In the unlikely event of a bioterrorism disaster requiring Bay Area counties and
cities to dispense antibiotics to entire populations, it is extremely important
that all Bay Area counties and cities are using the same screening practices.
Mass prophylaxis means providing preventive medications (pre or post
exposure) to the masses – all people in a community, city or county. In the case
of something like anthrax, it is the goal of mass prophylaxis planners to ensure
that the right pills get into people, minimizing adverse events and reactions.
When the governor declares a state of emergency for California, it will trigger
the California Board of Pharmacy lifting restrictions on who can dispense
antibiotics. In an infectious disease emergency like this, anyone can dispense
antibiotics, you don’t have to be licensed. But it’s important that all screening
practices in the Bay Area be the same, that is why health officers from the
entire Bay Area agreed on a screening algorithm. In the algorithm, a series of
questions are asked of patients to dispense the two primary drugs: doxycycline
Doxycycline and ciprofloxacin, also called doxy and cipro for short, are
supplied by the federal government. The federal government manages a large
stockpile of medicines and medical equipment that can be deployed anywhere
in the US in the case of a large-scale disease or medical emergency. This
stockpile is called the Strategic National Stockpile, or SNS. There is currently a
greater percentage of doxy in the SNS than there is of cipro. So, the screening
algorithm is called a “doxy dominant” algorithm, meaning doxycycline will be
antibiotics dispensed to most people. This algorithm is also based on the fact
that the SNS contains very little supply of liquid formulation or “suspension” of
cipro that can be used in small children.
If the ratio of doxy to cipro every flipped, meaning there was more available
ciprofloxacin than doxycycline, a different algorithm would be followed.
If there was a substantial quantity of ciprofloxacin suspension, that would also
result in a different algorithm being followed.
For basic instructional purposes, however, we will assume the antibiotic supply
to be about 80-90% doxycycline and 10-20% ciprofloxacin and we will assume a
very limited amount of liquid ciprofloxacin suspension.
For a patient who arrives at the clinic, the first question asked of them is
whether or not they are allergic to doxycycline or any other drugs that end in
“cycline” such as tetracycline. This question may be asked by the way of
signage or by the way of a screening form, or even in person. Being allergic to
a “cycline” drug means that a medical professional has told the patient that
they are allergic or the patient has experienced a life-threatening reaction in
the past as a result of taking that drug. A patient might be allergic to different
things, like penicillin or sulfa drugs, but being allergic to other things doesn’t
mean they are allergic to doxycycline. Even with other allergies, it is fine to
take doxycycline unless the patient knows they are allergic to a “cycline” drug.
The other question that is asked, is whether the person is pregnant. This
question means that the woman is currently pregnant, not thinking about
becoming pregnant. If the patient doesn’t know, then one should assume that
Patients who are not allergic to doxycycline and who are not pregnant will
receive doxycycline. This should be the vast majority of patients coming to a
POD as it is not common to have an allergy to a “cycline” drug and it is a
usually a minority of women who are pregnant.
Those who are dispensing medicines to patients who are not allergic to cycline
drugs and are not pregnant also need to ask about children. For any child who
is younger than age 18 AND weighs less than 90 pounds, the child will need a
smaller dose of doxycycline. Whoever is picking up for that child will need
crushing instructions too, so they can crush doxycycline at home and combine
it with a sweet tasting substance like chocolate or maple syrup.
If the patient is either allergic to doxycycline or pregnant, then they need to
1. Are they allergic to ciprofloxacin or any other “floxacin” drug? (the
same applies – they are allergic if a doctor has told them they are
allergic, or they have experienced a life-threatening reaction to the drug
2. Do they have a history of seizures or epilepsy?3. Are they currently taking the drug Tizanidine, which could also be known
If the answer to all of these questions is no, then the patient should be given
If the answer to any of these questions is yes, it means that the patient
potentially has issues with taking both doxycycline and ciprofloxacin. This
means that the patient will need to speak with a medical consultant at the
point of dispensing or POD site. Or this patient will need to speak to his/her
own primary care provider to receive an antibiotic that they can safely take.
At medical consultation within a POD site, a clinician will talk to the patient to
determine whether they are truly allergic to a certain antibiotic and they will
talk to the patient and discern if they can leave with one of the offered
antibiotics at the POD, or whether they need a written prescription, to be
taken and filled at a local pharmacy.
The number of patients that will have issues with taking both doxycycline and
It is very uncommon for a young child to be allergic to doxycycline, but
screeners at PODs must be prepared for this possibility. For a child who cannot
take doxy, the medical consultant associated with the POD would make the
Caregivers cannot be given instructions on how to crush ciprofloxacin for their
children and combine it with other things, because no matter how people try to
mask the taste of ciprofloxacin, it is unbearable. Crushed cipro can also induce
The methods for asking screening questions will vary by POD. Some PODs will
use individual screening forms for each person who will be receiving
antibiotics, some will use forms that can accommodate multiple people on one
form, others may use signs and not use a form for some of the questions at all.
Any staff that are tasked with working at a POD will not know the particular
method of screening until they arrive, but all Bay Area PODs will be asking the
1) Are you or the person for whom you are picking up antibiotics allergic to
2) Are you or the person for whom you are picking up antibiotics pregnant?
If the answer to both of these questions is no, the patient receives doxycycline.
If the patient cannot swallow pills, they will need pill crushing instructions for
If the answer to either of these questions is yes, the patient gets asked three
1) Are you or the person for whom you are picking up antibiotics allergic to
2) Do you or the person for whom you are picking up antibiotics have a
3) Are you or the person for whom you are picking up antibiotics currently
taking Tizanidine (also called Zanaflex).
If the answer to all of these questions is no, the patient receives ciprofloxacin.
If the answer to any of these questions is yes, the patient is referred to
medical consultation to have a conversation with a clinician.
All patients receiving antibiotics should also receive information about the
drugs they will be taking – and all children under age 18 and under 90 pounds
will need to have a smaller dose of doxycycline. For patients who have
questions about how the antibiotics will interact with other drugs or vitamins
they might already be taking, or other medical conditions that they may have,
it is important to refer them to the drug information sheets.
Following these steps ensures consistency and quality all throughout the Bay
Area, which keeps our population well protected and informed.
Visuals on this will include screening forms, drug information sheets, a graphic
of the algorithm itself, pictures of people getting screened, crushing
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