VOLUNTEER TRAINING at Points of Dispensing

1. VOLUNTEER TRAININGat Points of Dispensing Under the Direction of the PB County Health Department Office of Public Health Preparedness

2. Overview • What is Anthrax • Anthrax As A Weapon • Inhalational Anthrax Pathology • Is it FLU of ANTHRAX • How is Inhalation Anthrax Prevented/Treated • Dosing Modalities

3. Overview (continued) • How Registration Forms are TRIAGED • Acute Symptoms Screening • Medication Selection Algorithm • Affixing Labels to Medication Pre-Packs • Patient Through-Put and Twice a Day Reporting to ESF-8 at the EOC

4. What is Anthrax? • Anthrax is a serious disease caused by Bacillus anthracis, a bacterium that forms spores. • There are three types of anthrax: • Skin (cutaneous) • Lungs (inhalation) • Ingestion (gastrointestinal)

6. How Does One Get Anthrax? • Anthrax is not known to spread from person to person. • Humans can become infected with anthrax by • Handling products from infected animals • Breathing in anthrax spores from infected animal products, or intentional release • Eating uncooked meat from infected animal

7. Anthrax As A Weapon This happened in the US at the AMI Building, Boca Raton, in 2001 – • Anthrax was also delivered through the postal system by letters sent with powder containing anthrax. • This caused 22 cases of anthrax infection, nationwide. • Five people died of inhalation anthrax.

8. Anthrax As A Weapon (cont’d) Causing: • Widespread Fear and Anxiety • Psychological Footprint greatly exceeded Medical Footprint

10. How Dangerous Is Anthrax Anthrax is classified as a Category A Agent. • Poses the greatest threat for a bad effect on public health • May spread across a large area or need for public awareness • Needs a great deal of planning to protect the public’s health

11. Inhalational Anthrax Pathology • Spores enter the lungs • Eventually they fall deep into the lungs and grow • Bacteria multiply and release toxins • Symptoms and eventually death occur • Antibiotics must remain in your system to “cover” you as additional spores grow – (60 days, if exposed)

13. What Are The Symptoms Inhalation Anthrax, a bacteria, and Influenza (flu), a virus, can have similar symptoms. Many illnesses begin with flu-like symptoms. So, how does one distinguish between the flu and inhalation anthrax?

14. Is it FLU of ANTHRAX? Symptom during past 7 daysFluAnthrax • Fever Yes Yes • Aches Yes Yes • Chills Yes Yes • Cough Yes Possible • Tiredness Yes Yes • Vomiting Yes Yes • Runny Nose Yes No • Shortness of Breath Rare Rapid Onset • Chest discomfort/pain Rare Rapid Onset • Mediastinum Widening No Yes

15. Anthrax – Fatal Case – Mediastinum Widening

16. Laboratory Analysis of White Blood Cells Provides Clues Inhalation Flu Anthrax Toxin: (Virus)(Bacteria) White Blood Cells: Counts Low High Lymphocytes High No Increase Neutrophils Low High

17. Robert Stephens – First Inhalation Death in US, 2008 Larry Bush, MD, Infectious Diseases at JFK Medical Center, diagnosed Mr. Stephens with Inhalation Anthrax just prior to his death. • CXR – Mediastinum Widening • Lab Analysis of White Blood Cell Counts • PCR – Polymerase Chain Reaction – CDC Lab Analysis provided FINAL confirmation

18. Syndromic Surveillance Continual Monitoring of Chief Complaint upon Admission to Emergency Rooms coming soon to all Hospitals in Palm Beach County. “ESSENCE” Surveillance System was Developed by Johns Hopkins University.

19. Treatment Options • If Bacterial Infection (anthrax, plague), then treat with Antibiotics • If Viral Infection (smallpox, bird flu), then treat with Vaccines or Anti-Virals (TamiFlu, Relenza)

20. How is Inhalation Anthrax Prevented or Treated Three ORAL ANTIBIOTICS are available for the prevention/prophylaxis and treatment of Inhalation Anthrax: • Doxycycline • Cipro(floxacin) • Amoxicillin

21. Side Effects to Antibiotics • Common side-effects to antibiotics include: • Nausea • Vomiting • Diarrhea • Loss of appetite • Darkening of urine • Headache

22. Allergic Reactions If any of these allergic reactions occur, get emergency help immediately: • Swelling of tongue, hands, or feet • Fever • Difficulty breathing • Severe skin rash

23. What if I Miss a Dose? • Start again as soon as possible • Skip only if too near your next scheduled dose • Do NOT take 2 pills to make up for the missed dose • Finish all your pills, even if you feel OK, unless your doctor tells you to stop • If you stop taking this medicine too soon, you may become ill

24. Doxycycline – 100 mgOrallyTwice a Day For 10 Days • A Tetracycline, NOT in the penicillin family • Take with full glass of water • Avoid taking antacids (Maalox, Mylanta, Tums), Questran, Colestid, dairy, iron or vitamins for 4 hours before or 2 hours after taking • May make you more sensitive to sunlight – wear protective clothing and sunscreen • Do not take this medication if you are pregnant or suspect you may be pregnant

25. Cipro(floxacin) – 500 mgOrallyTwice a Day for 10 Days • A Quinoline, NOT in the penicillin family • Take 2 hours before/after a meal with full glass of water • If nausea or upset stomach, take w/food • Avoid dairy for 3 hours before/after taking • May make you more sensitive to sunlight – wear protective clothing and sunscreen • If you take warfarin (Coumadin) to thin your blood, be sure to tell your doctor you are taking Cipro

26. Amoxicillin – 500 mgOrally Three Times a Day for 10 Days • Do not take if allergic to penicillin or cephalosporins (Keflex, Ceclor), as Serious life-threatening reactions can occur with no previous history of allergy, including hives, swelling, and anaphylaxis • Take with full glass of water

27. Special Note For Children • Cipro(floxacin) may cause joint problems in infants and children under 18 years of age. Report any joint pain to your doctor while child is taking Cipro. • Doxycycline may cause permanent staining of the teeth in children younger than 8 years old. Teeth can become grayish in color and this color does not go away.

29. Mixing Instructions for Infants and Children • Put ONE tablet (or capsule) into small bowl • Crush the tablet with back of spoon until no large pieces are seen, or open capsule and empty contents into bowl • Add five (5) level teaspoons (tsps) of water or apple juice • Stir until medication looks evenly mixed with liquid or juice

30. Mixtures for Those Who Cannot Swallow Tablets or Capsules • Prepare the mixture for only one day at a time • Store mixture in a covered container and refrigerate • Throw away any remaining mixture at end of each day

31. Doxycycline forInfants and Children 2.2mg/kg Child’s Weight (lbs.)Morning DoseEvening Dose Under 11 lbs ½ teaspoon ½ teaspoon 11 - 20 lbs 1 teaspoon 1 teaspoon 21 – 30 lbs 1-1/2 teaspoons 1-1/2 teaspoons 31 – 40 lbs 2 teaspoons 2 teaspoons 41 – 50 lbs 2-1/2 teaspoons 2-1/2 teaspoons 51 – 59 lbs 3 teaspoons 3 teaspoons 60 – 69 lbs 3-1/2 teaspoons 3-1/2 teaspoons 70 – 79 lbs 4 teaspoons 4 teaspoons 80 – 89 lbs 4-1/2 teaspoons 4-1/2 teaspoons 90 – 99 lbs 5 teaspoons 5 teaspoons

32. Cipro(floxacin) forInfants and Children 15mg/kg Child’s Weight (lbs.)Morning DoseEvening Dose Under 8 lbs ½ teaspoon ½ teaspoon 8 – 15 lbs 1 teaspoon 1 teaspoon 16 - 22 lbs 1-1/2 teaspoons 1-1/2 teaspoons 23 - 29 lbs 2 teaspoons 2 teaspoons 30 - 37 lbs 2-1/2 teaspoons 2-1/2 teaspoons 38 - 44 lbs 3 teaspoons 3 teaspoons 45 - 51 lbs 3-1/2 teaspoons 3-1/2 teaspoons 52 - 59 lbs 4 teaspoons 4 teaspoons 60 - 66 lbs 4-1/2 teaspoons 4-1/2 teaspoons 61 - 73 lbs 5 teaspoons 5 teaspoons

33. Amoxicillin for Infants and Children 25mg/kg Child’s Morning Afternoon Evening Weight (lbs.)DoseDose Dose Under 10 lbs 1 tsp. 1 tsp. 1 tsp. 10 - 13 lbs 1-1/2 tsp. 1-1/2 tsp. 1-1/2 tsp. 14 - 18 lbs 2 tsp. 2 tsp. 2 tsp. 19 - 22 lbs 2-1/2 tsp. 2-1/2 tsp. 2-1/2 tsp. 23 - 26 lbs 3 tsp. 3 tsp. 3 tsp. 27 – 31 lbs 3-1/2 tsp. 3-1/2 tsp. 3-1/2 tsp. 32 - 35 lbs 4 tsp. 4 tsp. 4 tsp. 36 - 40 lbs 4-1/2 tsp. 4-1/2 tsp. 4-1/2 tsp. 41 - 44 lbs 5 tsp. 5 tsp. 5 tsp.

34. Food and Drug Administration Discourages Widespread Use of Cipro Random prescribing and extensive use of Cipro could speed up the development of drug-resistant organisms, and the usefulness of Cipro as an antibiotics may be lost.

35. Should Doctor Write an Advanced Prescription for Cipro for Emergency Use • Food and Drug Administration strongly recommends that physicians NOT prescribe Cipro for individual patients to have on hand for possible use against inhaled anthrax • Cipro should NOT be prescribed unless there is a clear need, so that the drug will be available when it is needed to treat other more common infections

36. Incident Command System – PODs Public Info Officer -PIO Safety Officer Liaison Officer

37. Notification via Telephone or E-Mail • Palm Beach County Health Department will notify POD Managers/Contacts • POD Managers/Contacts will notify POD Volunteers • POD Communication System will notify constituents

38. Patient Registration Form

39. Authorization and Signature I am picking up medication for the person(s) listed above. If I am picking up medication for people other than myself, I am authorized to sign for these people and I agree to provide the medication and instructions to all of them. Home Address: __________________________________________ City: __________________________, ZipCode: ___________ Primary Phone #: ________________ Alternate Phone #: _____________ E-Mail: ______________________________________ Signature (of Person picking up medication): ______________________________ Printed Name:______________________________ Date: __________

40. First Priority Dispensing Volunteer arrives at POD location with a Family Member who is provided First Priority position. With a completed Patient Registration Form in hand, the Family Member proceeds through the Forms Triage and onto the Medication Dispensing Line.

41. Following The Registration Form -1 • Patient Registration Forms are distributed to all residents by the RA or HOA to be filled out prior to coming to the R-POD. • Resident lists all members of household and possible others for whom medication will be picked up – for a maximum of 15 people. • To minimize traffic flow and congestion, one Family Member drives to clubhouse (the R-POD) and is directed as to where to park.

42. Flow Rate • Determine Weighted Average Number of People listed on Registration Forms • Multiply by Number of Residences to get Estimate of Number of People • To get Flow Rate, divide Number of Residences and Number of People, by Number of Hours POD will be Open

43. Following The Registration Form - 2 • Patient Registration Form is reviewed by aTriage volunteerwho directs resident to one of three lines – Express, Pregnant/ Breast or Children, Special Screening • Family Member receivesinstruction on the medicationto be provided for each member of household • Family Member proceeds to Medication Check-Out line

44. ACUTE SYMPTOMS SCREENING FORM For Anyone Who Presents With 3 Or More Acute Symptoms In Past 7 Days 1. Do you have a RUNNY NOSE? [ ] Yes [ ] No 2a. Have you recently found it DIFFICULT to BREATHE? [ ] Yes (Go To Q. 2b) [ ] No (Skip to Q.3a) 2b. Has it been getting worse? [ ] Yes [ ] No 2c. Do you have COPD? That is, do you have EMPHYSEMA or CHRONIC BRONCHITIS? [ ] Yes [ ] No 3a. Have you recently developed CHEST PAIN? [ ] Yes (Go to Q3b) [ ] No (End) 3b. Has it been getting worse? [ ] Yes [ ] No Summary of Responses (Circle Letters For All that Apply) A. Q.1 is “NO” B. Q.2a, is “YES,” and Q.2b ls “YES,” and Q.2c is “NO” C. Q.3a is “YES,” and Q.3b is “YES” REFER TO PHYSICIAN: Individual is to be advised to call his/her physician IMMEDIATELY, for assessment and evaluation, IF: “A” and “B,” or “B” only “A” and “C,” or “C” only “A” and “B” and “C,” or “B” and “C”. Dispense medication according to plan so that individual has it available for use after consulting with physician. Action Taken: Instructed Head of Household about Assessment and NEED for Consultation with Physician. [ ] Yes [ ] No Individual’s Name_____________________ Interviewer Initials _____ Date ________

45. Following The Registration Form - 3 • Antibiotics for entire household and other listed members/friends are picked up • Each family member’s dose bottle isto belabeled with Name and Date • Family Member exits POD and departs for home. • Family Member carefully dispenses medication to family members based on label

46. All Medication is Labeled with Name of Drug and Dosing DOH Palm Beach County Date and Patient DOH Surgeon General Date: _____ to be added by Patient: ______________________ Head of Household HCD Pharmacies: (561) 209-2575 Each package will contain a 10-day supply of the Named medication, its dosage, and how many times a day it is to be taken. An Anthrax Treatment Information sheet explaining the medication and how is to be taken will be available at Point of Dispensing (POD).

47. Head of Household Prints Date and Patient’s Name on Label Dept. of Health, Palm Beach County Dr. Surgeon General (FL) Date: ________ Patient: ____________________________ HCD Pharmacies: (561) 209-2575

48. Symptoms 3 plus 3 plus Symptoms Evaluation Mental Health well Check Out Exit Line 1 Line starts outside Exit well Line 2 Line 3 Instructions Pregnant or Children Registration Triage Dispensing

49. Antibiotic Dispensing at Point of Dispensing

50. Antibiotics Dispensing at POD • Through-put Summaries to be prepared hourly • Twice day reporting to ESF-8 at EOC, (561) 712-6408