Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
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Chapter 5. Recommendations
In reviewing disaster scenarios for expected community needs, it becomes
clear that we must help the public make informed decisions and care for themselves
during severe health events. It is only with such strategies that we can
hope to alleviate many potential demands on health care delivery systems
and to accommodate those most in need. Assisting community health call centers
to develop certain response capabilities is a part of that overall strategy.
By employing the scenario-specific models and tools in this report, health
call centers can increase their ability to support the following areas:
- Health information.
- Disease surveillance.
- Triage/decision support.
- Quarantine and isolation support/monitoring.
- Outpatient drug information/adverse event reporting.
- Mental health support/referral.
As this report has illustrated, four of the Department of Homeland Security
National Planning Scenarios afford the best opportunity to involve
most of the potential response capabilities for community health
- Biological attack—aerosol anthrax.
- Biological disease outbreak—pandemic influenza.
- Biological attack—plague.
- Biological attack—food contamination.
This does not imply that health call centers could not play an important
role in responses to other scenarios; rather, that developing tools related
to the response needs of these four biological scenarios affords the greatest
potential for success.
Poison control centers, nurse advice lines, drug information centers, health
agency hotlines and local/State/Federal public health agencies were chosen
as target audiences for the proposed scenario-specific models and applications
because they are familiar with basic physiological responses to particular
health threats due to the knowledge and skills gained in their area of health
care. The professionals employed by such centers have experience in assessing
patient status, problem-solving, and working with symptomatic patients over
During any health emergency, these centers could continue to provide
regular services while expanding services to provide information and support
related to the event. Much of the expansion of services could be handled
with nonclinical staff. In this way, these centers could help with surge
capacity and informing the public about health issues so that they can make
informed decisions and care for themselves.
It seems wise to build on the expertise, credibility, and infrastructure
of community health call centers when planning for emergency responses. Expanding
their capabilities to inform, educate, and assist the public with their health
concerns can free the health care delivery system to most effectively use
their limited resources to provide care to those most in need. This approach
can especially aid in handling those at low risk for injury or illness, who
may have valid fears and concerns that, without a mechanism to get information,
could lead them to overtaxed hospitals and health departments.
This does not guarantee compliance with official recommendations, but it
should help the public to understand the risks or consequences of their choices.
However, call centers that are embedded in the community and familiar to
the public should be well received when providing support during a health
Call centers attempting to provide the community services described here
should do so in cooperation with the public health authority that, by statute,
is responsible for coordinating health and medical services in response to
public health and medical care needs following a major disaster or emergency,
or during a developing potential medical situation. This coordination with
the public health authority will help to ensure consistency with other response
The model and tools proposed in this report should be used as part of a comprehensive
public information strategy that includes the use of:
- Mass media to provide the public with information on preventive measures,
home care management, and the appropriate time to seek health care services.
- Community health call centers to reinforce mass messaging and to provide
additional and more tailored information to individuals with questions
and concerns, as well as to review these issues for their value as potential
mass media messages.
- Community health call centers to assist with outpatient (home care)
monitoring and support, thereby helping to extend the reach of public
health and health care systems into households.
- Information collected by the call centers for situational awareness
and disease outbreak management and control.
In an emergency, the public may view hospitals as "safe havens"—places
to go for food, shelter, protection, and medical attention. However, particularly
in the event of a transmissible infectious disease in which hospitalized
patients represent the sickest patients in the community, the concept of
hospitals as "safe havens" may not be applicable. It may become
more advantageous to manage and support the public in their homes with the
assistance of health call centers. Community response planners will need
to reinforce the concept of the home as a "safe haven" in their
risk communication strategies and develop measures to support this concept
in all aspects of their planning efforts. The possibility that some rudimentary
degree of medical care will need to be delivered in the home setting should
be included in public preparedness and education campaigns.
Integration With Current Programs
The concept of using community health call centers, the proposed model,
and the IR applications fits well within programs and initiatives at the
State and Federal levels. Such response resources can easily fit within the
National Incident Management System (NIMS) that provides a consistent nationwide
template to enable all government, private-sector, and nongovernmental organizations
to work together during domestic incidents.
By working within the NIMS framework and coordinating with local authorities,
health call centers can ensure that the public receives accurate, coordinated
information, helping to decrease panic and calls to emergency management.
In the same manner, call centers can participate in ongoing operations, such
as quarantine and isolation management or Strategic National Stockpile support,
as part of the multi-agency coordination system, a combination of facilities,
equipment, personnel, procedures, and communications integrated into a common
framework for coordinating and supporting incident management.
Federal and State Governments have set forth several requirements to be
prepared for a disaster, including pandemic influenza. In Homeland Security
Presidential Directive 8: National Preparedness, there are 36 essential capabilities
on the Target Capabilities List (TCL) that various levels of government should
develop and maintain.31
Among those TCLs is the requirement to strengthen medical surge and mass prophylaxis
capabilities. Included in the National Preparedness Goal is supporting medical target
capabilities for medical surge, such as isolation and
proposed model and IR applications provide support for these efforts by allowing
residents to identify and locate their point of dispensing (POD) location for mass
prophylaxis and providing a mechanism to track and monitor patients in isolation
and quarantine in order to assist public health agencies.
The State of Colorado, like many others, has a quarantine and isolation
component in its pandemic influenza plan. The Pandemic Influenza Annex to
the Colorado Department of Public Health and Environment Internal Emergency
Response Implementation Plan gives the authority to isolate or quarantine
persons, groups of people, or buildings in Colorado, and at the recommendation
of the Governor's Expert Emergency Epidemic Response Committee, to
limit or close public gatherings and restrict the movement of people.
strategies range from those affecting individuals (e.g., isolation of patients)
to measures that affect groups or entire communities (e.g., monitoring of
contacts, cancellation of public gatherings). Guided by the current epidemiological
data, State and local public health officials will implement the most appropriate
of these measures to maximize the impact on influenza transmission and to
minimize the impact on individual freedom of movement. The HELP program is
included in the plan as a means to gather surveillance data for situational
awareness and to support efforts to monitor those individuals placed in isolation
or quarantine. Using the proposed IR applications will aid in providing this
Public Health Communications
The National Association of County and City Health Officials has some timely
recommendations to prepare for pandemic influenza. First is to engage the
community and bring all stakeholders together in a way that makes sense.
An essential piece to preparing any community for a public health emergency
is involving stakeholders in the planning. Community members need to be heard,
and if they feel that their views are not only being considered but also
incorporated into the planning process, they will be more likely to support
whatever plan is created. Second is to empower people to do their own planning.
Third is to establish excellent lines of communication, the key to education
about and awareness of any public health issue. These recommendations support
the concept of health call centers and their use of IR technology to communicate
with the public:
"Dissemination and sharing of timely and accurate information with
the health care community, the media, and the general public will be one
of the most important facets of the pandemic response. Advising the public
in actions they can take to minimize their risk of exposure or actions
to take if they have been exposed, will reduce the spread of the pandemic
and may also serve to reduce panic and unnecessary demands on vital services."33
The National Governors Association also stresses the importance of public
communications in order to build a trusted relationship with the response
community and enhance the public's understanding of pandemic influenza.
Responses to pandemic influenza must provide for effective communication
to the public to minimize negative behaviors, accentuate positive actions,
and limit the psychosocial and psychological impact of imposing public health
measures that include movement restrictions. These messages should be developed
and trained and trusted messengers should be selected now.34 For this reason,
established and community-embedded health call centers are a good fit to
partner with public health agencies to provide such communications.
A major goal of public health education messages is to ensure that the public
has the knowledge to protect itself. Prevention and infection control are
the first line of defense, but there are other education topics as well.
Dispelling rumors keeps the public properly informed and less prone to panic
because of misinformation. Public health authorities have the responsibility
to explain the rationale behind disease control measures, to explain why
these measures are necessary, and to ensure that information is current and
that messages do not contradict one another.35 Health call centers
can partner with public health agencies to relay such information to the
public in a consistent, accurate, and up-to-date manner.
In "Components of Effective Disaster Public Education and Information,"
(December 2005) a working group of the Emergency Management Accreditation Program emphasizes
the correlation between effective public education and coordinated, effective
disaster response and recovery outcomes. The report outlines steps for creating
comprehensive and understandable public education messages so that residents
can be better informed and better prepared. The report notes that, "Federal
and State Governments must support local capabilities to provide effective
public education and information through continuity of authority, emphasis,
message, and language, as local and State public education and information
have a direct impact on successful outcomes in a
disaster."36 It is
such local capabilities that health call centers have to offer the governments
and communities they serve.
Blendon et al. reported that most Americans favor the use of quarantine
as a weapon against contagious diseases like SARS and pandemic influenza
but are far less comfortable with strict enforcement and monitoring measures.
While 76 percent of Americans surveyed said that they favor quarantining
those potentially exposed to serious contagious diseases, only 42 percent
supported a compulsory quarantine under which those who refused to comply
could be arrested. However, 75 percent of those surveyed would favor periodic
telephone calls to monitor those in
suggests that a quarantine strategy using a health call center and a tool such
as the QI Monitoring Application would be favorable to most Americans and likely
to experience good compliance.
The HELP model, which has become established in the community and is used
on a daily basis, can be a resource for times of disaster, giving people
the risk-based messages that include how to care for themselves and their
families in order to mitigate a threat. The various call flows are designed
to give reassurance as well as direction and information on the appropriate
response measures. Such information can substantially change the behavior
of the caller.
Our report on the Denver Health NurseLine demonstrated that
70 percent of patients complied with nurse advice line recommendations, though
the same percentage had a different plan for their health care prior to
who called were already aware of a need for information and were receptive
to changing their behavior based on the information they received. It is
not unlikely that the same behavioral changes would be seen in an emergency
situation with persons contacting a health call center and perhaps even those
receiving information via an IR system.
Special Needs Populations
Special needs populations will need customized forms of contact during an
emergency. The proposed IR applications take into consideration some special
needs communities, in particular the Spanish-speaking population. By developing
most of the IR applications to accommodate both English and Spanish, a majority
of callers will have the option to use such strategies to get information
on the disaster. Depending on a community's demographics, it may want
to offer additional language options for callers.
Planners will need to determine
if there will be sufficient demand to have announcements recorded in a particular
language or to have those callers speak with a staff person using a translation
service. The vision impaired will also likely find it easy to retrieve information
via their telephone rather than from printed materials or the Internet. Many
call centers have relied on TTY/TDD technology to communicate with the hearing
impaired, though text messaging and e-mail communications are becoming more
prevalent. The IR applications do not support TTY/TDD, and those callers
would need to interact with a staff person to get information. The use of
toll-free numbers should enable those without a phone in their home, a cell
phone, or without even their own residence to call from any public phone
at no cost.
Volunteer Use in Call Centers
Volunteers can assist health call centers in responding to public inquiry.
The volunteers would need to have a vested interested in the community and
be able to think on their feet, work under pressure, and answer the questions.
To find these individuals, a call center can look to established volunteer
groups, church organizations, or recognized nongovernment organizations like
the Salvation Army or the American Red Cross. Planners who choose to use
health care workers to staff a call center may want to look for volunteers
through the Health Resources Services Administration (HRSA) Emergency Systems
for Advance Registration of Volunteer Health Professionals program that each
State is developing. An important caveat made by HRSA is that these individuals
will need to identify themselves to callers as volunteers helping the
When using volunteers in a call center, it is best to be aware of the legal
implications of volunteer use in a disaster situation. Good Samaritan statutes
are laws enacted by various States that protect health care providers and
other rescuers from being sued when they are giving emergency help to a victim.
The rescuer has to use reasonable, prudent guidelines for care during the
response. Under such laws, the assistance must be voluntary, the person receiving
the help must not object to being helped, and the rescuer's actions must be a
good-faith effort to help.38
The Federal Volunteer Protection Act provides that no volunteer of a nonprofit
organization or governmental entity shall be liable for harm caused by an
act or omission of the volunteer on behalf of the organization or entity
if the volunteer meets certain requirements.39 It is very important to note
that this Federal law preempts State laws to the extent that such laws are
inconsistent, except that it does not preempt any State law that provides
additional protection from liability relating to volunteers or to any category
of volunteers in the performance of services for a nonprofit organization
or government entity. Health call centers that use volunteers should contact
their legal counsel to ensure that their use is in compliance with applicable
laws, that volunteers are covered under their liability insurance for such
use, and that volunteers are properly trained for such activities.
Public Information Partnerships
Public information partnerships between health call centers and public health
agencies prove that together they can meet the expected needs of communities
during health emergencies including: improving information support and surge
capacity, expanding surveillance signals, and collecting data for situational
awareness. These partnerships help meet the new demands on public health
agencies, increasing their response capabilities and access outside of the
9:00 a.m. to 5:00 p.m. work day, handling rapidly evolving information while
maintaining control, and enabling members of the public to care for
themselves and their families by supplying the information to help them make
The need for such partnerships will remain constant or potentially increase,
since public health events will continue to occur. These events will require
effective, structured, and coordinated systems for providing public information
and support as part of the response. The HELP model has been proven to be
a cost-effective, efficient, reliable, and adaptable component of Colorado's
readiness response model for any public health emergency. The HELP model
offers the promise for similar response capabilities for other community
health call centers working in partnership with their public health agencies.
These community resources will likely have robust infrastructure to serve
as strong platforms that can incorporate the proposed tools and adapt them
Model Utility and Adaptability
This model and the IR applications were applied locally and statewide, but
they could potentially be adapted for interstate and Federal use. There may
be legal risk implications for clinical personnel using decision support
and triage strategies across State lines. The National Council of State Boards
of Nursing (www.ncsbn.org) is working to secure mutual recognition of nurse
licensure across States that may help with this issue. However,
a larger issue concerns the coordination of messages across various levels
of government to ensure consistency and public trust. It may be difficult
for public health and safety agencies across all levels of government to
agree on specific strategies and develop unified messages. It may be easier
to develop response resources such as the HELP model and IR applications
on a statewide or smaller scale to avoid the difficulties in regional and
national coordination. Planners at various levels of government should consider
this challenge in their planned application of such resources.
The model and applications that we have developed are largely informational in nature
and can be delivered easily with trained nonclinicians or can be automated.
However, the applications should all be employed with sufficient back-up
support such as the HELP platform so that users can always get the proper
In our experience, it has been valuable to have systems and processes that
can be adjusted to the changing needs of emerging public health events.
This has included the ability to:
- Rapidly change FAQ content and public health messages.
- Handle surge responses through a variety of mechanisms
- Using recordings/announcements
- Using an interactive response system with interactive response applications
- Partnering with media to deliver information
- Having trained ancillary staff.
- Learn from experiences.
Some of the lessons learned from more than 3 years of operating the HELP
- Call volume is driven by the event and media attention—anticipate
call volume surges related to morning, afternoon, and evening news broadcasts.
- Media organizations are willing to assist with disseminating information,
including hotline numbers regularly displayed in television news crawlers.
- Adaptation to include the latest local and State health department
messages is necessary to meet both public health and public needs.
- Surveillance, though not an intended purpose of the program, became
an important function due to the utility of structured data collection
(situational awareness) and the ability to identify emerging issues (sentinel
Operating a public informational resource requires the ongoing need to adapt,
reassess, and improve. There always will be further challenges to address:
- Testing the IR applications in various community groups (non-English
speakers, seniors) and determining if there are any issues with their
- Improving public messages and FAQ information content.
- Determining other information and tools for meeting the needs of health
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