any of these side effects: rash or hives; swelling of face, throat, or lips; shortness of breath or trouble breathing; seizures; or severe diarrhea. Less serious side effects include nausea, mild diarrhea, stomach pain, dizziness, and headache. Talk with your doctor if you have problems with these side effects. Cipro 500mg - Tularemia.doc NJDHSS January

179 Información para el Paciente: CIPRO (ciprofloxacin) TABLETA ORAL 500 mg Organización Estatal de Salud Pública: Número de Teléfono para Obtener Información 24 Horas al Día: Este fármaco se emplea para el tratamiento de infecciones. Pertenece a los grupos antibióticos de las quinolonas (quilonone). Esta droga le ha sido administrada a Ud. para su protección contra la posible exposición a bacterias que causan infecciones. Este fármaco se emplea para el tratamiento de: Tularemia Usted ha sido provisto con una cantidad limitada de medicamento. Los profesionales locales de la salud para casos de emergencia o su proveedor del cuidado de la salud le informarán si Ud. necesitara más medicina después que este abastecimiento haya sido agotado. Si así ocurriera, durante su próxima consulta Ud. será informado de cómo conseguir más medicina. Usted también será informado si no tuviera necesidad de tomar más medicina. Tome esta medicina según las indicaciones: una tableta, por vía oral, dos veces al día. Si Ud. tuviera hijos menores, recibirá instrucciones especiales con respecto a las dosis para niños. No deje de tomar la medicina aunque se sienta bien. Deje de tomar esta medicina únicamente si su médico o profesional de la salud así lo indicara. Si Ud. dejara de tomar esta medicina prematuramente, podría ser infectado, o su infección podría reaparecer. Esta medicina debe ser ingerida con un vaso lleno de agua. Tome varios vasos de agua por día, mientras se encuentre tomando esta medicina. Lo mejor es tomar esta medicina dos horas después de las comidas. Si le produjera malestar estomacal podría tomarla con la comida, pero no debe tomarla con leche, yogur o queso. Si dejara de tomar una dosis, tómela tan pronto como sea posible. Si fuera ya casi hora de tomar su próxima dosis regular, tome esa próxima dosis y olvídese de la que dejó de tomar. Nunca tome una dosis doble. DROGAS Y ALIMENTOS QUE SE DEBEN EVITAR: No tome las siguientes drogas hasta pasadas las 2 horas después de tomar CIPRO: antiácidos tales como Maalox o Mylanta, vitaminas o suplementos de hierro, suplementos de zinc, o sucralfate (Carafate). Puede tomarlas dos horas después o seis horas antes de tomar el CIPRO. Asegúrese también que su médico sepa que Ud. está tomando medicinas para el asma, tales como theophylline, medicinas para la gota, tales como probenecid (Benemid), o adelgazadores de sangre, tales como Coumadin. Evite tomar más de una (1) ó dos (2) tazas de bebidas con cafeína (café, té, refrescos con cafeína) por día. Evite tomar esta medicina con alimentos que contengan un gran porcentaje de calcio, tales como la leche, el yogur o queso. ADVERTENCIA: Si Ud. sufriera de epilepsia o padeciera de los riñones, o si estuviera o existiera la posibilidad de que estuviera embarazada, o si estuviera amamantando, infórmelo a los profesionales de la salud para casos de emergencia, antes de comenzar a tomar la medicina. No tome esta medicina si Ud. hubiera tenido una reacción alérgica al ciprofloxacin u otras medicinas de la quinolone, tales como norfloxacin (Noroxin), ofloxacin (Floxin), o nalidixic acid (NegGram). Esta medicina puede provocar mareos. Evite conducir un automóvil u operar cualquier tipo de maquinaria hasta que sepa cómo habrá de afectarle la medicina. El uso de esta medicina aumenta la posibilidad de susceptibilidad a las quemaduras de sol; asegúrese de proteger su piel, utilizando productos con protección contra el sol. EFECTOS SECUNDARIOS: Llame a su médico o procure atención médica inmediata, si sufriera de cualquiera de los siguientes efectos secundarios: salpullido, urticaria o picazón; hinchazón de la cara, los labios o de garganta; jadeo o dificultad para respirar, convulsiones o diarrea aguda. Los efectos secundarios de menor gravedad incluyen: náuseas, diarrea benigna, dolor estomacal, mareos y dolores de cabeza. Hable con su médico si sufriera de cualquiera de estos efectos secundarios. Spanish - Cipro 500mg - Tularemia.doc NJDHSS January

180 Patient Information: DOXYCYCLINE 100 MG ORAL TABLET State Public Health Organization: 24-hour Information Telephone Number: This drug treats infections. It belongs to a class of drugs called tetracycline antibiotics. You have been given this drug for protection against possible exposure to an infectioncausing bacteria. This drug treats: Tularemia You have been provided a limited supply of medicine. Local emergency health workers or your healthcare provider will inform you if you need more medicine after you finish this supply. If so, upon your follow-up visit, you will be told how to get more medicine. You will also be told if no more medicine is needed. Take this medicine as prescribed. one tablet by mouth, two times a day. You will be provided special dosing instructions if you have a child under 8 years of age. Keep taking your medicine, even if you feel okay, unless your healthcare provider tells you to stop. If you stop taking this medicine too soon, you may become infected, or your infection may come back. You may take your medicine with or without food or milk, but food or milk may help you avoid upset stomach. If you miss a dose, take the missed dose as soon as possible. If it is almost time for your next regular dose, wait until then to take your medicine, and skip the missed dose. Do not take two doses at the same time. DRUGS AND FOODS TO AVOID: Do not take the following medicines within 2 hours of taking DOXYCYCLINE: antacids such as Maalox or Mylanta, calcium or iron supplements, cholestyramine (Questran) or colestipol (Colestid). While you are taking this medicine, birth control pills may not work as well; make sure to use another form of birth control. WARNINGS: If you have liver disease, or if you are or might be pregnant, or if you are breastfeeding, tell emergency healthcare workers before you start taking this medicine. This medicine increases the chance of sunburn; make sure to use sunscreen to protect your skin. Do not take this medicine if you have had an allergic reaction to any tetracycline antibiotics. Women may have vaginal yeast infections from taking this medicine. SIDE EFFECTS: Call your doctor or seek medical attention right away if you are having any of these side effects: skin rash, hives, or itching; wheezing or trouble breathing; swelling of the face, lips, or throat. Less serious side effects include diarrhea, upset stomach, nausea, sore mouth or throat, sensitivity to sunlight, or itching of the mouth or vagina lasting more than 2 days. Talk with your doctor if you have problems with these side effects. Doxycycline 100mg - Tularemia.doc NJDHSS January

181 Información para el Paciente: DOXYCYCLINE 100 MG TABLETA ORAL Organización Estatal de Salud Pública: Número de Teléfono para Obtener Información 24 Horas al Día: Este fármaco se emplea para el tratamiento de infecciones. Pertenece a los grupos antibióticos de las tetraciclinas (tetracycline). Esta droga le ha sido administrada a Ud. para su protección contra la posible exposición a bacterias que causan infecciones. Este fármaco se emplea para el tratamiento de: Tularemia Usted ha sido provisto con una cantidad limitada de medicamento. Los profesionales locales de la salud para casos de emergencia o su proveedor del cuidado de la salud, le informarán si Ud. necesitara más medicina después que este abastecimiento haya sido agotado. Si así ocurriera, durante su próxima consulta Ud. será informado de cómo conseguir más medicina. Usted también será informado si no tuviera necesidad de tomar más medicina. Tome esta medicina según las indicaciones: una tableta, por vía oral, dos veces al día. Si Ud. tuviera niños de 8 años de edad o menores, recibirá instrucciones especiales con respecto a las dosis para niños. No deje de tomar la medicina aunque se sienta bien. Deje de tomar esta medicina únicamente si su médico o profesional de la salud así lo indicara. Si Ud. dejara de tomar esta medicina prematuramente, podría ser infectado, o su infección podría reaparecer. Esta medicina puede ser ingerida con o sin alimento o leche, pero es posible que comer o tomar leche ayudará a evitar molestias estomacales. Si dejara de tomar una dosis, tómela tan pronto como sea posible. Si fuera ya casi hora de tomar su próxima dosis regular, tome esa próxima dosis y olvídese de la que dejó de tomar. Nunca tome una dosis doble. DROGAS Y ALIMENTOS QUE SE DEBEN EVITAR: No tome las siguientes medicinas hasta pasadas las 2 horas después de tomar DOXYCYCLINE: antiácidos tales como Maalox o Mylanta, suplementos de calcio o de hierro, cholestyramine (Questran) o colestipol (Colestid). Es posible que mientras esté tomando esta medicina, las pastillas anticonceptivas no surjan completo efecto. Le recomendamos que utilice otro método anticonceptivo. ADVERTENCIA: Si padeciera de enfermedades hepáticas o si estuviera o existiera la posibilidad de que estuviera embarazada, o si estuviera amamantando, infórmelo a los profesionales de la salud para casos de emergencia, antes de comenzar a tomar la medicina. El uso de esta medicina aumenta la posibilidad de susceptibilidad a las quemaduras de sol; asegúrese de proteger su piel utilizando productos con protección contra el sol. No tome esta medicina si Ud. hubiera tenido una reacción alérgica a los antibióticos de las tetraciclinas (tetracycline). Es posible que esta medicina induzca infección vaginal por levadura, en algunas mujeres. EFECTOS SECUNDARIOS: Llame a su médico o procure atención médica inmediata, si sufriera de cualquiera de los siguientes efectos secundarios: salpullido, urticaria o picazón; jadeo o dificultad para respirar; hinchazón de la cara, los labios o de garganta. Los efectos secundarios de menor gravedad incluyen: diarrea, malestar estomacal, náuseas, dolor de garganta o en la boca, sensibilidad a la luz del sol y picazón de la boca o de la vagina que dure más de 2 días. Hable con su médico si sufriera de cualquiera de estos efectos secundarios. Spanish - Doxycycline 100mg - Tularemia.doc NJDHSS January

182 Chapter 7: Communication Often overlooked but vitally important to the success of any mass organization event is communication. Communication is the key to allay fears and concerns as well as to provide instructions for all involved in a mass prophylaxis clinic model. It is critical to use the time before the clinic opens to educate the public about the disease, its etiology, treatment and what they should do if they believe they have been exposed. Clear and consistent information should be disseminated quickly and updated regularly to avoid misinformation and reduce anxiety. This chapter provides an overview of communication issues to be considered and addressed before the clinic is opened and while the clinic is operational. Risk Communication According to the CDC, crisis and emergency risk communication encompasses the urgency of disaster communication with the need to communicate risks and benefits to stakeholders and the public. Crisis and emergency risk communication is the effort to provide information to allow an individual, stakeholder, or an entire community to make the best possible decisions about their well-being (Reynolds, 2002). Risk communication principles cite the phrase: be first, be right, be credible. This means communicating early and often and informing the public what is/is not known about a situation. A basic premise of risk communication is that perception of risk varies, and some risks are more accepted than others. Providing the public with timely, complete, accurate and easy to understand information will assist them in their decision making. The New Jersey Mass Prophylaxis Model relies on risk communication messages to inform the public about a public health emergency, which empowers them to make decisions about their health. NJHDHSS and LINCS agencies have staff who are trained in effective risk communication strategies and techniques. These individuals have access to the emergency risk communication materials referenced at the end of this chapter, are integral components to planning and implementing a public education and information campaign and working with the media. NJDHSS - January

183 One Voice, One Message The NJDHSS Office of Communications is the lead agency for providing updates and coordinating communications around the state. Any communications that occur within county and municipal jurisdictions must be consistent with those that are disseminated by NJDHSS. The NJDHSS Office of Communications will provide information to the media and the public regarding the incident and the need to prophylax exposed individuals. LINCS agencies are responsible for tailoring this information to meet their needs and corresponding with local health departments and public health partners regarding the clinics in their jurisdictions. Keeping the public informed of clinic location(s) and hours of operation, as well as providing them with knowledge that the public health system is working to assure their safety are essential. Public health professionals need to clearly define the population at risk and provide this group with specific instructions. General information for the unexposed population ( worried well ) must also be included. This information should advise them about the situation and provide them with actions they can take to keep themselves healthy. Public information and risk communication protocols are included in each jurisdiction s Emergency Operating Plan and should be implemented. The modes of communicating should include, but are not limited to: radio, television, web, and print. Employing traditional and non-traditional methods of information distribution is important to get the message to as many individuals as possible. It is advisable that hotlines and phone banks be used to answer questions from the public regarding the incident. Those individuals staffing phone lines must have a script to ensure a consistent message. Scripts should be drafted in advance of a public health emergency; details of the event should be filled in as necessary. Local jurisdictions should create the scripts and coordinate the message with NJDHSS Office of Communications, to ensure one voice, one message consistency. Each POD site must designate a Clinic Communication Officer. Because communication needs are urgent during a public health emergency, the POD Manager and Clinic Communication Officer should determine a process for clearing public messages well in advance of need. It is the role of this individual to function as a liaison between the site NJDHSS - January

184 manager, the incident Public Information Officer (PIO), the LINCS/local health officer, the media and the NJDHSS Office of Communications. The Clinic Communication Officer is also responsible for preparing the spokesperson, should the need arise. Working with the Media In the event that multiple PODs are opened in a jurisdiction, one location should be selected to receive media. This ensures consistent information and will help to decrease unnecessary clinic disruption. It must be realized that a mass prophylaxis clinic is a newsworthy event and local media will most likely arrive at any/all POD sites, regardless of a pre-designated media staging area. The POD Manager consults with the Clinic Communication Officer to designate a staging area for the media, to alleviate crowding and confusion and to maintain security during the clinic. The media area should be physically located in a different room/area from the clinic and should be large enough to accommodate a podium, rows of seating and television cameras. In addition, despite the best efforts to provide media access, reporters may try to infiltrate the clinic proper. If the POD Manager decides to allow the media into the clinic, they should be escorted by the Clinic Communication Officer at all times. Security personnel should be ready to escort media representatives from restricted areas. Depending on the incident and the structure of the jurisdiction, the Clinic Communication Officer may act as a spokesperson or be responsible for preparing a designated media spokesperson. A pre-designated list of spokespersons must be determined prior to a public health emergency. It is essential to identify a Clinic Communication Officer for each POD to liaise with the incident PIO and NJDHSS Office of Communications and respond to media inquiries. In the event that a Joint Information Center (JIC) is opened up, media inquiries should be directed to the appropriate representatives. However, the media will interview whomever they feel is important to their story. This may or may not include a designated spokesperson. Risk communication experts identified questions that the media ask during a crisis. Anticipating the questions asked by the media in advance assists in preparing press NJDHSS - January

185 statements and strengthens the likelihood that correct public health message is disseminated. Below are examples of questions asked by the media in an emergency: What happened? Why did this happen/what was the cause? Was anyone hurt or killed? When did you begin working on this (i.e., were notified of this)? Did you have forewarning this might happen? Has this ever happened before? Is this emergency being contained? What can we expect? What should we do now? Who is to blame? Internal Communication Within the clinic, the need to communicate among and within stations is the key to smooth operations and maintaining clinic flow. Communication between the Clinical Manager and the POD Manager is also essential (see Appendix A). Inventory supply and staffing issues will require constant attention and communication among the appropriate individuals. The POD Manager is responsible for maintaining communication with the staff at the various workstations both inside and outside the POD. This communication covers all aspects of clinic operation and ranges from re-ordering supplies from the local Office of Emergency Management to reporting on-site security needs. Each station should designate one person to act as the contact for the workstation. This individual is responsible for communicating to the team and connecting with other workstations regarding issues that arise during the clinic. This person will them communicate with the Area Leader assigned to oversee the various units within the clinic. These contacts form an internal communication chain that may be used to disseminate information throughout the clinic. See the POD Operations Organizational Chart (Appendix B) for more information. Communication devices should be available at each workstation, such as: NJDHSS - January

186 walkie-talkies two-way radios landline telephones cellular telephones This equipment must be tested and serviced prior to the clinic opening to ensure proper functioning (e.g., adequate reception, charged batteries, extra batteries). Staff using this equipment must be trained to operate it correctly. If cellular telephones are used, providing the correct phone numbers for each workstation and other emergency contact information is essential. Each clinic should enlist the assistance of a Communication Technician to assist with the set-up of internal communication equipment. This individual may be tasked to work in several capacities, as needed, but should be designated as the internal communications liaison. In addition to communication devices, each station should be equipped with paper and pens/pencils for staff to handwrite messages. In the event of a power outage, technical difficulties, and as a redundancy measure, written messages are an acceptable alternative method of communication within the clinic. Designated individuals who function as runners should be utilized to physically distribute written and verbally messages within the clinic. Notification NJDHSS will notify LINCS agencies of the intent to open a mass prophylaxis clinic and the provide guidelines regarding the targeted population to be prophylaxed. County and jurisdictions are responsible for alerting their own staff and public health partners of the plans to open and staff a POD. Notification lists must be developed and distributed, in advance of a public health emergency, to those individuals responsible for contacting staff and other public health partners and stakeholders. These lists should be verified and updated regularly to ensure correct contact information. Multiple methods of contact (e.g., telephone, cell phone, pager, ) must be gathered to ensure that essential personnel are notified. Contacting workers and others directly involved in POD operations in a timely manner is critical to ramping up and opening a clinic. Staff and volunteers must be aware how they NJDHSS - January

187 will be contacted and where to report. In the event of a power outage, HAM radio operators, both amateur and those affiliated with OEM, may be utilized to relay information between the EOC and the POD(s). Public Information Strategies to educate clinic participants and the public are covered in detail in Chapter 8. Some of the information and dissemination strategies listed in this section overlap with public education outreach. In a post-event situation, communications disseminated to the public should demonstrate basic risk communication principles to control fear and panic and optimize their compliance with public health recommendations. Each LINCS agency has individuals trained in risk communication who should be instrumental in crafting these messages, which can be drafted in advance. An information campaign for the public regarding a mass prophylaxis clinic should begin immediately after a public health emergency occurs. Providing the public with current information about the incident, steps to take if exposed to the agent, and the medical regimen for treatment is necessary. Targeting those individuals who are appropriate to receive prophylaxis and providing information regarding clinic locations, hours of clinic operation, public education and registration materials must be a coordinated effort by all involved in the planning and implementation of a POD. In the event a mass prophylaxis clinic(s) is/are needed, public information is a vital link to provide current and correct information. As the situation changes and information is updated, details to the public should be reflected in the messages. Messages using multiple dissemination methods that direct individuals to access education and clinic registration materials are imperative. Areas with reverse 911 might also consider using this method to contact residents within an affected area. Public information must reach many populations and must incorporate non-traditional distribution strategies; Chapter 10 discusses special populations in more detail. In addition to the media, local community leaders, who are perceived as trusted sources of information, should be used as messengers to deliver public health messages to hard-to-reach populations. Word of mouth is a communication strategy that is often NJDHSS - January

188 overlooked, but in some communities/populations, it is the most credible and best way to reach these groups. Contacting community leaders and organizers with a prepared message is an effective method of reaching individuals who may not access other channels. Preparation for communication in the event that television, radio and electronic equipment are unavailable is also encouraged. To be most effective, however, the word-of-mouth approach require, work in advance of a crisis. Public health must identify and secure commitments from community leaders so they will be ready to deliver messages when needed. Educational materials and registration forms must be available electronically via state and local health department websites, but printed copies should also be published in newspapers and be available at other easily accessible public venues, such as community centers, libraries, grocery stores and places of worship. Many of these materials are included in this manual and can be photocopied or scanned onto a website. The turn-around time for copying forms and educational materials will be short. In advance of a public health emergency, clinic planners should establish Memoranda of Agreement (MOA) with printing businesses that can photocopy materials in bulk. It is not recommended that clinic planners stockpile the forms and materials, as disease information and medical regimens may change. The New Jersey Mass Prophylaxis Clinic Model is designed with the premise that participants will arrive at the clinic having been educated about the disease and treatment as well as having completed a registration form. In order for the model to succeed, public education is a key component. Education is vital and is equally, if not more important, to the POD as the clinical aspects of the mass prophylaxis clinic. Communicating with the public in a high stress situation is difficult but it is necessary. This model recognizes and appreciates the value of providing risk communication and timely information dissemination. Samples of NJDHSS approved media templates (e.g., press release, public service announcement, media release) and risk communication package (e.g., FAQ, fact sheet and message maps) are included at the end of this chapter. This information has been developed and drafted in advance of a biological event, but can be tailored as needed. To ensure that public information is consistent at both the state and local level, the use of NJDHSS approved materials is strongly recommended. NJDHSS - January

189 References Reynolds, B. (2002). Crisis Emergency Risk Communication. Centers for Disease Control and Prevention. Atlanta: GA. Emergency Risk Communication CDCynergy. (2003). Centers for Disease Control and Prevention. Atlanta: GA. NJDHSS - January

190 Sample Fact Sheet NJDHSS - January

191 Fact Sheet Adapted from the Centers for Disease Control and Prevention Facts about Pneumonic Plague* Plague is an infectious disease that affects animals and humans. It is caused by the bacterium Yersinia pestis. This bacterium is found in rodents and their fleas and occurs in many areas of the world, including the United States. Y. pestis is easily destroyed by sunlight and drying. Even so, when released into air, the bacterium will survive for up to one hour, although this could vary depending on conditions. Terrorists who can aerosolize the bacterium would be able to spray it in the air and cause lung infections in a large group of people. Pneumonic plague can also be spread when an infected person coughs or sneezes near a healthy person. Becoming infected in this way usually requires direct and close contact with the ill person. Pneumonic plague may also occur if a person with bubonic or septicemic plague is untreated and the bacteria spread to the lungs. Symptoms and Treatment With pneumonic plague, the first signs of illness are fever, headache, weakness, and rapidly developing pneumonia with shortness of breath, chest pain, cough, and sometimes bloody or watery sputum. The pneumonia progresses for 2 to 4 days and may cause respiratory failure and shock. Without early treatment, patients may die. Early treatment of pneumonic plague is essential. To reduce the chance of death, antibiotics must be given within 24 hours of first symptoms. Streptomycin, gentamicin, the tetracyclines, and chloramphenicol are all effective against pneumonic plague. Antibiotic treatment for 7 days will protect people without symptoms but who have had direct, close contact with infected patients. Wearing a close-fitting surgical mask also protects against infection. A plague vaccine is not currently available for use in the United States. *This fact sheet is based on CDC s best current information. It may be updated as new information becomes available. NJDHSS - January

192 Sample Frequently Asked Questions (FAQs) NJDHSS - January

193 Frequently Asked Questions Adapted from the Centers for Disease Control and Prevention Frequently Asked Questions about Plague What is plague? Plague is a disease caused by bacteria called Yersinia pestis. It is found in rodents and their fleas in many areas around the world, including the southwest United States. What are the signs and symptoms of pneumonic plague? Patients usually have fever, weakness, and rapidly developing pneumonia with shortness of breath, chest pain, cough, and sometimes bloody or watery sputum. Nausea, vomiting, and abdominal pain may also occur. Without early treatment, pneumonic plague usually leads to respiratory failure, shock, and rapid death. Why are we concerned about pneumonic plague as a bioweapon? The bacteria which cause plague could be aerosolized and sprayed in the air which could be breathed in and cause lung infection. One to six days after becoming infected with the bacteria, people would develop pneumonic plague, which has a high death rate. However, manufacturing an effective weapon using plague bacteria would require advanced knowledge and technology. Can a person exposed to pneumonic plague avoid becoming sick? Yes. People who have had close contact with an infected person but have not shown symptoms can greatly reduce the chance of becoming sick if they begin treatment within 7 days of their exposure. Treatment consists of taking antibiotics for at least 7 days. How quickly would someone get sick if exposed to plague bacteria through the air? Someone exposed to plague bacteria through the air either from an intentional aerosol release or from close and direct exposure to someone with plague pneumonia could become ill within 1 to 6 days. Can pneumonic plague be treated? Yes. To prevent a high likelihood of death, antibiotics should be given within 24 hours of the first symptoms. Several types of antibiotics are effective for curing the disease and for preventing it. Available oral medications are a tetracycline (such as doxycycline) or a fluoroquinolone (such as ciprofloxacin). For injection or intravenous use, streptomycin or gentamicin antibiotics are used. Early in the response to a bioterrorism attack, these drugs would be tested to determine which is most effective against the particular weapon that was used. NJDHSS - January

194 Someone who is sick with the plague will be isolated for at least 48 hours after the start of antibiotics. Would enough medication be available in the event of a bioterrorism attack involving pneumonic plague? The Strategic National Stockpile comprises a large supply of antibiotics, antidotes and other medical supplies that is available to New Jersey as well as all other states. These can be deployed to anywhere in the United States within 12 hours. New Jersey also has a stockpile of medications that can be deployed quickly to any region of our state. What should someone do if they suspect they or others have been exposed to plague? *Get immediate medical attention: To prevent illness, a person who has been exposed to pneumonic plague must receive antibiotic treatment without delay. If an exposed person becomes ill, antibiotics must be administered within 24 hours of their first symptoms to reduce the risk of death. * Notify authorities: Immediately notify local or state health departments so they can begin to investigate and control the problem right away. If bioterrorism is suspected, the health departments will notify the CDC, FBI, and other appropriate authorities. How can someone reduce the risk of getting pneumonic plague from another person or giving it to someone else? People having direct and close contact with someone with pneumonic plague should wear tightly fitting disposable surgical masks. Patients with the disease should be isolated and medically supervised for at least the first 48 hours of antibiotic treatment. People who have been exposed to a contagious person can be protected from developing plague by receiving prompt antibiotic preventive treatment. How is plague diagnosed? The first step is evaluation by a health care worker. If the health care worker suspects pneumonic plague, samples of the patient s blood, sputum, or fluid from the lymph nodes are sent to a laboratory for testing. Once the laboratory receives the sample, preliminary results can be ready in less than two hours. Confirmation will take longer, usually 24 to 48 hours. How long can plague bacteria exist in the environment? Yersinia pestis is easily destroyed by sunlight and drying. Even so, when released into air, the bacterium will survive for up to one hour, depending on environmental conditions. Is a vaccine available to prevent pneumonic plague? Currently, no plague vaccine is available in the United States. Research is in progress, but we are not likely to have vaccines for several years or more. How many cases of plague occur in the U.S.? Human plague in the United States has occurred as mostly scattered cases in rural areas (an average of 10 to 20 persons each year). Globally, the World Health Organization reports 1,000 to 3,000 cases of plague every year. These cases are usually scattered and occur in rural to semi-rural areas. Most cases are of the bubonic form of the disease. NJDHSS - January

195 Naturally occurring pneumonic plague is uncommon, although small outbreaks do occur. Both types of plague are readily controlled by standard public health response measures. What is the mortality rate of plague? About 14% (1 in 7) of all treated plague cases in the United States are fatal. If untreated, 50-90% of infected people die. Is pneumonic plague different from bubonic plague? Yes. Both are caused by the same bacteria, but they are transmitted differently and their symptoms differ. Pneumonic plague can be transmitted from person to person; bubonic plague cannot. Pneumonic plague affects the lungs and is transmitted when a person breathes in bacterial particles in the air. Bubonic plague is transmitted through the bite of an infected flea or exposure to infected material through a break in the skin. Bubonic plague symptoms include swollen, tender lymph glands called buboes. Buboes are not present in pneumonic plague. If bubonic plague is not treated, however, the bacteria can spread through the bloodstream and infect the lungs, causing a secondary case of pneumonic plague. NJDHSS - January

196 Sample Message Maps NJDHSS - January

197 Message Map Plague: How Do I Get It? Stakeholders: General Public Key Message 1: People can get plague from being bitten by a rodent or flea that is carrying the disease. Key Message 2: A person can also get plague by handling an infected animal. Key Message 3: Only pneumonic plague can be spread from one person to another. Millions of people died from plague in the Middle Ages, when human homes were inhabited by flea-infested rats. The bacteria can be transmitted through a break in a person s skin. Transmission can take place if a person breathes in the aerosolized bacteria. This can happen when an infected person coughs or sneezes, and the droplets are released in the air. The plague bacteria are maintained in the blood system of rodents. Close personal contact is necessary for this form of plague to be spread. Plague bacteria are easily destroyed by sunlight and drying, only surviving up to one hour depending on environmental conditions. Decontamination of the patient s household or belongings is not necessary. NJDHSS - January

198 Message Map Plague: How Can I Protect Myself? Stakeholders: General Public Key Message 1: If you suspect you have been exposed to plague, contact your medical provider as soon as possible. Key Message 2: Avoid exposure to rodents and their fleas. Take all medication as prescribed to you. Remove potential nesting areas for rodents. Report all side effects of the medication to your doctor. Cover your mouth and nose when coughing or sneezing. Do not handle dead rodents without wearing gloves and a mask. Use flea control products, and closely supervise children and pets when they are outside in areas with large rodent populations. Treat pet dogs and cats for flea control regularly. NJDHSS - January

199 Message Map Plague: What are the symptoms? Stakeholders: General Public Key Message 1: A typical sign of bubonic plague is a swollen, sore lymph node called buboes. Key Message 2: Pneumonic plague affects the lungs causing pneumonialike symptoms. Lymph nodes affected are usually found in the neck, underarm and groin area. Symptoms include signs of pneumonia such as chest pain, difficulty breathing and cough with bloody sputum. Once a person is bitten, the bacteria travel through the lymphatic system, inflaming the first lymph node they reach. An infected person may also experience sudden onset of fever and chills, headache, extreme fatigue. Other symptoms include fever, chills, headache, extreme exhaustion and muscle aches. If left untreated, septicemic (in the blood) plague can develop. Symptoms are similar to bubonic and pneumonic plague accompanied by abdominal pain, diarrhea and vomiting. NJDHSS - January

200 Message Map Plague: What is the treatment? Stakeholders: General Public Key Message 1: Effective treatment measures enable almost all plague patients to be cured if diagnosed on time. Key Message 2: Treatment methods include antibiotics and supportive therapy. Patients with plague should be hospitalized and isolated to prevent further spread. Antibiotic treatment should begin as soon as possible, within 24 hours of the first symptoms. Symptoms usually begin 1 to 6 days after exposure. Antibiotics may be given to close contacts of the patient in an effort to prevent further infection. These should begin within 7 days of exposure. Antibiotics such as streptomycin, gentamycin, doxycycline, ciprofloxacin are used. Antibiotics can be administered orally (by mouth) or intravenously (through the veins.) Supportive therapy includes respiratory support, intravenous fluids and oxygen NJDHSS - January

201 Message Map Plague: What is it? Stakeholders: General Public Key Message 1: Plague is a disease caused by bacteria (Yersinia pestis). There are three forms of plague: bubonic, pneumonic and bloodborne. Plague bacteria can be naturally aerosolized through disturbing rodent droppings, or droplets discharged during coughing or sneezing. Key Message 2: The bacteria that cause plague are found in nature in rodents and their fleas. Fleas become infected when they bite rodents infected with the bacteria, including prairie dogs. Bubonic plague is the most common and is associated with swollen glands (buboes). Key Message 3: 1,000-3,000 people worldwide suffer from plague each year people are diagnosed with plague each year in the U.S. It is most commonly in the bubonic form, but pneumonic plague does occur. These cases are generally found in the Southwestern states such as New Mexico and Arizona. However, public health officials believe that in a biological attack, the pneumonic form would be seen. Bubonic and pneumonic plague are readily controlled by standard public health measures. NJDHSS - January

202 Sample Press Release Template NJDHSS - January

203 Press Release For release: (date) For further information, contact: (name and phone number) New Jersey Continues to Investigate Pneumonic Plague Outbreak TRENTON The New Jersey Department of Health and Senior Services (NJDHSS) continues to investigate an outbreak of pneumonic plague in xx counties. At this time (number) confirmed cases have been identified in xxx counties. Additionally, there are (number) suspected cases in xxx counties. This is a terrible outbreak and the Department will continue to work in collaboration with the Centers for Disease Control and Prevention (CDC), hospitals and local and county health agencies to control this outbreak and prevent more people from becoming ill, said New Jersey Health and Senior Services Commissioner The Department is recommending that anyone who has been in close contact with an infected person receive a seven-day course of antibiotics. Antibiotics will be available at (number) clinics in xxx County. Specific information about county clinics will be announced at a press briefing (when). The Department has also opened its toll-free hotline at xxx-xxx-xxxx for the general public. This hotline will answer general questions about pneumonic plague. Information is also available on the NJDHSS website at New Jersey has comprehensive, robust plans in place to protect the health and safety of its residents during a public health emergency, said Eddy Bresnitz, MD, State Epidemiologist and Senior Assistant Commissioner. We have trained staff and exercised these plans continuously. I urge our residents to remain vigilant but calm as these plans are implemented. The NJDHSS has provided medication to those first responders and health care workers who may be at risk of exposure to ensure they are able to respond to the needs of the public. The NJDHSS has instructed all first responders to wear the appropriate personal protective equipment when treating individuals with suspected cases of pneumonic plague. NJDHSS - January

204 Plague is a naturally occurring infectious disease that affects animals and humans. It is caused by the bacterium Yersinia pestis (Y. pestis), which is found in rodents and their fleas and occurs in many areas of the world, including the United States. The symptoms of pneumonic plague include fever, weakness, rapidly developing pneumonia with shortness of breath, chest pain, cough and sometimes bloody or watery sputum. Without early treatment, pneumonic plague can lead to respiratory failure and rapid death. Someone exposed to Y. pestis through the air either from an intentional aerosol release or from close contact with someone who is infected may become ill within 1 to 6 days. Taking antibiotics within 24 hours of the onset of symptoms can reduce the risk of death. ### NJDHSS - January

205 Plague Press Release/PSA 1: (Your agency) is responding to a report of cases of plague in New Jersey. (Your agency) urges everyone to know the symptoms of pneumonic plague, which include: Chest pain Sometimes bloody or watery sputum Headache Fever Weakness Cough Shortness of breath If you or some one you know has symptoms, go to the hospital immediately. Plague is spread by breathing, coughing or sneezing. Avoid contact with anyone who appears to be ill. For more information, call To learn more about plague, visit the New Jersey Department of Health and Senior Services website at or the Centers for Disease Control and Prevention website at NJDHSS - January

206 Plague Press Release/PSA 2: (Your agency) is working to protect you and your family during the current response to an outbreak of pneumonic plague in New Jersey. Here is what you can do to help. Avoid: Close contact with anyone who appears to be ill. Plague can spread from one person to another by breathing, coughing or sneezing. Traveling in affected areas. Listen for updates from emergency and healthcare authorities to know where affected areas are and when it will become safe to visit them. Know these symptoms and report them immediately to your family doctor or nearest emergency room if you or someone you know becomes ill: Chest pain Sometimes bloody or watery sputum Headache Fever Weakness Cough Shortness of breath To learn more about plague, visit the New Jersey Department of Health and Senior Services website at or the Centers for Disease Control and Prevention website at For more information, call #### NJDHSS - January

207 Plague Press Release/PSA 3: (Your agency) is working to protect you and your family in response to the current outbreak of pneumonic plague in New Jersey. Pneumonic plague is a serious health threat that requires prompt medical attention as soon as symptoms appear. Symptoms include: Chest pain* Sometimes bloody or watery sputum* Headache Fever Weakness Cough* Shortness of breath* * respiratory symptoms People with fever and respiratory symptoms should seek medical treatment immediately. If you live in an area that has been identified with a possible plague incident, go immediately to (name of dispensing site) for preventive treatment. Early treatment can save your life. If you are exhibiting symptoms, go to your local hospital emergency department immediately. If you have not been exposed: The best thing to do is to stay home, unless you feel ill. Avoid close contact with people or animals who appear to be ill. Plague is spread by breathing, coughing and sneezing. If there is any possibility that you might have been or could be exposed: Go to (name of dispensing site) to get preventive treatment. Bring a completed form for each exposed member of your household. Forms are available online at. or from. (Your agency) is continuing to take measures to protect you and your family. The Department reminds you to stay tuned to local radio and TV stations for continuing updates. To learn more about plague, visit the New Jersey Department of Health and Senior Services website at or the Centers for Disease Control and Prevention website at For more information, call ### NJDHSS - January

208 NJDHSS SNS Statement: (Your agency) is working with the New Jersey Department of Health and Senior Services (NJDHSS) and other health officials across the U.S. to investigate possible cases of pneumonic plague. The NJDHSS has asked the Centers for Disease Control and Prevention (CDC) to send the Strategic National Stockpile (SNS) to New Jersey. The stockpile contains life-saving medicines and supplies and is available to everyone who needs medical attention. SNS assets are kept ready to use at a moment s notice, and are already on their way to New Jersey. These medications supplement New Jersey s stockpile of medications, which will be used to prevent disease in residents who have been exposed to plague. Post-exposure medications will be available at the following locations: LINCS agencies to provide clinic information here. For more information, call To learn more about plague, visit the NJDHSS website at or the CDC website at ### NJDHSS - January

209 Sample Public Service Announcement (PSA) NJDHSS - January

210 Public Service Announcement [20 seconds] Questions about Plague? New Jersey Residents Can Call Hot Line If you live in New Jersey and have questions about plague, the New Jersey Department of Health and Senior Services can help. Call their toll-free hot line at and get the facts. Protect yourself and your loved ones. Call NJDHSS - January

211 Sample Media Advisory NJDHSS - January

212 Media Advisory PO Box 360, Trenton, NJ For release: (date) For further information, contact: (name and phone number) PRESS CONFERENCE Commissioner of Health To Discuss Pneumonic Plague The New Jersey Department of Health and Senior Services will hold a press conference to discuss the outbreak of pneumonic plague (on day, date, year at 00 am/pm) in the auditorium of the New Jersey Department of Health and Senior Services in Trenton. Health and Senior Services Commissioner and State Epidemiologist/Senior Assistant Commissioner Eddy Bresnitz, M.D., will discuss plague, a potentially fatal disease, and what New Jersey residents can do to protect themselves. #### The Department of Health and Senior Services is located at the corner of Market and Warren Streets, Trenton. NJDHSS - January

213 Sample News Release NJDHSS - January

214 News Release For release: (date) For further information, contact: (name and phone number) New Jersey Confirms Resident Infected with Pneumonic Plague TRENTON The New Jersey Department of Health and Senior Services (NJDHSS) has received positive laboratory confirmation that a xx-year-old male/female New Jersey resident hospitalized on date has pneumonic plague. NJDHSS received the confirmation when from the Centers for Disease Control and Prevention (CDC) in Atlanta, and immediately notified local health departments throughout the state. Background could include: 1. Symptoms at onset. 2. Patients exposure. 3. Clinical status. 4. Health status of close contacts. 5. Circumstances of exposure (e.g., natural or intentional) (If intentional, information will be added about working with law enforcement.) New Jersey has comprehensive, robust plans in place to protect the health and safety of its residents during a public health emergency, said the Commissioner of Health and Senior Services. We have trained staff and exercised these plans continuously. I urge our residents to remain vigilant but calm as these plans are implemented. NJDHSS has advised the patient, family members, hospital staff and first responders who may have been in contact with the individual to receive antibiotics. Other individuals are not being advised to receive medications at this time. Doxycycline is the first-choice antibiotic for post exposure prophylaxis; other antibiotics, including ciprofloxacin (Cipro), may also be recommended. People without symptoms who have had household, hospital, or other close contact (3 feet or less) with persons with untreated pneumonic plague should receive post exposure prophylaxis antibiotics for 7 days and be monitored for fever and cough. Because plague is an unusual disease and could be a bioterrorist attack, we are asking all hospitals and local and county health officials to report any potential cases of plague to our Communicable Disease Service immediately, said Eddy Bresnitz, MD, State Epidemiologist NJDHSS - January

215 and Senior Assistant Commissioner. Anyone who suspects he or she may have been exposed to the pneumonic plague should immediately seek medical attention. The Department has also opened its toll-free hotline at xxx-xxx-xxxx for the general public who have questions about plague. Updates and information are also available on the NJDHSS website at Plague is an infectious disease that affects animals and humans. It is caused by a bacteria found in rodents and their fleas and occurs in many areas of the world, including the United States. Pneumonic plague occurs when the bacteria infects the lungs. According to the CDC, pneumonic plague can be grown in a laboratory and pose a biological threat if it were made airborne and inhaled. Pneumonic plague can spread from person to person through the air. Transmission can take place if someone breathes in aerosolized bacteria, which could happen in a bioterrorist attack. Pneumonic plague is also spread by breathing in contaminated respiratory droplets from a person (or animal) with pneumonic plague. Becoming infected in this way usually requires direct and close contact with the ill person or animal. Pneumonic plague may also occur if a person with bubonic or septicemic plague is untreated and the bacteria spread to the lungs. The symptoms of pneumonic plague include fever, weakness, rapidly developing pneumonia with shortness of breath, chest pain, cough and sometimes bloody or watery sputum. Without early treatment, pneumonic plague can lead to respiratory failure, shock and rapid death. Someone exposed to pneumonic plague through the air either from an intentional aerosol release or from close contact with someone who is infected may become ill within 1 to 6 days. But taking antibiotics within 24 hours can reduce the risk of death. ### NJDHSS - January

216 Chapter 8: Education and Training This chapter addresses education and training issues surrounding a mass prophylaxis event. Education is the information that will be made available to the public both prior to and during the clinic. Training refers to the information staff and volunteers need to perform their jobs. Education Education plays a key role in helping individuals understand the benefits and risks of medication regimens and to assist them in making an informed decision. In the clinic model presented here, it is critical that the major educational effort take place before and outside of the clinic site so that throughput within the clinic can be maximized. Additionally, phone banks and crisis counselors must be in place prior to clinic operation to maximize clinic throughput and address individual issues and concerns in a more private setting. Educating the general public, especially non-targeted individuals (i.e., not at-risk), is equally as important as educating those individuals who are in the targeted (i.e., at-risk) population. Collaborating with public information personnel to release timely and appropriate education messages is key in helping to diffuse panic and anxiety. Post-event education for the public advises about the degree of threat, the population targeted for prophylaxis, and medical contraindications to specific medications serves two purposes. First, it helps to keep large numbers of ineligible (not exposed) persons from arriving at the clinic. Second, it provides a means for participants to self-screen for educational or medical concerns, prior to arrival at the clinic. Individuals who state, in writing, that they are informed about the benefits and risks of prophylaxis and have no medical contraindications to receiving the medical regimen, will be able to proceed directly to the dispensing station. However, those individuals whose registration forms indicate the need for further education or medical screening will be directed to the appropriate workstation before receiving prophylaxis. Education provided in advance allows the majority of participants to by-pass additional workstations within the clinic. Therefore, they will be processed quickly and efficiently, and staff time can be devoted to those individuals who need additional assistance. NJDHSS - January

217 Public education must be made available in a wide variety of formats to reach as many individuals as possible. No matter how it is presented, though, its main goal is the same: to assist individuals to make a decision about taking prophylactic medications. Decision-making is facilitated when individuals have information about the nature of the biological threat and the risks and benefits of taking prophylactic medications, including possible side effects and potential contraindications. It is best if the educational needs of a population can be anticipated before a public health emergency. Health educators are trained to assess the needs of a community to determine its needs and provide appropriate educational interventions. Knowing the population within a jurisdiction, their language(s) and culture(s), and the best method(s) to distribute educational materials should be determined before a public health emergency. Types of Education Videos Videos are a visual means to educate individuals. The videos used in a pre-clinic education setting or at a mass prophylaxis clinic should be informative yet directed at nonhealth professionals. Videos may be shown on a TV/VCR, or on public access television; videos may also be loaded on a website or burned to a CD. Closed-captioned videos are helpful for hearing-impaired individuals. Whatever method of projection is chosen, it is important that the information provided in the video adequately address the risk and benefits of medical treatment and contraindications to prophylaxis. In a mass clinic setting, videos may be used to educate participants as they wait in line between workstations. This will provide participants with additional information and will keep them occupied if there is a delay between stations. Videos may also be used to educate the worried well outside the clinic. Providing non-exposed individuals with additional information via video will assist in decreasing panic and fear of the unknown. These videos may also be forwarded to local media to broadcast. It is recommended that clinic planners identify and contact existing media outlets to make arrangements for airtime during an event. TV/VCR equipment is easy to obtain and set-up is easy. The video should be short, to the point and should provide participants with information such as what to expect at the clinic NJDHSS - January

218 and information about the disease agent. Consider adding a crawler at the bottom of the video; crawlers highlight main messages for participants and they are not transcripts. The information contained in the crawler may be translated into different languages to accommodate the target audience. In place of a crawler, a sign language interpreter may also be used to reach the hearing-impaired. The interpreter should be minimized on the video, as not to distract from the main spokesperson. For the 2003 National Smallpox Vaccination Program, the CDC developed a video, narrated by Dr. Julie Gerberding, CDC Director, to inform individuals who were considering receiving the smallpox vaccine. This video is available from the CDC or NJDHSS as an example for development of other educational videos. The negative aspects of using videos are that they are expensive to develop and produce and cannot be quickly adapted as information changes. Written Materials Using written materials to provide education is an effective strategy. Written materials can be tailored to meet the needs of the event and the audience and can be crafted to relay key messages in high anxiety situations. Print materials are quickly and easily posted on websites, published in newspapers, and can be faxed and/or photocopied. In a mass clinic setting, education using written materials can be used to keep large groups occupied. When using written materials, such as fact sheets, FAQs (Frequently Asked Questions) and newsletters, literacy is a major concern. Materials should be written at or below the 6th grade reading level. This can be assessed using Microsoft Word software, which is available on most computer systems: Click on Tools at the top of the screen Click on Options Check Readability at the bottom of the drop down menu Readability (i.e., average sentence length, average number of syllables per word and the reading grade level of the document) will be listed after Word has completed Spell check. Arial font is preferred and should be no smaller than size 12 point. If possible, appropriate graphics should accompany the narrative portion, as these assist those with limited reading NJDHSS - January

219 skills. Materials may also need to be translated. Translation services should be acquired prior to a public health emergency and a MOA should be in place to expedite the process. The CDC ( the Strategic National Stockpile (SNS) Program s Public Information and Communications Toolkit ( and the American Red Cross ( websites offer bioterrorism and emergency preparedness materials in various languages on their websites. The SNS website is password protected; however, LINCS Health Educators/Risk Communicators, BT Nurses and Public Health Planners have the ability to access materials. Samples of written materials (e.g., fact sheets and FAQs) developed and used by the NJDHSS are included at the end of this chapter. In addition, samples of patient medication information sheets, from the SNS Public Information and Communication Toolkit, in a variety of languages are included at the end of Chapter 3. Posters A poster is an oversized print item. Posters can be made in-house, purchased or downloaded. In a mass clinic setting, posters that can be hung on walls or propped on easels can assist with education. They may be mounted on a large piece of poster board or a flipchart with information in various languages. These should be stationed around highvolume areas to engage clinic participants as they wait in line. Keeping clinic participants actively informed using posters as they move from station to station is an easy and effective education strategy. Consider using posters to provide basic information about the disease agent, what individuals can do to protect themselves and emergency contact information. Posters are low-cost educational tools that can be developed quickly. The information contained in posters should be easily understood and translated into as many languages as is necessary. Oral Presentations Scripted messages that are delivered by workers or volunteers are another effective method for educating individuals. An example of how this method might be implemented in a mass clinic setting includes staff who provide presentations to clinic participants on a bus as they are shuttled to the clinic, waiting in line, or arriving at workstations. NJDHSS - January

220 It is important to note that staff should be provided with pre-scripted communication messages to maintain consistent information to the public. Scripted messages should be drafted prior to a public health emergency; scripts should be developed at the local level in coordination with NJDHSS. Staff who are charged with delivering oral scripted messages must be trained in public speaking strategies and responding and dealing with difficult and anxious individuals. Telephone Messages Pre-recorded telephone messages are another method of education. Phone trees are phone systems that prompt individuals to retrieve specific information by pressing a certain button or number. These messages should be available on commonly used public phone numbers. Opening a hotline to answer calls is another method of communicating with the public. Staff must be trained in phone etiquette and effectively communicate with angry, frightened or anxious callers before the phone lines are open. Scripts for workers should also be written before the phone lines are open. Providing staff with written scripts ensures that the information being disseminated is clear, consistent and correct. Scripts should be updated as information evolves. Reverse 911 is also another quick method of educating individuals. In communities that offer this service, residents receive a call and may be directed to a website, television or radio station or hotline number to receive more information. Radio Radio is a form of communication that is often overlooked as a medium to educate individuals. Use of radio is an important vehicle if there is a lack of electricity. Most emergency preparedness go kits advise the public to keep a battery-operated radio for this reason. Radio communication for educational purposes will be utilized most often prior to the opening of a clinic. Clinic planners should include radio communication in their public education plans. Radio announcements that inform the public about the status of the incident, eligibility criteria for prophylaxis, clinic location(s), operating hours, the disease agent and reassuring the NJDHSS - January

221 public that health officials are working to protect their health can assist in crowd control and decrease fear and anxiety in the community. Again, relationships with media outlets should be made in advance of an incident. Training In order for workers and volunteers to be effective in a mass clinic atmosphere, they must understand what is expected of them and be provided with the tools to function in their assigned role(s). Staff should be assigned to clinic work stations based not only on their professional abilities and credentials but also by the needs of the clinic. Individuals may be qualified to fill multiple stations; however they must understand that it is important that they function in the capacities that are needed. Each workstation has a role in a mass clinic setting, and workers must recognize that the overall goal of the POD is to put pills in people. To optimize clinic throughput, workers and volunteers should operate within the roles that they have been assigned to, and if individuals require additional assistance, the clinic staff should refer them to another workstation. Ideally, recruiting and training of individuals to staff a clinic should occur before a public health emergency. Recruiting qualified workers to staff the workstations is not covered in this manual. However clinic planners should consider the types of staff that are needed. An overview of staffing requirements are found in Appendix D, at the end of Chapter 3. Efforts to coordinate a statewide database of clinical and non-clinical professionals are underway. Training should be consistent and provide prospective staff with an overview of their roles and responsibilities. Briefings are quick updates for workers that take place after training has occurred and are not a substitute for training. Trainings and/or briefings for all individuals involved with the Pre-POD and POD are critical; these should be coordinated by those individuals who are designated supervisors. Supervisors should train/brief Area Leaders and Area Leaders should train/brief the remainder of the staff. These trainings and briefings should be duty-specific (e.g., law enforcement, mental health, medical screening). It is important in a large-scale event that control and command is exercised and recognized by all involved. NJDHSS - January

222 Even if workers have attended a pre-event training, a training session on the day of the clinic is necessary. Training may take place an hour before the clinic opens but should be considered a mandatory component for all staff. This training, also known as just in time training should, at minimum, consist of a walk-through of the clinic, an orientation to the different workstations, an overview of clinic operations and introductions to the various Area Leaders. It is essential to the smooth flow of the clinic that ALL workers understand what actions occur at each clinic workstation. Area Leaders are briefed regularly by the POD Manager and/or the Clinical Manager and are responsible for providing workers assigned to their area(s) with training updates that are specific to their duties and responsibilities during their shift at the workstation. The Area Leader is responsible for explaining duties and responsibilities, which are specific to the workstation, as well as discussing correct use of PPE, when appropriate. A packet of information that has been developed in advance is a quick and easy way to familiarize all staff of their roles in the mass prophylaxis clinic. All individuals responsible for providing training and/or briefing must become familiar with the information that is being distributed at the POD and the roles and responsibilities of all workstations within the clinic. The registration form that will be used should be provided to all staff before the clinic opens. Workers must recognize that the registration form becomes the official medical record and must be collected. The training should explain the form, specifically where/how individuals may access the form before/during the clinic, the concept of self-screening, the eligibility criteria, the referral procedure, who collects the registration form from clinic participants, and what to do and who to contact if questions arise. Training should be streamlined to accommodate the large number of workers and plans to train multiple shifts must also be considered. If a large group is being addressed, be certain to have a working public announcement system or a bullhorn. The training should also take place in a room where the lighting is adequate and the individual providing the training can be observed and heard by all. At the end of Chapter 3, Job Action Sheets define and describe tasks for workers at each workstation. These Job Action Sheets should be included at each training session and provided to every worker and volunteer at the clinic. Having tangible descriptions of tasks NJDHSS - January

223 and duties in an easy to follow format, help workers to know what is expected of them during their time at the POD. It is also strongly recommended that each workstation have a laminated copy of the Job Action Sheet; which should be posted at the workstation for quick reference. Experience in New Jersey s 2004 Point of Dispensing Exercise taught us that the first hour of the clinic is a learning opportunity for workers. Individuals were unfamiliar with the registration form and were unsure of the procedures related to the form and had many questions. Staff and volunteers needed at least one hour to become comfortable with their jobs and the POD operations. While the staff at the clinics performed well, a lesson learned is that training is a critical component to successful operations. Providing workers with adequate training to effectively execute and carry out their duties will unquestionably help maximize throughput and foster efficacy for future mass prophylaxis endeavors. NJDHSS - January

224 Chapter 9: Special Populations Special populations comprise a heterogeneous group of people in terms of age and types of disabilities or needs. Some may have multiple disabilities/needs to address with (e.g., have a physical impairment and be non-english speaking). Where feasible, the clinic planner should attempt to recruit representatives from professional and community groups working with any special needs populations to become partners in the mass prophylaxis clinic planning process. POD Managers should assess their jurisdiction to determine the types and numbers of special populations they will need to accommodate. This can be done using such references as census data information, community groups, or noting special facilities (e.g., correctional facilities, long term care facilities, colleges). Please consider the following: 1. The Americans with Disabilities Act (ADA) defines a person with a disability as: A person with a physical or mental impairment that substantially limits one or more major life activities; or A person with a record of such a physical or mental impairment; or A person who is regarded as having such impairment. 2. Make allowances at blockades, shelters, and other impacted areas for access by attendants, home health aides, visiting nurses, guide animals, and other individuals crucial to the immediate health care needs of people with disabilities. Non-English speaking populations within the clinic s catchment area require translators, and written materials or videos in their native language must be supplied. NJDHSS - January

225 Native Americans in New Jersey are not included in the category of Special Populations because they speak English and have been integrated into the community. NJDHSS - January

226 Chapter 10: Evaluation Evaluation and feedback are important aspects of any clinic planning process. Evaluation allows clinic planners to assess the clinic s strengths and/or weaknesses and offers insight for improvement in future clinics. A cross section of persons participating in any capacity (staff, volunteers and participants) of the clinic should be urged to give their critiques of the clinic experience. Assessments of the clinic experience range from formal paper and pencil surveys to informal briefings during and/or immediately following a clinic. Clinic planners should determine what type of evaluation they wish to use while planning the clinic. Lessons learned from evaluations help adjust or modify plans for future clinics. If clinic planners choose to make use of paper surveys, they should note that separate evaluations should be used for participants and staff so that all viewpoints may be considered. Paper surveys are a preferred evaluation method, as they allow individuals to provide constructive criticism surrounding their clinic experience. Surveys should not contain personal identification information (name, address, etc.), to allow for anonymous and honest feedback. The drawback to paper surveys is that they are time-consuming to analyze, which often means that the feedback may come too late to improve subsequent clinic procedures. Holding a debriefing session or a hotwash immediately after the clinic is another evaluation method. At a hotwash, staff and volunteers report their observations of clinic events. This technique yields information about what was observed by the staff during the clinic. It should be noted that not all staff may wish to report negative aspects of the clinic or inadequacies of fellow clinic staff or volunteers. Therefore, this method is not as effective in obtaining complete feedback. Nevertheless, valuable information can be obtained. It is helpful to have a list of questions prepared so that information gathering at the hotwash can be maximized. The overall goal of the hotwash is to obtain information that can be used to improve future clinic operations. Some examples of questions are: Were you able to access assistance quickly and easily? Was the pace of the clinic too fast/slow? NJDHSS - January

227 What overall rating would you give to the clinic in terms of its efficiency and organization? Did you have adequate resources/supplies at your station to meet your needs and those of participants? Were you able to identify any traffic flow problems during the clinic? What was the most frequently asked question by participants at your station? Another type of immediate feedback mechanism might occur while the clinic is running. This involves monitors asking clinic participants and clinic staff questions about waiting time or other issues. Staff might ask participants how long they waited in line, their experience with navigating through the workstations, whether they had difficulty locating the clinic site, etc.. Likewise, staff could be questioned about physical considerations such as lighting and temperature, or ease of performing routine tasks. This information should be reported during the hotwash but may also be brought directly to the clinic planner so immediate modifications can be made when possible. In closing, evaluation is an important component of clinic planning. Every clinic is unique with its own set of issues that might have been overlooked or unaccounted for by planners. Lessons learned during the clinic are important and should be shared with others. Information exchange is an integral aspect of evaluation; individuals should feel able to express their observations and opinions about their roles during the clinic. A sample of a POD operations evaluation form is included at the end of this chapter. NJDHSS - January

228 POD Operations Evaluation Form Participant s Name: Agency: Job responsibility/role: Recommendations and Action Steps: 1. From your observation, list the top three issues and/or areas that need improvement. 2. Identify the action steps that should be taken to address the issues listed above. Please indicate it as high, medium or low priority. 3. Describe the action steps that should be taken in your area of responsibility. Who should be assigned the responsibility for each action item above. 4. List the plans, policy or procedures that should be reviewed, revised or developed to address issues raised during the clinic. NJDHSS - January