EMSPandemic

InfluenzaGuidelines

forStatewide

Adoption

U.S.DepartmentofTransportation

May3,2007

Task6.1.13.6

NationalStrategyforPandemicInfluenza:

ImplementationPlan

TABLE OF CONTENTS 

FOREWORD ...................................................................................................................1

AN OVERVIEW OF THE EMS PLANNING ASSUMPTIONS AND GUIDELINES 3

Introduction .............................................................................................................................................................. 3

EMS Pandemic Influenza Planning Assumptions .................................................................................................... 3

EMS Pandemic Influenza Guidelines for Statewide Adoption................................................................................. 5

Figure 1: Sample Call Flow for Standard EMD Calls vs. Pandemic Flu Calls......................................................... 8

Figure 2: Sample Pandemic Influenza EMS Dispatch Protocol ............................................................................... 9

Figure 3: Sample Pandemic Influenza EMS Operating Protocols.......................................................................... 10

INTRODUCTION AND BACKGROUND .......................................................................11

Purpose ................................................................................................................................................................... 11

How the document was developed ......................................................................................................................... 11

Pandemic Influenza – Overview............................................................................................................................. 12

Influenza – What is it and how is it transmitted?.................................................................................................... 13

Likelihood of an Influenza Pandemic..................................................................................................................... 14

Global Perspective.................................................................................................................................................. 14

Potential Impacts of an Influenza Pandemic........................................................................................................... 15

Pandemic Influenza Phases..................................................................................................................................... 16

Federal Disease Containment Strategies................................................................................................................. 21

Federal Planning Assumptions ............................................................................................................................... 22

Federal Preparedness Documents ........................................................................................................................... 24

SECTION 1 – EMS PLANNING 26

Guideline 1.1 – Plans and Operational Procedures................................................................................................ 26

Rationale................................................................................................................................................................. 26

Considerations ........................................................................................................................................................ 26

Background............................................................................................................................................................. 26

Guideline 1.2 – Leadership and Authority.............................................................................................................. 27

Rationale................................................................................................................................................................. 27

Considerations ........................................................................................................................................................ 27

Background............................................................................................................................................................. 27

Guideline 1.3 – Training and Exercising ................................................................................................................. 29

Rationale................................................................................................................................................................. 29

Considerations ........................................................................................................................................................ 29

Background............................................................................................................................................................. 29

Guideline 1.4 – A Systems Approach....................................................................................................................... 30

Rationale................................................................................................................................................................. 30

Considerations ........................................................................................................................................................ 30

Background............................................................................................................................................................. 30

Guideline 1.5 – Public and Media Communications .............................................................................................. 32

Rationale................................................................................................................................................................. 32

Considerations ........................................................................................................................................................ 32

Background............................................................................................................................................................. 32

iii 
SECTION 2 - THE ROLE OF EMS IN INFLUENZA SURVEILLANCE AND MITIGATION

.......................................................................................................................................34

Guideline 2.1 – EMS Role in Surveillance............................................................................................................... 34

Rationale................................................................................................................................................................. 34

Considerations ........................................................................................................................................................ 34

Background............................................................................................................................................................. 35

Guideline 2.2 – Statewide Tracking System............................................................................................................ 37

Rationale................................................................................................................................................................. 37

Considerations ........................................................................................................................................................ 37

Background............................................................................................................................................................. 37

Guideline 2.3 – EMS and Community Mitigation .................................................................................................. 40

Rationale................................................................................................................................................................. 40

Considerations ........................................................................................................................................................ 40

Background............................................................................................................................................................. 41

SECTION 3 – MAINTAINING CONTINUITY OF EMS OPERATIONS DURING AN 

INFLUENZA PANDEMIC ..............................................................................................45

Guideline 3.1 – Maintaining the Day-to-Day Response.......................................................................................... 45

Rationale................................................................................................................................................................. 45

Considerations ........................................................................................................................................................ 45

Background............................................................................................................................................................. 46

Guideline 3.2 – Continuity of Operations Plan....................................................................................................... 48

Rationale................................................................................................................................................................. 48

Considerations ........................................................................................................................................................ 48

Background............................................................................................................................................................. 48

Guideline 3.3 – Workforce Augmentation............................................................................................................... 50

Rationale................................................................................................................................................................. 50

Considerations ........................................................................................................................................................ 50

Background............................................................................................................................................................. 51

Guideline 3.4 – Disruption of Equipment, Supplies and Services ......................................................................... 52

Rationale................................................................................................................................................................. 52

Considerations,,....................................................................................................................................................... 52

Background............................................................................................................................................................. 53

Guideline 3.5 - Interoperable Communications..................................................................................................... 54

Rationale................................................................................................................................................................. 54

Considerations ........................................................................................................................................................ 54

Background............................................................................................................................................................. 54

Guideline 3.6 – Compatible Communications Equipment and Communications Frequencies.......................... 56

Rationale................................................................................................................................................................. 56

Considerations ........................................................................................................................................................ 56

Background............................................................................................................................................................. 56

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SECTION 4 - LEGAL AUTHORITY...............................................................................58

Guideline 4.1 – Deviation from Established Procedures........................................................................................ 58

Rationale................................................................................................................................................................. 58

Considerations ........................................................................................................................................................ 58

Background – Scope of Practice............................................................................................................................. 59

Background – Other legal issues ............................................................................................................................ 60

Guideline 4.2 – EMS Freedom of Movement .......................................................................................................... 62

Rationale................................................................................................................................................................. 62

Considerations ........................................................................................................................................................ 62

Background............................................................................................................................................................. 62

SECTION 5 - CLINICAL STANDARDS AND TREATMENT PROTOCOLS .................63

Guideline 5.1 – EMS Medical Direction .................................................................................................................. 63

Rationale................................................................................................................................................................. 63

Considerations ........................................................................................................................................................ 63

Background............................................................................................................................................................. 63

Guideline 5.2 – Modification of Treatment and Triage Protocols......................................................................... 65

Rationale................................................................................................................................................................. 65

Considerations ........................................................................................................................................................ 65

Background............................................................................................................................................................. 66

Guideline 5.3 – Rapid Distribution of New Protocols............................................................................................. 67

Rationale................................................................................................................................................................. 67

Considerations ........................................................................................................................................................ 67

Background............................................................................................................................................................. 67

Guideline 5.4 – Just-in-Time Training .................................................................................................................... 69

Rationale................................................................................................................................................................. 69

Considerations ........................................................................................................................................................ 69

Background............................................................................................................................................................. 69

Guideline 5.5 – Fatality Management...................................................................................................................... 71

Rationale................................................................................................................................................................. 71

Considerations ........................................................................................................................................................ 71

Background............................................................................................................................................................. 71

Guideline 5.6 – EMS Treat and Release .................................................................................................................. 73

Rationale................................................................................................................................................................. 73

Considerations ........................................................................................................................................................ 73

Background............................................................................................................................................................. 73

SECTION 6 - EMS WORKFORCE PROTECTION........................................................75

Guideline 6.1 – Protection of EMS and 9-1-1 Workforce and Families................................................................ 75

Rationale................................................................................................................................................................. 75

Considerations ........................................................................................................................................................ 75

Background............................................................................................................................................................. 76

Guideline 6.2 – Infection Control and Decontamination ....................................................................................... 78

v 
Rationale................................................................................................................................................................. 78

Considerations ........................................................................................................................................................ 78

Background............................................................................................................................................................. 79

Guideline 6.3 – Vaccines and Anti-Virals for EMS Personnel .............................................................................. 81

Rationale................................................................................................................................................................. 81

Considerations ........................................................................................................................................................ 81

Background............................................................................................................................................................. 81

Guideline 6.4 – Isolation and Quarantine Considerations..................................................................................... 83

Rationale................................................................................................................................................................. 83

Considerations ........................................................................................................................................................ 83

Background............................................................................................................................................................. 83

Guideline 6.5 – Support for EMS Personnel and Their Families.......................................................................... 85

Rationale................................................................................................................................................................. 85

Considerations ........................................................................................................................................................ 85

Background............................................................................................................................................................. 85

Appendix A - Glossary of Terms.............................................................................................................................. 87

Appendix B - EMS and Non-Emergent (Medical) Transport Organizations Pandemic Influenza Planning 

Appendix H - Excerpt from the White Paper on Scene Operations, to Include Identification, Medico-legal 

Investigation Protocols and Command and Control of Mass Fatalities Resulting from a Pandemic Influenza 

Checklist..................................................................................................................................................................... 98

Appendix C – Excerpt from National Response Plan, Emergency Support Function #8 ................................. 103

Appendix D – Sample TIIDE Fact Sheet ............................................................................................................... 105

Appendix E – Excerpt from Model State Emergency Health Powers Act.......................................................... 107

Appendix F – Colorado Executive Orders ............................................................................................................ 109

Appendix G – Excerpt from Altered Standards of Care in Mass Casualty Events........................................... 112

(PI) in the United States.......................................................................................................................................... 115

Appendix I - National Incident Management System (NIMS) Training Requirements................................... 120

Appendix J - Excerpts from the HHS Pandemic Influenza Plan, Appendix D.................................................. 121

Appendix K – Infection Control: Excerpts from Federal Documents ................................................................ 126

Appendix L - Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient-Care Areas ....... 136

Appendix M - Pandemic Influenza Resources ...................................................................................................... 140

Appendix N - Continuity of Operations Program Elements................................................................................ 148

Appendix O - Special Needs Patients................................................................................................................. 156

Appendix P – Other Legal and Regulatory Issues................................................................................................ 158

Appendix Q – OSHA Guidance.............................................................................................................................. 160

vi 
Appendix R – Suggested 9-1-1 & EMS Activities/Readiness Steps Based on Different Phases of Pandemic 

Influenza................................................................................................................................................................... 162 

Appendix S – Participating Organizations and Representatives ........................................................................ 167

vii 
viii
FOREWORD 

An influenza pandemic could seriously impact the Nation – its health care delivery system, its 

transportation system, its economy and its social structure. As the Nation’s health care “safety 

net,” emergency medical services (EMS) will be faced with higher demands for services while 

experiencing problems similar to the rest of the Nation – increased employee absenteeism, 

disruption of supply chains and increased rates of illness and death. 9-1-1 Public Safety Answering 

Points (PSAPs) serve as the public’s single point of access to EMS, law enforcement and fire 

services – as well as an avenue for requesting many other services. Ensuring both 9-1-1 and EMS 

are well-integrated into the Nation’s pandemic influenza planning and response is essential to the 

Nation’s health and safety in the event of a pandemic. 

The National Strategy for Pandemic Influenza: Implementation Plan (May 2006) directed the 

Department of Transportation, in cooperation with its Federal partners, to develop statewide EMS 

pandemic influenza guidelines, as well as model protocols for 9-1-1 call centers and PSAPs. With 

its long-standing commitment to improving the Nation’s EMS system and sharing responsibility 

with the National Telecommunications Information Administration (NTIA) for the National E9-1­

1 office, the National Highway Traffic Safety Administration (NHTSA) was delegated 

responsibility for both tasks. 

From the outset, the need for joint development of the EMS guidelines and the 9-1-1 protocols was 

clear. 9-1-1 call taking and dispatching must be coordinated with the EMS response system and 

with public health officials. EMS response is dependent on 9-1-1 and upon public health 

coordination. Consistency of both messaging and response is essential. 

Two stakeholder meetings were convened by the National Association of State EMS Officials 

(NASEMSO) to address the tasks and to solicit stakeholder guidance. The meetings were attended 

by a wide variety of national stakeholder organizations within the EMS, 9-1-1 and public health 

communities and by Federal agencies. 

The dialogue among participants was robust and valuable. Their interactions, advice, and insights 

resulted in two excellent documents. Although the format of each document is slightly different, 

the stakeholders worked hard to ensure that the two are closely related and interconnected. It is 

recommended that both documents, “EMS Pandemic Influenza Guidelines for Statewide 

Adoption” and “Preparing for Pandemic Influenza: Recommendations for Protocol Development 

for 9-1-1 Personnel and Public Safety Answering Points (PSAPs),” be reviewed together. 

The audience for both documents is statewide EMS agencies, statewide 9-1-1 managers, local 

EMS agencies, 9-1-1 Public Safety Answering Point managers and other key stakeholders who 

could assist these agencies in the event of an influenza pandemic. Both documents are intended to 

provide guidance to State and local agencies in developing their pandemic influenza plans and 

operational protocols. Given the unique configuration of systems and local resources, it was not 

feasible to develop detailed national operational protocols for EMS or for 9-1-1. However, a 

sample 9-1-1 call flow sheet, integrated with the EMS system, is provided as well as sample 

protocols (inter-related) for both EMS and for 9-1-1. 

1
The documents can be used to provide a framework for pandemic influenza planning. They 

provide general guidance, considerations, references and ideas that can enhance the optimal 

delivery of emergency care and 9-1-1 services during an influenza pandemic. In the process of 

preparing these documents, stakeholders noted an important additional benefit that PSAPs and 

EMS agencies can take from the effort of getting ready for pandemic influenza: The collaboration 

with pubic health can be a catalyst and model for other community initiatives for everyday 

operations, as well as disaster planning. 

2
AN OVERVIEW OF THE EMS PLANNING ASSUMPTIONS 

AND GUIDELINES 

Introduction 

While this document provides broad-based Pandemic Influenza Guidelines for consideration by 

State and local emergency medical services agencies, the specifics of pandemic influenza 

preparation and response are unique to the configuration and resources of each State EMS system 

and local EMS agency. 

The EMS Pandemic Influenza Planning Assumptions provide the basic underpinnings of the 

recommended guidelines. Each of the guidelines is presented in this section; the remainder of the 

document provides detailed information about each guideline including the rationale, 

considerations and pertinent background material. 

Coordination among the 9-1-1 Public Safety Answering Point, the Emergency Medical Services 

System and the Public Health System is of paramount importance. The Sample Call Flow for 

Standard EMD Calls vs. Pandemic Flu Calls (Figure 1) illustrates a sample call flow decision to 

be made in a period of pandemic influenza vs. an agency’s regular day-to-day operation; 

coordination between EMS and 9-1-1 is essential to system operation. The Sample Pandemic 

Influenza EMS Dispatch Protocol (Figure 2) shows examples of modified EMS and 9-1-1 system 

response plans based on the CDC’s Pandemic Severity Index - again demonstrating the need for 

close coordination between 9-1-1 and EMS. The Sample Pandemic Influenza EMS Operating 

Protocol (Figure 3) demonstrates the potential need for EMS protocol modifications, and also 

utilizes the Pandemic Severity Index for planning. Each of these is a sample only and is intended 

to demonstrate the need for systems coordination and the difference in “conceptual thinking” 

necessitated by a potential influenza pandemic. State EMS agencies and local EMS and 9-1-1 

systems should adopt protocols and response plans unique to their specific resources and 

circumstances. 

EMS Pandemic Influenza Planning Assumptions 

The following assumptions are the basis for the EMS Pandemic Influenza Planning Guidelines: 

1. State, local, tribal, and territorial EMS agencies should integrate pandemic influenza 

surveillance, mitigation and response into their EMS system. An EMS system’s 

response to pandemic influenza should be flexible, scaleable, dynamic and timely with 

the ability to change rapidly based on new information about the virus and other public 

health emergencies. Standards, protocols and other guidelines will be modified based 

on the specific threat to the public’s health. 

2. EMS must be “at the table” to provide leadership during planning of State and 

community pandemic influenza surveillance, mitigation and response. EMS must be a 

part of community-wide planning and exercises. 

3
3. The principles of EMS systems are essential to pandemic influenza planning and 

response and should include medical direction, quality improvement, education, 

training, communications, coordination and appropriate supplies and personal 

protective equipment. Sufficient legal authority must be in place while still allowing 

the system to be responsive to the exigencies of the situation. 

4. EMS is one component of a coordinated system response to an influenza pandemic 

involving 9-1-1, public health, public safety, emergency management, health care and 

others. 

5. One solution or protocol may not be applicable for all EMS systems at a State or a local 

level. It is impossible to establish one set of protocols/procedures that works for every 

single jurisdiction. 

6. Optimal patient outcomes will depend on an EMS system’s pre-planned ability to 

quickly integrate emerging medical research/information. The effectiveness of patient 

care will require responsive medical direction, training and coordinated system 

oversight. 

7. EMS and 9-1-1 stakeholders must be integrated into the Incident Command System and 

be fully engaged as collaborative partners in the response to pandemic influenza. 

Pandemic influenza mitigation and response may require the integration of disciplines 

not traditionally involved in incident mitigation and response, such as medical 

direction, EMS education, disease surveillance and 9-1-1. 

8. EMS providers can play a role in pandemic influenza mitigation due to their capability 

to rapidly respond, assess, treat and report patients with signs and symptoms of 

pandemic influenza. Their early involvement in community mitigation strategies such 

as Targeted Layered Containment may help to control the spread of the virus and 

reduce the subsequent use of health care resources. 

9. EMS pandemic influenza plans should address all patient populations including 

children, the elderly, and those with special needs. (See Appendix O) 

4
EMS Pandemic Influenza Guidelines for Statewide Adoption 

The guidelines below are listed for quick reference. However, each are expanded upon more fully 

in the following pages and are accompanied by a rationale, considerations, and supporting 

background to provide additional assistance to EMS pandemic influenza planners. 

Section 1: EMS Planning 

1.1 State, local, tribal, and territorial EMS agencies should adopt EMS pandemic influenza 

plans and operational procedures that define the role of EMS in preparing for, mitigating 

and responding to pandemic influenza. 

1.2 State, local, tribal, and territorial pandemic influenza plans and operational procedures 

should identify leadership and authority that are consistent with the National Response 

Plan and the National Incident Management System, including the Incident Command 

System, and be carefully coordinated with local emergency management plans. 

1.3 EMS pandemic influenza plans should establish a program of pre-pandemic training and 

exercising to prepare EMS personnel for their role in the local pandemic influenza plan. 

1.4 State, local, tribal and territorial EMS agencies, in coordination with Federal, State and 

local public health, 9-1-1, emergency management and health care officials should ensure 

that EMS pandemic influenza plans define a process for gathering and developing updated 

pandemic influenza information, including clinical standards, treatment protocols and justin-time training and disseminate it to local EMS medical directors and EMS agencies. 

1.5 State, local, tribal, and territorial EMS and 9-1-1 agencies should define a public and media 

communications plan that is coordinated with the Incident Command System and public 

health officials to assure consistent education and instructions to the public. 

Section 2: The Role of EMS in Influenza Surveillance and Mitigation 

2.1 State, local, tribal, and territorial EMS pandemic influenza plans should identify the role 

that EMS agencies should play in ongoing disease surveillance. 

2.2 State EMS pandemic influenza plans should establish or identify a statewide system that 

tracks: a) patient location, b) healthcare facility availability, and c) patient disposition to 

allow public health and epidemiologic analysis. 

2.3 State, local, tribal, and territorial EMS agencies, in coordination with public health 

authorities and consistent with resources, legal authority and education, should define 

procedures for involving EMS providers in pandemic influenza community mitigation 

strategies, including Targeted Layered Containment. 

5
Section 3: Maintaining Continuity of EMS Operations During an Influenza Pandemic 

3.1 As part of a systematic all-hazards approach to EMS pandemic influenza planning, State, 

local, tribal, and territorial EMS agencies should have plans in place that allow EMS to 

maintain its response to day-to-day emergencies while addressing the demands of 

pandemic influenza mitigation. 

3.2 State, local, tribal, and territorial EMS pandemic influenza plans should include a 

continuity of operations (COOP) plan that ensures essential functions and vital services can 

be performed during an influenza pandemic or other major public health emergency. 

3.3 State, local, tribal, and territorial EMS agencies should have backup plans to augment the 

EMS workforce. 

3.4 EMS agencies should plan for disruptions in the availability of equipment, supplies 

and services. 

3.5 State, local, tribal, and territorial EMS pandemic influenza plans should include effective, 

reliable interoperable communications systems among EMS, 9-1-1, emergency 

management, public safety, public health and health care agencies. 

3.6 EMS pandemic influenza plans should include compatible communications equipment and 

communications radio frequency plans for common hospital diversion and bed capacity 

situational awareness at the local, State and regional level. 

Section 4: Legal Authority 

4.1 State EMS pandemic influenza plans should establish procedures for EMS providers to 

deviate legally from their established treatment procedures to support mitigation of and 

response to pandemic influenza and other public health emergencies while still assuring 

appropriate education, medical oversight and quality assurance. 

4.2 State EMS pandemic influenza plans should, in coordination with public health, emergency 

management, and law enforcement agencies, identify mechanisms to ensure freedom of 

movement of EMS assets (vehicles, personnel, etc.) when faced with restricted travel laws, 

isolation/quarantine or security measures. 

Section 5: Clinical Standards and Treatment Protocols 

5.1 Each State, local, tribal, and territorial EMS system should have an EMS medical director 

to provide medical oversight of EMS pandemic influenza planning, mitigation and 

response. 

5.2 State, local, tribal and territorial EMS pandemic influenza plans should define mechanisms 

for rapid development, adoption or modification of prehospital clinical standards and triage 

and treatment protocols before or during an influenza pandemic that are based upon the 

most recent scientific information. 

6
5.3 State, local, tribal, and territorial EMS pandemic influenza plans should define consistent, 

system-wide procedures for the rapid distribution of new or modified prehospital EMS 

treatment and triage protocols before or during an influenza pandemic. 

5.4 State, local, tribal, and territorial EMS pandemic influenza plans should define a process 

for providing just-in-time training for EMS agencies, EMS providers, EMS medical 

directors and PSAPs. 

5.5 State, local, tribal, and territorial EMS pandemic influenza plans should coordinate with 

public health and 9-1-1 officials and the local medical examiner/coroner to define protocols 

and processes for fatality management during pandemic influenza. 

5.6 EMS pandemic influenza plans should consider the role EMS providers could serve in 

“treating and releasing” patients without transporting them to a healthcare facility. 

Section 6: EMS Workforce Protection 

6.1 State, local, tribal, and territorial EMS pandemic influenza plans should identify strategies 

to protect the EMS and 9-1-1 workforce and their families during an influenza pandemic. 

6.2 EMS agencies should consistently practice basic infection control procedures including 

vehicle/equipment decontamination, hand hygiene, cough and respiratory hygiene, and 

proper use of FDA cleared or authorized medical personal protective equipment (PPE) 

regardless of the likelihood of an influenza pandemic. 

6.3 State, local, tribal, and territorial EMS pandemic influenza plans should define systemwide processes for providing vaccines and anti-viral medication to EMS personnel. 

6.4 State, local, tribal, and territorial EMS agencies, in coordination with public health 

authorities, should identify a mechanism to address issues associated with isolation and 

quarantine of EMS personnel. 

6.5 State, local, tribal, and territorial EMS pandemic influenza plans should define a process 

for offering support services, including mental health services, to EMS personnel and their 

families during an influenza pandemic. 

7
15

Figure 1: Sample Call Flow for Standard EMD Calls vs. 

PandemicFlu Calls

This chart is for illustrative purposes only, to be modified to locally adopted protocols as need. 

Standard EMD Call Flow Pandemic Flu Call Flow 

(using local Pan Flu protocols) 

1. Telephone answered at 9-1-1 PSAP Telephone answered at 9-1-1 PSAP 

2. EMD call taker obtains address, call back phone number and 

chief complaint 

EMD call taker obtains address, call back phone number and 

chief complaint (1) 

3. EMD queries caller with standard questions using existing EMD 

process 

EMD queries caller with standard questions using existing EMD 

process 

4. EMD call taker assigns an incident type code to case. For those callers meeting predetermined criteria (established 

with local EMS authorities) EMD call taker queries caller using 

PAN FLU SPECIFIC PROTOCOL QUESTIONS (developed by 

State and/or local EMS and public health authorities in advance) 

then assigns an incident type code to case. 

5. EMS units are selected for response based on 

pre-determined response schemes for standard EMS operations 

EMS or alternative units are selected for response OR call taker 

transfers caller to alternative call center (1) based on predetermined PAN FLU EMS DISPATCH PROTOCOLS (modified 

response developed by State and/or local EMS and public health 

authorities in advance) 

6. EMS units are alerted and respond to the scene EMS units are alerted and respond to the scene ONLY on 

designated incident types from PAN FLU EMS DISPATCH 

PROTOCOLS 

7. EMD call taker provides standard pre-arrival or post-dispatch 

instructions while EMS units respond 

EMD call taker provides standard pre-arrival or post-dispatch 

instructions, or modified PAN FLU POST-DISPATCH 

INSTRUCTIONS (developed by State and/or local EMS and 

public health authorities in advance) 

8. EMS units arrive at scene EMS units arrive at scene ONLY on designated incident types 

from PAN FLU EMS DISPATCH PROTOCOLS 

9. Patient is transported to hospital or ED or other appropriate 

destination via ambulance 

Patient is transported ONLY on designated incident types from 

PAN FLU EMS OPERATING PROTOCOLS 

(1) At different points in the Pandemic Flu Call Flow process, an EMD call taker may transfer a call to an alternative call 

center (e.g. poison control centers, nurse advice lines, health care call centers) based on pre-determined Pan Flu EMS 

Dispatch Protocols. PSAPs should also plan to accept incoming calls from alternative call centers. A community’s 

mitigation strategy may include call takers instructing callers on social distancing, home care or other care options. 

8
Figure 2: Sample Pandemic Influenza EMS Dispatch Protocol 

The “Sample Pandemic Influenza EMS Dispatch Protocol” is for illustrative purposes only. It is one example of how resources 

may be reallocated within the system during an influenza pandemic utilizing the Pandemic Severity Index. EMS planners should 

consider other factors, including community mitigation strategies, that will impact how resources will be used. 

These factors may include:

1. Increased Demand for Services

2. Reduction of EMS/Dispatch Workforce

3. Healthcare Facility BedAvailability

Dispatch Priority Level

(should match vendor or call 

center based dispatch 

protocol/tiered algorithm) 

(Standard

Operating Mode) 

Response 

Index 

1 

Pandemic 

Severity

Category 

Severity dex 

2-3 

Pandemic 

In 

Category 

Severity dex 

2-3 

Pandemic 

In 

Category 

Classification 1 

Confirmed/Suspected Cardiac 

Arrest (Not Breathing, 

Unresponsive per 911 call) 

Closest AED Unit; 

Closest 1st 

Responder; 

Closest ALS 

Ambulance 

(HOT) 

Closest AED Unit; Closest 1st 

BLS 

) 

Responder; Closest 

Ambulance if available (HOT 

Closest AED Unit (HOT); 

Closest 1st Responder if 

available (HOT) 

Closest AED Unit if 

available (HOT) 

Classification 2 

Life Threatening 

Emergency/Potentially Life 

Threatening/Confirmed Unstable 

Patient(s) 

Closest 1st 

Responder; 

Closest ALS 

Ambulance (HOT) 

Closest 1st Responder; 

Closest ALS Ambulance if 

available; BLS ambulance if 

ALS unit not available (HOT) 

Closest 1st Responder; 

Closest Ambulance 

available (ALS or BLS) 

(HOT) 

Closest 1st Responder if 

available; Closest 

Ambulance available (ALS 

or BLS) (HOT) 

Classification 3 

Non-Critical/Currently Stable 

Patient(s) Requiring ALS 

Assessment 

Closest ALS 

Ambulance (COLD) 

Closest Ambulance available 

(ALS or BLS)(COLD) 

Closest Ambulance 

Available (ALS or BLS) 

(COLD) 

Referral to Alternate call 

center; or advise selftransport to Alternate 

Treatment Site 

Classification 4 

BLS Assessment for 

unknown/possibly dangerous 

scenes 

Closest 1st 

Responder (HOT); 

Closest BLS 

Ambulance (COLD) 

Closest 1st Responder (HOT); 

Closest BLS Ambulance if 

available 

Closest 1st Responder 

(HOT) 

Closest 1st Responder if 

available; or Closest standin responder unit 

Classification 5 

BLS Treatment 

BLS Ambulance 

(COLD) 

BLS Ambulance 

(COLD) 

Alternate call center (such 

as Poison Control Center, 

Nurse advice line, health 

care call center, etc.) 

Alternate call center (such 

as Poison Control Center, 

Nurse advice line, health 

care call center, etc.) 

Classification 6 

Non Ambulance Care 

Alternate call 

center (such as 

Poison Control 

Center, Nurse 

advice line, health 

care call center, 

etc.) 

Alternate call center (such as 

Poison Control Center, Nurse 

advice line, health care call 

center, etc.) 

Alternate call center (such 

as Poison Control Center, 

Nurse advice line, health 

care call center, etc.) 

Alternate call center (such 

as Poison Control Center, 

Nurse advice line, health 

care call center, etc.) 

(HOT and COLD defined in glossary, Appendix A) 

*See also SAMPLE PANDEMIC INFLUENZA EMS OPERATING PROTOCOLS

9
Figure 3: Sample Pandemic Influenza EMS Operating Protocols 

The “Sample Pandemic Influenza EMS Operating Protocol” is for illustrative purposes only. It is one example 

of how resources may be reallocated within the system during an influenza pandemic utilizing the Pandemic 

Severity Index. EMS planners should consider other factors, including community mitigation strategies, that 

will impact how resources will be used. These factors may include: 

1. Increased Demand for Services 

2. Reduction of EMS/Dispatch Workforce 

3. Healthcare Facility Bed Availability 

*See also SAMPLE PANDEMIC INFLUENZA EMS DISPATCH PROTOCOL 

Sample Protocols Pandemic Severity 

Index Category 1 

Pandemic Severity Index 

Category 2-3 

Pandemic Severity 

Index Category 4-5 

Triage

(to occur both at the 

 9-1-1 center and on scene) 

Determine whether to 

implement triage and treatment 

protocols that differentiate 

between non-infected and 

potentially infected patients 

based on CDC case definition. 

Triage would focus on identifying and 

reserving immediate treatment for 

individuals who have a critical need 

for treatment and are likely to 

survive. The goal would be to 

allocate resources in order to 

maximize the number of lives saved. 

Using screening algorithm to 

ensure only severe get response 

Treatment Ambulatory patients will be 

redirected to alternate care sites 

within or outside of the hospital. 

Treatment protocols may be modified 

to enable and encourage patients to 

receive care at home. 

Consider provision of antiviral 

prophylaxis if effective, feasible and 

quantities sufficient. 

Certain lifesaving efforts may 

have to be discontinued. 

Provision of antiviral prophylaxis 

if effective, feasible and 

quantities sufficient. 

Equipment Prudent use of equipment 

Implementation of strict 

PPE/infection control protocols 

for patients meeting case 

definition established by CDC 

during the response phase of a 

9-1-1 call. 

Selective criteria in place for priority 

use. 

Some scarce and valuable 

equipment, such as ventilators, may 

not be used without staff available 

who are trained to operate them. 

Strict criteria in place for 

equipment use. 

Some scarce and valuable 

equipment, such as ventilators, 

may not be used without staff 

available who are trained to 

operate them. 

Transportation 

Non-urgent and ambulatory 

victims may have to walk or selftransport to the nearest facility 

or hospital. 

Emergency medical services may 

transport victims to specific 

quarantine or isolation locations and 

other alternate care sites. 

Only severe cases transported 

via ambulance 

Destination Alternate care sites will be used 

for triage and distribution of 

vaccines or other prophylactic 

measures, as well as for 

quarantine, minimum care, and 

hospice care. 

Ambulatory and some nonambulatory patients may be diverted 

to alternate care sites (including nonmedical space, such as cafeterias 

within hospitals, or other non-medical 

facilities) 

Emergency department access 

may be reserved for immediateneed patients. 

10
Introduction and Background 

Purpose 

The National Strategy for Pandemic Influenza1 guides our Nation’s preparedness and 

response to an influenza pandemic and provides a framework for coordinating planning 

efforts consistent with the National Security Strategy and the National Strategy for 

Homeland Security. The National Strategy for Pandemic Influenza: Implementation 

Plan2 directs Federal departments and agencies to undertake more than 300 actions in 

support of the National Strategy for Pandemic Influenza. Among these are two tasks 

assigned to the Department of Transportation (DOT), one with a focus on emergency 

medical services and one with a focus on 9-1-1. These tasks are: 

• 6.1.13.6. DOT, in coordination with HHS, DHS, State, local, and tribal officials 

and other EMS stakeholders, shall develop suggested EMS pandemic influenza 

guidelines for statewide adoption that address: clinical standards, education, 

treatment protocols, decontamination procedures, medical direction, scope of 

practice, legal parameters, and other issues, within 12 months. Measure of 

performance: EMS pandemic influenza guidelines completed. 

• 6.1.4.2. DOT, in cooperation with HHS, DHS, and DOC, shall develop model 

protocols for 9-1-1 call centers and public safety answering points that address the 

provision information to the public, facilitate caller screening, and assist with 

priority dispatch of limited emergency medical services, within 12 months. 

Measure of performance: model protocols developed and disseminated to 9-1-1 

call centers and public safety answering points. 

While two separate documents were developed to address each task, the documents are 

intended to be used in tandem. 

How the document was developed 

The document was developed based on existing Federal guidelines; international, 

national, State and regional pandemic influenza and disaster response plans; and relevant 

research, publications and expert interviews. In addition, two stakeholder meetings 

(October 12-13, 2006 and March 1-2, 2007) were convened by the National Association 

of State EMS Officials (NASEMSO) to address the tasks and gain stakeholder guidance, 

with funding from the National Highway Traffic Safety Administration. The meetings 

were attended by a wide variety of national stakeholder organizations within the EMS, 9­

1-1 and public health communities. In addition, Federal agency representation and 

expertise was involved from the Department of Health and Human Services, Department 

of Homeland Security, Department of Commerce, Department of Transportation, 

Department of Justice and others. The stakeholders provided input throughout the 

1

 Homeland Security Council. ONLINE. 2005. National Strategy for Pandemic Influenza. The White 

House. Available: http://www.pandemicflu.gov/plan/federal/index.html [18 March 2007]. 2

 Homeland Security Council. ONLINE. 2006.National Strategy for Pandemic Influenza: Implementation 

Plan. The White House. Available: http://www.pandemicflu.gov/plan/federal/index.html [20 March 2007].

11
development of these guidelines. A list of the participating stakeholder organizations, as 

well as a list of participants in the development process, may be found in Appendix S. 

Pandemic Influenza – Overview 

An influenza pandemic may occur when a novel influenza virus emerges that infects 

humans, causes illness in humans, and can be efficiently transmitted between humans. 

Novel influenza viruses are newly identified influenza viruses to which the population 

has little or no immunity and that require close monitoring to determine whether they are 

capable of causing a pandemic. 

To better understand the role of EMS before and during an influenza pandemic, it is 

useful to identify how the term “pandemic influenza,” commonly referred to as 

“pandemic flu,” is used to distinguish between an influenza pandemic and other influenza 

outbreaks. 

• Pandemic Influenza (or pandemic flu) is virulent human influenza A virus 

that causes a global outbreak, or pandemic, of serious illness in humans. 

Because there is little natural immunity, the disease spreads easily and 

sustainably from person to person. At the time of publication of this 

document, there is no pandemic influenza. 

• Seasonal (or common) Influenza is a respiratory illness caused by both 

human influenza A and B viruses that can be transmitted person to person. 

Most people have some immunity and a vaccine is available. 

• Avian (or bird) Influenza is caused by influenza A viruses that occur 

naturally among wild birds. Low pathogenic avian influenza is common in 

birds and causes few problems. Highly pathogenic avian influenza A (H5N1), 

or HPAI H5N1, is deadly to domestic fowl and can be transmitted from birds 

to humans. There is no human immunity and at this point in time only one 

Food and Drug Administration (FDA) approved human vaccine has been 

approved. The FDA has approved this vaccine for individuals who may be at 

increased risk of exposure to the HPAI H5N1 virus, but it is not commercially 

available. This vaccine has been included within the Strategic National 

Stockpile (SNS). 

Animals are the most likely reservoir for an emerging influenza virus. Avian influenza 

viruses played a role in the development of the human influenza viruses associated with 

the last three influenza pandemics. Two of these viruses remain in circulation among 

humans today and are responsible for the majority of seasonal influenza cases each year. . 

There will be very little discussion of specifics regarding avian influenza in this 

document as it is impossible to predict whether an avian influenza virus will in fact be the 

cause of a future pandemic. Concern is high with the current circulating HPAI H5N1 

virus due to its high mortality among reported human cases and its broad geographic 

distribution. Most cases of HPAI H5N1 virus infection in humans have resulted from 

direct or close contact with infected poultry (e.g., domesticated chicken, ducks, and 

turkeys) or surfaces possibly contaminated from feces and/or respiratory secretions from 

12
infected birds. While there have been a few cases of probable person-to-person spread of 

HPAI H5N1, it has been limited, inefficient and unsustained as of this point in time. 

EMS planners should be able to distinguish among the following: 

• Endemic Levels is the constant presence of a disease or infectious agent 

in a certain geographic area or population group. 

• Epidemic is the rapid spread of a disease in a specific area or among a 

certain population group. 

• Pandemic is a worldwide epidemic - an epidemic occurring over a wide 

geographic area and affecting a large number of people. 

For example, the Severe Acute Respiratory Syndrome (SARS) epidemic from 2002-2003 

never progressed to a pandemic even though SARS moved to Canada from its origins in 

Asia. Although SARS covered a wide geographic area, the number of people affected by 

the disease was limited. 

Additional terms used in this document are defined in the Glossary (Appendix A). 

Influenza – What is it and how is it transmitted? 

Although it is recognized that a pandemic influenza virus may not present and/or affect 

patients in the same fashion as seasonal influenza, a general awareness of the clinical 

presentation and transmission of seasonal influenza may assist in planning and 

responding to an influenza pandemic. In addition, information about prior pandemics as 

well as the circulating HPAI H5N1 viruses is useful in establishing considerations for 

planning a response. 

As described by the Department of Health and Human Services3, seasonal influenza 

typically has an abrupt onset, with symptoms of fever (usually high), headache, extreme 

tiredness, dry cough, sore throat, runny or stuffy nose, muscle aches. Stomach symptoms 

such as nausea, vomiting and diarrhea also can occur, but are more common in children 

than adults. The time from exposure to illness onset is usually 1 to 4 days, with an 

average of 2 days. Most patients recover within 3 to 7 days. Most healthy adults may be 

able to infect others beginning 1 day before symptoms develop and up to 5 days after 

becoming sick. Children can be infectious for 10 or more days, and young children can 

shed the virus for several days before the onset of illness. 

Influenza is primarily transmitted from person to person via large virus-laden droplets 

(particles >5 μm in diameter) that are generated when infected persons cough or sneeze; 

these large droplets can then settle on the mucosal surfaces of the upper respiratory tracts 

of susceptible persons who are near (e.g., within 3 feet of) infected persons. Transmission 

3

 US Department of Health and Human Services. ONLINE. 2005. HHS Pandemic Influenza Plan. 

Department of Health and Human Services. Available: http://www.hhs.gov/pandemicflu/plan/ [3 April 

2007] 

13
may also occur through direct contact or indirect contact with respiratory secretions such 

as when touching surfaces contaminated with influenza virus and then touching the eyes, 

nose or mouth.4 

Likelihood of an Influenza Pandemic 

Three conditions must be met for a pandemic to begin: 

• A new influenza virus must emerge for which there is little or no human 

immunity; 

• It must infect humans and cause illness; and 

• It must spread easily and sustainably (continue without interruption) 

among humans 

Although these three conditions were met in previous pandemics, to date the first two 

conditions have been met with the HPAI H5N1 virus, but the third condition has not been 

met. 

Global Perspective 

Pandemics have occurred intermittently for centuries. The last three pandemics, in 1918, 

1957 and 1968, killed approximately 50 million, 1-2 million and 700,000 people 

worldwide, respectively. Although neither timing nor severity can be predicted, history 

and science suggest that we will face one or more pandemics in this century. 

The most concerning current pandemic threat stems from widespread and expanding 

outbreaks of HPAI H5N1 virus infection among birds in Asia, Europe, Middle East and 

Africa. HPAI H5N1 virus does not usually infect people, but infections with these viruses 

have occurred in humans. In fact, of the few avian influenza viruses that have crossed the 

species barrier to infect humans, HPAI H5N1 has caused the largest number of detected 

cases of severe disease and death in humans. However, at this time, the HPAI H5N1 virus 

has not shown an ability to transmit efficiently between humans as is seen with the 

seasonal influenza viruses. There is concern that the HPAI H5N1 virus may acquire this 

capability through genetic mutation or exchange of genetic material with a human 

influenza virus. 

It is impossible to know whether the currently circulating HPAI H5N1 viruses will cause 

a human influenza pandemic. The widespread occurrence of HPAI H5N1 in birds and the 

likelihood of mutations over time raise concerns that the virus will become transmissible 

between humans, with potentially catastrophic consequences. Even if this does not 

happen with the current HPAI H5N1 viruses, history suggests that a different influenza 

virus will emerge and result in the next pandemic. 

4

 Centers for Disease Control and Prevention. ONLINE. 2007. Guidelines and Recommendations Infection 

Control Guidance for the Prevention and Control of Influenza in Acute-Care Facilities. CDC. Available: 

http://www.cdc.gov/flu/professionals/infectioncontrol/healthcarefacilities.htm [3 April 2007] 

14
New information continues to emerge about the threat of an influenza pandemic and may 

be found online at www.pandemicflu.gov. [See Appendix M for additional resources and 

Web sites that are updated regularly with the latest information about pandemic 

influenza.] 

Potential Impacts of an Influenza Pandemic 

The global impact of pandemic influenza could be severe in terms of lives lost and 

individual and community suffering, as well as severe negative impact upon social and 

economic systems. The following are potential impacts of pandemic influenza: 

• Rapid Worldwide Spread: When a pandemic influenza virus emerges, its global 

spread is likely inevitable. Preparedness activities should assume that the entire 

world population will be affected by the virus. Countries might, through 

measures such as border closures and travel restrictions, delay arrival of the virus, 

but would not be able to stop it. 

• Health Care Systems Overloaded: Most people have little or no immunity to a 

pandemic virus. Infection and illness rates will be very high. A substantial 

percentage of the world’s population will require some form of medical care. 

Nations are unlikely to have the staff, facilities, equipment and hospital beds 

needed to cope with large numbers of people who suddenly fall ill. Death rates 

may be high, depending on four factors: the number of people who become 

infected, the virulence of the virus, the underlying characteristics and 

vulnerability of affected populations and the effectiveness of preventive measures. 

• Medical Supplies Inadequate: The need for vaccine and antiviral medications is 

likely to outstrip supply early in a pandemic period. In addition, a pandemic may 

create a shortage of hospital beds, ventilators and other supplies. Surge capacity at 

non-traditional sites such as schools may be created to cope with demand. 

Shortages may result in the need for difficult 

decisions regarding who should get antiviral Pandemic Influenza in History 

drugs and vaccines. Historically, the 20th century has seen 

• Economic and Social Disruption: Travel bans, three pandemics of influenza: 

closings of schools and businesses and • 1918 influenza pandemic caused at 

least 675,000 U.S. deaths and up to cancellations of events could have major impact 50 million deaths worldwide 

on communities and citizens. Care for sick • 1957 influenza pandemic caused at 

family members and fear of exposure can result least 70,000 U.S. deaths and 1-2 

in significant worker absenteeism. million deaths worldwide 

• 1968 influenza pandemic caused 

As part of the effort to prepare for pandemic influenza, about 34,000 U.S. deaths and 

State and local EMS and 9-1-1 planners will want to 700,000 deaths worldwide 

predict how such a disease outbreak might impact their Source: www.pandemicflu.gov 

community. The Centers for Disease Control and 

Prevention (CDC) offers a software program, FluAid, to assist planners in determining 

the impact that pandemic influenza may have in their community. 

FluAid is a test version of software designed to assist State and local level planners by 

providing estimates of potential impact specific to their locality. FluAid provides only a 

range of estimates of impact in terms of deaths, hospitalizations and outpatient visits due 

15
to pandemic influenza. The software cannot describe when or how people will become 

ill, or how a pandemic may spread through a society over time. FluAid is available at 

http://www.cdc.gov/flu/tools/fluaid/index.htm 

Pandemic Influenza Phases 

EMS and 9-1-1 planners should familiarize themselves with the phases of pandemic 

influenza identified by the World Health Organization (WHO) and the US Government 

pandemic stages. EMS and 9-1-1 planning for pandemic influenza should be done in the 

context of these phases. 

The WHO recognizes six phases of pandemic influenza as well as specific objectives and 

strategic actions for each phase (See Figure 4). In Appendix R there are a list of 

suggested 9-1-1 and EMS activities and readiness steps that could be taken based on the 

different WHO pandemic phases. 

16
Figure 4: WHO Influenza Stages and Strategies
Figure 5: WHO and Federal Government Response Phases

WHO Global Pandemic Phases and the 

Stages for Federal Government Response 

PANDEMIC INFLUENZA 

W HO Phases Federal Government Response Stages 

I N T E R A N DE M I C P E R I OD 

1 

No new influenza virus subtypes have been 

detected in humans. An influenza virus subtype 

that has caused human infection may be present 

in animals. If present in animals, the risk of 

human disease is considered to be low. 

0 New domestic animal outbreak 

in at–risk country 

2 

No new influenza virus subtypes have been 

detected in humans. However, a circulating 

animal influenza virus subtype poses a substantial 

risk of human disease. 

PA N DE M I C A L E RT P E R I OD 

3 

Human infection(s) with a new subtype, but 

no human-to-human spread, or at most rare 

instances of spread to a close contact. 

0 New domestic animal outbreak 

in at–risk country 

1 Suspected human outbreak overseas 

4 

Small cluster(s) with limited human-to-human 

transmission but spread is highly localized, 

suggesting that the virus is not well adapted 

to humans. 

2 Confirmed human outbreak overseas 

5 

Larger cluster(s) but human-to-human spread still 

localized, suggesting that the virus is becoming 

increasingly better adapted to humans, but 

may not yet be fully transmissible (substantial 

pandemic risk). 

PA N D E M I C P E R IO D 

6 Pandemic phase: increased and sustained 

transmission in general population. 

3 Widespread human outbreaks in 

multiple locations overseas 

4 First human case in North America 

5 Spread throughout United States 

6 Recovery and preparation for 

subsequent waves 

18
Figure 6: Stages for Federal Government Response 

CDC has created the Pandemic Severity Index (Figure 7) which uses case fatality ratio a s 

the critical driver for categorizing the severity of a pandemic. The index is designed to 

estimate the severity of a pandemic on a population level, allow better forecasting of the 

impact of a pandemic and enable recommendation s on the use of mitigation interventions 

matched to the severity of influenza pandemics. 

Pandemics will be assigned to one of five discrete categories of increasing severity 

(Category 1 to Category 5). The Pandemic Severity Index provides communities a to ol 

for scenario-based contingency planning to guide local pre-pandemic preparedness 

efforts. Accordingly, communities facing the imminent arrival of pandemic disease wil l 

be able to use the pandemic severity assessment to define which pandemic mitigatio n

interventions are indicated for implementation.

5 This document uses the Pandemic 

Severity Index to guide planning of protocol development and alteration of response 

mechanisms. 

5 US Department of Health and Human Services. ONLINE. 2007. Community Strategy for Pandemic 

Influenza Mitigation. Department of Health and Human Services. Available: 

http://www.pandemicflu.gov/plan/community/commitigation.html [21 March 2007] 

19
Figure 7: CDC Pandemic Severity Index

Case Fatality Projected 

Number of Deaths* Ratio US Population , 2006 

Category 4 

>2.0% >1,800,000 

900,000 - <1,800,000 

450,000 - <900,000 

90,000 - <450,000 

<0.1% Category 1 <90,000 

*assumes 30% illness rate and

unmitigated pandemic without

interventions

Category 2 

Category 3 

Category 3

1.0 - >2.0% 

0.5 - <1.0% 

0.1 - <0.5% 

20
Federal Disease Containment Strategies

The National Strategy for Pandemic Influenza : Implementation Plan6 lists four primary 

strategies for preventing pandemic influenza: 

o Early detection; 

o Treatment with antiviral medications; and 

o The use of infection control measures to prevent transmission. 

o Vaccination;

CDC’s Interim Pre-pandemic Planning Guidance: Community Strategy for Pandemic 

Influenza Mitigation in the United States7, issued on February 1, 2007, advocates for a 

pandemic mitigation framework that is based upon an early, targeted, layered application 

of multiple partially effective non-pharmaceutical measures. The curve below (Figure 8) 

demonstrates the overall goals of the community mitigation strategy in reducing th e 

burdens of an influenza pandemic on a community. As shown, these include: (1) 

delaying the pandemic outbreak peak to allow for additional time to plan and respond, (2) 

decompressing the peak burden on th e local infrastructure and (3) diminishing the overall 

number of cases and health impacts. 

Figure 8: Goals of Community Mitigation 

1 Delay outbreak peak 

2 Decompress peak burden on hospitals/infrastructure 

3 Diminsh overall cases and health impacts 

1 

Pandemic outbreak: 

No intervention 

Pandemic outbreak: 

With intervention 

Daily Cases 

2 

3 

Days Since First Case 

To accomplish these goals, the pandemic community mitigation interventions 

recommended by CDC, used in combination with ind ividual infection control measures, 

such as hand-washing and cough etiquette, include: 

6 Homeland Security Council. ONLINE. 2006.National Stra tegy for Pan demic Influenza: Implementation 

Plan. The White House. Available: http://www.pandemicflu.gov/plan/federal/index.html [20 March 2007]. 7 US Department of Health and Human Services. ONLINE. 2007. Community Stra tegy for Pand emic 

Influenza Mitigation. Department of Health and Human Services. Available: 

http://www.pandemicflu.gov/plan/community/commitigation.html [21 March 2007] 

21
• Isolation and treatment (as appropriate) with influenza antiviral 

medications of all persons with confirmed or probable pandemic 

influenza. Isolation may occur in the home or healthcare setting, 

depending on the severity of an individual’s illness and /or the current 

capacity of the healthcare infrastructure. 

• Voluntary home quarantine of members of households with confirmed 

or probable influenza case(s) and consideration of combining this 

intervention with the prophylactic use of antiviral medications, providing 

sufficient quantities of effective medications exist and that a feasible 

means of distributing them is in place. 

• Dismissal of students from school (including public and private schools 

as well as colleges and universities) and school-based activities and 

closure of childcare programs, coupled with protecting children and 

teenagers through social distancing in the community to achieve 

reductions of out-of-school social contacts and community mixing. 

• Use of social distancing measures to reduce contact between adults in the 

community and workplace, including, for example, cancellation of large 

public gatherings and alteration of workplace environments and schedules 

to decrease social density and preserve a healthy workplace to the greatest 

extent possible without disrupting essential services. Enable institution of 

workplace leave policies that align incentives and facilitate adherence with 

the non-pharmaceutical interventions (NPIs). 

These community containment strategies, along with vaccination and the use of antiviral 

medications for prevention, should they be available, comprise the Targeted Layered 

Containment (TLC) strategy. The TLC strategy is based on the concept that when 

multiple methods of containment and treatment are appropriately coordinated at the 

community level, the effects of an influenza pandemic may be decreased. 

CDC recommends a strategy that initiates these measures based on the severity of 

pandemic influenza as defined in the Pandemic Severity Index (Figure 7).8 

Federal Planning Assumptions 

While history offers useful benchmarks, the characteristics of a pandemic influenza viral 

strain are not known before it emerges. However, to facilitate planning, the Federal 

planning efforts make the following assumptions, based on the National Strategy for 

Pandemic Influenza: Implementation Plan: 

 US Department of Health and Human Services. ONLINE. 2007. Community Strategy for Pandemic 

Influenza Mitigation. Department of Health and Human Services. Available: 

http://www.pandemicflu.gov/plan/community/commitigation.html [21 March 2007] 

22

8
• Susceptibility to the pandemic influenza virus will be universal. 

• Efficient and sustained person-to-person transmission signals an imminent 

pandemic. 

• The clinical disease attack rate will be 30 percent in the overall population during 

the pandemic. Illness rates will be highest among school-aged children (about 40 

percent) and decline with age. Among working adults, an average of 20 percent 

will become ill during a community outbreak. 

• Some persons will become infected but not develop clinically significant 

symptoms. Asymptomatic or minimally symptomatic individuals can transmit 

infection and develop immunity to subsequent infection. 

• While the number of patients seeking medical care cannot be predicted with 

certainty, in previous pandemics about half of those who became ill sought care. 

With the availability of effective antiviral medications for treatment, this 

proportion may be higher in the next pandemic. 

• Rates of serious illness, hospitalization, and deaths will depend on the virulence 

of the pandemic virus and differ by an order of magnitude between more and less 

severe scenarios. Risk groups for severe and fatal infection cannot be predicted 

with certainty but are likely to include infants, the elderly, pregnant women, and 

persons with chronic or immunosuppressive medical conditions. 

• Rates of absenteeism will depend on the severity of the pandemic. In a severe 

pandemic, absenteeism attributable to illness, the need to care for ill family 

members and fear of infection may reach 40 percent during the peak weeks of a 

community outbreak, with lower rates of absenteeism during the weeks before 

and after the peak. Certain public health measures (closing schools, quarantining 

household contacts of infected individuals) are likely to increase rates of 

absenteeism. 

• The typical incubation period (interval between infection and onset of symptoms) 

for seasonal influenza is approximately 2 days. 

• Persons who become ill may shed virus during and before the onset of illness. 

Viral shedding and the risk of transmission are likely to be greatest during the first 

2 days. Children will play a major role in transmission of infection as their illness 

rates are likely to be higher, they shed more virus over a longer period of time, 

and they control their secretions less well. 

• On average, infected persons will transmit infection to approximately two other 

people. 

• Epidemics will last 6 to 8 weeks in affected communities. 

• Multiple waves (periods during which community outbreaks occur across the 

country) of illness are likely to occur with each wave lasting 2 to 3 months. 

Historically, the largest waves have occurred in the fall and winter, but the 

seasonality of a pandemic cannot be predicted with certainty. 

Federal planning assumptions are subject to change as new information about pandemic 

influenza becomes available. 

23
Federal Preparedness Documents 

EMS and 9-1-1 planners may find the following documents useful to their Pandemic 

Influenza preparedness efforts: 

National Strategy for Pandemic Influenza9 

The National Strategy for Pandemic Influenza identifies responsibilities for 

Federal, State and local government as well as non-governmental organizations, 

businesses and individuals. It is built on three pillars: preparedness and 

communication, surveillance and detection, and response and containment. 

• Preparedness and Communication: Activities that should be undertaken 

before a pandemic to ensure preparedness, and the communication and 

coordination of roles and responsibilities to all levels of government, 

segments of society and individuals. 

• Surveillance and Detection: Domestic and international systems that provide 

continuous situational awareness to ensure the earliest warning possible to 

protect the population. 

• Response and Containment: Actions to limit the spread of the outbreak and 

to mitigate the health, social and economic impacts of a pandemic. 

National Response Plan10 

Pandemic influenza in the United States may result in activation of the National 

Response Plan (NRP). The NRP is the primary mechanism for coordination of the 

Federal Government response to terrorist attacks, major disasters and other 

emergencies, and forms the basis of the Federal pandemic response. Management 

of a pandemic response during NRP activation will be driven by decisions at the 

State and local level. Additional information about the NRP may be found in 

Appendix C. 

National Incident Management System (NIMS)11 

While most emergency situations are handled locally, a major incident may 

require help from other jurisdictions, the State and the Federal Government. The 

National Incident Management System (NIMS) was developed so that responders 

from different jurisdictions and disciplines can work together better to respond to 

natural disasters and emergencies, including acts of terrorism. NIMS benefits 

include a unified approach to incident management; standard command and 

management structures; and emphasis on preparedness, mutual aid and resource 

management. Additional information about NIMS requirements may be found in 

9

 Homeland Security Council. ONLINE. 2006.National Strategy for Pandemic Influenza: Implementation 

Plan. The White House. Available: http://www.pandemicflu.gov/plan/federal/index.html [20 March 2007]. 10 US Department of Homeland Security. ONLINE. 2004. National Response Plan. Department of 

Homeland Security. Available: www.dhs.gov/xlibrary/assets/NRP_FullText.pdf [18 March 2007]. 11 US Department of Homeland Security. ONLINE. 2004. National Incident Management System. 

Department of Homeland Security. Available: www.fema.gov/pdf/emergency/nims/nims_doc_full.pdf [18 

March 2007]. 

24
Appendix I. An influenza pandemic has the potential of affecting the entire 

country simultaneously. Therefore certain aspects of NIMS, such as mutual aid, 

may be less pertinent than during other location specific disasters. However, 

many of the other concepts within NIMS, such as the incident command system 

(ICS), will continue to be vital to pandemic influenza planning and response. 

Guidelines published by other Federal agencies may also be useful to EMS and 9-1-1 

planners. The EMS system and the 9-1-1 system must be dynamic and capable of 

responding quickly to new guidance and new or revised treatment modalities. Current 

guidance documents are listed in Appendix M. 

25
EMS Pandemic Influenza Guidelines for 

Statewide Adoption 

Section 1 – EMS Planning 

Guideline 1.1 – Plans and Operational Procedures 

State, local, tribal, and territorial EMS agencies should adopt EMS pandemic 

influenza plans and operational procedures that define the role of EMS in 

preparing for, mitigating and responding to pandemic influenza. 

Rationale 

EMS pandemic influenza plans and operational procedures help assure thoughtful 

pre-event consideration of the role of EMS in mitigating and responding to 

pandemic influenza. 

Considerations 

• State, local, tribal, and territorial EMS agencies should coordinate with their 

public health, health care, emergency management, 9-1-1 and public safety 

counterparts to ensure a coordinated, integrated community-wide mitigation 

of and response to pandemic influenza. 

• Public involvement in the planning process is encouraged. 

• Steps should be taken to ensure that EMS pandemic influenza plans are 

consistent with Federal, State, and local guidance, plans, and policies in order 

to support a coordinated approach. 

Background 

The threat of pandemic influenza has caused both non-governmental and public 

sector agencies throughout the world to recognize the need for pandemic 

influenza planning as essential to preparing for a severe public health threat. As a 

discipline within the emergency services sector, EMS is critical to the protection 

of all Critical Infrastructure/Key Resources12 in the United States. Therefore, 

early and consistent planning regarding the EMS role will help ensure that when a 

pandemic reaches the United States the most appropriate actions can be taken to 

support the Nation. 

 US Department of Homeland Security. ONLINE. 2006. Pandemic Influenza Preparedness, Response, 

and Recovery Guide for Critical Infrastructure and Key Resources. Department of Homeland Security. 

Available: www.pandemicflu.gov/plan/pdf/cikrpandemicinfluenzaguide.pdf [18 March 2007]. 

26

12
Guideline 1.2 – Leadership and Authority 

State, local, tribal, and territorial pandemic influenza plans and operational 

procedures should identify leadership and authority that are consistent with the 

National Response Plan and the National Incident Management System, 

including the Incident Command System, and be carefully coordinated with local 

emergency management plans. 

Rationale 

Pre-established delegations of authority and methods of operation are vital to 

ensuring that all organizational personnel know who has the authority to make 

key decisions during a public health emergency, as well as the appropriate 

operational procedures to follow. 

Considerations 

• EMS operations and personnel should already have clearly established authority 

under their EMS medical director and in accordance with the Incident Command 

System (ICS) and the National Incident Management System (NIMS). This 

authority should be maintained during an influenza pandemic. 

• Drills and exercises, coordinated with public health and emergency management 

officials, should be used to validate pandemic influenza response plans and 

training programs. 

• All Federal, State, local, tribal, and non-governmental personnel with a direct role 

in emergency management and response should be NIMS compliant, including 

ICD training. This includes EMS, 9-1-1, healthcare, emergency management, 

public health, fire service, law enforcement, public works/utilities and other 

personnel. 

Background 

National Response Plan (NRP) 

The National Response Plan13 establishes a comprehensive all-hazards approach to 

enhance the ability of the United States to manage domestic incidents. The plan 

incorporates best practices and procedures from incident management disciplines — 

homeland security, emergency management, law enforcement, firefighting, public works, 

public health, responder and recovery worker health and safety, emergency medical 

services, and the private sector — and integrates them into a unified structure. It forms 

 US Department of Homeland Security. ONLINE. 2004. National Response Plan. Department of 

Homeland Security. Available: www.dhs.gov/xlibrary/assets/NRP_FullText.pdf [18 March 2007]. See also: 

www.dhs.gov/nrp 

27

13
the basis of how the Federal Government coordinates with State, local, and tribal 

governments and the private sector during incidents. Pandemic influenza in the United 

States may result in activation of the NRP. Management of a pandemic response during 

NRP activation will be driven by decisions at the State, local, tribal, and territorial level. 

Excerpted information about the NRP may be found in Appendix C. 

National Incident Management System (NIMS) 

The National Incident Management System14 was developed so responders from different 

jurisdictions and disciplines can work together better to respond to natural and manmade 

disasters, including acts of terrorism. NIMS benefits include a unified approach to 

incident management; standard command and management structures; and emphasis on 

preparedness, mutual aid and resource management. While most emergency situations are 

handled locally, a major incident likely will warrant help from other jurisdictions, the 

State and the Federal Government.15 However, during a pandemic additional assets may 

be limited or unavailable for mutual aid because they are already committed to service 

within their own communities. Regional coordination prior to the event may optimize the 

utilization of assets among multiple jurisdictions during an event. 

NIMS Training Requirements: 

The applicable NIMS and ICS training requirements16 are included in Appendix I. 

14 US Department of Homeland Security. ONLINE. 2004. National Incident Management System.

Department of Homeland Security. Available: www.fema.gov/pdf/emergency/nims/nims_doc_full.pdf [18 

March 2007]. 15 See http://www.fema.gov/emergency/nims/index.shtm

 US Department of Homeland Security. ONLINE. 2006. NIMS Alert 004-06. Our Top Five Most 

Frequently Asked Questions. FEMA. Available: 

http://www.fema.gov/pdf/emergency/nims/5_common_faqs.pdf [18 March 2007]. 

28

16
Guideline 1.3 – Training and Exercising 

EMS pandemic influenza plans should establish a program of pre-pandemic 

training and exercising to prepare EMS personnel for their role in the local 

pandemic influenza plan. 

Rationale 

A pre-pandemic preparedness training and exercising program will help EMS 

agencies ensure EMS personnel have baseline training to support and understand 

their role in responding to pandemic influenza. 

Considerations 

• Drills and exercises, coordinated with public health and emergency management, 

should be used to validate pandemic influenza response plans and training 

programs. 

• Priority should be given to all-hazards preparedness training that incorporates 

pandemic influenza as a scenario to consider.

• Pre-pandemic exercises should test mechanisms to provide just-in-time training 

needed during an event. 

• Exercises should incorporate NIMS principles to ensure responders are 

comfortable with NIMS principles and to allow problems to be identified and 

remedied prior to an actual event. 

Background 

Exercises allow EMS and 9-1-1 personnel, as well as personnel from other disciplines, to 

train and practice prevention, protection, response, and recovery capabilities in a realistic but 

risk-free environment. Exercises are also a valuable tool for assessing and improving 

performance, while demonstrating community resolve to prepare for major incidents. 

The Homeland Security Exercise and Evaluation Program (HSEEP) is a capabilities and 

performance-based exercise program which provides a standardized policy, methodology, 

and terminology for exercise design, development, conduct, evaluation, and improvement 

planning. 

Further information on the HSEEP is available at http://www.hseep.dhs.gov. 

29
Guideline 1.4 – A Systems Approach 

State, local, tribal and territorial EMS agencies, in coordination with Federal, 

State and local public health, 9-1-1, emergency management and health care 

officials should ensure that EMS pandemic influenza plans define a process for 

gathering and developing updated pandemic influenza information, including 

clinical standards, treatment protocols and just-in-time training and disseminate 

it to local EMS medical directors and EMS agencies. 

Rationale 

Establishing a dynamic, coordinated and sustainable process will assure that State, 

local, tribal, and territorial EMS and 9-1-1 systems are able to rapidly incorporate 

updated disease and treatment information on pandemic influenza and other 

emerging public health threats into their practices. 

Considerations 

• There should be clearly defined procedures for rapid dissemination of 

pandemic influenza information among EMS, public health, 9-1-1 PSAPs and 

other officials. This should include coordination with the CDC’s Health Alert 

Network,17 Public Health Information Network (PHIN),18 and/or Public 

Health Information Rapid Exchange (PHIRE)19. 

• There should be a dynamic statewide system for developing and implementing 

EMS response and treatment protocols for pandemic influenza and other 

public health emergencies consistent with legal authorities and medical 

direction and accompanied by just-in-time training. 

• Medical direction, education, quality improvement and legal authority are 

essential components of the EMS system’s role in mitigating and responding 

to Pandemic Influenza and other public health emergencies. 

• EMS and 9-1-1 should be integrated into comprehensive pandemic influenza 

planning efforts. 

Background 

During a pandemic, the medical community must have awareness of the ongoing 

epidemiological analysis and community-wide interventions being recommended 

by public health leaders. Likewise, the public health community must have 

situational awareness of the evolution of disease that can come from collaboration 

with 9-1-1, EMS, emergency departments and other acute care and outpatient 

17 Centers for Disease Control and Prevention. ONLINE. 2007. Health Alert Network. CDC. Available: 

http://www.bt.cdc.gov/documentsapp/HAN/han.asp [18 March 2007] 18 Centers for Disease Control and Prevention. ONLINE. 2007. Public Health Information Network. CDC.

Available: http://www.cdc.gov/phin/ [3 April 2007] 19 Centers for Disease Control and Prevention. ONLINE. 2007. Public Health Information Rapid

Exchange. CDC. Available: http://www.cdc.gov/phire/ [3 April 2007]

30
settings where patients seek medical care. The pre-pandemic planning period 

presents an opportunity to establish and test these relationships. 

A goal of the PHIN is to enable real-time data flow, computer assisted analysis, 

decision support, professional collaboration, and rapid dissemination of 

information to public health officials, the clinical care community and the public. 

The Health Alert Network functions as PHIN’s Health Alert component. This 

includes collaborating with Federal, State and city/county partners to develop 

protocols and stakeholder relationships that will ensure a robust interoperable 

platform for the rapid exchange of public health information. 

The Centers for Disease Control and Prevention is a trusted source of important, 

timely information concerning actual or potential public health emergencies. 

PHIRE, the CDC Public Health Information Rapid Exchange, is a system that 

sends important real-time health information to select subscribers based on their 

preferences. For example, the system enables CDC to rapidly disseminate alerts 

about evidence of suspected pandemic influenza in the United States. 

PHIRE is a secure electronic communication system designed to keep health care 

providers informed to protect our Nation’s health. The information is provided in 

real time during an emergency and also allows subscribers the ability to have 

scheduled moderated forums. The information registrants provide regarding their 

county and work setting enables CDC to target relevant emergency health 

information specific to the registrants needs. 

More information, including the ability to register can be done at 

www.cdc.gov/phire. 

31
Guideline 1.5 – Public and Media Communications 

State, local, tribal, and territorial EMS and 9-1-1 agencies should define a public 

and media communications plan that is coordinated with the Incident Command 

System and public health officials to assure consistent education and instructions 

to the public. 

Rationale 

A clear, coordinated communications strategy will provide information so the 

public can understand the potentially evolving and changing role of EMS during 

an influenza pandemic. 

Considerations 

• Message coordination with public health and emergency management 

officials, elected officials and others is essential to ensuring public confidence. 

• The role of EMS in Pandemic Influenza mitigation and response should be 

clearly communicated to the public. 

• There should be early public feedback to ensure the messages are 

understandable and useful to the public. 

Background 

To maintain public confidence and enlist the support of individuals and families 

in disease containment efforts, EMS and 9-1-1 agencies should coordinate their 

public messages and guidance with the Incident Command System. The public 

will respond favorably to messages from EMS that acknowledge their concerns, 

allay anxiety and uncertainty, and provide clear direction. 

This may include dissemination of information on what individuals can do to 

protect themselves, how to care for family members at home, when and where to 

seek medical care, and how to protect others and minimize the risks of disease 

transmission. The public will respond favorably to messages which are 

coordinated and consistent between authorities. 

The language, timing, and detail of key messages will depend on a number of 

factors, including demographics and group psychological profiles of intended 

audiences, available or preferred media, and urgency.20 The Department of 

Health and Human Services will provide communications materials for states and 

localities throughout all pandemic phases. Many of these resources will be made 

20 US Department of Health and Human Services. ONLINE. 2005. HHS Pandemic Influenza Plan. 

Department of Health and Human Services. Available: http://www.hhs.gov/pandemicflu/plan/ [3 April 

2007] 

32
available at appropriate times on the www.pandemicflu.gov website. Others will 

be disseminated by using the Health Alert Network (HAN), Epidemic Information 

Exchange (Epi-X), and other resources for health professionals. Additional 

resources for information such as links to fact sheets are included in Appendix 

M. 

One of the resources for communications professionals is the CDCynergy CDROM set produced by CDC. Emergency Risk Communication CDCynergy is 

applicable to communicating before and during an influenza pandemic. 

Communications staff also may find the CDCynergy 3.0 disk helpful. 

Information about CDCynergy is available on CDC’s website at 

http://www.cdc.gov/communication/cdcynergy.htm. 

Communicating in a Crisis: Risk Communication Guidelines for Public Officials 

is available on SAMHSA’s website at 

http://www.riskcommunication.samhsa.gov/index.htm. This reference describes 

basic skills and techniques for clear, effective crisis communications and 

information dissemination, and provides some of the tools of the trade for media 

relations. 

CDC's Office of Communication is offering Emergency Risk Communication 

Training for appropriate public health workers and communicators both inside 

and outside the government. Additional information on this program including 

slide sets and course books can be found at http://www.bt.cdc.gov/erc/index.asp. 

Section 1: EMS Planning 

SEE RELATED APPENDICES 

1. Appendix B-- EMS and Non-Emergent Medical Transport Organizations 

Pandemic Influenza Planning Checklist from the Centers for Disease Control 

and Prevention 

2. Appendix C—National Response Plan, ESF 8 (Excerpt) 

3. Appendix M—Pandemic Influenza Resources 

33
Section 2 - The Role of EMS in Influenza Surveillance 

and Mitigation 

Guideline 2.1 – EMS Role in Surveillance 

State, local, tribal, and territorial EMS pandemic influenza plans should identify 

the role that EMS agencies should play in ongoing disease surveillance. 

Rationale 

EMS systems are ubiquitous and collect patient information, including signs and 

symptoms, of persons calling 9-1-1 and persons receiving prehospital emergency care for 

a defined geographic area. Aggregation of this patient information may be useful in 

disease surveillance. 

Considerations 

• Disease surveillance plays an important role in pandemic influenza mitigation. 

• EMS and 9-1-1 agencies should have a secure system for managing and collecting 

patient and system data. 

• A real-time EMS and 9-1-1 data collection and reporting system enhances its 

utility as a component of the surveillance system; 

• EMS agencies should define policies, procedures and legal authorities for 

sharing EMS and 9-1-1 data with public health agencies as part of a 

comprehensive surveillance system. 

• EMS and 9-1-1 agencies should address any legal and technological barriers to 

participating in a disease surveillance process. 

• EMS and 9-1-1 data elements for pandemic influenza surveillance should be 

outlined clearly among all appropriate agencies, including public health. 

• There should be a mechanism for rapid modification of data elements and 

reporting mechanisms based upon updated information on an emerging pathogen 

(e.g., during the SARS epidemic, questions pertaining to foreign travel were 

pertinent). 

• In coordination with State and local public health authorities, a mechanism should 

be identified to relay probable signs and symptoms of an emerging viral strain 

(i.e. “pandemic influenza symptom set”) to EMS and 9-1-1 as soon as such 

information becomes available from the CDC. 

• Because fever is a typical symptom of influenza, EMS agencies may consider 

acquiring and recording patient temperature as part of their influenza surveillance. 

34
Collaboration with public health officials may help identify other opportunities 

for improving surveillance. 

Background 

The CDC recognizes the important role that EMS plays in disease surveillance. 

The EMS and Non-Emergent Medical Transport Organizations Pandemic 

Influenza Checklist (Appendix B) recommends “a system ... to track influenzalike illness in patients transported to hospitals and among EMS staff and to report 

this information to the pandemic response coordinator...” 

There are several EMS systems that are participating in community disease 

surveillance systems. For example, Richmond, Virginia, has access to real-time 

awareness of emerging threats by monitoring 9-1-1, law enforcement, fire and 

emergency medical services data from computer aided dispatch (CAD) and 

advanced telephone triage, as well as poison control center data. [See companion 

document Preparing for Pandemic Influenza: Recommendations for 9-1-1 

Personnel and Public Safety Answering Points.] 

Most health surveillance efforts are not focused on specific patients, but are 

looking at trends and patterns in the aggregate. However, there may be cases 

when public health officials are called upon to investigate specific cases which 

would require receiving and working with Protected Health Information (PHI), as 

that term is defined by the Privacy Rule promulgated pursuant to the Health 

Insurance Portability and Accountability Act (HIPAA) of 1996. The HIPAA 

Privacy Rule is the Federal law governing the use and disclosure of PHI by 

“covered entities” (certain health care providers, health plans and health care 

clearinghouses). Some government agencies are “covered entities” and some are 

not. State law may also address such use and disclosure, and the HIPAA Privacy 

Rule does not preempt contrary state laws that provide greater privacy protection. 

The Privacy Rule does not cover the use and disclosure of health information by 

non-covered entities. Moreover, the Privacy Rule permits “covered entities” to 

disclose PHI to public health authorities to prevent or control disease, injury or 

disability (including the conduct of public health surveillance.) 

When considering mechanisms to obtain and share EMS data from CAD systems 

and patient care reports, EMS planners should coordinate with local and State 

public health agencies to identify data elements that will be most useful in 

tracking influenza-like symptoms. The National EMS Information System

21 

(NEMSIS) data elements may provide an additional mechanism for uniformity of 

data collection. 

As part of a coordinated, community-wide strategy, PSAPs and other emergency 

call centers should be authorized to use modified caller queries containing the 

21 The National EMS Information System (NEMSIS) information and NHTSA Dataset is available at 

www.nemsis.org 

35
pandemic influenza symptom set when the community considers the threat of a 

local outbreak to be elevated. Such information must be coordinated with EMS. 

The CDC notes that the symptoms

22 typically associated with influenza 

(“pandemic influenza symptom set”) are: 

• Fever (usually high) 

• Headache 

• Extreme tiredness 

• Dry cough 

• Sore throat 

• Runny or stuffy nose 

• Muscle aches 

• Stomach symptoms, such as nausea, vomiting, and diarrhea, also can 

occur but are more common in children than adults 

These influenza symptoms are meant for guiding planning only. The definitive 

“pandemic influenza symptom set” affiliated with a pandemic influenza strain 

will not be known until the actual strain emerges and is appropriately monitored. 

22 US Department of Health and Human Services Centers for Disease Control and Prevention. ONLINE. 

2006. Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization 

Practices (ACIP) MMWR 2006 Jul 28;55(RR10):1-42). CDC. Available: 

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5510a1.htm [28 March 2007] 

36
Guideline 2.2 – Statewide Tracking System 

State EMS pandemic influenza plans should establish or identify a statewide 

system that tracks: a) patient location, b) health care facility availability, and c) 

patient disposition to allow public health and epidemiologic analysis. 

Rationale 

Improved situational awareness through information sharing regarding both 

patients and resources will enable better management of assets during a pandemic 

and provide for real time epidemiological analysis. 

Considerations 

• Compatible communications equipment and communications radio frequency 

plans should be in place for common hospital diversion and bed capacity 

situational awareness at the local, State and regional levels. 

• A statewide interoperable patient tracking system should be in place that allows 

patient tracking from the first response site to a healthcare facility and allows data 

to be accessible among statewide users. 

• The ability to track healthcare facility availability in real-time allows EMS 

providers to make timely patient destination decisions in the field. 

• Information that allows public health officials to make links between original 

patient location and patient disposition can strengthen the ability for public health 

officials to track disease spread. 

• Although not identical, this guideline is generally consistent with the current 

version of the Department of Homeland Security’s Target Capability List23 for 

“Triage and Pre-hospital Treatment.” 

• The plan should address patient confidentiality issues in establishing the statewide 

tracking system. 

Background 

Mechanisms for tracking EMS calls, emergency department visits and hospital 

admissions and discharge of pandemic influenza patients is needed to monitor the 

progress and impact of the pandemic. Several examples currently exist: 

 US Department of Homeland Security. ONLINE. 2005. Target Capabilities List Version 1.1. ODP 

Secure Portal. Available: https://odp.esportals.com. Lessons Learned Information Sharing. Available: 

www.llis.gov [18 March 2007]. 

37

23
Patient Identification/Location Tracking 

The ability to track patient location from the initial site of response to arrival at a 

health care facility has previously been demonstrated to be of vital importance 

(including Hurricanes Katrina and Rita). In an influenza pandemic, this is also 

essential to support the community mitigation strategies that may help protect the 

public’s health (e.g., voluntary isolation and quarantine and social distancing 

measures in areas where patients have been positively diagnosed with the 

pandemic influenza strain). 

Hospital Resource Availability 

The National Hospital Available Beds for Emergencies and Disasters (HAvBED) 

System24, funded by the Agency for Healthcare Research and Quality (AHRQ), 

explores the feasibility of a national real-time hospital-bed tracking system to 

address a surge of patients during a mass casualty event. 

The Health Emergency Response Data System25 (HERDS) is a statewide 

electronic web based data collection system linked to health care facilities (all 

New York State hospitals) through a secure internet site that allows hospitals to 

relay resources or needs to the New York State Department of Health during 

emergencies, or respond immediately to rapid request surveys in preparedness 

planning efforts. HERDS combines Geographic Information Systems and a 

comprehensive, interactive database to provide health officials with online, real 

time data describing available hospital beds, medical supplies, personnel, 

numbers, status and immediate care needs of ill or injured persons, along with 

other urgent information to facilitate a rapid and effective emergency response. 

Operational features of HERDS: 

• Routine Data Collection and Surveillance Surveys 

• Emergency Events Data Collection 

• Secure Messaging Forum 

• Patient Locator/Tracking Function 

• Activation/Deactivation Alerting Tool 

FRED is the Facility Resource Emergency Database26, a secure Internet-based 

system that provides rapid, efficient, alert-driven emergency event or disaster 

vetted notification with reporting of resources available to mitigate mass casualty 

incidents or similar situations that produce a surge of patients. It was originally 

developed by the Maryland Institute for EMS Systems (MIEMSS) and has since 

24 Agency for Healthcare Research and Quality. ONLINE. 2005. National Hospital Available Beds for 

Emergencies and Disasters (HAvBED) System: Final Report. AHRQ Publication No. 05-0103 Available:

http://www.ahrq.gov/research/havbed/ [3 April 2007] 25 New York State Department of Health. Health Emergency Response Data System resides on NYSDOH 

secure network requiring user authentication for access.

26 Maryland Institute of Emergency Medical Services System. Facility Resource Emergency Database 

resides on a MIEMSS secure network requiring user authentication for access. 

38
been adopted by the Pennsylvania Department of Health (PA DOH). In 

Maryland, FRED allows MIEMSS to send an alert to all hospitals requesting an 

update on their current status. This includes not only beds, but also staffing and 

medications, as well as information from the local jurisdictions regarding EMS 

staffing. Initial plans call for establishing Continuous FRED Monitoring Sites at 

all Pennsylvania receiving hospitals, Public Safety Answering Points (PSAPs / 

911 centers), Emergency Management Agencies, and emergency information 

centers such as Poison Centers. 

Public Health/Epidemiologic Issues 

Public health is a field that is concerned with any and all threats to the overall 

health of a community and is based on analysis done at the population level, 

rather than at that of the individual patient. Epidemiology is a subsection of the 

public health structure that deals with incidence, distribution, and control of 

disease within a population. By identifying the numerous factors that affect the 

health of a specific population, epidemiologic studies further guide interventions 

that can be made to preserve the health of the public. 

Utilizing public health surveillance and epidemiologic techniques during an 

influenza pandemic would not only help with situational awareness by detecting 

disease in the area, but then would lead to appropriate response and containment 

mechanisms necessary to protect both the community and the providers. This can 

only occur if proper mechanisms are in place to securely communicate influenza 

patient disposition to the appropriate authorities within the public health, EMS, 9­

1-1, and health care arenas. The ability to track patient disposition and suspected 

influenza contacts allows for important information regarding disease severity, 

characteristics of the affected population, and impacts on the healthcare system to 

be followed and addressed. 

One method of tracking patient disposition is through an Electronic Health 

Record (EHR). There are a number of Federal EHR initiatives underway 

including those at: the Department of Health and Human Services (HHS), the 

Department of Homeland Security (DHS), the Department of Defense (DOD), the 

Department of Veterans Affairs (VA), and the Department of Transportation 

(DOT). 

39
Guideline 2.3 – EMS and Community Mitigation 

State, local, tribal, and territorial EMS agencies, in coordination with public 

health authorities and consistent with resources, legal authority and education, 

should define procedures for involving EMS providers in pandemic influenza 

community mitigation strategies, including Targeted Layered Containment. 

Rationale 

A comprehensive community mitigation strategy may slow the spread of 

pandemic influenza ultimately saving lives and reducing demand on healthcare 

resources including EMS. EMS operational infrastructure, including 9-1-1, is well 

positioned for supporting community mitigation strategies. 

Considerations 

• An investment of resources in the pandemic alert phase may help to significantly 

reduce the spread of pandemic influenza, reduce mortality and reduce the 

consumption of healthcare resources that would otherwise occur. Early 

intervention by EMS could reduce the surge during the response phase. The 

primary mission of EMS is the reduction of patient morbidity and mortality 

through the delivery of fast and efficient prehospital care. EMS agencies should 

be engaged with State and local planners to define their role in community 

mitigation strategies such as distribution of medical countermeasures (i.e. 

vaccines and antiviral medications) to the general population. 

• EMS pandemic influenza plans should address how EMS providers will care for 

isolated and quarantined patients in support of a community mitigation strategy. 

• EMS pandemic influenza plans should address how EMS providers will 

adequately protect themselves when treating isolated and quarantined patients in 

support of a community mitigation strategy. 

• Drills and exercises, coordinated with public health and emergency management 

officials, should be used to validate EMS agencies’ roles in community mitigation 

strategies. 

• Although public health authorities will be primarily responsible for coordination 

of community mitigation strategies, EMS system involvement may be beneficial. 

• EMS agencies should have contingency plans in the event that community 

mitigation strategies have varying levels of effectiveness. 

• EMS planners should be aware of ethical decision-making considerations that 

may affect public perceptions and response to community mitigation strategies. 

40
Background 

In its EMS and Non-Emergent (Medical) Transport Organizations Pandemic 

Influenza Planning Checklist27, the Centers for Disease Control and Prevention 

(CDC) calls upon EMS agencies to hold discussions with local and/or State health 

departments regarding the role of EMS organizations in a large-scale program to 

distribute vaccine and antivirals to the general population. 

EMS agencies have successfully piloted influenza immunization programs.28 

Authors of a 2003 article in Prehospital and Disaster Medicine29 stated that, “As 

soon as the next pandemic is identified, a large-scale vaccination program will be 

needed. Paramedics and other EMS personnel could be a valuable supplement to 

the public health workforce in such a situation. However, in order for such a 

project to be successful, early preparation, training, and, in some cases, legislative 

changes must be implemented in advance of the catastrophe. ...With >70,000 

paramedics in the US, paramedics are a substantial medical resource in most 

communities in the US.” It should be noted that vaccines are not likely to be 

available early in a pandemic. 

EMS system planners should work closely with their local public health officials 

to further explore the role that EMS should play as part of a community-wide, 

integrated disease surveillance and mitigation system. EMS planners are 

encouraged to develop comprehensive, well-defined systems, planned ahead of 

time, to assure sufficient legal authority to permit EMS to participate in 

community mitigation strategies, including modifications to scopes of practice if 

needed, medical direction, just-in-time training and quality improvement. 

The States and their political subdivisions are primarily responsible for isolation 

and quarantine within their borders. Public health officials generally have the 

authority to declare and enforce mandatory isolation and/or quarantine. 

Coordination of isolation and/or quarantine policies with EMS and 9-1-1 will be 

critical to the success of community mitigation strategies. 

27 US Department of Health and Human Services. ONLINE. 2006. Emergency Medical Services and NonEmergent (Medical) Transport Organizations Pandemic Influenza Planning Checklist. Department of 

Health and Human Services. Available: http://www.pandemicflu.gov/plan/healthcare/emgncymedical.html 

[18 March 2007]. 

28 Mosesso VN Jr, Packer CR, McMahon J, Auble TE, Paris PM. Influenza immunizations provided by

EMS agencies: the MEDICVAX Project. Prehosp Emerg Care. 2003 Jan-Mar;7(1):74-8. 29 Walz BJ, Bissell RA, Maguire B, Judge JA.Vaccine administration by paramedics: 

A model for bioterrorism and disaster response preparation. 

Prehosp Disast Med 2003;18(4):321–326. 

41
Community Mitigation 

The CDC’s Interim Pre-pandemic Planning Guidance: Community Strategy for 

Pandemic Influenza Mitigation in the United States30 advocates for a pandemic 

mitigation framework that is based upon an early, targeted, layered application of 

multiple partially effective non-pharmaceutical measures, in combination with 

pharmaceutical measures, when available. The interim guidance includes a 

Pandemic Severity Index to characterize the severity of a pandemic, provides 

planning recommendations for specific interventions that communities may use 

for a given level of pandemic severity, and suggest when these measures should 

be started and how long they should be used. 

Researchers using computer models31 have investigated the effectiveness of 

containment strategies in limiting an emerging influenza strain at the source. 

Simulations showed that a prepared response with targeted strategies would have 

a high probability of limiting the spread of a pandemic. Preliminary analysis of 

historical data and mathematical modeling suggest that the early, coordinated 

application of multiple interventions may be more effective in reducing 

transmission than the use of a single intervention. 

The pandemic community mitigation interventions recommended by CDC, to be 

used in combination with individual infection control measures, such as handwashing and cough etiquette, include: 

• Isolation and treatment (as appropriate) with influenza antiviral 

medications of all persons with confirmed or probable pandemic 

influenza. Isolation may occur in the home or healthcare setting, 

depending on the severity of an individual’s illness and /or the current 

capacity of the healthcare infrastructure. 

• Voluntary home quarantine of members of households with confirmed 

or probable influenza case(s) and consideration of combining this 

intervention with the prophylactic use of antiviral medications, providing 

sufficient quantities of effective medications exist and that a feasible 

means of distributing them is in place. 

• Dismissal of students from school (including public and private schools 

as well as colleges and universities) and school-based activities and 

closure of childcare programs, coupled with protecting children and 

teenagers through social distancing in the community to achieve 

reductions of out-of-school social contacts and community mixing. 

• Use of social distancing measures to reduce contact between adults in the 

community and workplace, including, for example, cancellation of large 

public gatherings and alteration of workplace environments and schedules 

30 US Department of Health and Human Services. ONLINE. 2007. Community Strategy for Pandemic 

Influenza Mitigation. Department of Health and Human Services. Available:

http://www.pandemicflu.gov/plan/community/commitigation.html [21 March 2007] 31 Institute of Medicine Board on Population Health and Public Health Practice. ONLINE. 2006. Modeling 

Community Containment for Pandemic Influenza: A Letter Report. 2006. The National Academies Press. 

Available: www.nap.edu/catalog/11800.html [28 March 2007]

42
to decrease social density and preserve a healthy workplace to the greatest 

extent possible without disrupting essential services. Enable institution of 

workplace leave policies that align incentives and facilitate adherence with 

the non-pharmaceutical interventions (NPIs). 

These community containment strategies, along with vaccination and anti-viral 

prophylaxis, should they be available, comprise the Targeted Layered 

Containment (TLC) strategy. The TLC strategy is based on the concept that when 

multiple methods of containment and treatment are targeted at the local level in an 

appropriate manner, the effects of an influenza pandemic could potentially be 

decreased. 

CDC recommends a strategy that initiates these measures based on the severity of 

pandemic influenza as defined in the Pandemic Severity Index.32 

The curve below (Figure 9) demonstrates the overall goals of the community 

mitigation strategy in reducing the burdens of an influenza pandemic on a 

community. As shown, these include: (1) delaying the pandemic outbreak peak to 

allow for additional time to plan and respond, (2) decompressing the peak burden 

on the local infrastructure and (3) diminishing the overall number of cases and 

health impacts. 

Figure 9: Goals of Community Mitigation 

1 Delay outbreak peak 

2 Decompress peak burden on hospitals/infrastructure 

3 Diminsh overall cases and health impacts 

1 

Pandemic outbreak: 

No intervention 

Days Since First Case 

Pandemic outbreak: 

With intervention 

Daily Cases 

2 

3 

Community mitigation strategies may slow the spread of pandemic influenza 

ultimately saving lives and reducing demand on healthcare resources including 

US Department of Health and Human Services. ONLINE. 2007. Community Strategy for Pandemic 

Influenza Mitigation. Department of Health and Human Services. Available: 

http://www.pandemicflu.gov/plan/community/commitigation.html [21 March 2007] 

43

32 
EMS. EMS operational infrastructure, including 9-1-1, is well positioned for 

supporting community mitigation strategies. EMS providers are an established 

mobile healthcare workforce experienced in providing prehospital care to patients 

in their homes. EMS agencies should be engaged with State and local planners to 

define their role in community mitigation strategies such as distribution of 

medical countermeasures (i.e. vaccines and antiviral medications) to the general 

population. 

The CDC worked with the Ethics Subcommittee of the Advisory Committee to 

the CDC Director to identify ethical considerations relevant to public health 

decision-making during planning for and responding to pandemic influenza. The 

Ethics Subcommittee provided input on ethical considerations in vaccine and antiviral drug distribution prioritization and in the development of interventions that 

would limit individual freedom and create social distancing. The resulting 

document, Ethical Guidelines in Pandemic Influenza

33 provides guidance that the 

Ethics Subcommittee proposes serve as a foundation for ethical decision making 

for pandemic influenza. 

The Federal strategy34 for community mitigation is evolving and will be updated 

when new information emerges. Planners should check www.pandemicflu.gov for 

the most current information and strategies to assist in their planning efforts. 

Section 2 - Surveillance and Mitigation 

SEE RELATED APPENDICES 

1. Appendix B—EMS and Non-Emergent Medical Transport Organizations 

Pandemic Influenza Planning Checklist from the Centers of Disease Control 

and Prevention 

2. Appendix C—National Response Plan, ESF 8 (Excerpt) 

3. Appendix M--Pandemic Influenza Resources 

33 Centers for Disease Control and Prevention. ONLINE. 2007. Ethical Guidelines in Pandemic Influenza. 

CDC. Available: www.cdc.gov/od/science/phec/panFlu_Ethic_Guidelines.pdf [2 April 2007]. 

 US Department of Health and Human Services. ONLINE. 2007. Community Strategy for Pandemic 

Influenza Mitigation. Department of Health and Human Services. Available: 

http://www.pandemicflu.gov/plan/community/commitigation.html [21 March 2007] 

44

34
Section 3 – Maintaining Continuity of EMS Operations

During an Influenza Pandemic 

Guideline 3.1 – Maintaining the Day-to-Day Response 

As part of a systematic all-hazards approach to EMS pandemic influenza 

planning, State, local, tribal, and territorial EMS agencies should have plans in 

place that allow EMS to maintain its response to day-to-day emergencies while 

addressing the demands of pandemic influenza mitigation. 

Rationale 

As the provider of prehospital emergency medical triage, treatment and transport, 

EMS plays an important role in every community’s efforts to reduce morbidity 

and mortality from all sudden illness and injury. Community-wide efforts to 

mitigate the spread of pandemic influenza may increase the demand for EMS 

services. 

Considerations 

• To ensure continued delivery of critical services during a pandemic, EMS 

agencies should function within an established Incident Command System. 

• As part of the coordinated community-wide effort to mitigate the spread of 

pandemic influenza, EMS may experience an increase in demand for its 

services. 

• EMS agencies should systematically manage and adapt resources, capabilities 

and procedures to provide maximum benefit to the public’s health in response 

to varying surges in demand. 

• Establish coordinated procedures for the use of alternate resources (e.g. call 

centers) to reduce demand on EMS resources. (See Figure 1) 

• EMS agencies should implement surge capacity procedures as appropriate. 

• EMS and 9-1-1 agencies’ medical directors, in coordination with local public 

health authorities, should modify dispatch procedures and treatment and 

transport protocols as appropriate. (See Figures 1, 2, & 3) 

• Illness and absenteeism during a pandemic may impact an EMS agency’s 

ability to satisfy demand for services. Flexibility in staffing configurations, 

recruitment and training programs may help alleviate the impact of worker 

illness and absenteeism. 

45
Background 

The National Strategy for Pandemic Influenza: Implementation Plan35 addresses 

the importance of prehospital EMS during a pandemic scenario: 

Pre-hospital EMS transportation capability will play a 

critical role in responding to requests for assistance, 

providing treatment, and in triaging patients. 9-1-1 call 

centers/public safety answering points (PSAPs) will 

experience a significant surge in calls and will determine 

how and when EMS units are dispatched. Coordination and 

communication among public health, PSAPs, EMS, and 

hospital officials will be necessary to ensure optimal patient 

care as hospital bed availability and pre-hospital resources 

are strained. Planners should consider modifying PSAP 

call-taker and dispatch protocols and developing pandemicspecific prehospital triage and treatment protocols. A robust 

statewide or regional system for monitoring PSAP medical 

calls, EMS responses and transports, and hospital bed 

availability will be critical for tracking and responding to a 

pandemic. 

In planning for an influenza pandemic, it must be recognized that persons with 

medical conditions unrelated to influenza will continue to require emergency, 

acute and chronic care. Alterations to an EMS system’s practices during an 

influenza pandemic will likely impact all EMS patients, regardless of the nature 

of their illness. It is important to keep the EMS system functioning as effectively 

as possible and to deliver optimal care to both these patients (e.g. motor vehicle 

crashes and cardiac events) as well as to patients with influenza related 

symptoms. 

At the same time as it experiences a surge in calls, EMS is likely to be adversely 

impacted by illness and absenteeism among its workforce, as well as by increases 

in hospital diversion. EMS will be tasked with providing high-quality EMS care 

and patient transportation to the community despite a surge in demand and a 

concomitant loss of trained personnel, an increase in ED diversion and the 

potential for shortages of necessary prehospital equipment and supplies. 

While planners should address the potential for additional duties associated with 

pandemic influenza mitigation, the public demand for EMS services may limit 

this ability. 

FluSurge is a spreadsheet-based model that estimates the surge in demand for 

hospital-based services during the next influenza pandemic. FluSurge estimates 

the number of hospitalizations and deaths of an influenza pandemic (whose length 

35 Homeland Security Council. ONLINE. 2006.National Strategy for Pandemic Influenza: Implementation 

Plan. The White House. Available: http://www.pandemicflu.gov/plan/federal/index.html [20 March 2007]. 

46
and virulence are determined by the user) and compares the number of persons 

hospitalized, the number of persons requiring ICU care, and the number of 

persons requiring ventilator support during a pandemic with existing hospital 

capacity. FluSurge may be downloaded from 

http://www.cdc.gov/flu/tools/flusurge/. 

47
Guideline 3.2 – Continuity of Operations Plan 

 State, local, tribal, and territorial EMS pandemic influenza plans should include 

a continuity of operations (COOP) plan that ensures essential functions and vital 

services can be performed during an influenza pandemic or other major public 

health emergency. 

Rationale 

One of the challenges that EMS may face during an influenza pandemic is to keep 

operations functioning despite increases in call volume, workforce shortages and 

absenteeism, supply chain disruptions and other threats to continued operations. 

Considerations 

• EMS agencies should develop and test their COOP plans based on guidance from 

Federal, State and local governments. 

• EMS COOP plans should be coordinated with emergency management agencies. 

• Pre-established delegations of authority are vital to ensuring that all 

organizational personnel know who has the authority to make key decisions in a 

COOP situation. 

• An order of succession is essential to an organization’s COOP plan. Personnel 

should know who has authority and responsibility if the leadership is 

incapacitated or unavailable. 

• EMS COOP plans should address workforce health protection. 

• EMS agencies should establish policies for flexible worksite (e.g. telecommuting) 

and flexible work hours (e.g. staggered shifts) whenever possible. 

• EMS agencies should establish policies for employee compensation and sickleave absences unique to a pandemic (e.g. non-punitive liberal leave), 

Background 

Maintaining operations during crisis situations is referred to as Continuity of 

Operations, or COOP. The foundation of a viable COOP program is the 

development and documentation of a COOP plan that, when implemented, will 

provide for the continued performance of an organization’s essential functions 

under all circumstances. 

The National Strategy for Pandemic Influenza: Implementation Plan36, references 

the following Continuity of Operations (COOP) program elements: 

36 Homeland Security Council. ONLINE. 2006.National Strategy for Pandemic Influenza: Implementation 

Plan. The White House. Available: http://www.pandemicflu.gov/plan/federal/index.html [20 March 2007]. 

48
1. Planning 

2. Essential functions 

3. Delegation of authority 

4. Succession planning 

5. Alternate physical facilities 

6. Effective communications 

7. Business record-keeping 

8. Human capital 

9. Training 

10. Devolution 

11. Reconstitution. 

Appendix N contains a description of these eleven program elements. Two 

additional elements that do not appear in the original document, Logistics and 

Supplies and Financial Continuity, have been suggested. 

The Department of Homeland Security’s Pandemic Influenza Preparedness, 

Response, and Recovery Guide for Critical Infrastructure and Key Resources37 

was developed to assist the private sector in addressing business continuity during 

a pandemic. The framework, Continuity of Operations Plan-Essential (COP-E) 

supports DHS’s national-level Critical Infrastructure/Key Resources (CI/KR) 

preparedness and protection mission and urges private sector business planners to 

expand upon their traditional notions of business continuity. The Guide states that 

“Eighty-five percent of critical infrastructure resources reside in the private 

sector, which generally lacks individual and system-wide business continuity 

plans specifically for catastrophic health emergencies such as a pandemic 

influenza.” 

 US Department of Homeland Security. ONLINE. 2006. Pandemic Influenza Preparedness, Response, 

and Recovery Guide for Critical Infrastructure and Key Resources. Department of Homeland Security. 

Available: www.pandemicflu.gov/plan/pdf/cikrpandemicinfluenzaguide.pdf [18 March 2007]. 

49

37
Guideline 3.3 – Workforce Augmentation 

State, local, tribal, and territorial EMS agencies should have backup plans to 

augment the EMS workforce. 

Rationale 

Illness, absenteeism, increased workload, and death during a pandemic may 

impact an EMS agency’s ability to satisfy demand for services. Planned flexibility 

in staffing configurations, recruitment and expedited training programs may help 

augment the EMS workforce. 

Considerations 

• Planning for alternative workforce strategies should include medical 

direction, quality improvement, education, supervision and legal authority. 

• EMS planners should be mindful that the primary purpose of regulatory 

models for licensing professionals is to protect the public’s health, safety, 

and welfare. 

• EMS systems might consider a variety of mechanisms to augment their 

workforce including: 

o Mechanisms for temporary licensure of EMS providers from other 

jurisdictions 

o Innovative mechanisms to rapidly recruit, train and license new 

EMS providers 

o Consider non-traditional system configurations and alternate 

staffing configurations 

o Utilization of retired EMS and healthcare personnel 

o Coordination with local Medical Reserve Corps38 (MRC) 

Community Emergency Response Teams

39 (CERT), or cross 

staffing between EMS, healthcare and other sectors 

o Proactively determine competencies and bridge courses from other 

professions and levels of EMS licensure 

o Temporary modification of licensure and credentialing procedures 

to meet the exigencies of the situation while assuring public health 

and safety. 

o Engaging temporary workers, contractors and recent retirees, 

and/or cross-training the existing workforce 

• EMS agencies should support telecommuting when feasible. 

38 http://www.medicalreservecorps.gov/HomePage 39 https://www.citizencorps.gov/cert/ 

50
Background 

The Federal Government, as mentioned in the National Strategy for Pandemic 

Influenza: Implementation Plan,40 recommends that government entities and the 

private sector plan with the assumption that up to 40 percent of their staff may be 

absent for periods of about two weeks at the height of a pandemic wave, with 

lower levels of staff absent for a few weeks on either side of the peak. 

Absenteeism will increase not only because of personal illness or incapacitation 

but also because employees may be caring for ill family members, under 

voluntary home quarantine due to an ill household member, minding children 

dismissed from school, following public health guidance, or simply staying at 

home out of safety concerns. 

FluWorkLoss41 is a tool available from the CDC that estimates the potential 

number of days lost from work due to an influenza pandemic. Users can change 

almost any input value, such as the number of workdays assumed lost when a 

worker becomes ill or the number of workdays lost due to a worker staying home 

to care for a family member. Users can also change the length and virulence of the 

pandemic so that a range of possible impacts can be estimated. FluWorkLoss 

provides a range of estimates of total workdays lost, as well as graphic 

illustrations of the workdays lost by week and percentage of total workdays lost to 

influenza-related illnesses. 

 US Department of Homeland Security. ONLINE. 2006. Pandemic Influenza Preparedness, Response, 

and Recovery Guide for Critical Infrastructure and Key Resources. Department of Homeland Security. 

Available: www.pandemicflu.gov/plan/pdf/cikrpandemicinfluenzaguide.pdf [18 March 2007]. 41 Praveen Dhankhar, Zhang X, Meltzer MI, Bridges CB. ONLINE. 2006. FluWorkLoss 1.0: a manual to 

assist state and local public health officials in estimating the impact of an influenza pandemic on work day 

loss (Beta test version). CDC. Available: www.cdc.gov/flu/pdf/FluWorkLoss_Manual_102306.pdf [22 

March2007] 

FluWorkLoss software may be downloaded from http://www.cdc.gov/flu/tools/fluworkloss/ 

51

40
Guideline 3.4 – Disruption of Equipment, Supplies and 

Services 

EMS agencies should plan for disruptions in the availability of equipment, 

supplies, and services. 

Rationale 

The unpredictable nature of an influenza pandemic makes it difficult to ensure the 

consistent availability of essential equipment, supplies and services. 

Considerations42,43,44 

• EMS planners should: 

o work with suppliers and clients to maintain business continuity in the 

event of transportation or distribution disruptions in accordance with local 

priorities and critical needs. 

o recognize that normal supply lines may be slowed or inoperable for an 

extended period of time and to make personal and business preparations 

for pandemics for up to 12 weeks (e.g., stockpiling food, water, oxygen 

and delivery supplies, suction unit disposables, IV and medical supplies, 

and medications). 

o identify business functions that could be outsourced or transferred to other 

facilities within the organization in the event of high employee 

absenteeism. 

• EMS agencies should: 

o maintain a contact list of current suppliers and develop an alternate list of 

suppliers for critical supplies and essential resources and services 

including fuel distributors. 

o maintain sufficient and accessible, infection control supplies (e.g., handhygiene products, tissues, PPE(gloves, FDA-approved surgical masks, 

NIOSH-certified N95 or higher respirators, etc.) and receptacles for their 

disposal) 

42 US Department of Health and Human Services. ONLINE. 2006. Pandemic Preparedness Planning for

US Businesses with Overseas Operations Checklist. Department of Health and Human Services. Available:

http://www.pandemicflu.gov/plan/workplaceplanning/index.html [18 March 2007]. 43 US Department of Health and Human Services. ONLINE. 2006. Business Pandemic Influenza Planning

Checklist Department of Health and Human Services. Available:

http://www.pandemicflu.gov/plan/workplaceplanning/index.html [18 March 2007]. 44 Vermont Department of Health. ONLINE. 2007. EMS Strategies for Pandemic Flu Response Working 

Draft. VT Department of Health. Available: 

http://healthvermont.gov/hc/ems/documents/EMSStrategiesforPandemicFluResponse.pdf [21 March 

2007]. 

52
o work with local law enforcement and security firms to develop security 

plans to protect operations, facilities, supplies, and other infrastructure 

critical to an EMS response. 

o should maintain a supply of food staples or other feeding arrangements at 

work facilities to avoid personnel needs to shop or eat out while on duty 

• EMS and 9-1-1 planners should coordinate with State, local, tribal, and territorial 

public health authorities in planning for the storage and distribution of 

medications and other medical materiel, including countermeasures to support 

Targeted Layered Containment, consistent with local laws and regulations. 

Background 

The impact of disasters is generally felt most severely at the local level. During an 

influenza pandemic, State, local, and private stocks of material may be depleted quickly. 

A severe pandemic could have substantial impact on the global economy and on the 

functioning of society. Worker absenteeism, and other difficulties, will likely impact 

transportation networks, manufacturers, and other sectors upon which EMS systems rely. 

Public and private sector businesses should familiarize themselves with the various 

community mitigation strategies in the jurisdictions where they operate including social 

distancing, quarantine laws, and movement restrictions. 

The Department of Homeland Security45 encourages system planners to assess legal and 

regulatory authorities, issues, and restraints that could affect the supply chain, 

transportation of goods and services, priority for delivery, and workplace safety issues. 

Additionally, EMS planners should consider the risks, impacts, and implications of 

pandemic-related disruptions to international production, supply chain, goods, and 

personnel movement. The majority of U.S. businesses rely on a global network of 

essential material and support functions. Disruptions in international trade could result in 

cascading impacts across EMS agencies even before pandemic disease outbreaks reach 

the United States. 

45 US Department of Homeland Security. ONLINE. 2006. Pandemic Influenza Preparedness, Response, 

and Recovery Guide for Critical Infrastructure and Key Resources. Department of Homeland Security. 

Available: www.pandemicflu.gov/plan/pdf/cikrpandemicinfluenzaguide.pdf [18 March 2007]. 

53
Guideline 3.5 - Interoperable Communications 

State, local, tribal, and territorial EMS pandemic influenza plans should include 

effective, reliable interoperable communications systems among EMS, 9-1-1, 

emergency management, public safety, public health and health care agencies. 

Rationale 

Coordination of reliable communications systems among public health, 9-1-1 

PSAPs, EMS, emergency management, public safety and health care officials is 

necessary to ensure optimal patient care. 

Considerations 

• EMS pandemic plans should address the ability of emergency communications 

systems to support the incident command system. 

• Communications systems should support the EMS provider’s role in providing 

optimal patient care during a pandemic (e.g., just-in-time training, disease 

surveillance, patient tracking, resource tracking, etc.). 

• This guideline is consistent with the current version of the Department of 

Homeland Security’s Target capability List46 for “Triage and Pre-hospital 

Treatment.” 

Background 

EMS agencies rely on communications systems at multiple points in the 

emergency response process. EMS communications systems may include: 

• Accepting communications into a 9-1-1 center. 

• Dispatching communications from a 9-1-1 center. 

• Routing communications to and between emergency operations centers 

including lateral transfer of 9-1-1 calls when appropriate. 

• Routing selected communications to non-emergency call centers as 

defined by local policies or protocols. 

• Coordination of communications between field EMS personnel, incident 

command, medical control and healthcare facilities. 

• Emergency communication with the public (e.g., emergency alert system 

and outbound emergency communications systems). 

EMS pandemic influenza planners should consider each of these communications 

systems and their capacities in terms of call volume, interoperability, and 

 US Department of Homeland Security. ONLINE. 2005. Target Capabilities List Version 1.1. ODP 

Secure Portal. Available: https://odp.esportals.com. Lessons Learned Information Sharing. Available: 

www.llis.gov [18 March 2007]. 

54

46
redundancy and consider how to ensure the effectiveness of theses 

communications systems during an influenza pandemic. 

The communications discipline is one of the keys to effective incident 

management, and ideally, these systems would be centralized through established 

ICS channels. There should also be a plan for backup or redundant 

communication strategies in case there are failures in primary communication 

methods. Similarly, other backup procedures for actions that can be taken when 

systems fail should be planned, tested in advance, and integrated into the planning 

process. 

55
Guideline 3.6 – Compatible Communications Equipment

and Communications Frequencies 

EMS pandemic influenza plans should include compatible communications 

equipment and communications radio frequency plans for common hospital 

diversion and bed capacity situational awareness at the local, State and regional 

level. 

Rationale 

Communications is important to maintaining situational awareness and to 

effective EMS operations during an influenza pandemic or other public 

health emergency. 

Considerations 

• The use of an Internet-Protocol based communications system could facilitate 

redundancy and real-time communications. 

• Alternative or secondary telephone systems and radio frequencies could be 

established to reduce the load on the primary systems. 

• This guideline is consistent with the current version of the Department of 

Homeland Security’s Target capability List47 for “Triage and Pre-hospital 

Treatment” 

Background 

Using existing communications systems is critical to maintaining efficient and 

effective EMS operations during an evolving pandemic. As the availability of 

EMS response, hospital beds, and regional pandemic influenza status changes, it 

is essential that all entities receive consistent communication in a timely fashion. 

This involves planning for the use of the communications infrastructure and may 

also involve nontraditional use of existing communication systems. 

There should be backup or redundant communication strategies in case there are 

failures in primary communication methods. Similarly, other backup procedures 

for actions that can be taken when systems fail should be planned, tested in 

advance, and integrated into the planning process. 

Upgrading emergency communications technology offers additional advantages. 

“Next Generation” 9-1-1 technology enhances emergency communications and 

enables the transmission of voice, data, text, and video/photographs from a variety 

 US Department of Homeland Security. ONLINE. 2005. Target Capabilities List Version 1.1. ODP 

Secure Portal. Available: https://odp.esportals.com. Lessons Learned Information Sharing. Available: 

www.llis.gov [18 March 2007]. 

56

47
of communication devices, directly to the PSAP and on to emergency responders 

via their communication networks. Based upon Internet Protocol enabled (IPenabled) technology, it transmits information as a digital data packet, from the 

source to the PSAP, and on to emergency responders, as deemed appropriate. 

Within the context of Pandemic Influenza, this technology offers the following 

advantages to 9-1-1 service: 

• Allows voice, data, text and video/photographs to be transmitted directly 

to the PSAP 

• Allows all transmissions to arrive at the PSAP as a native 9-1-1 call (some 

data currently is shared by person-to-person transmission, or via an 

administrative phone line versus 9-1-1 trunk line. 

• Allows call centers to transfer calls directly to the appropriate PSAP as a 

9-1-1 call. 

• Allows data to be shared with emergency responders and other health care 

provider agencies, as deemed appropriate. 

• Allows 9-1-1 calls to be transferred to other PSAPs locally as well as 

“long distance,” enabling call transfer, rerouting, and back-up in the event 

of system overload or PSAP closure. 

• Allows interoperable communications between 9-1-1 and traditional 

“push-to-talk” radio communications systems. 

Additional information on Next Generation 9-1-1 technology can be found on the 

Department of Transportation’s Intelligent Transportation System website at: 

http://www.its.dot.gov/ng911/index.htm or the National Emergency Number 

Association’s Next Generation 9-1-1 Partner Program, at: http://www.nena.org/. 

Section 3 - The Role of EMS in Pandemic Influenza Response 

SEE RELATED APPENDICES 

4. Appendix B—EMS and Non-Emergent Medical Transport Organizations 

Pandemic Influenza Planning Checklist from the Centers of Disease Control 

and Prevention 

5. Appendix N—Continuity of Operations Program Elements 

57
Section 4 - Legal Authority 

Guideline 4.1 – Deviation from Established Procedures 

State EMS pandemic influenza plans should establish procedures for EMS 

providers to deviate legally from their established treatment procedures to 

support mitigation of and response to pandemic influenza and other public 

health emergencies while still assuring appropriate education, medical oversight 

and quality assurance. 

Rationale 

Providing established and dynamic procedures for EMS providers to deviate 

legally from their established, day-to-day treatment procedures supports the 

evolving role of EMS while still providing for high quality patient care. 

Considerations 

• State and local EMS pandemic influenza plans should provide for expedited 

review and approval of new treatment modalities and procedures. They 

should provide sufficient flexibility to EMS Medical Directors to credential 

EMS providers to perform procedures and to administer medications to match 

the exigencies of the situation while still protecting public safety through 

appropriate education, medical oversight and quality assurance. 

• There should be an EMS statewide system to “trigger” the authorization of 

new procedures and medications by EMS providers in coordination with 

public health officials. 

• A just-in-time training program, combined with appropriate and coordinated 

information to the EMS medical directors and EMS providers, will help to 

ensure appropriate and competent medical care. 

• There should be mechanisms for temporary licensure of EMS providers from 

other jurisdictions or those who may be retired or inactive providing there are 

sufficient safeguards to protect public health and safety. 

• EMS pandemic influenza plans might consider opportunities to make 

optimum use of volunteer health personnel through the Emergency System for 

Advance Registration of Volunteer Health Professionals (ESAR-VHP48). 

48 Public Health Security and Bioterrorism Preparedness and Response Act of 2002, Pub. L.No. 107-188 § 

107, 116 STAT. 595 (2002). See also http://www.hrsa.gov/esarvhp/ 

58
• EMS pandemic influenza plans should integrate the capabilities and resources 

of various governmental jurisdictions, incident management and emergency 

response disciplines, and the private sector to conform to the National Incident 

Management System49 (NIMS). 

• There should be pre-event coordination between those administering the EMS 

licensing laws and those administering laws that may waive certain health 

occupation licensing provisions in emergency situations such as emergency 

health powers acts. 

• Public health, law enforcement, emergency management officials and fire 

officials, Public Safety Answering Points (PSAPs) and EMS first responders 

will benefit from joint training on the legal authorities essential to effective 

response in public health emergencies before the emergency occurs. 

• Deviation from established treatment protocols might, for instance, also 

include administration of vaccines and anti-virals, new medications, 

declaration of death or other activities. 

Background – Scope of Practice 

Scope of practice is a description of what a licensed individual legally can, and 

cannot, do. Each State has the statutory authority and responsibility to regulate 

EMS within its borders and to determine the scope of practice of State-licensed 

EMS personnel. Scopes of practice are typically defined in law, regulations or 

policy documents. In contrast, credentialing is a local process by which an 

individual is permitted by a specific entity (EMS medical director) to practice in a 

specific setting (EMS agency). 

It is virtually impossible to create a scope of practice that takes into account every 

unique situation, extraordinary circumstance, and possible practice situation. This 

is further complicated by the fact that EMS personnel are an essential component 

of disaster preparedness and response. In many cases, EMS personnel are the only 

medically trained individuals at the scene of a disaster when other healthcare 

resources may be overwhelmed. 

The National EMS Scope of Practice Model50 states that it cannot account for 

every situation, but rather is designed to establish a system that works for entrylevel personnel under normal circumstances. It is assumed that the scope of 

practice of EMS personnel may be modified or changed in times of disaster or 

crisis with proper education, medical oversight and quality assurance to 

reasonably protect patient safety. 

If predictions about the surge of patients and the concomitant increase in 

absenteeism among EMS personnel become a reality, EMS providers’ regular 

49 US Department of Homeland Security. ONLINE. 2004. National Incident Management System.

Department of Homeland Security. Available: www.fema.gov/pdf/emergency/nims/nims_doc_full.pdf [18 

March 2007]. 50 National Highway Traffic Safety Administration. 2007. National EMS Scope of Practice Model.

Washington, DC, National Highway Traffic Safety Administration.

59
day-to-day practices may need to be modified during pandemic influenza. In 

addition, staff may be apprehensive about leaving home, need to care for sick 

family members and/or may find it difficult to travel to work. Burnout from stress 

and long hours may occur, and replacement staff may be needed. 

EMS pandemic influenza plans should identify sufficient State legislative 

authority, administrative rules/regulations and liability protection to support the 

role of EMS providers during a pandemic influenza event or other major public 

health emergencies. The legal authority should provide for a system in which the 

procedures and medications that EMS providers are authorized to use may be 

dynamically modified, if necessary, to reflect the evolving roles of EMS providers 

during an influenza pandemic, while simultaneously assuring medical direction, 

appropriate education and quality assurance. 

Background – Other legal issues 

The organization and delivery of healthcare is highly regulated. During a public 

health emergency such as an influenza pandemic, it is likely there may be 

temporary modification of other regulatory requirements at all levels of 

government. For instance, the National Strategy for Pandemic Influenza: 

Implementation Plan51 suggests waivers and modification of certain legal 

requirements during pandemic influenza. It asserts, “Depending on the severity of 

a pandemic, certain requirements may be waived or revised to facilitate efficient 

delivery of health care services.” 

While significant progress has been made since the terrorist attacks on September 

11, 2001, in establishing joint investigative protocols and linkages among the key 

components of public health, emergency management, Public Safety Answering 

Points, law enforcement and emergency response communities, pandemic 

influenza will present new challenges. As a result, it is important that all 

concerned understand their roles and the governing legal authorities so that they 

can coordinate their efforts under a complex set of Federal, State, tribal, and local 

laws. Federal, State, local and tribal governments should review their legal 

authorities to respond to an influenza pandemic and identify needed changes. 

To the extent possible, existing laws and other mechanisms should be used to the 

fullest. It is therefore important to examine existing State public health laws, 

licensing/certification laws, interstate emergency management compacts and 

mutual aid agreements, and other legal and regulatory arrangements to determine 

the extent to which they permit necessary planning for pandemic influenza. 

A summary of several different applicable Federal laws and a variety of legal, 

regulatory and accreditation issues is included in Appendix P. The Draft Checklist 

51 Homeland Security Council. ONLINE. 2006.National Strategy for Pandemic Influenza: Implementation 

Plan. The White House. Available: http://www.pandemicflu.gov/plan/federal/index.html [20 March 2007] 

60
for State and Local Government Attorneys to Prepare for Possible Disaster52 may 

also provide helpful information to EMS services. The checklist includes lists of 

questions pertaining to authority in general, authority for surveillance, and 

intergovernmental joint powers agreements. In addition, it addresses public 

information, administrative and fiscal issues, contracting, personnel, and liability. 

The Model State Emergency Health Powers Act53 grants specific emergency 

powers to State governors and public health authorities in the event of a large 

public health emergency and addresses liability issues. The Model Act was 

developed for the Centers for Disease Control and Prevention (CDC) by the 

Center for Law and the Public’s Health at Georgetown and Johns Hopkins 

Universities to ensure an effective response to large-scale emergency health 

threats while protecting the rights of individuals. (Additional information is 

provided in Appendix E.) 

Colorado has chosen to plan for disaster emergencies by using draft executive 

orders54 to create a legal framework for an emergency including the suspension of 

certain statutory provisions. These may provide another option for states to 

consider when seeking regulatory relief in an emergency. (Document included as 

Appendix F.) 

52 American Bar Association. ONLINE. 2003. Draft Checklist for State and Local Government Attorneys 

to Prepare for Possible Disasters. American Bar Association. Available: 

www.abanet.org/statelocal/disaster.pdf [18 March 2007]. 53 Lawrence O. Gostin, et al. The Model State Emergency Health Powers Act: Planning for and Response 

to Bioterrorism and Naturally Occurring Infectious Diseases, 288 JAMA 622 (2002). See also The Center 

for Law and the Public’s Health web site http://www.publichealthlaw.net/Resources/Modellaws.htm 

54 Colorado Department of Public Health and Environment. ONLINE 2006. CDPHE Internal Emergency 

Response Plan Governor’s Emergency Epidemic Response Committee (GEEERC) Draft Executive Orders 

Updated Oct. 23, 2006. CDPHE. Available: 

http://www.cdphe.state.co.us/bt/HealthProviders/Attachment3.pdf [20 March 2007] 

61
Guideline 4.2 – EMS Freedom of Movement 

State EMS pandemic influenza plans should, in coordination with public health, 

emergency management, and law enforcement agencies, identify mechanisms to 

ensure freedom of movement of EMS assets (vehicles, personnel, etc.) when faced 

with restricted travel laws, isolation/quarantine or security measures. 

Rationale 

Ensuring EMS personnel are able to move freely even though there may be travel 

restrictions is essential to the performance of their duties. 

Considerations 

• Movement of EMS personnel and resources during isolation and quarantine 

should be coordinated, in advance, with public health, emergency management, 

and law enforcement officials. 

• This guideline is consistent with the current version of the Department of 

Homeland Security’s Target capability List55 for “Triage and Pre-hospital 

Treatment” 

Background 

A jurisdiction’s chief executive may have the authority, depending upon State and 

local law, to order quarantine in coordination with the local health authority. 

Quarantine has the potential to impact the transportation of patients by 

ambulance, as well as the ability of EMS and Public Safety Answering Point 

(PSAP) personnel to travel from their homes to their places of employment. State 

and local planners must be cognizant of this possibility and include processes in 

their pandemic influenza plans to allow EMS and PSAPs to maintain continuity of 

operations during these extraordinary circumstances. 

Section 4 - Legal Authority 

SEE RELATED APPENDICES 

1. Appendix E-- Model State Emergency Health Powers Act (excerpt) 

2. Appendix F-- Colorado Draft Executive Orders 

3. Appendix P—Other legal and regulatory issues 

 US Department of Homeland Security. ONLINE. 2005. Target Capabilities List Version 1.1. ODP 

Secure Portal. Available: https://odp.esportals.com. Lessons Learned Information Sharing. Available: 

www.llis.gov [18 March 2007]. 

62

55
Section 5 - Clinical Standards and Treatment Protocols 

Guideline 5.1 – EMS Medical Direction 

Each State, local, tribal, and territorial EMS system should have an EMS 

medical director to provide medical oversight of EMS pandemic influenza 

planning, mitigation and response. 

Rationale 

An EMS medical director provides medical leadership, oversight, coordination, 

system quality management, and research to ensure the safest and highest-quality 

care for patients. 

Considerations 

• EMS medical directors should play a lead role in pandemic influenza planning 

efforts in collaboration with public health officers. 

• EMS medical directors should have knowledge and experience with the clinical 

and operational aspects of the EMS System. 

• EMS medical directors should provide medical oversight of the EMS system, 

including 9-1-1, during an influenza pandemic. 

• There should be a statewide system, coordinated with public health and 

emergency management officials, that ensures EMS medical directors are 

promptly notified of the latest disease information.

• Local EMS medical director oversight, including credentialing of additional EMS 

personnel skills, modification of treatment protocols should be consistent with 

State laws, rules and policies. 

Background 

Given the uncertainty of the disease, its treatment and progression, the ongoing 

role of EMS medical directors is critically important. The guidance provided in 

this document is based on current knowledge of routes of influenza transmission, 

the pathogenesis of influenza, and the effects of influenza control measures used 

during past pandemics and inter-pandemic periods. Given some uncertainty about 

the characteristics of a new pandemic strain, all aspects of preparedness planning 

for pandemic influenza must allow for flexibility and real-time decision-making 

that take new information into account as the situation unfolds. 

63
The specific characteristics of a new pandemic virus—virulence, transmissibility, 

initial geographic distribution, clinical manifestation, risk to different age groups 

and subpopulations, and drug susceptibility—will remain unknown until the viral 

strain is identified. Therefore, the ongoing involvement of EMS medical directors 

is essential. 

Appendix M contains suggested resources for EMS medical director training. 

64
Guideline 5.2 – Modification of Treatment and Triage

Protocols 

State, local, tribal and territorial EMS pandemic influenza plans should define 

mechanisms for rapid development, adoption or modification of prehospital 

clinical standards and triage and treatment protocols before or during an 

influenza pandemic that are based upon the most recent scientific information. 

Rationale 

If a pandemic exceeds the healthcare capacity of a community, it may be 

necessary to modify the provision of emergency medical care during an influenza 

pandemic. 

Considerations 

• EMS and 9-1-1 planning efforts should include thresholds for modification of 

triage and treatment algorithms (e.g., trigger points). 

• Local EMS plans should establish rapid mechanisms for modifying prehospital 

treatment and triage protocols taking into consideration current State and Federal 

guidance that are consistent with established “trigger points”. 

• EMS medical directors should play a lead role in planning efforts that identifies 

areas for potential protocol modification related to dispatch, triage, and treatment 

concerns in advance of a pandemic. 

• The prehospital triage protocols and 9-1-1 triage protocols should be coordinated 

to determine who receives emergency care or transport. (See sample Figure 2) 

• The system should include points of referral for patients who need information 

but do not need emergency care or transport. [Refer to companion document 

Preparing for Pandemic Influenza: Recommendations for Protocol Development 

for 9-1-1 Personnel and Public Safety Answering Points for more information.] 

• In support of community mitigation strategies, the appropriate care may be to 

have individuals stay at home and practice social distancing and quarantine 

measures rather than be transported to a healthcare facility. 

• Local EMS plans should coordinate with receiving facilities (e.g., hospital 

emergency departments), other EMS and non-emergent (medical) transport 

organizations, and local planning groups to manage the transportation of large 

numbers of patients during an evolving pandemic. 

• EMS should be involved in community-wide planning for establishing alternatecare sites. 

• The process for allocating health and medical resources during an influenza 

pandemic should be fair, clinically sound, and include public input. 

65
Background 

The allocation of scarce resources56 and the decision-making that allocates 

resources to the most viable patients is at the heart of existing EMS triage 

protocols. EMS planners are familiar with the difficult challenges of triaging 

multiple patients. Alternate Care Facilities may be established to function as 

primary triage sites, providing limited supportive care, offering alternative 

isolation locations to influenza patients, and serving as recovery clinics to assist in 

expediting the discharge of patients from hospitals. 

Planning should therefore include thresholds for modifying triage algorithms and 

otherwise optimizing the allocation of scarce resources. In addition, the 

appropriate method of care for certain patients may involve social distancing and 

quarantine strategies rather than transport to a health care facility. These 

community mitigation strategies may help to ensure health care resources are best 

utilized. Additionally they may be the best method of managing a section of the 

population who would otherwise be exposed to additional illness at overwhelmed 

health care facilities. Where prospective and mature data are available, changes 

in clinical care algorithms should be evidence-based. 

According to the National Strategy for Pandemic Influenza: Implementation 

Plan57, should pandemic influenza occur, preference should be given to “those 

patients whose medical condition suggests that they will obtain greatest benefit 

from them.” This rationale differs from approaches to care in which resources are 

provided on a first-come, first-served basis or to patients with the most severe 

illnesses or injuries. 

Altered Standards of Care in Mass Casualty Events58 offers a framework and 

guiding principles for planning for health and medical care in a mass casualty 

event. Excerpts from that document can be found in Appendix G. 

In planning for a prolonged public health emergency, it must be recognized that 

persons with unrelated medical conditions will continue to require emergency, 

acute and chronic care. It is important to keep the healthcare system functioning 

as effectively as possible for these patients, as well as for influenza patients. 

A sample of an EMS protocol, modified according to the Pandemic Influenza 

Severity Index, is included in the PLANNING ASSUMPTIONS AND GUIDELINE 

OVERVIEW- A SUMMARY. (Figure 3) 

56 Agency for Healthcare Research and Quality. ONLINE. 2006. Providing Mass Medical Care with 

Scarce Resources: A Community Planning Guide. AHRQ. Available: http://www.ahrq.gov/research/mce/ 

[21 March 2007]. 57 Homeland Security Council. ONLINE. 2006.National Strategy for Pandemic Influenza: Implementation 

Plan. The White House. Available: http://www.pandemicflu.gov/plan/federal/index.html [20 March 2007]. 58 Agency for Healthcare Research and Quality. ONLINE. 2005. Altered Standards of Care in Mass 

Casualty Events: Bioterrorism and Other Public Health Emergencies. AHRQ. Available: 

www.ahrq.gov/research/altstand/ [21 March 2007]. 

66
Guideline 5.3 – Rapid Distribution of New Protocols 

State, local, tribal, and territorial EMS pandemic influenza plans should define 

consistent, system-wide procedures for the rapid distribution of new or modified 

prehospital EMS treatment and triage protocols before or during an influenza 

pandemic 

Rationale 

EMS providers’ practice should be based on the most up-to-date pandemic 

influenza clinical recommendations and treatment protocols/information from 

appropriate public health authorities and EMS medical direction. 

Considerations 

• EMS pandemic influenza plans must be sufficiently dynamic and flexible to allow 

EMS treatment protocols to be developed and distributed as soon as information 

about the viral strain and Federal and State treatment recommendations become 

available. 

• EMS agencies should coordinate with local public health authorities to include a 

process to obtain and disseminate a “pandemic influenza symptom set” (case 

definition) that helps identify potential pandemic influenza patients as soon as the 

information becomes available. 

• EMS pandemic influenza plans must include specific, time-sensitive processes for 

State, local, tribal, and territorial EMS agencies and EMS medical directors to 

coordinate with Federal, State, and local public health authorities to immediately 

obtain new information about emerging disease threats. 

• There should be clearly defined procedures for rapid dissemination of pandemic 

influenza information among EMS, 9-1-1, public health, PSAPs and other 

officials. This should include coordination with the CDC’s Health Alert Network 

and/or PHIRE59. 

• Available technologies should be considered in distributing information in a 

timely fashion. 

Background 

Given the uncertainty about the characteristics of a new pandemic strain, all aspects of 

preparedness planning must allow for flexibility and real-time decision-making based on 

evolving information. The specific characteristics of a new pandemic virus—virulence, 

transmissibility, initial geographic distribution, clinical manifestation, risk to different 

59 Centers for Disease Control and Prevention. ONLINE. 2007. Health Alert Network. CDC. Available: 

http://www.bt.cdc.gov/documentsapp/HAN/han.asp [18 March 2007] 

67
age groups and subpopulations, and drug susceptibility—will remain unknown until the 

viral strain is identified. 

The Centers for Disease Control and Prevention is a trusted source of important, timely 

information concerning actual or potential public health emergencies. PHIRE, the CDC 

Public Health Information Rapid Exchange, is a system that sends important real-time 

health information to select subscribers based on their preferences. For example, the 

system enables CDC to rapidly disseminate alerts about evidence of suspected pandemic 

influenza in the United States. 

PHIRE is a secure electronic communication system designed to keep health care 

providers informed to protect our Nation’s health. The information is provided in real 

time during an emergency and also allows subscribers the ability to have scheduled 

moderated forums. The information registrants provide regarding their county and work 

setting enables the CDC to target relevant emergency health information specific to the 

registrants needs. 

More information, including the ability to register can be done at www.cdc.gov/phire. 

68
Guideline 5.4 – Just-in-Time Training 

State, local, tribal, and territorial EMS pandemic influenza plans should define a 

process for providing just-in-time training for EMS agencies, EMS providers, 

EMS medical directors and PSAPs. 

Rationale 

Just-in-time training (information) will ensure that EMS providers and PSAPs 

receive information and education to support the rapid adoption of new or 

modified clinical algorithms, treatment protocols or other pertinent information. 

Considerations 

• There should be clearly defined procedures for rapid dissemination of 

pandemic influenza information (clinical and non-clinical) among EMS, 9-1­

1, public health, PSAPs and other officials. 

• The adoption of modified triage and treatment protocols will require sufficient 

information related to the emerging viral strain, as well as medical oversight 

to ensure quality of care. 

• Drills and exercises, coordinated with public health and emergency 

management officials, should be used to validate pandemic influenza response 

plans and training programs. 

• Various technologies may be useful in assuring just-in-time training. 

Background 

“Just-in-time” training and education refers to the timely provision of information 

and instructions as they become available, and when users need them. 

As an example of just-in-time training, the Centers for Disease Control and 

Prevention (CDC), National Center for Injury Prevention and Control (NCIPC), 

Division of Injury Response (DIR) has been working with seven communities as 

best practice models for how emergency medical services (EMS) can work with 

other safety and public health agencies in times of disaster. 

Constructed around the interrelated activities of partnership building, learning 

lessons from terrorist events, and disseminating information, the Terrorism 

Injuries Information, Dissemination and Exchange (TIIDE) Project60 was 

established through a cooperative agreement in response to the urgent, ongoing 

need to develop, disseminate and exchange information about injuries from 

60 Centers for Disease Control and Prevention. ONLINE. 2006. Terrorism Injuries Information, 

Dissemination and Exchange (TIIDE) Project. CDC. Available: 

http://www.bt.cdc.gov/masscasualties/tiidefacts.asp [21 March 2007] 

69
terrorism. As part of CDC's TIIDE Project, Model Communities identify where 

relationships between the emergency care community and public health officials 

are established and operate at levels that effectively respond to events that may 

cause large numbers of injuries. Fact sheets61 will be developed for health care 

audiences such as EMS providers and a variety of prehospital care professionals, 

in-hospital clinicians and others. (A sample is included as Appendix D.) Such 

models could be used by local planners to enhance HAN notices and to 

disseminate case definitions, fact sheets, and other important information to EMS 

medical directors, PSAPs, and EMS providers during an influenza pandemic. 

Guidance regarding just-in-time pandemic influenza training is incorporated in 

the CDC EMS and Non-Emergent (Medical) Transport Organizations Pandemic 

Influenza Planning Checklist62. 

61 Sample fact sheet available at http://www.bt.cdc.gov/masscasualties/pdf/blastinjuries.pdf 

 US Department of Health and Human Services. ONLINE. 2006. Emergency Medical Services and NonEmergent (Medical) Transport Organizations Pandemic Influenza Planning Checklist. Department of 

Health and Human Services. Available: http://www.pandemicflu.gov/plan/healthcare/emgncymedical.html 

[18 March 2007]. 

70

62
Guideline 5.5 – Fatality Management 

State, local, tribal, and territorial EMS pandemic influenza plans should 

coordinate with public health and 9-1-1 officials and the local medical 

examiner/coroner to define protocols and processes for fatality management 

during pandemic influenza. 

Rationale 

While not traditionally part of their day-to-day duties, EMS personnel may be 

called upon to assist with fatality management during an influenza pandemic or 

other public health emergency. 

Considerations 

• EMS planners should collaborate with appropriate State authorities to identify 

roles, policies, and procedures for handling fatalities during a pandemic. 

• EMS plans for pandemic influenza should coordinate with the State and local 

medical examiner/coroner to determine legal authority and appropriate protocols 

for the presumption or pronouncement of death including documentation 

requirements and proper handling of human remains during an influenza 

pandemic. 

Background 

An influenza pandemic is expected to result in an increased number of deaths 

both in and out of medical facilities. Existing fatality management systems in 

communities will require an increased capacity and capability to manage deaths 

resulting from a pandemic. 

Deaths of persons at home or away from healthcare facilities fall under the 

jurisdiction and surveillance of medicolegal death investigators. Medical 

Examiners/Coroners have State statutory authority to investigate deaths that are 

sudden, suspicious, violent, unattended, or unexplained; therefore, these 

investigators have a role in recognizing and reporting fatal outbreaks as part of the 

larger public health system and can be instrumental in developing relevant local 

protocols that help mitigate the burden that case fatalities can place on the 

system63. 

 Centers for Disease Control and Prevention.. ONLINE. 2004. Medical examiners, coroners, and 

biologic terrorism: a guidebook for surveillance and case management. MMWR 2004;53(No. RR8):[inclusive page numbers]. CDC. Available: http://www.cdc.gov/mmwr/PDF/RR/RR5308.pdf [21 March 

2007] 

71

63
Additional information on the role of EMS in fatality management64 may be 

found in Appendix H as excerpted from the White Paper: The Provision of Family 

Assistance and Behavioral Health Services in the Management of Mass Fatalities 

Resulting from a Pandemic Influenza in the United States. 

64 Excerpted from US Northern Command and Department of Health and Human Services Fatality 

Management Pandemic Influenza Working Group Conference. ONLINE. 2006. White Paper: The 

Provision of Family Assistance and Behavioral Health Services in the Management of Mass Fatalities 

Resulting from a Pandemic Influenza in the United States. Joint Task Force Civil Support. Available 

www.jtfcs.northcom.mil/pages/WP_SceneOps(FINAL).pdf [21 Macrh 2007]. 

72
Guideline 5.6 – EMS Treat and Release 

EMS pandemic influenza plans should consider the role EMS providers could 

serve in “treating and releasing” patients without transporting them to a 

healthcare facility. 

Rationale 

Community containment strategies designed to limit the spread of the influenza 

virus may require patients be treated and released without transport. Additionally, 

healthcare facilities may become overwhelmed with patients, making it necessary 

to consider alternative options for patients who can be safely treated without 

transport. 

Considerations 

• If a treatment without transport role is deemed appropriate for EMS providers, the 

EMS medical director, in coordination with local public health authorities, should 

establish criteria and reporting requirements. 

• “Treat and release” and “treatment without transport” protocols require oversight 

by EMS medical directors. 

• EMS agencies and EMS medical directors should coordinate with the local public 

health authorities to pre-determine the destination of both suspected influenza and 

non-influenza patients. 

• EMS provider credentialing and Scope of Practice issues should be addressed, as 

appropriate. In many cases (e.g., treatment of hypoglycemia Type I diabetics with 

IV D50, listening to lung sounds, providing IVs for hydration, and assessment of 

oxygen saturation levels) may fall within existing Scopes of Practice. 

• Appropriate education programs for EMS personnel, physicians, and the public 

should be established before the implementation of non-transport policies. 

• Educational materials and referral services should be established and provided to 

patients who are not transported to medical facilities, including instructional 

material for follow-up care and other services. 

Background 

The concept of “treat and release” is familiar to EMS providers. During an 

influenza pandemic the “treat and release” concept is vital to maintain community 

mitigation strategies, such as social distancing and voluntary quarantine. 

Additionally “treat and release” may be the best method of managing a section of 

the population who would otherwise be exposed to additional illness at 

overwhelmed health care facilities. 

73
Several studies have been reported regarding successful in-home EMS treatment 

of patients such as IV hydration and limited pharmacologic intervention (i.e., 

hypoglycemia) that does not include patient transport to a healthcare facility. 

According to the 2005 JEMS 200-City Survey, 71.3% of U.S. EMS systems allow 

providers to treat patients without transporting them, and 35.7% have a policy that 

allows EMS to refuse transport65. 

Section 5 - Clinical Standards and Treatment Protocols 

SEE RELATED APPENDICES 

1. Appendix B—EMS and Non-Emergent Medical Transport Organizations 

Pandemic Influenza Planning Checklist from the Centers of Disease Control 

and Prevention 

2. Appendix D—Sample TIIDE Fact Sheet 

3. Appendix G—Excerpt from Altered Standards of Care in Mass Casualty Events 

4. Appendix H—Excerpt from the: White Paper on Scene Operations, to 

Include Identification, Medico-legal Investigation Protocols and Command and 

Control of Mass Fatalities Resulting from a Pandemic Influenza (PI) in the 

United States 

5. Appendix M—Pandemic Influenza Resources 

65 Maggiore WA. ONLINE. 2006. To Transport or Not to Transport? Part 1 of 2. Journal of Emergency 

Medical Services. Available: http://www.jems.com/columnists/Maggiore/articles/15830/ [21 March 

2007] 

74
Section 6 - EMS Workforce Protection 

Guideline 6.1 – Protection of EMS and 9-1-1 Workforce 

and Families 

State, local, tribal, and territorial EMS pandemic influenza plans should 

identify strategies to protect the EMS and 9-1-1 workforce and their 

families during an influenza pandemic. 

Rationale 

As a component of the Nation’s critical infrastructure, emergency medical 

services will play a vital role in responding to requests for assistance, triaging 

patients, and providing emergency treatment to patients during a pandemic. 

Strategies to protect the EMS and 9-1-1 workforce and their families are essential 

to maintaining an EMS systems’ ability to satisfy demand for services. 

Considerations 

• EMS and 9-1-1 agencies should promote educational and operational 

strategies for infectious disease control and prevention that contribute to 

personnel health and safety. 

• EMS and 9-1-1 pandemic influenza planners should work with public health 

officials and occupational health personnel to establish internal surveillance 

protocols and tracking systems to monitor the health of workers and to 

determine whether ongoing strategies of ensuring workplace safety and 

operational continuity are successful or need to be altered as a pandemic 

evolves. 

• EMS planners should consider the impact of an influenza pandemic on 

workers and their families and include labor and non-labor representatives 

whenever possible in planning efforts intended to protect the workforce. 

• EMS planners should consider mechanisms that could be sustained throughout 

a pandemic period to maintain physical and mental capabilities of providers. 

• EMS pandemic influenza plans should consider opportunities for off-duty 

EMS personnel to have alternative housing arrangements during a pandemic, 

thereby protecting providers from transmitting disease to family members or 

visa versa. 

• EMS planners should consider methods to offer prophylaxis/treatment to EMS 

providers.66 

66 US Department of Health and Human Services. ONLINE. 2005. HHS Pandemic Influenza Plan 

Appendix D: NVAC/ACIP Recommendations for Prioritization of Pandemic Influenza Vaccine and NVAC 

Recommendations on Pandemic Antiviral Drug Use. Department of Health and Human Services. 

Available: http://www.hhs.gov/pandemicflu/plan/appendixd.html [20 March 2007]. 

75
67

• Contingent upon the availability of countermeasures, EMS planners should 

also consider methods to offer medications to family members of personnel. 

• EMS agencies should ensure ongoing availability of and encourage proper use 

of infection control measures and personal protective equipment to reduce risk 

of exposure (e.g., eye protection, personal respirators such as N95s for 

providers and masks for patients as appropriate, gowns for responders, gloves, 

hand disinfectant, disposable tissues, and effective containment of 

contaminated materials that may require disposal into biohazardous waste 

containers.) 

Background 

An influenza pandemic is expected to have substantial impact on the healthcare 

system with large increases in demand for healthcare services. EMS will be 

treating influenza-infected patients and will be at risk of repeated exposures. To 

support continued work in a high-exposure setting and to help lessen the risk of 

EMS workers transmitting influenza to other patients and EMS family members, 

their protection must be given high priority67,68,69 

The prospect of absenteeism due to illness, quarantine, fear, or death reinforces 

the need to develop plans to proactively protect and support the workforce and 

their families before and during an influenza pandemic. The vulnerability of the 

healthcare workforce was apparent when both Hong Kong and Toronto dealt with 

SARS. Transmission of SARS appeared to result primarily from direct patient 

contact or contact with large respiratory droplets in the close vicinity of an 

infected person. Despite apparent limited modes of transmission, SARS has been 

known to spread extensively among HCWs [health care workers] in various 

settings. For example, among 138 cases of secondary and tertiary spread in Hong 

Kong, 85 (62%) occurred among HCWs; among 144 cases in Toronto, 73 (51%) 

were HCWs. SARS infection of HCWs might be related to increased contact with 

respiratory secretions, contact with patients during a more contagious phase of 

critical illness, contact with particular patients at increased likelihood of spreading 

SARS (i.e., super spreaders), or exposure to aerosol-generating patient-care 

procedures.70 

 US Department of Health and Human Services. ONLINE. 2006. Emergency Medical Services and NonEmergent (Medical) Transport Organizations Pandemic Influenza Planning Checklist. Department of 

Health and Human Services. Available: http://www.pandemicflu.gov/plan/healthcare/emgncymedical.html 

[18 March 2007]. 68 . US Department of Health and Human Services. ONLINE. 2005. HHS Pandemic Influenza Plan 

Appendix D: NVAC/ACIP Recommendations for Prioritization of Pandemic Influenza Vaccine and NVAC 

Recommendations on Pandemic Antiviral Drug Use. Department of Health and Human Services. 

Available: http://www.hhs.gov/pandemicflu/plan/appendixd.html [20 March 2007]. 

For the most current information about vaccines and antivirals, including the latest prioritization strategies, 

see http://www.pandemicflu.gov/vaccine/index.html 69 Occupational Safety and Health Administration. Pandemic Influenza Preparedness and Response 

Guidance for Healthcare Workers and Healthcare Employers. Unpublished. 70 Centers for Disease Control and Prevention. ONLINE. 2003. Cluster of Severe Acute Respiratory 

Syndrome Cases Among Protected Health-Care Workers --- Toronto, Canada, April 2003 

76
EMS agencies and personnel should practice infection control procedures. In the 

Morbidity and Mortality Weekly Report Cluster of Severe Acute Respiratory 

Syndrome Cases Among Protected Health-Care Workers --- Toronto, Canada, 

April 2003, the CDC reports that although infections among health care workers 

were a common feature of severe acute respiratory syndrome (SARS), the 

majority of these infections occurred in locations where infection-control 

precautions either had not been instituted or had been instituted but were not 

followed. In addition, Health Canada and the CDC are aware of several 

unpublished reports of SARS clusters among unprotected healthcare workers 

involved with intubation, both in Canada and outside North America. The cluster 

described in this report might be unique, as healthcare workers appear to have 

followed infection-control precautions recommended by Health Canada. The 

Health Canada recommendations, although similar to those of CDC, differ from 

CDC guidelines with respect to respiratory protection. CDC guidelines specify 

use of respirators certified the National Institute for Occupational Safety and 

Health (NIOSH) and rated at an N95 level of protection or greater. Health Canada 

recommends use of "N95 equivalent" respirators. The respirators used by one 

hospital, although compliant with Canadian public health recommendations, were 

not NIOSH-certified. In addition, at the time these exposures occurred, fit testing 

was not recommended by Canadian public health authorities; such testing has 

been mandated in the United States since 1972.71 72 

MMWR. May 16, 2003 / 52(19);433-436. CDC. Available: 

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5219a1.htm [3 April 2007] 71 OSHA Respiratory Protection Standard, 29 CFR 1910.134 72 Occupational Safety and Health Administration. Pandemic Influenza Preparedness and Response 

Guidance for Healthcare Workers and Healthcare Employers. For complete document go to 

www.osha.gov 

77 
Guideline 6.2 – Infection Control and Decontamination 

EMS agencies should consistently practice basic infection control procedures 

including vehicle/equipment decontamination, hand hygiene, cough and 

respiratory hygiene, and proper use of FDA cleared or authorized medical 

personal protective equipment (PPE) regardless of the likelihood of an influenza 

pandemic. 

Rationale 

The consistent practice of basic infection control and decontamination measures is 

essential to protect EMS providers and their patients by reducing transmission of 

infectious diseases and other pathogens. 

Considerations 

• EMS agencies should adopt day-to-day infection control and decontamination 

procedures consistent with the most recent CDC and OSHA guidance. 

(Appendices K, L, and Q) 

• EMS agencies should define mechanisms of rapidly modifying infection 

control and decontamination procedures based on the most recent research and 

scientific information, including Federal, State and local pandemic influenza 

guidelines. 

• When a pandemic influenza symptom set is available from the CDC, EMS 

and 9-1-1 agencies should consider a screening algorithm to identify 

potentially infected patients and ensure proper use of PPE and infection 

control practices. 

• EMS agencies should ensure ongoing availability of and encourage proper use 

of infection control measures and personal protective equipment to reduce risk 

of exposure (e.g., eye protection, personal respirators such as N95s for 

providers and masks for patients as appropriate, gowns for responders, gloves, 

hand disinfectant, disposable tissues, and effective containment of 

contaminated materials that may require disposal into biohazardous waste 

containers.) 

• For office staff, consideration should be given to having in place social 

distancing measures (e.g., spacing people farther apart in the workplace, 

teleworking when feasible, substituting teleconferences for meetings.) 

78
Background 

Potential Contamination from Direct Patient Contact73 

The ability to limit transmission of pandemic influenza in healthcare settings will 

rely heavily on the appropriate and thorough application of infection control 

measures. 

The CDC EMS and Non-Emergent (Medical) Transport Organization Pandemic 

Influenza Planning Checklist74 identifies infection control elements for EMS. 

CDC makes numerous additional recommendations regarding infection control in 

the healthcare setting in Supplement 4 of the Department of Health and Human 

Services Pandemic Influenza Plan75. 

The Supplement states: 

While it is commonly accepted that influenza transmission 

requires close contact—via exposure to large droplets (droplet 

transmission), direct contact (contact transmission), or nearrange exposure to aerosols (airborne transmission)—the relative 

clinical importance of each of these modes of transmission is not 

known... Given some uncertainty about the characteristics of a 

new pandemic strain, all aspects of preparedness planning for 

pandemic influenza must allow for flexibility and real-time 

decision-making that take new information into account as the 

situation unfolds. The specific characteristics of a new pandemic 

virus—virulence, transmissibility, initial geographic distribution, 

clinical manifestation, risk to different age groups and 

subpopulations, and drug susceptibility—will remain unknown 

until the pandemic gets underway. If the new virus is unusual in 

any of these respects, HHS and its partners will provide updated 

infection control guidance. 

These recommendations, edited to include only those recommendations that are 

relevant to EMS are provided in Appendix K. 

A CDC guideline76,77 that addresses isolation precautions in hospitals can also be 

useful in developing EMS and 9-1-1 policies and procedures for infection control. 

73 Occupational Safety and Health Administration. Pandemic Influenza Preparedness and Response 

Guidance for Healthcare Workers and Healthcare Employers. For complete document, go to 

www.osha.gov 74 US Department of Health and Human Services. ONLINE. 2006. Emergency Medical Services and NonEmergent (Medical) Transport Organizations Pandemic Influenza Planning Checklist. Department of 

Health and Human Services. Available: http://www.pandemicflu.gov/plan/healthcare/emgncymedical.html 

[18 March 2007]. 75 US Department of Health and Human Services. 2005. HHS Pandemic Influenza Plan Supplement 4 

Infection Control Department of Health and Human Services. Available: 

http://www.hhs.gov/pandemicflu/plan/sup4.html [20 March 2007]. 76 US Department of Health and Human Services. ONLINE. 1996. Guideline for isolation precautions in 

hospitals. CDC. Available: http://www.cdc.gov/ncidod/dhqp/gl_isolation.html [18 March 2007]. 

79
This guideline is particularly informative with regard to standard precautions78 

and droplet precautions79. 

Potential Contamination from Environmental Contact 

“Some microbes are infectious at very low doses and can survive for hours to 

weeks on nonporous surfaces, such as countertops and telephone headpieces. A 

number of viruses, including influenza A virus... can be found in oral secretions 

of those infected and survive 2-24 hours on hard surfaces.”80 A University of 

Arizona81 study using an invisible fluorescent tracer showed that artificial 

contamination from outside surfaces (e.g. such as doorknobs, telephones, faucets, 

and copier buttons) was transferred to 86% of 35 exposed individual’s hands. In 

addition, 82% of the 35 participants subsequently tracked the contaminant to their 

home or personal belongings. The study identified phones, desktops, and 

keyboards among the top five “dirtiest” work surfaces. Viruses detected using 

such a tracer method may no longer be viable (able to infect a human with 

disease), however, the study illustrates the potential transfer rates of human 

pathogens. 

77 Centers for Disease Control and Prevention. ONLINE. 2007. Guidelines and Recommendations 

Infection Control Guidance for the Prevention and Control of Influenza in Acute-Care Facilities. CDC. 

Available: http://www.cdc.gov/flu/professionals/infectioncontrol/healthcarefacilities.htm [3 April 2007] 78 Excerpted from US Department of Health and Human Services. ONLINE. 1996. Guideline for isolation 

precautions in hospitals. CDC. Available: http://www.cdc.gov/ncidod/dhqp/gl_isolation.html [18 March 

2007]. Standard precautions available: http://www.cdc.gov/ncidod/dhqp/gl_isolation_standard.html [20 

March 2007] 79 Excerpted from US Department of Health and Human Services. ONLINE. 1996. Guideline for isolation 

precautions in hospitals. CDC. Droplet precautions available: 

http://www.cdc.gov/ncidod/dhqp/gl_isolation_droplet.html [20 March 2007] 80 Reynolds KA, Watt PM, Boone SA, Gerba CP. 2005. Occurrence of bacteria and biochemical markers 

on public surfaces. Int J Environ Health Res. Jun;15(3):225-34 81 Reynolds KA, Watt PM, Boone SA, Gerba CP. 2005. Occurrence of bacteria and biochemical markers 

on public surfaces. Int J Environ Health Res. Jun;15(3):225-34 

80
Guideline 6.3 – Vaccines and Anti-Virals for EMS 

Personnel 

State, local, tribal, and territorial EMS pandemic influenza plans should define 

system-wide processes for providing vaccines and anti-viral medication to EMS 

personnel. 

Rationale 

Assuring the viability of the EMS workforce is essential to supporting their role in 

mitigating and responding to an influenza pandemic. As a component of the 

Nation’s critical infrastructure, EMS will play a vital role in responding to 

requests for assistance, triaging patients, and providing emergency treatment to 

patients during a pandemic. Strategies to provide pharmaceutical countermeasures 

to protect the EMS workforce are essential to maintaining an EMS systems’ 

ability to satisfy demand for services. 

Considerations 

• EMS pandemic flu planners should maintain familiarity with Federal guidance 

on prioritization of vaccinations and administration of anti-viral 

medications82. (See Appendix J) 

• EMS agencies should be engaged with State and local pandemic influenza 

planners in allocation decisions regarding pharmaceutical and nonpharmaceutical countermeasures and ensure EMS and 9-1-1 personnel are 

included in the allocation plans. 

• There should be an EMS agency-specific plan for the acquisition, distribution 

and administration of pharmaceutical and non-pharmaceutical 

countermeasures to EMS and 9-1-1 personnel. EMS pandemic influenza 

planners can establish this process through collaboration and planning with 

State and local public health agencies. 

Background 

Federal priorities for vaccine and antiviral drug use will vary based on pandemic 

severity as well as the vaccine and drug supply. Federal vaccination guidelines are 

subject to change as the Federal Government refines its guidelines to assist State, 

local, tribal, and territorial governments and the private sector in defining groups 

that should receive priority access to medical countermeasures. Priority 

recommendations will reflect the pandemic response goals of limiting mortality 

 US Department of Health and Human Services. ONLINE. 2005. HHS Pandemic Influenza Plan 

Appendix D: NVAC/ACIP Recommendations for Prioritization of Pandemic Influenza Vaccine and NVAC 

Recommendations on Pandemic Antiviral Drug Use. Department of Health and Human Services. 

Available: http://www.hhs.gov/pandemicflu/plan/appendixd.html [20 March 2007]. 

81

82
and severe morbidity; maintaining critical infrastructure and societal function; 

diminishing economic impacts; and maintaining national security. Currently, the 

EMS workforce is considered a high priority group for vaccination. EMS agencies 

are encouraged to monitor revised guidance at 

http://www.pandemicflu.gov/vaccine/index.html. The Federal guidance 

(Appendix J) relating to vaccine and antiviral prioritization has been undergoing 

extensive review and will be updated in the near future. Readers should consult 

www.pandemicflu.gov for the latest information. 

82
Guideline 6.4 – Isolation and Quarantine Considerations 

State, local, tribal, and territorial EMS agencies, in coordination with public 

health authorities, should identify a mechanism to address issues associated with 

isolation and quarantine of EMS personnel. 

Rationale 

As one element of a community mitigation strategy, isolation and quarantine may 

prevent transmission of disease by separating ill and exposed persons from those 

who have not yet been exposed. EMS and 9-1-1 agencies should anticipate the 

potential need to isolate and quarantine staff who have been exposed to pandemic 

influenza or become ill. 

Considerations 

• EMS agencies should establish policies for employees who have been exposed 

to pandemic influenza or are suspected to be ill. 

• EMS agencies should establish a clear expectation that staff do not come into 

work when ill with a febrile respiratory illness and support this expectation 

with appropriate attendance policies. 

• EMS and 9-1-1 agencies should collaborate with occupational health and 

public health officials to establish policies on when a previously ill person is 

no longer infectious and can return to work after illness. 

• EMS pandemic influenza plans should consider opportunities for off-duty 

EMS personnel to have alternative housing arrangements during a pandemic. 

Alternative housing arrangement may be used to protect the provider from 

infecting family members or vice versa. 

Background 

According to the National Strategy for Pandemic Influenza: Implementation 

Plan83, the response to an influenza pandemic could require, if necessary and 

appropriate, measures such as isolation or quarantine. Isolation is a standard 

public health practice applied to persons who have a communicable disease. 

Isolation of pandemic influenza patients may prevent transmission of the disease 

by separating ill persons from those who have not yet been exposed. Quarantine is 

a contact management strategy that separates individuals who have been exposed 

to infection but are not yet ill from others who have not been exposed to the 

transmissible infection; quarantine may be voluntary or mandatory. 

83 Homeland Security Council. ONLINE. 2006.National Strategy for Pandemic Influenza: Implementation 

Plan. The White House. Available: http://www.pandemicflu.gov/plan/federal/index.html [20 March 2007]. 

83
Persons who become ill may shed virus and can transmit infection for one-half to 

one day before the onset of illness. Viral shedding and the risk for transmission 

will be greatest during the first two days of illness

84. 

84 US Department of Health and Human Services. ONLINE. 2007. Community Strategy for Pandemic 

Influenza Mitigation. Department of Health and Human Services. Available: 

http://www.pandemicflu.gov/plan/community/commitigation.html [21 March 2007] 

84
Guideline 6.5 – Support for EMS Personnel and

Their Families 

State, local, tribal, and territorial EMS pandemic influenza plans should define a 

process for offering support services, including mental health services, to EMS 

personnel and their families during an influenza pandemic. 

Rationale 

Assuring the viability of the EMS workforce and their families through social 

support services is essential to supporting the workforce’s role in mitigating and 

responding to an influenza pandemic. 

Considerations 

• EMS planners should collaborate with psychosocial or mental health 

professionals to assist in formulating messages and communications strategies 

that will minimize negative impacts on emergency workers by managing 

expectations and helping achieve desired behaviors and outcomes. 

• Planning should involve identifying and providing additional support services, 

including mental health services, which EMS providers and their families may 

need during an influenza pandemic. 

• EMS planners should identify and coordinate with community resources to 

support workers and their families at the onset, during, and following a 

pandemic. (e.g., Community Emergency Response Teams

85 (CERT), the 

American Red Cross, faith-based organizations, and other family assistance 

groups). 

Background 

It is important that planning efforts consider the impact of pandemic influenza on 

EMS personnel and their families. The National Strategy for Pandemic Influenza: 

Implementation Plan86 recognizes that during a pandemic, psychosocial issues 

may “significantly contribute to, or hinder, the effectiveness of the response.” 

Public anxiety and subjective perception of risk during the initial phases will 

impact the degree of medical surge; overall compliance with quarantine, office 

closures, and other control procedures; and participation of the workforce, 

including healthcare workers, in response efforts. 

85 For additional information regarding the CERT program, see https://www.citizencorps.gov/cert/ 

 Homeland Security Council. ONLINE. 2006.National Strategy for Pandemic Influenza: Implementation 

Plan. The White House. Available: http://www.pandemicflu.gov/plan/federal/index.html [20 March 2007]. 

85

86
During the 1918-1919 Spanish influenza, for example, people experienced 

significant distress due to loss of family members and anxiety about work, food, 

transportation, and basic infrastructure.87 

During a modern-day pandemic, EMS and 9-1-1 workers will likely be called 

upon to implement policies and protocols that evoke a range of responses, 

including decisions of a moral and ethical nature. They may witness human pain 

and suffering on the job and may experience illness and death in their personal 

lives. The SARS outbreak in 2003 led to psychological distress for healthcare 

workers and the general public because of social isolation, stigmatization of 

groups perceived to be high risk, and general fears about safety and health.88 

Research on social behavior following disasters by the National Science 

Foundation suggests that “Recovery processes are significantly influenced by 

differential societal and group vulnerability; by variations in the range of recovery 

aid and support that is available; and by the quality and effectiveness of the help 

that is provided. The available ‘mix’ of recovery activities and post-disaster 

coping strategies varies across groups, societies, and different types of 

disasters.”89 

Section 6 - EMS Workforce Protection 

SEE RELATED APPENDICES 

1. Appendix K—Infection Control: Excerpts from Federal Documents 

2. Appendix J—Excerpts from the HHS Pandemic Influenza Plan, Appendix O 

3. Appendix M– Pandemic Influenza Resources 

4. Appendix Q–OSHA Guidance 

 Homeland Security Council. ONLINE. 2006.National Strategy for Pandemic Influenza: Implementation 

Plan. The White House. Available: http://www.pandemicflu.gov/plan/federal/index.html [20 March 2007]. 88 Homeland Security Council. ONLINE. 2006.National Strategy for Pandemic Influenza: Implementation 

Plan. The White House. Available: http://www.pandemicflu.gov/plan/federal/index.html [20 March 2007]. 89 Institute of Medicine. ONLINE. 2006. Committee on Disaster Research in the Social Sciences: Future 

Challenges and Opportunities, National Research Council. Facing Hazards and Disasters: Understanding 

Human Dimensions. National Academies Press. Available: www.nap.edu 

86

87
Appendix A - Glossary of Terms 

Avian influenza 

Avian (or bird) influenza is caused by influenza viruses that occur 

naturally among wild birds. The highly pathogenic avian influenza A 

(H5N1), or HPAI H5N1, viruses are deadly to domestic fowl and 

can be transmitted from birds to humans. There is no human 

immunity and only one FDA vaccine has been approved, but it is not 

commercially available. The vaccine is approved for those who may 

be at increased risk of exposure to the HPAI H5N1 virus and has 

been included in the Strategic National Stockpile. Most cases of 

HPAI H5N1 virus infections in humans have resulted from direct or 

close contact with infected poultry (e.g., domesticated chicken, 

ducks, and turkeys) or surfaces possibly contaminated from feces 

and/or respiratory secretions of infected birds. 

Chief Complaint 

Reason the patient is seeking medical care (in some cases the 

mechanism of injury). It must contain sufficient information to allow 

categorization according to the PSAP’s established protocols. 

Cold 

An EMS vehicle involved in a non-emergency response or transport 

while not using emergency signaling equipment (i.e., no lights and 

siren). 

Command and 

Control Center 

(Central Communications Center) - A place where responsibility 

rests for establishing communications channels and identifying the 

necessary equipment and facilities to permit immediate management 

and control of an EMS patient. This operation provides access and 

availability to public safety resources essential for efficient 

management of the immediate EMS problem. 

Communication 

The act of communicating. The exchange of thoughts, messages or 

information, as by speech, signals, writing or behavior. The art and 

technique of using words effectively and with grace in imparting 

one’s ideas. Something communicated; a message. 

Communications 

A means of communicating, especially: a system, such as mail, 

telephone, television or radio, for sending and receiving messages. A 

network of routes or systems for sending messages. The technology 

employed in transmitting messages. 

87
Community 

Health Resource 

Capability that may be offered within a neighborhood or community 

to aid in the detection, surveillance, and support of community health. 

This may include a municipal organization such as the fire service or 

EMS, department of public health, social service organization, 

volunteer organization, and others. 

Component An individual element, aspect, subgroup, or activity within a system. 

Complex systems (such as EMS) are composed of many components. 

Computerized 

Record 

Data maintained on computer for easy access, manipulation, 

refinement and review. 

Continuity of 

Operations 

Planning: 

Planning the ability to survive and sustain critical core business 

operations and functions during an unforeseen enterprise interruption 

event, such as an Influenza Pandemic. 

Cost-effective Providing the maximal improved health care outcome improvement at 

the least cost. 

Cost-effective 

Analysis 

Analysis that determines the costs and effectiveness of an intervention 

or system. This includes comparing similar alternative activities to 

determine the relative degree to which they obtain the desired 

objective or outcome. The preferred alternative is the one that requires 

the least cost to produce a given level of effectiveness or provides the 

greatest effectiveness for a given level of cost. 

Credentialing 

Agency 

An organization that certifies an institution’s or individual’s authority 

or claim to confidence for a course of study or completion of 

objectives. 

Data Crude, isolated, unanalyzed measures that reflect the status or degree 

of a measured attribute of a component or system. 

Effective Capable of producing or designed to produce a particular desired 

effect in “real world” circumstances. 

Efficacy 

The effect of an intervention or series of interventions on patient 

outcome in an idealized setting (e.g. a randomized, placebo controlled 

trial).. 

88
Efficiency 

The effect or results achieved in relation to the effort expended 

(resources, money, time). It is the extent to which the resources used to 

provide an effective intervention or service are minimized. Thus, if two 

services are provided that are equally effective, but one requires the 

expense of fewer resources, that service is said to be more efficient. 

Emergency 

Medical 

Dispatch 

The function of providing prompt and accurate processing of calls, for 

emergency medical assistance by trained individuals, using a medically 

approved dispatch protocol system and functioning under medical 

supervision. 

Emergency 

Medical 

Dispatcher 

(EMD) 

A trained public safety telecommunicator with additional training and 

specific emergency medical knowledge essential for the efficient 

management of emergency medical communications. 

Emergency 

Medical 

Technician 

(EMT) 

A member of the emergency medical services team who provides outof-facility emergency care; includes certifications of EMT-Basic, EMTIntermediate, and EMT-Paramedic progressively advancing levels of 

care. 

Emergency 

Physician 

A physician specialized in the emergency care of acutely ill or injured 

patients. 

EMS Emergency Medical Services 

EMS Medical 

Director 

The physician who has the ultimate responsibility and authority to 

provide management, supervision, and guidance for all aspects of EMS 

in an effort to assure its quality of care (may be on a local, regional, 

State, and national level). 

EMS Personnel 

Paid or volunteer individuals who are qualified, by satisfying 

formalized existing requirements, to provide some aspect of care or 

service within the EMS system. 

EMS Physician 

A physician with specialized knowledge and skills in the area of 

emergency medical services, including clinical care and systems 

management; a physician who specializes in emergency medical 

services system management, in which the provision of direct patient 

care is only one component. 

EMS Protocol 

Written medical instructions or algorithms authorized by an EMS 

medical director to be used by personnel in the field without the 

necessity of on-line or real-time consultation with the physician or 

nurse providing medical direction. 

89
EMS System 

Any specific arrangement of emergency medical personnel, 

equipment, and supplies designed to function in a coordinated 

fashion. May be local, regional, State, or National. 

Enabling EMS 

Legislation 

Law that grants authority to specific entities to undertake activity 

related to the provision or establishment of an EMS system. 

Generally, enabling legislation represents a legislature’s 

delegation of authority to a State agency to regulate some or all 

aspects of an EMS delivery system. This may include technical 

support, funding, or regulation. 

Endemic Levels 

Endemic levels are the constant presence of a disease or infectious 

agent in a certain geographic area or population group. 

Epidemic 

Epidemic is the rapid spread of a disease in a specific area or 

among a certain population group. 

Episodic care An acute, relatively brief, intervention representing a segment of 

continuous health care experience. 

Expanded Role/ 

Expanded Scope 

Increased dimensions of the services, activities, or care provided 

by EMS. 

Federal 

Communications 

Commission (FCC) 

A board of five commissioners appointed by the President under 

the Communications Act of 1934 to formulate rules and 

regulations and to authorize use of radio communications. FCC 

regulates all communications in the United States by radio or 

wireline, including television, telephone, radio, facsimile, and 

cable systems, and maintains communications in accordance with 

applicable treaties and agreements to which the United States is a 

party. 

First Responder The initial level of care within an EMS system as defined by the 

EMS Education and Practice Blueprint, as opposed to a bystander. 

Health Alert 

Network 

The Health Alert Network (HAN) is a nationwide program to 

establish the communications, information, distance-learning, and 

organizational infrastructure for a new level of defense against 

health threats, including the possibility of bioterrorism. The HAN 

will link local health departments to one another and to other 

organizations critical for preparedness and response: community 

first-responders, hospital and private laboratories, State health 

departments, CDC, and other Federal agencies 

Health Care Delivery 

System 

A specific arrangement for providing preventive, remedial, and 

therapeutic services; may be local, regional, or national. 

90
Health Care 

Facility 

A site at which dedicated space is available for the delivery of health 

care. This may include physicians’ offices and urgent care centers, as 

well as hospitals and other medical facilities. 

Health Care 

Provider 

Network 

Conglomerate of both community and hospital resources participating 

in a common contractual agreement to provide all health care needs to 

individual members of society. 

Hot 

An EMS vehicle involved in an emergency response or transport while 

using appropriate audible and visual emergency signaling equipment 

(i.e., lights and siren) in accordance with statutes. 

Information 

A combination of data, usually from multiple sources, used to derive 

meaningful conclusions about a system (health resources, costs, 

utilization of health services, outcomes of populations, etc.). 

Information cannot be developed without crude data. However, data 

must be transformed into information to allow decision making that 

improves a given system. 

Informed 

Consent 

Voluntary consent by a given subject, or by a person responsible for a 

subject, for participation in an investigation, treatment program, 

medical procedure, etc., after being informed of the purpose, methods, 

procedures, benefits, and potential risks. Awareness of risk is 

necessary for any subject to make an informed choice. 

Infrastructure 

The basic facilities, equipment, services, and installations needed for 

functioning; the substructure, components, or underlying foundation of 

a community or system. 

Interpandemic 

Period 

WHO Phases 1 & 2. (See Figure 5) 

Isolation 

Isolation is a standard public health practice applied to persons who 

have a communicable disease. Isolation of pandemic influenza patients 

may prevent transmission of the disease by separating ill persons from 

those who have not yet been exposed. 

Just-in-time 

training 

Timely provision of information and instructions as they become 

available, and when users need them. 

Legislation Lawmaking; the procedure of legislating; law or laws made by such a 

procedure. 

91
Licensing 

The act of granting an entity permission to do something which the entity 

could not legally do absent such permission. Licensing is generally 

viewed by legislative bodies as a regulatory effort to protect the public 

from potential harm. In the health care delivery system, an individual 

who is licensed tends to enjoy a certain amount of autonomy in 

delivering health care services. Conversely, the licensed individual must 

satisfy certain initial proficiency criteria and may be required to satisfy 

ongoing requirements which assure certain minimum levels of expertise. 

A license is generally considered a privilege and not a right. 

Linkage 

Connected; combining crude data from various sources to provide 

information that can be analyzed. This analyzed information allows 

meaningful inferences to be made about various aspects of a system. 

(Example: linking EMS dispatch records, out-of-hospital patient care 

records, and hospital discharge data.) 

Medicaid 

A Federal program, administered by the States, designed to provide 

health care coverage to the indigent. Established by Title XIX of the 

Social Security Act. 

Medical 

Direction 

The provision of management, supervision, and guidance for all aspects 

of EMS to assure its quality of care. 

Medical 

Facility 

A stationary structure with the purpose of providing health care services 

(e.g., hospital, emergency department, physician office, and others). 

Medical 

Oversight 

The ultimate responsibility and authority for the medical actions of an 

EMS system. 

Medicare 

A Federal program designed to provide health care coverage to 

individuals 65 and over. Established on July 30, 1965, by Title XVIII of 

the Social Security Act. 

Network A formal system linking multiple sites or units. 

Next 

Generation 

9-1-1 

Technology 

The enabling of the transmission of voice, data, or video from different 

types of communication devices to the Public Safety Answering Points 

(PSAPs) and onto emergency responder networks; wireless, IP-enabled 

technology that significantly enhances communications into the PSAP 

and back out to the public safety community. 

Noninvasive 

Monitoring 

Measurement/scanning accomplished without penetrating the viscera or 

superficial tissues. 

92
Novel 

influenza 

strain 

Novel strains of influenza are newly identified influenza viruses against 

which the population has little or no immunity. There is potential to 

spread among humans. 

On-line 

Medical 

Direction 

The moment-to-moment contemporaneous medical supervision/guidance 

of EMS personnel in the field, provided by a physician or other specialty 

qualified health professional (e.g., mobile intensive care nurse), via radio 

transmission, telephone, or on the scene. 

Outcome 

The short, intermediate, or long-term consequence or visible result of 

treatment, particularly as it pertains to a patient’s return to societal 

function. 

Pandemic 

Pandemic is a worldwide epidemic; an epidemic occurring over a wide 

geographic area and affecting a large number of people. Note: Even 

though SARS transferred to North America from its origins in Asia, it 

was considered an epidemic, not a pandemic, because of the limited 

number of people affected by the disease. 

Pandemic 

Influenza 

Symptom Set 

As established by CDC, those symptoms associated with pandemic 

influenza infection. 

Pandemic 

Alert Period WHO Phases 3, 4, & 5. (See Figure 5) 

Pandemic 

Influenza 

Pandemic influenza is virulent human influenza that causes a global 

outbreak, or pandemic, of serious illness. Because there is little natural 

immunity, the disease can spread easily from person to person. Currently, 

there is no pandemic influenza. 

Pandemic 

Period 

WHO Phase 6. (See Figure 5) 

Primary 

PSAP 

A PSAP to which 9-1-1 calls are routed directly from the 9-1-1 Control 

Office (see Public Safety Answering Point). 

93
Private 9-1-1 

Emergency 

Answering Point 

An answering point operated by non-public safety entities with 

functional alternative and adequate means of signaling and 

directing response to emergencies. Includes training to 

individuals intercepting call for assistance that is in accordance 

with applicable local emergency telecommunications 

requirements. Private 9-1-1 Emergency Answering Points are an 

adjunct to public safety response and as such must provide 

incident reporting to the public safety emergency response 

centers per local requirements. 

Protocol 

The plan for a course of medical treatment; the current standard 

of medical practice. In emergency dispatch, it is the specified 

steps, in particular order with a specific script, in which a trained 

public safety telecommunicator is to question a caller or to 

provide instructions. 

Provider 

An individual within an EMS system with a specific credential(s) 

that defines a specific level of competency (i.e., first responder, 

EMT- Basic, EMT-Intermediate, EMT-Paramedic, or other). 

Public Education Activities aimed at educating the general public concerning EMS 

and health related issues. 

Public Health The science of providing protection and promotion of community 

health through organized community effort. 

Public Safety 

Answering Point 

(PSAP) 

A facility equipped and staffed to receive and control 9-1-1 

emergency telephone calls. (See also Primary PSAP, Secondary 

PSAP, and Private 9-1-1 Answering Point.) 

Public Safety 

Telecommunicator 

An individual trained to communicate remotely with persons 

seeking emergency assistance and with agencies and individuals 

providing such assistance. 

Quarantine 

A contact management strategy that separates individuals who 

have been exposed to infection but are not yet ill from others who 

have not been exposed to the transmissible infection; quarantine 

may be voluntary or mandatory. 

Real-time Patient 

Data 

Current patient information provided by a field technician at the 

patient location to a physician or health care facility at a remote 

site, potentially for the purpose of assisting the physician to make 

a better informed decision on patient treatment and/or transport. 

94
Reciprocity The ability for a license or certificate to be mutually interchangeable 

between jurisdictions. 

Redundancy 

Duplication of components, running in parallel, to increase reliability. 

A backup system (either a device or a connection) that serves in the 

event of a primary system failure. 

Regional EMS 

System 

A systematic approach to the delivery of Emergency Medical Services 

defined by distinct geographic boundaries that may or may not cross 

State boundaries. 

Regulation 

Either a rule, or standard which prescribes the management, 

governance, or operating parameters for a given group; tends to be a 

function of administrative agencies to which a legislative body has 

delegated authority to promulgate rules/regulations to “regulate a 

given industry or profession. Many regulations are intended to protect 

the public health, safety and welfare. 

Reimbursement To compensate; to repay. 

Research The study of questions and hypotheses using the scientific method. 

Safe 

Communities 

An integrated injury control system—incorporating prevention, acute 

care, and rehabilitation—to understand and solve injury problems and 

identify new partners to help develop and implement solutions. 

Scope of Practice 

Defined parameters of various duties or services which may be 

provided by an individual with specific credentials. Whether regulated 

by a rule, regulation, statute, or court decision, it tends to represent 

the limits of what services an individual may perform. 

Seasonal 

influenza 

Seasonal (or common) influenza is caused by influenza viruses that 

circulate annually among humans. Most people have some immunity, 

and a vaccine is available. 

Secondary PSAP A PSAP to which 9-1-1 calls are transferred from a Primary PSAP. 

(See Public Safety Answering Point) 

Stabilizing Care The medical attention needed to achieve physical equilibrium in a 

person. 

Standardized 

Nomenclature 

An authoritative system of designated names for a specific item or 

configuration. 

State-of-the-art The highest use of technology or technique known at the time. 

95
Statute 

An act of a legislative body which has been adopted pursuant to 

constitutional authority, by certain means and in such form that it 

becomes a law governing conduct or actions. 

Subscription 

Program 

A prepayment program; a prepayment made to secure future events; a 

prepayment made to secure a reduced ambulance bill either through 

assignment or discount. Must be actuarially sound. 

System 

Preparedness 

Efforts necessary to ensure the readiness to provide a specific standard 

of care. 

Systems 

Analysis 

The research discipline that evaluates efficacy, effectiveness, and 

efficiency based upon all relevant components that contribute to a 

system. This entails the examination of various elements of a system to 

ascertain whether the proposed solution to a problem will fit into the 

system and, in turn, effect an overall improvement in the system. 

Targeted 

Layered 

Containment 

Targeted Layered Containment includes a combination of interventions 

to mitigate the impact of pandemic influenza, including: 

• targeted antiviral treatment and isolation of 

ascertained cases, 

• targeted prophylaxis and quarantine of household 

contacts of index cases, 

• school closure and keeping children at home for the 

duration of the closure, 

• social distancing in workplace (e.g., via 

telecommuting), and 

• social distancing in the community (e.g., cancellation 

of public events) 

Telephone Aid 

Ad-libbed telephone instructions provided by either trained or untrained 

dispatchers, differing from “dispatch life support pre-arrival 

instructions” in that the instructions provided to the caller are based on 

the dispatcher’s knowledge or previous training in a procedure or 

treatment without following a scripted pre-arrival instruction protocol. 

They are not medically pre-approved since they do not exist in written 

form. 

Telephone 

Treatment 

Protocol 

Specific treatment strategy designed in a conversational script format 

that directs the EMD step-by-step in giving critical pre-arrival 

instructions such as CPR, Heimlich maneuver, mouth-to-mouth 

breathing, and childbirth instruction. 

Third Party 

Payor 

Insurance; an entity which is responsible to pay for services even 

though it is not directly involved in the transaction. 

96
Triage is the process of sorting of patients into categories and assigning them 

priority for care and transport based on the severity of their injury or illness 

(and their ability to survive). The initial triage process can be followed by Triage secondary triage, in which additional sorting and assignments for care and 

transportation are made in the attempt to best match resources to need. 

Virulence Measure of severity of a disease caused by an infectious agent or toxin. 

97
Appendix B - EMS and Non-Emergent (Medical)

Transport Organizations Pandemic Influenza Planning

Checklist 

Source: US Department of Health and Human Services. 2006. Emergency Medical Services and NonEmergent (Medical) Transport Organizations Pandemic Influenza Planning Checklist. Washington, DC, 

Department of Health and Human Services retrieved March 18, 2007 at 

http://www.pandemicflu.gov/plan/healthcare/emgncymedical.html 

98
EMERGENCY MEDICAL SERVICE AND NON-EMERGENT (MEDICAL) 

TRANSPORT ORGANIZATIONS PANDEMIC INFLUENZA PLANNING CHECKLIST

Planning for pandemic influenza is critical for ensuring a sustainable health care response. The Department of Health and

Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) have developed the following checklist

to help emergency medical services (EMS) and non-emergent (medical) transport organizations assess and improve their preparedness

for responding to pandemic influenza. EMS organizations will be involved in the transport of acutely ill patients with known or suspected

pandemic influenza to emergency departments; some of these patients might require mechanical ventilation for life support and/or other

lifesaving interventions. Non-emergent (medical) transport organizations will be called upon to transport recovering pandemic influenza

patients to their home, residential care facility, or possibly to alternate care sites set up by state or local health departments. This checklist

is modeled after one included in the HHS Pandemic Influenza Plan (www.hhs.gov/pandemicflu/plan/sup3.html#app2). The list is

comprehensive but not complete; each organization will have unique and unanticipated concerns that also will need to be addressed as part of

a pandemic planning exercise. Also, some items on the checklist might not be applicable to all organizations. Collaborations among hospital,

public health and public safety personnel are encouraged for the overall safety and care of the public. Further information can be found at

www.pandemicflu.gov.

This checklist identifies key areas for pandemic influenza planning. EMS and non-emergent (medical) transport organizations can use this

tool to self-assess and identify the strengths and weakness of current planning. Links to websites with information are provided throughout

the document. However, actively seeking information that is available locally or at the state level will be necessary to complete the

development of the plan. Also, for some elements of the plan (e.g., education and training programs), information may not be immediately

available and monitoring of selected websites for new and updated information will be necessary

1. Structure for planning and decision making. 

Pandemic influenza has been incorporated into emergency management planning and exercises for

the organization.

A planning committee1 has been created to specifically address pandemic influenza preparedness. 

A person has been assigned responsibility for coordinating pandemic influenza preparedness 

planning (hereafter referred to as the pandemic response coordinator) for the organization.

(Insert name, title, and contact information.)

Members of the planning committee include the following: (Insert below or attach a list with name 

title and contact information for each.)

Administration: 

 Medical staff: 

 EMS providers: 

 Phone triage personnel/dispatch center: 

 Emergency management officer: 

 State/local health official: 

 Law enforcement official (for quarantine/security): 

 Other member2: 

A point of contact (e.g., internal staff member assigned infection control responsibility for the 

organization or an outside consultant) for questions/consultation on infection control has been 

identified. (Insert name, title, and contact information.)

Completed In Progress Not Started

❑ ❑ ❑

❑ ❑ ❑

❑ ❑ ❑

❑ ❑ ❑

❑ ❑ ❑

❑

❑

❑

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March 1, 2006 Version 2.1

1. Size of committee can vary, depending on the size and needs of the organization. 

2. Some organizations may need or want to include a school official or volunteer coordinator for local civic and preparedness groups 

(e.g., Medical Reserve Corps, Citizen Corps, Community Emergency Response Teams, Rotary Club, Lions, Red Cross).

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A plan is in place for surveillance and detection of pandemic influenza in the population served and 

the appropriate organizational response. 

Responsibility has been assigned for monitoring national and state public health advisories (e.g., 

www.cdc.gov/flu/weekly/fluactivity.htm) and informing the pandemic response coordinator and 

members of the pandemic influenza planning committee when cases of pandemic influenza have 

been reported in the United States and when they are nearing the geographic area (e.g., state or city). 

(Insert name, title, and contact information of person responsible.) 

A system has been created to track influenza-like illness in patients transported to hospitals and 

among EMS staff and to report this information to the pandemic response coordinator (i.e., weekly 

or daily number of patients with influenza-like illness). For more information see www.cdc.gov/flu/

professionals/diagnosis/. (Having a system for tracking illness trends in patients and staff during 

seasonal influenza will ensure that organizations can detect stressors that may affect operating 

capacity, such as staffing and supply needs, and hospital and emergency department capacity during 

a pandemic.)

A communication plan has been developed.

Key public health points of contact for pandemic influenza have been identified. (Insert below or 

attach a list with the name, title, and contact information for each.)

Local health department contact: 

State health department contact: 

Local emergency management contact: 

State emergency management contact: 

Federal health emergency contact(s): 

The organization’s point person for external communication has been assigned. 

(Insert name, title, and contact information.) 

(Having one person who speaks with the health department, and if necessary, media, local 

politicians, etc., will help ensure consistent communication is provided by the organization.)

A list of healthcare entities and their points of contact (e.g., other local EMS and non-emergent 

[medical] transport organizations, local hospitals and their emergency departments, community 

health centers, residential care facilities has been created. (Insert location of or attach copy of contact 

list.) 

The pandemic response coordinator has contacted local or regional pandemic influenza planning 

groups to obtain information on communication and coordination plans, including how EMS will be 

represented in the planning process. (For more information on state and local planning, 

see www.hhs.gov/pandemicflu/plan/part2.html#overview.)

The pandemic response coordinator has contacted other EMS and non-emergent (medical) transport 

organizations regarding pandemic influenza planning and coordination of services.

2. Development of a written pandemic influenza plan. 

Copies of relevant sections of the Department of Health and Human Services Pandemic Influenza 

Plan have been obtained. www.hhs.gov/pandemicflu/plan.

Copies of available community and state pandemic plans have been obtained.

A written plan has been completed or is in progress that includes the elements listed in #3 below.

The plan describes the organizational structure (i.e., lines of authority) that will be used to 

operationalize the plan.

The plan complements or is part of the community response plan.

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A plan is in place to ensure that education and training on pandemic influenza is provided to ensure 

that all personnel understand the implications of, and control measures for, pandemic influenza and the 

current organization and community response plans.

A person has been designated to coordinate education and training (e.g., identify and facilitate access 

to education and training programs, ensure that staff attend, and maintain a record of attendance at 

education and training programs). (Insert name, title, and contact information.)

Current and potential opportunities for long-distance (e.g., web-based) and local (e.g., health department 

or hospital sponsored programs, programs offered by professional organizations or federal agencies) 

education of EMS and medical transport personnel have been identified. (For more information see 

www.cdc.gov/flu/professionals/training/.)

Language and reading-level-appropriate materials for professional and non-professional personnel on 

pandemic influenza (e.g., available through state and federal public health agencies and professional 

organizations) have been identified and a plan is in place for obtaining these materials.

Education and training include information on infection control measures to prevent the spread of 

pandemic influenza.

Differences between responding to pandemic influenza and a mass casualty event have been incorporated 

into education and training programs.

A plan has been developed for triage and management of patients during a pandemic that includes the 

following: 

A system for phone triage of patients calling 911 or other emergency numbers that might be used 

(provide/post list of appropriate numbers) that includes pre-established criteria and coordination 

protocols to determine who needs emergency transport. The system includes points of referral for 

patients who do not need emergency transport.

A plan for coordination with receiving facilities (e.g., hospital emergency departments), other EMS and 

non-emergent (medical) transport organizations, and local planning groups to manage the transportation 

of large numbers of patients at the height of the pandemic. 

A policy and procedure for transporting multiple patients with pandemic influenza during a single 

ambulance run.

The plan considers the possible necessity of sharing transportation resources or using vehicles other than 

those designed for emergency or medical transport (e.g., buses).

An infection control plan is in place and includes the following: (For information on infection control 

recommendations for pandemic influenza, see www.hhs.gov/pandemicflu/plan/sup4.html).

A plan for implementing Respiratory Hygiene/Cough Etiquette for patients with a possible respiratory 

illness.

The plan includes distributing masks3

 to symptomatic patients who are able to wear them (adult and 

pediatric sizes should be available), providing facial tissues and receptacles for their disposal, and hand 

hygiene materials in EMS and medical transport vehicles.

Implementation of Respiratory Hygiene/Cough Etiquette has been exercised during seasons when 

seasonal influenza and other respiratory viruses (e.g., respiratory syncytial virus, parainfluenza virus) are 

circulating in communities. 

A policy that requires healthcare personnel to use Standard Precautions (www.cdc.gov/ncidod/dhqp/gl_

isolation_standard.html) and Droplet Precautions (i.e., mask for close contact) (www.cdc.gov/ncidod/

dhqp/gl_isolation_droplet.html) with symptomatic patients. 

3. Elements of an influenza pandemic plan. (continued)

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3. Masks include both surgical and procedure types. Procedure masks that are affixed to the head with ear loops might be used more easily by patients and are available in 

pediatric and adult sizes. Either surgical or procedure masks may be used as a barrier to prevent contact with respiratory droplets.
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3. Elements of an influenza pandemic plan. (continued)

An occupational health plan has been developed that includes the following:

A liberal/non-punitive sick leave policy for managing EMS and non-emergent (medical) transport 

personnel who have symptoms of, or documented illness with, pandemic influenza.

The policy considers the following:

 • Handling of staff who become ill at work.

 • When personnel may return to work after recovering from pandemic influenza.

 • When personnel who are symptomatic but well enough to work will be permitted to continue 

working.

 • Personnel who need to care for their ill family members.

A system for evaluating symptomatic personnel before they report for duty that has been tested 

during a non-pandemic influenza period. 

A list of mental health and faith-based resources available to provide counseling to personnel during 

a pandemic. 

Management of personnel who are at increased risk for influenza complications (e.g., pregnant 

women, immunocompromised healthcare workers) by placing them on administrative leave or 

altering their work locations.

The ability to monitor seasonal influenza vaccination of personnel.

Offering annual influenza vaccine to personnel. 

A vaccine and antiviral use plan has been developed.

Websites containing current CDC and state health department recommendations for the use and 

availability of vaccines and antiviral medications have been identified. (For more information, see 

www.hhs.gov/pandemicflu/plan/sup6.html and www.hhs.gov/pandemicflu/plan/sup7.html.) 

An estimate has been made of the number of personnel who will be targeted as first and second 

priority for receipt of pandemic influenza vaccine and antiviral prophylaxis, based on HHS guidance 

for use. (For more information, see www.hhs.gov/pandemicflu/plan/appendixd.html.)

Discussions have been held with the local and/or state health department regarding the role of the 

organization in a large-scale program to distribute vaccine and antivirals to the general population. 

Concerns related to surge capacity during a pandemic have been addressed. 

A plan is in place for managing a staffing shortage within the organization because of illness in 

personnel or their family members. 

The minimum number and categories of personnel necessary to sustain EMS and non-emergent 

(medical) transport services on a day-to-day basis have been determined.

Contingency staffing plans have been developed in collaboration with other local EMS and nonemergent (medical) transport providers.

Hospitals and regional planning groups have been consulted regarding contingency staffing 

resources.

Anticipated consumable resource needs (e.g., masks, gloves, hand hygiene products) have been 

estimated.

A primary plan and contingency plan to address supply shortages have been developed. These 

include detailed procedures for the acquisition of supplies through normal channels and requesting 

resources for replenishing supplies when normal channels have been exhausted. 

Plans include stockpiling at least a week’s supply of resources when evidence exists that pandemic 

influenza has reached the United States. 

An understanding of the process exists for requesting and obtaining assets for the organization made 

available through the community response plan. 

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Appendix C – Excerpt from National Response Plan,

Emergency Support Function #8 

Source: US Department of Homeland Security. 2004. National Response Plan. Washington, DC, 

Department of Homeland Security available at www.dhs.gov/xlibrary/assets/NRP_FullText.pdf 

Emergency Support Function (ESF) #8 – Public Health and Medical Services provides 

the mechanism for coordinated Federal assistance to supplement State, local and tribal 

resources in response to public health and medical care needs for potential or actual 

Incidents of National Significance and/or during a developing potential health and 

medical situation. 

ESF #8 is coordinated by the Secretary of the Department of Health and Human Services 

(HHS) principally through the Assistant Secretary for Public Health Emergency 

Preparedness (ASPHEP). 

ESF #8 resources can be activated through the Robert T. Stafford Act or the Public 

Health Service Act (pending the availability of funds) for the purposes of Federal-toFederal support or in accordance with the memorandum for Federal mutual aid included 

in the National Response Plan (NRP) Financial Management Support Annex. 

ESF #8 provides supplemental assistance to State, local, and tribal governments in 

identifying and meeting the public health and medical needs of victims of an Incident of 

National Significance. This support is categorized in the following core functional areas: 

• Assessment of public health/medical needs (including behavioral health); 

• Public health surveillance; 

• Medical care personnel; and 

• Medical equipment and supplies. 

As the primary agency for ESF #8, HHS coordinates the provision of Federal health and 

medical assistance to fulfill the requirements identified by the affected State, local and 

tribal authorities. ESF #8 uses resources primarily available from: 

• HHS, including the Operating Divisions and Regional Offices; 

• The Department of Homeland Security (DHS); and 

• Other ESF #8 support agencies and organizations. 

ESF #8 continuously acquires and assesses information on the incident. The staff 

continues to identify the nature and extent of public health and medical problems, and 

establishes appropriate monitoring and public surveillance. Other sources of information 

may include: 

• ESF #8 support agencies and organizations; 

• Various Federal officials in the incident area; 

• State health, agricultural or animal health officials; 

• State emergency medical services authorities; 

• Tribal officials; 

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• State incident management authorities; and 

• Officials of the responsible jurisdiction in charge of the disaster scene. 

Because of the potential complexity of the public health and medical response, conditions 

may require ESF #8 subject-matter experts to review public health and medical 

information and advise on specific strategies to manage and respond to a specific 

situation most appropriately. 

Activation of Health/Medical Response Teams: Assets internal to HHS are deployed 

directly as part of the ESF #8 response. Public health and medical personnel and teams 

provided by ESF #8 organizations are requested by HHS and deployed by the respective 

organizations to provide appropriate public health and medical assistance. 

Coordination of Requests for Medical Transportation: In a major public health or 

medical emergency, local transportation assets may not be sufficient to meet the demand. 

State or tribal requests for Federal medical transportation assistance are executed by ESF 

#8 in coordination with ESF #1 (Transportation) 

Coordination for Obtaining, Assembling and Delivering Medical Equipment and 

Supplies to the Incident Area: Representatives of HHS, DHS, the Department of 

Veterans Affairs (VA), the Department of Defense (DOD), the Department of 

Transportation (DOT), and the General Services Administration (GSA) coordinate 

arrangements for the procurement and transportation of medical equipment and supplies. 

Communications: ESF #8 establishes communications necessary to coordinate Federal 

public health and medical assistance effectively. 

Information Requests: Requests for information may be received at ESF #8 from 

various sources, such as the media and the general public, and are referred to ESF #15 

(External Affairs) for action and response. 

After-Action Reports: HHS, on completion of the incident, prepares a summary afteraction report. The after-action report identifies key problems, indicates how they were 

solved, and makes recommendations for improving response operations. ESF #8 

organizations assist in the preparation of the after-action report. 

In the event State and local emergency medical services resources are overwhelmed, the 

Emergency Response Team ESF #9 Urban Search and Rescue leader, in conjunction with 

the Joint Management Team leader and JMT Medical Unit Leader, coordinate with field 

representatives of ESF #8 – Public Health and Medical Services to develop procedures 

for the transfer of victims extricated from collapsed structures to Disaster Medical 

Assistance Teams (DMATs) for stabilization and transport to definitive medical care 

locations. 

[Source: National Response Plan, 2004] 

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Appendix D – Sample TIIDE Fact Sheet 

Terrorism Injuries Information, Dissemination and Exchange (TIIDE)

Source: Centers for Disease Control and Prevention. 2006. Terrorism Injuries Information, Dissemination 

and Exchange (TIIDE) Project retrieved March 21, 2007 at 

http://www.bt.cdc.gov/masscasualties/pdf/blastinjuries.pdf 

Note: While not specific to pandemic influenza, this fact sheet is an example of “just-in-time” training that 

provides concise, updated information about a specific, infrequent event. 

Blast Injuries: Essential Facts 

Key Concepts 

Bombs and explosions can cause unique patterns of injury seldom seen outside combat 

Half the initial casualties seek medical care over a one-hour period 

Most severely injured arrive after the less injured, who bypass EMS triage and go directly to the 

closest hospitals 

Most injuries involve multiple penetrating wounds and blunt trauma 

Confined space explosions (buildings, vehicles, mines) and explosions resulting in structural 

collapse lead to greater morbidity and mortality 

Primary blast injuries among survivors usually result from confined-space explosions 

Standard protocols apply for triage, trauma resuscitation, treatment, and transfer 

Blast Injuries 

Primary: Injury from overpressurization force (blast wave) impacting the body surface (i.e., TM 

rupture, pulmonary damage, hollow viscus rupture) 

Secondary:Injury from projectiles such as bomb fragments or flying debris (i.e., penetrating trauma, 

blunt trauma) 

Tertiary: Injuries from displacement of victim by the blast wind or structural collapse (i.e., crush 

injuries, blunt/penetrating trauma, fractures, traumatic amputations) 

Quaternary: Other injuries from the blast (i.e., burns, asphyxia, toxic exposures) 

Primary Blast Injury 

Lung Injury 

Signs are usually present at initial evaluation, but may be delayed up to 48 hours 

More common among patients with skull fractures, greater than 10% BSA burns, or penetrating 

injury to the head or torso 

Presentation varies from scattered petechiae to confluent hemorrhages 

Suspect in anyone with dyspnea, cough, hemoptysis, or chest pain following blast 

Characteristic “butterfly” pattern produced on CXR 

Sufficient high-flow O2 to prevent hypoxemia is administered via NRB mask, CPAP, or ET tube 

Fluid management is similar to that of pulmonary contusion; ensure adequate tissue perfusion, 

but avoid volume overload 

Endotracheal intubation mandated for massive hemoptysis, impending airway compromise, or 

respiratory failure 

- Selective bronchial intubation may be necessary for significant air leaks or massive 

hemoptysis 

- Positive pressure ventilation may result in alveolar rupture or air embolism 

Clinical signs of pneumothorax or hemothorax require prompt decompression 

Prophylactic chest tube must be considered before general anesthesia or air transport 

Air embolism can present as stroke, MI, acute abdomen, blindness, deafness, spinal cord injury, 

or claudication 

September 08, 2006 Page 1 of 2 

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Blast Injuries: Essential Facts 

(continued from previous page) 

- Administer high-flow O2; prone, semi-left lateral, or left lateral positioning 

- Transfer for hyperbaric O2 therapy may be considered 

Abdominal Injury

Gas-filled structures are most vulnerable, especially the colon 

Presentation may include bowel perforation, hemorrhage (small petechiae to large 

hematomas), mesenteric shear injuries, solid organ lacerations, or testicular rupture 

Suspect in anyone with abdominal pain, nausea, vomiting, hematemesis, rectal pain, tenesmus, 

testicular pain, or unexplained hypovolemia 

Clinical signs can be initially subtle until acute abdomen or sepsis is advanced 

Ear Injury

Tympanic membrane is the most common primary blast injury 

Signs of ear injury are usually evident on presentation (hearing loss, tinnitus, otalgia, vertigo, 

bleeding from external canal, otorrhea) 

Isolated TM rupture is not a marker for morbidity 

Other Injury

Traumatic amputation of a limb is a marker for multisystem injuries 

Concussions are common and easily overlooked; symptoms of mild TBI and post-traumatic 

stress disorder can be similar 

Grossly contaminated wounds are candidates for delayed primary closure 

Compartment syndrome, rhabdomyolysis, and acute renal failure are associated with structural 

collapse, prolonged extrication, severe burns, and some poisonings 

Exposure to inhaled toxins (CO, CN, MetHgb) must be considered in industrial and terrorist 

explosions 

Significant percentage of survivors have serious eye injuries 

Disposition

No definitive guidelines exist for observation, admission, or discharge 

Discharge decisions depend on associated injuries 

Second- and third-trimester pregnancies should be admitted for monitoring 

Follow-up is needed for wounds; head injury; and eye, ear, and stress-related complaints 

Patients with ear injury may have tinnitus or deafness and need written instruction 

For more information, visit www.bt.cdc.gov/masscasualties,

or call CDC at 800-CDC-INFO (English and Spanish) or 888-232-6348 (TTY).

September 08, 2006 Page 2 of 2 

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Appendix E – Excerpt from Model State Emergency 

Health Powers Act 

Source: The Center for Law and the Public’s Health at Georgetown and Johns Hopkins 

Universities. (2001) Model State Emergency Health Powers Act retrieved March 23, 

2007 at http://www.publichealthlaw.net/Resources/Modellaws.htm 

The Model State Emergency Health Powers Act (Model Act) grants specific emergency 

powers to State governors and public health authorities in the event of a large public 

health emergency. The Model Act was developed for the Centers for Disease Control by 

the Center for Law and the Public’s Health at Georgetown and Johns Hopkins 

Universities to ensure an effective response to large-scale emergency health threats while 

protecting the rights of individuals. It provides a broad set of powers for an entity called 

the Public Health Authority. 

As it may relate to altered standards of care, the Model Act provides that a declaration of 

an emergency activates the disaster response and recovery aspects of State, local and 

interjurisdictional disaster emergency plans. There is no mention of local-level 

involvement. The Public Health Authority is empowered to take control over facilities 

(health care and other) and "materials," such as food, fuel, clothing and other 

commodities, and roads. It may control health care supplies by rationing resources; 

establishing priority distribution to health care providers, disaster response personnel and 

mortuary staff; and establishing a general distribution to all others. It may establish and 

enforce quarantine and other infection control measures. 

The following provisions of the Model Act have provoked considerable discussion 

among public health scholars and practitioners: 

Quarantine: "Special Powers" of the Public Health Authority apply to: performing 

physical examinations, necessary tests, and/or vaccination. Any person refusing 

examination, tests, or vaccination may be isolated or quarantined. These sections (§601, 

§603) have been subject to media and public scrutiny. States have designed widely 

differing solutions. However, the Model act has helped to modernize State laws on 

quarantine and encourages greater consistency among State laws regarding quarantine 

provisions. 

Liability: Health care providers are not held liable for any civil damages, except in 

cases where they are found to be negligent in treating or in failing to provide 

treatment. This includes out-of-State health care providers for whom relevant permits to 

practice have been waived by the Public Health Authority. The Model Act also explicitly 

states that except in cases of gross negligence or willful misconduct, the State (and the 

State and local officials specified in the act) is not liable for any property damage, death, 

or injury incurred as a result of complying with the Act (§804(a)). 

Compelling Provider Participation: The Model Act states (§608(a)) that the Public 

Health Authority can compel in-State health care providers to assist in vaccination, 

testing, treatment, or examination of an individual as a licensure condition. 

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Other Provisions: Other provisions of the Model Act include the use of otherwise 

protected private medical information, public information obligations, access to mental 

health services and personnel, compensation for private property (calculated according to 

non-emergency eminent domain procedures) and reimbursement for health care supplies. 

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Appendix F – Colorado Executive Orders 

Source: CDPHE Internal Emergency Response Plan Governor’s Emergency Epidemic Response

Committee (GEEERC) Draft Executive Orders Updated Oct. 23, 2006 retrieved March 20, 2007 at

http://www.cdphe.state.co.us/bt/HealthProviders/Attachment3.pdf 

CDPHE Internal Emergency Response Plan Appendix 1: 

DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Pandemic Influenza 

Annex U: Disease Outbreak Attachment 3 

Attachment 3

Governor’s Expert Emergency Epidemic Response Committee

Draft Executive Orders

In 2000, the Governor’s Expert Emergency Epidemic Response Committee (GEEERC) was 

statutorily created in 2000 to develop a public health response to “acts of bioterrorism, pandemic 

influenza and epidemics caused by novel and highly fatal infectious agents.” See. C.R.S. § 24-

32-2104(8). 

This 22-member committee was established to serve in an advisory capacity to the Governor in 

the event of an emergency epidemic caused by bioterrorism, pandemic influenza or novel and 

highly fatal infectious agents or biological toxins. The Committee’s priorities include: protecting 

human life (highest priority); controlling the further spread of disease; meeting the immediate 

emergency needs of people, specifically medical services, shelter, food, water and sanitation; 

restoring and continuing operations of facilities and services essential to the health, safety and 

welfare of people and the environment; preserving evidence for law enforcement investigations 

and prosecutions. The following executive orders have been drafted for the Governor to use in a 

public health emergency. These orders are not in effect now; they would have to be signed by the 

Governor at the time of the emergency. 

The Governor has the broad powers to meet an emergency. See C.R.S. § 24-32-2104(7). In any 

disaster, the Governor may “Suspend the provisions of any regulatory statute prescribing the 

procedures for conduct of state business or the orders, rules, or regulations of any state agency, if 

strict compliance with provisions of any statute, order, rule, or regulation would in any way 

prevent, hinder, or delay necessary action in coping with the emergency.” C.R.S. § 24-32-

2104(7)(a) 

Executive Order 0.0 - Declaration of a State of Disaster Emergency due to Criminal Acts of 

Biological Terrorism. 

This order activates the Colorado Emergency Operations Plan. 

Executive Order 1.0 - Ordering Hospitals to Transfer or Cease the Admission of Patients to 

Respond to the Current Disaster Emergency 

Authorizes the CDPHE to order hospital emergency departments to cease admissions and 

transfer patients to a hospital or facility as directed by CDPHE. CDPHE would control the 

determination of when a hospital has reached capacity and when the hospital may resume 

admission. 

Executive Order 1.1 - Ordering Hospitals to Transfer or Cease the Admission of Patients to 

Respond to the Current Disaster Emergency 

Directly authorizes hospitals to cease admissions and transfer patients. Provides that hospital 

emergency departments may determine on their own, without central direction from CDPHE, 

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whether they have reached capacity to examine and treat patients. Authorizes hospital emergency 

departments to resume admissions when they have determined that they have the capacity. 

Executive Order 2.0 - Concerning the Procurement and Taking of Certain Medicines and 

Vaccines Required to Respond to the Current Disaster Emergency 

Authorizes the seizure of named drugs from “outlets” (as defined in the pharmacy statutes.) 

Embargoes the supply of the named drugs in the possession of the outlets except for those 

supplies that CDPHE regulation requires certain facilities and organizations to keep for 

chemoprophylaxis of their employees. 

Executive Order 3.0 - Concerning the Suspension of Certain Statutes and Regulations to 

Provide for the Rapid Distribution of Medication in Response to the Current Disaster 

Emergency 

Implements Colorado’s Strategic National Stockpile Plan. Provides for the rapid distribution of 

medication by suspending the pharmacy statutes and regulations pertaining to the compounding, 

dispensing and delivery of any drug. Suspends the “single patient- single prescription” 

requirement and authorizes the Executive Director or Chief Medical Officer of the CDPHE or 

the director of a local department of health to direct listed health care providers to compound, 

dispense or deliver prescription drugs. 

Executive Order 3.1 – Concerning the Rapid Distribution of Influenza Vaccine in response 

to the Current Disaster Emergency 

Authorizes volunteers to administer vaccines. Authorizes rapid distribution of vaccines to 

specified groups. Requires data collection and reporting of the vaccinations. May implement 

Colorado’s Strategic National Stockpile Plan for mass dispensing. 

Executive Order 3.2 – Concerning the Rapid Distribution of Antiviral Medication in 

Response to the Current Influenza Pandemic Disaster Emergency 

Authorizes volunteers to administer vaccines. Authorizes rapid distribution of antiviral 

medication to specified groups. Requires data collection and reporting of the vaccinations. May 

implement Colorado’s Strategic National Stockpile Plan for mass dispensing. 

Executive Order 4.0 - Concerning the Suspension of the Physician and Nurse Licensure 

Statues to Response to the Current Disaster Emergency 

Authorizes physicians and nurses who hold a license issued by another state to practice under the 

supervision of a Colorado licensed physician or nurse to meet the current emergency epidemic. 

Executive Order 5.0 - Concerning the suspension of Certain Licensure Statutes to Enable 

More Colorado Licensed Physician Assistants and Emergency Medical Technicians to 

Assist in Responding to the Current Disaster Emergency 

Authorizes Colorado licensed physician assistants and EMT’s to practice outside of their normal 

supervision but under the supervision of another physician to meet the emergency epidemic. 

Appendix 1 - Pandemic Influenza Attachment 3-2

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CDPHE Internal Emergency Response Plan Appendix 1: 

DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Pandemic Influenza 

Annex U: Disease Outbreak Attachment 3 

Executive Order 6.0 - Concerning the Isolation and Quarantining of Individuals and 

Property in Response to the Current Disaster Emergency Epidemic 

Authorizes CDPHE to establish, maintain, and enforce isolation of all individuals infected with 

the disease or to quarantine all individuals exposed to the disease. 

Executive Order 7.0 - Ordering Facilities to Transfer or Receive Patients with Mental 

Illness and Suspending Certain Statutory Provisions to Respond to the Current Disaster 

Emergency 

Authorizes the transfer of mental patients to different facilities when necessary to combat the 

current epidemic and promote the public health. 

Executive Order 8.0 - Concerning the Suspension of Certain Statutes Pertaining to 

Presumptions of Death and Burial Practices in Response to the Current Disaster 

Emergency 

Authorizes suspension of statutes to allow for the rapid burial of epidemic victims without 

following normal funeral procedures, religious practices or death certificates in all cases. 

Executive Order 9.0 – Concerning the Cancellation of Public Events and the Closure of 

Public Buildings in Response to the Current Public Health Emergency 

Orders cancellation of public events and closure of certain public buildings and schools. 

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Appendix G – Excerpt from Altered Standards of Care in

Mass Casualty Events 

(Chapter 3, pp. 15-18) 

Source: Agency for Healthcare Research and Quality. 2005. Altered Standards of Care in Mass Casualty 

Events: Bioterrorism and Other Public Health Emergencies. Washington, DC, Agency for Healthcare 

Research and Quality. 

A Framework and Guiding Principles When Planning for Health and 

Medical Care in a Mass Casualty Event 

A framework for planning should take into account the ways in which response to a mass 

casualty event is both similar to and different from responses to current surge capacity 

issues. The goal is to devise a framework that is applicable to both ordinary (daily 

routine) and extraordinary situations. To this end, plans for a medical care response to a 

mass casualty event should: 

• Be compatible with or capable of being integrated with day-to-day operations; 

• Be applicable to a broad spectrum of event types and severities; 

• Be flexible, to permit graded responses based on changing circumstances; and 

• Be tested, to determine where gaps in the framework exist. 

AHRQ articulates five principles that should steer the development of pandemic 

influenza clinical guidelines. Incorporating these five principles will ensure that standards 

of care are altered sufficiently to respond to issues arising from a mass casualty event, 

such as pandemic influenza. 

Principle 1: In planning for a mass casualty event, the aim should be to keep the 

healthcare system functioning and to deliver acceptable quality of care to preserve 

as many lives as possible. 

Adhering to this principle will involve: 

• Allocating scarce resources in order to save the most lives. 

• Developing a basis for the allocation of resources that is fair, open, 

transparent, accountable and well understood by both professionals and the 

public. 

• Ensuring, to the possible extent, a safe environment for the provision of care, 

and placing a high priority on infection control measures, and other 

containment processes. 

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Principle 2: Planning a health and medical response to a mass casualty event must 

be comprehensive, community-based, and coordinated at the regional level. 

Effective planning should: 

• Be done at the facility level. However, facility-level planning alone is not 

sufficient. 

• Integrate facility-level planning into a regional systems approach. 

• Involve a broad array of public and private community stakeholders. 

• Begin with the agreement on shared responsibility among all partners in the 

planning process. It is not adequate for individual institutions and systems to have 

emergency response plans unless those plans are coordinated into a single unified 

response system. 

• Be consistent. Planning also should be integrated with Federal, State and local 

emergency plans. 

Principle 3: There must be an adequate legal framework for providing health and 

medical care in a mass casualty event. 

An adequate legal framework for providing health and medical care in a mass casualty 

event would do the following: 

• Include a designation of the authority to declare an emergency and implement 

temporary alterations in standards of care. 

• Define the conditions for temporary modification of laws and regulations that 

govern medical care under normal conditions. 

• Be simple, clear, and easy to communicate to providers and the public. 

• Be flexible enough to accommodate the demands of events that vary in size and 

velocity, such as an explosive or biological event. 

Principle 4: The rights of individuals must be protected to the extent possible and 

reasonable under the circumstances. 

The rights of individuals must be protected to the extent possible and reasonable: 

• In establishing and operationalizing an adequate legal framework for the delivery 

of care. 

• In determining the basis on which scarce resources will be allocated. 

• When considering limiting personal freedom through quarantine or isolation as 

well as the conditions for release. 

• When privacy and confidentiality may have to be breached. 

Principle 5: Clear communication with the public is essential before, during, and 

after a mass casualty event. 

It may be necessary to vary the modes of communication according to the type of 

information to be communicated, the target audience for which it is intended, and the 

operating condition of media outlets, which may be directly affected. Variations that 

illustrate this point but that do not reflect expert discussion include the need to use 

languages other than English and the need to use alternatives to usual media outlets in the 

113
affected area. Also, national audience messages would be less detailed and specific than 

messages to the affected area. 

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Appendix H - Excerpt from the White Paper on Scene

Operations, to Include Identification, Medico-legal

Investigation Protocols and Command and Control of 

Mass Fatalities Resulting from a Pandemic Influenza (PI) 

in the United States 

Source: US Northern Command and Department of Health and Human Services Fatality Management 

Pandemic Influenza Working Group Conference. 2006. White Paper: The Provision of Family Assistance 

and Behavioral Health Services in the Management of Mass Fatalities Resulting from a Pandemic Influenza 

in the United States. 

Key Assumptions 

• Pandemic influenza will result in a surge of deaths above which is normally 

managed by a community’s “normal” medico legal systems. 

• Medico legal systems will continue to experience a “normal” case load for their 

jurisdiction with the possibility of an increase in accidental deaths, (due to 

therapeutic complications as well as those resulting from the increased use and 

operation of motor vehicles/heavy equipment), homicidal (due to civil unrest) 

and/or suicide cases. 

• Some medical examiner/coroner jurisdictions are required to investigate/autopsy 

and certify deaths of persons dying “in custody” regardless of the circumstances, 

thus further overwhelming these systems in pandemic influenza. 

• Human remains will require proper identification for the issuance of a death 

certificate. 

• Deaths will require an adequate investigation to determine the cause and manner 

of death. 

• Many people will seek medical attention during the event and will have primary 

care physicians and/or medical treatment facilities, which will have documented 

and confirmed laboratory results indicating influenza. 

• In all US jurisdictions, treating or primary care physicians are authorized to sign a 

death certificate provided the patient dies from natural causes. 

• A pandemic influenza death is a natural manner of death. 

• Some jurisdictions may have a Medical Examiner/Coroner system, which is 

capable of managing a surge in the number of unattended deaths resulting from of 

pandemic influenza in addition to its normal caseload. 

• Many Medical Examiner/Coroner systems will not be able to manage pandemic 

influenza due to limitations of personnel, resources, funding and lack of planning. 

• Some deceased will not have primary care physicians to sign death certificates, 

requiring Medical Examiner/Coroner to assume jurisdiction over the deaths. 

• There will be a general lack of available physicians due to illness. 

• There may be a lack of available personal protective equipment and 

chemoprophylaxis to support the mortuary community. 

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• Location of bodies will not be restricted to a geographical or jurisdictional area 

with a percentage (50% to 75%) of the deaths occurring outside of a hospital or 

medical treatment facility; this will place additional stress on all community 

responders in the field. 

• Most human remains will be intact and will allow for traditional identification 

means (visualization by witnesses and/or fingerprinting). Some human remains 

will be found in a decomposed state will require further investigation by a 

medical examiner/coroner possibly utilizing more scientific methods such as 

dental, radiological, anthropological, or DNA to confirm identification. 

• Existing laws authorizing the pronouncement of death (jurisdictional dependent) 

may need to be amended in order to increase the personnel strength to manage the 

surge in influenza deaths. 

• Existing laws on the certification of death (jurisdictional dependent) may need to 

be amended in order to increase the personnel strength to manage the surge in 

influenza deaths. 

• Federal or military assistance in fatality management may not be available to the 

local jurisdictions. 

• Human remains may be positively identified, by a certifying physician or medical 

examiner/coroner with a known cause and manner of death but next-of-kin may 

not be available or known or may refuse to claim human remains for final 

disposition through a funeral home. 

• There is no need for extreme urgency in managing the human remains processing, 

as the human remains from the event should not pose additional health risks to the 

community. 

• Those who physically handle remains may be at risk of blood borne or body fluid 

exposure requiring universal precautions and proper training for handling the 

dead. 

• Behavioral health professionals, social service organizations and religious leaders 

will have to be educated in the human remains process at all levels to ensure the 

process is understood and can be properly communicated to the general 

population in their response activities. 

• It is more important to ensure accurate and complete death investigations and 

identification of the dead than it is to quickly end the response. 

• The time to complete fatality management of pandemic influenza may exceed six 

months to a year. 

Notification and Tracking of Deaths to the Appropriate Authorities 

Medico-legal death investigation systems are not designed to be the first responders in 

death reporting by private citizens and/or medical institutions. Emergency dispatch 

systems managed by local law enforcement/fire/EMS will receive the calls from citizens 

(via the 9-1-1 system) and will dispatch resources to respond to death scenes. Depending 

upon the jurisdictional code, medical examiner/coroner staff, will be notified by the first 

responders at the scene. The dispatching of resources to the initial death scenes by 

traditional first responders will be stretched due to the first priority calls – those 

pertaining to life safety missions. Actionable recommendation to senior leaders: 

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• Separate call dispatch systems may be required for death reporting by private 

citizens to ensure life safety calls are dispatched by the most expeditious system 

in existence. 

• Establishing “Family Assistance/Patient Tracking Centers” to manage death calls 

and patient tracking information from medical treatment facilities and community 

care centers would establish a centralized data collection and dispatch point. 

• Request that all medical treatment facilities and private care physicians report 

their influenza patient contacts to the central facility to allow for a complete and 

accessible patient tracking information for medical examiner/coroner, law 

enforcement and other death investigation responders. 

• Amending HIPAA regulations to accommodate additional investigative medicolegal authorities (LE, EMS, CERT, etc. as dictated by communities) during a 

confirmed influenza event for the purposes of collecting the required medical data 

on influenza patients for the determination of cause and manner of death and 

victim identity. 

A central data base for confirmed patient and primary care physicians/treatment facilities 

would allow for the investigating and certifying authorities to quickly coordinate the 

required response by the scene investigators. 

Identified human remains could be immediately transported and released to the funeral 

home (or appropriate holding facility) of the next-of-kin’s choice for final disposition 

processing and the death certificate requirements would be immediately established and 

acted upon by the certifying officials. 

Response of Appropriate Medico-legal Death Authorities to Unattended Deaths 

In some jurisdictions, medical examiners/coroners rely upon police, fire, EMS, and 

trained lay investigators (funeral directors) to “initially screen” deaths. Medical 

examiners/coroners, police, fire and EMS resources will require a surge capacity to 

respond to the increased number of out of medical treatment facility or “unattended” 

deaths. Responders will need the knowledge and capability to identify influenza-related 

deaths verses non-influenza-related deaths to ensure proper actions are taken at the scene. 

Actionable recommendation to senior leaders: 

• Medical examiners/coroners, police and public health should develop specific 

investigative checklists, which clarifies the concepts of medico-legal 

determination of cause and manner of death, victim identification procedures, 

scene documentation, overall investigative requirements, as well as required PPE 

and personal decontamination, for all call centers and responders to unattended 

deaths during pandemic influenza 

• Communities could reach out to retired or non-practicing medical 

examiners/coroners, law enforcement and EMS providers to augment the 

community death investigation response. 

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• Medical examiners/coroners systems should train all other first responders in the 

field about the symptoms of influenza deaths and the actions to take when a 

suspected influenza-related death is found verses when non-influenza-related 

deaths are found. 

• The centralized patient tracking system with the patient/doctor data base should 

be made available to all identified responders in the field to allow for the most 

expeditious means of case management from the field into the system. (i.e. Can 

human remains be released to the funeral home with a primary care physician 

signing the death certificate or will human remains require processing by the 

medical examiner/coroner at another location?) 

• Establish a process to provide an adequate training program managed by the 

medical examiner/coroner and law enforcement to increase the lay investigator 

staff to support operations in the field before an event occurs. 

Taking these steps will ensure accurate death reporting and investigation and reassure the 

public that deaths have been accurately investigated and certified by the proper 

authorities: pubic confidence. 

Pronouncement of Unattended Deaths 

Local/state laws dictate who may or may not pronounce deaths in each jurisdiction. Some 

jurisdictions do not have pronouncement laws. In areas with pronouncement laws, there 

may not be enough personnel resources. Actionable recommendation to senior leaders: 

• Legal requirements for pronouncement may require amendment during a 

pandemic event to allow for additional personnel to complete the task. 

• Areas with pronouncement laws may have to bring additional personnel under 

their control and supervision to act in their behalf during pandemic influenza as 

well as amending their pronouncement laws/statutes. 

The result will be an increased number of trained personnel to augment the medical 

examiner/coroner during pandemic influenza, increased response resources, better public 

relations and public confidence. 

Medico-legal Determination of the Cause and Manner of Deaths for Unattended 

Deaths 

 Medico-legal death investigations demand trained responders with appropriate 

backgrounds. Many medical examiner/coroner systems rely upon police investigations 

and/or lay deputy coroners (trained funeral directors) to conduct an initial investigation 

and then to notify the medical examiner/coroner of the death for response. Police and 

medical examiner/coroner systems will be overwhelmed during pandemic influenza 

requiring additional trained staff 

Some families/friends may deliver the deceased directly to funeral homes, medical 

facilities (including urgent care centers) police and fire stations and medical 

examiner/coroner offices which will impact the scene investigations since the remains 

have been moved from the place of death. Appropriate and timely interviews are required 

for these circumstances. Attending physicians who hold the records for their patients may 

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not have the ability to respond to telephone calls from the scene responders. Actionable 

recommendation to senior leaders: 

• Identify additional personnel to train (based upon the medico-legal checklist 

procedures previously mentioned) and assist the medical examiner/coroner and 

police operations in death investigations (i.e. other sworn officers such as 

correctional officers, school truancy officers, etc.). 

• If not already in use, recruit former medical examiner/coroner, police, fire, EMS, 

funeral directors, personnel and train to assist in the scene determination 

investigations. 

• Establish a call-in line for medical examiner/coroner consultations and physicianpatient data to assist in the determination of the cause of death. 

• Training funds should be made available to communities for medico legal death 

instruction to those groups identified who will augment existing systems. 

By accomplishing these objectives, responders will have ready access to medicolegal resources to assist in the investigations. Physicians have access to resources 

to assist in the determination of the cause and manner of death. Individual “athome” cases can be tracked in a centralized database. 

Transportation of PI Human Remains to Appropriate Facilities 

Some medical examiner/coroner, EMS and law enforcement systems have human 

remains transport capabilities built into their existing systems. EMS will most likely 

require every available vehicle to transport the living to treatment facilities. Some 

medical examiner/coroner and police only utilize existing contractors (Funeral Directors 

and/or transport companies) who will be overwhelmed during pandemic influenza. 

Families and or friends may transport human remains to a facility in their private 

vehicles. Non-traditional human remains transporters may be required to conduct 

movement from homes, scenes, hospitals, morgues, funeral homes, cemeteries, and 

crematories. Human remains pouches, PPE, gurneys, and other basic morgue supplies 

will be in short supplies. Actionable recommendation to senior leaders: 

• Review existing codes on the requirements to transport human remains in your 

jurisdiction. Amend code, if necessary, to allow for surge capacity with nontraditional vehicles if required. 

• Solicit volunteers from other communities (churches, social services, salvation 

army, etc.) to assist in human remain transport, and provide training to ensure 

standard procedures are followed (including documentation, PPE usage and 

human and respectful treatment). 

• Obtain additional transport vehicles to augment the existing “fleet”. (School buses 

with seats removed, rented cargo vans, vehicles from funeral homes, etc.) 

• Human remains supplies should be purchased by communities with the pandemic 

influenza funding provided by the Federal government. 

The accomplishment of these measures will increase capacity to transport the increased 

number of human remains to appropriate facilities and freeing up funeral homes to 

complete their human remains preparations and allow for more timely response and less 

waiting times for families. 

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Appendix I - National Incident Management System

(NIMS) Training Requirements 

At publication time, the following are the NIMS training requirements. Review of 

current requirements and resources at: http://www.fema.gov/emergency/nims/index.shtm 

is encouraged. 

Entry Level 

• FEMA IS-700: NIMS, An Introduction 

• ICS-100: Introduction to ICS or equivalent 

First Line, Single Resource, Field Supervisors 

• IS-700, ICS-100 and ICS-200: Basic ICS or its equivalent 

Middle Management: Strike Team Leaders, Division Supervisors, EOC Staff, etc. 

• IS-700, IS-800 NRP, ICS-100, ICS-200 and in FY07, ICS-300 

Command and General Staff; Area, Emergency and EOC Managers 

• IS-700, IS-800, ICS-100, ICS-200 and in FY07, ICS-300 and ICS-400 

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Appendix J - Excerpts from the HHS Pandemic Influenza

Plan, Appendix D 

NVAC/ACIP Recommendations for Prioritization of Pandemic Influenza Vaccine 

and NVAC Recommendations on Pandemic Antiviral Drug Use 

 (The priority group recommendations are currently under revision) 

Source: US Department of Health and Human Services. 2005. HHS Pandemic Influenza Plan Appendix D: 

NVAC/ACIP Recommendations for Prioritization of Pandemic Influenza Vaccine and NVAC 

Recommendations on Pandemic Antiviral Drug Use. Washington, DC Department of Health and Human 

Services at http://www.hhs.gov/pandemicflu/plan/appendixd.html 

Two Federal advisory committees, the Advisory Committee on Immunization Practices 

(ACIP) and the National Vaccine Advisory Committee (NVAC), provided 

recommendations to the Department of Health and Human Services on the use of 

vaccines and antiviral drugs in an influenza pandemic. Advisory Committee 

recommendations presented in that report are intended to provide guidance for planning 

purposes and to form the basis for further discussion of how to equitably allocate medical 

countermeasures that will be in short supply early in an influenza pandemic. 

Based on this guidance, State, local and tribal implementation plans should be developed 

to 1) include more specific definitions of the priority groups (e.g., which functions are 

indeed critical to maintaining continuity) and their size; 2) define how persons in these 

groups will be identified; and 3) establish strategies for effectively and equitably 

delivering vaccines and antiviral drugs to these populations. 

The committees acknowledged that further work is needed, in particular, to identify the 

functions that must be preserved to maintain effective services and critical infrastructures 

and to identify the groups that should be protected to achieve this goal. The committees 

also acknowledge that the specific composition of some priority groups may differ 

between states or localities based on their needs and that priority groups should be 

reconsidered when a pandemic occurs and information is obtained on its epidemiology 

and impacts. 

On July 19, 2005, ACIP and NVAC voted unanimously in favor of the vaccine priority 

recommendations. These votes followed deliberations of a joint Working Group of the 

two committees, which included as consultants representatives of public and private 

sector stakeholder organizations and academic experts. There was limited staff level 

participation from DoD, DHS, and VA. Several ethicists also served as consultants to the 

Working Group. 

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Vaccine Priority Group Recommendations* 

Tier Subtier Population Rationale 

1 A Vaccine and antiviral 

manufacturers and others essential 

to manufacturing and critical 

support (~40,000) 

Medical workers and public health 

workers who are involved in direct 

patient contact, other support 

services essential for direct patient 

care, and vaccinators (8-9 million) 

Need to assure maximum production 

of vaccine and antiviral drugs 

Healthcare workers are required for 

quality medical care (studies show 

outcome is associated with staff-topatient ratios). There is little surge 

capacity among healthcare sector 

personnel to meet increased demand 

*The committee focused its deliberations on the U.S. civilian population. ACIP and NVAC recognize that Department of Defense 

needs should be highly prioritized. DoD Health Affairs indicates that 1.5 million service members would require immunization to 

continue current combat operations and preserve critical components of the military medical system. Should the military be called 

upon to support civil authorities domestically, immunization of a greater proportion of the total force will become necessary. These 

factors should be considered in the designation of a proportion of the initial vaccine supply for the military. 

Other groups also were not explicitly considered in these deliberations on prioritization. These include American citizens living 

overseas, non-citizens in the U.S., and other groups providing national security services such as the border patrol and customs 

service. 

Definitions and rationales for priority groups: Healthcare workers and essential 

healthcare support staff 

 a) Definition 

Healthcare workers (HCW) with direct patient contact (including acute-care hospitals, 

nursing homes, skilled nursing facilities, urgent care centers, physician’s offices, clinics, 

home care, blood collection centers, and EMS) and a proportion of persons working in 

essential healthcare support services needed to maintain healthcare services (e.g. dietary, 

housekeeping, admissions, blood collection center staff, etc.). Also included are 

healthcare workers in public health with direct patient contact, including those who may 

administer vaccine or distribute influenza antiviral medications, and essential public 

health support staff for these workers. 

 b) Rationale 

The pandemic is expected to have substantial impact on the healthcare system with large 

increases in demand for healthcare services placed on top of existing demand. HCW will 

be treating influenza-infected patients and will be at risk of repeated exposures. Further, 

surge capacity in this sector is low. To encourage continued work in a high-exposure 

setting and to help lessen the risk of healthcare workers transmitting influenza to other 

patients and HCW family members, this group was highly prioritized. In addition, 

increases in bed/nurse ratios have been associated with increases in overall patient 

mortality. Thus, substantial absenteeism may affect overall patient care and outcomes. 

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NVAC Recommendation 

On July 19, 2005, NVAC voted unanimously in favor of the antiviral drug use priority 

recommendations. These votes followed deliberations of a Working Group, which 

included as consultants representatives of public and private sector stakeholder 

organizations and academic experts. There was limited staff level participation from 

DoD, DHS, and VA. Several ethicists also served as consultants to the Working Group. 

The recommendations were made considering pandemic response goals, assumptions on 

the impacts of a pandemic, and after thorough review of past pandemics, annual influenza 

disease, data on antiviral drug impacts, and recommendations for pandemic vaccine use. 

Recommendations were made to guide planning needed for effective implementation at 

State and local levels. The committee recognizes that recommendations will need to be 

reconsidered at the time of a pandemic when information on the available drug supply, 

epidemiology of disease, and impacts on society are known. 

The committee considered the primary goal of a pandemic response to decrease health 

impacts including severe morbidity and death. Minimizing societal and economic impacts 

were considered secondary and tertiary goals. 

Antiviral Drug Priority Group Recommendations* 

Group 

Estimated 

population 

(millions) 

Strategy** 

# Courses 

(millions) 

Rationale For 

target 

group 

Cumulative 

1 Patients admitted to 

hospital*** 

10.0 T 7.5 7.5 Consistent with 

medical practice and 

ethics to treat those 

with serious illness 

and who are most 

likely to die. 

2 Health care 

workers (HCW) 

with direct patient 

contact and 

emergency 

medical service 

(EMS) providers 

9.2 T 2.4 9.9 Healthcare workers 

are required for 

quality medical care. 

There is little surge 

capacity among 

healthcare sector 

personnel to meet 

increased demand. 

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3 Highest risk outpatients— 

immunocompromised persons and 

pregnant women 

2.5 T 0.7 10.6 Groups at greatest risk of 

hospitalization and death; 

immunocompromised cannot be 

protected by vaccination. 

4 Pandemic health responders (public 

health, vaccinators, vaccine and 

antiviral manufacturers), public safety 

(police, fire, corrections), and 

government decision-makers 

3.3 T 0.9 11.5 Groups are critical for an 

effective public health response 

to a pandemic. 

*The committee focused its deliberations on the domestic U.S. civilian population. NVAC recognizes that Department of Defense 

(DoD) needs should be highly prioritized. A separate DoD antiviral stockpile has been established to meet those needs. Other groups 

also were not explicitly considered in deliberations on prioritization. These include American citizens living overseas, non-citizens in 

the U.S., and other groups providing national security services such as the border patrol and customs service. 

**Strategy: Treatment (T) requires a total of 10 capsules and is defined as 1 course. Post-exposure prophylaxis (PEP) also requires 

a single course. Prophylaxis (P) is assumed to require 40 capsules (4 courses) though more may be needed if community outbreaks 

last for a longer period. 

***There are no data on the effectiveness of treatment at hospitalization. If stockpiled antiviral drug supplies are very limited, the 

priority of this group could be reconsidered based on the epidemiology of the pandemic and any additional data on effectiveness in 

this population. 

Definitions and rationale for draft priority groups: Healthcare workers and 

emergency medical service providers who have direct patient contact 

 a) Definition 

Persons providing direct medical services in inpatient and outpatient care settings. This 

includes doctors, nurses, technicians, therapists, EMS providers, laboratory workers, 

other care providers who come within 3 feet of patients with influenza, and persons 

performing technical support functions essential to quality medical care. 

 b) Strategy 

Treatment within 48 hours of symptom onset. 

 c) Rationale 

Maintaining high quality patient care is critical to reduce health impacts of pandemic 

disease and to prevent adverse outcomes from other health conditions that will present for 

care during the pandemic period. Treatment of healthcare providers will decrease 

absenteeism due to influenza illness and may decrease absenteeism from fear of 

becoming ill, given the knowledge that treatment can prevent serious complications of 

influenza. Good data exist documenting the impacts of early treatment on duration of 

illness and time off work, and on the occurrence of complications such as lower 

respiratory infections. Treating healthcare providers is feasible to implement, especially 

for inpatient care providers who can be provided drugs through the occupational health 

clinic. It also would be acceptable to the public, who would recognize the importance of 

maintaining quality healthcare and would understand that persons with direct patient 

contact are putting themselves at increased risk. 

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d) Population size 

There are about 12.6 million persons designated as healthcare workers by the Bureau of 

Labor Statistics and about 820,000 EMS providers. Among HCWs, two-thirds are 

estimated to provide direct patient care services. 

e) Unresolved issues 

Further work is needed to hone definitions and estimate population sizes. Implementation 

issues include the approach to identifying healthcare providers who would be eligible for 

treatment and where the treatment would be provided, particularly for outpatient care 

providers. 

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Appendix K – Infection Control: Excerpts from Federal

Documents 

The following comments are excerpted from the HHS Pandemic Influenza Plan, 

Supplement 4: Infection Control (pp 220-225)90: 

The following infection control principles apply in any setting where persons with 

pandemic influenza might seek and receive healthcare services (e.g. hospitals, emergency 

departments, out-patient facilities, residential care facilities, homes), according to the 

CDC. 

• Limit contact between infected and non-infected persons 

• Isolate infected persons 

• Limit contact between nonessential personnel and other persons and patients 

who are ill with pandemic influenza. 

Protect persons caring for influenza patients in healthcare settings from contact with the 

pandemic influenza virus. Persons who must be in contact should: 

• Wear a surgical or procedure mask for close contact with infectious patients. 

• Use contact and airborne precautions, including the use of NIOSH-certified 

N95 respirators, when appropriate. 

• Wear gloves (gown if necessary) for contact with respiratory secretions. 

• Perform hand hygiene after contact with infectious patients. 

Contain infectious respiratory secretions: 

• Instruct persons who have “flu-like” symptoms to use respiratory 

hygiene/cough etiquette. 

• Promote use of masks by symptomatic persons in common areas (e.g., waiting 

rooms in physician offices or emergency departments) or when being 

transported (e.g., in emergency vehicles). 

Respiratory Hygiene/Cough Etiquette 

Respiratory hygiene/cough etiquette has been promoted as a strategy to contain 

respiratory viruses at the source and to limit their spread in areas where infectious 

patients might be awaiting medical care. 

The impact of covering sneezes and coughs and/or placing a mask on a coughing patient 

on the containment of respiratory secretions or on the transmission of respiratory 

infections has not been systematically studied. In theory, however, any measure that 

limits the dispersal of respiratory droplets should reduce the opportunity for transmission. 

Masking may be difficult in some settings, e.g., pediatrics, in which case the emphasis 

will be on cough hygiene. 

90 US Department of Health and Human Services. 2005. HHS Pandemic Influenza Plan Supplement 4 

Infection Control Washington, DC, Department of Health and Human Services retrieved March 20, 2007 at 

http://www.hhs.gov/pandemicflu/plan/sup4.html 

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The elements of respiratory hygiene/cough etiquette include: 

• Education of healthcare facility staff, patients, and visitors on the importance 

of containing respiratory secretions to help prevent the transmission of 

influenza and other respiratory viruses 

• Posted signs in languages appropriate to the populations served with 

instructions to patients and accompanying family members or friends to 

immediately report symptoms of a respiratory infection as directed 

• Source control measures (e.g., covering the mouth/nose with a tissue when 

coughing and disposing of used tissues; using masks on the coughing person 

when they can be tolerated and are appropriate) 

• Hand hygiene after contact with respiratory secretions, and 

• Spatial separation, ideally >3 feet, of persons with respiratory infections in 

common waiting areas when possible. 

Droplet Precautions 

Patients with known or suspected pandemic influenza should be placed on droplet 

precautions for a minimum of 5 days from the onset of symptoms. Because 

immunocompromised patients may shed virus for longer periods, they may be placed on 

droplet precautions for the duration of their illness. 

Healthcare personnel should wear appropriate PPE. If the pandemic virus is associated 

with diarrhea, contact precautions (i.e., gowns and gloves for all patient contact) should 

be added. 

CDC will update these recommendations if changes occur in the anticipated pattern of 

transmission (www.cdc.gov/flu). 

PPE for Standard and Droplet Precautions 

PPE is used to prevent direct contact with the pandemic influenza virus. PPE that may be 

used to provide care includes surgical or procedure masks, as recommended for droplet 

precautions, and gloves and gowns, as recommended for standard precautions. 

Additional precautions may be indicated during the performance of aerosol-generating 

procedures (see below). Information on the selection and use of PPE is provided at 

www.cdc.gov/ncidod/hip/isolat/isolat.htm/. 

At a minimum, prehospital care providers who directly handle a patient with respiratory 

disease or who are in the compartment with the patient should wear PPE as recommended 

for Standard, Contact, and AII Precautions. 

These include the following: 

• Disposable isolation gown, pair of disposable patient examination gloves, eye 

protection (i.e., goggles or face shield). 

• Respiratory protection (i.e., NIOSH-certified N-95 or higher-level respirator) 

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Personnel in the driver’s compartment who will have no direct patient contact should 

wear a NIOSH-certified N-95 or higher-level respirator during transport. Drivers who 

also provide direct patient care (e.g., moving patients on stretchers) should wear the 

recommended PPE for patient contact. This PPE, with the exception of the respirator, 

should be removed and hand hygiene performed after completing patient care and before 

entering driver’s compartment to avoid contaminating the compartment. Instructions on 

how to safely don, use, and remove PPE is available on CDC’s website. 

Masks 

• Wear a mask when entering a patient’s room. A mask should be worn once 

and then discarded. If pandemic influenza patients are cohorted in a common 

area or in several rooms on a nursing unit, and multiple patients must be 

visited over a short time, it may be practical to wear one mask for the duration 

of the activity; however, other PPE (e.g., gloves, gown) must be removed 

between patients and hand hygiene performed. 

• Change masks when they become moist. 

• Do not leave masks dangling around the neck. 

• Upon touching or discarding a used mask, perform hand hygiene. 

Gloves 

• A single pair of patient care gloves should be worn for contact with blood and 

body fluids, including during hand contact with respiratory secretions (e.g., 

providing oral care, handling soiled tissues). Gloves made of latex, vinyl, 

nitrile, or other synthetic materials are appropriate for this purpose; if 

possible, latex-free gloves should be available for healthcare workers who 

have latex allergy. 

• Gloves should fit comfortably on the wearer’s hands. 

• Remove and dispose of gloves after use on a patient; do not wash gloves for 

subsequent reuse. 

• Perform hand hygiene after glove removal. 

• If gloves are in short supply (i.e., the demand during a pandemic could exceed 

the supply), priorities for glove use might need to be established. In this 

circumstance, reserve gloves for situations where there is a likelihood of 

extensive patient or environmental contact with blood or body fluids, 

including during suctioning. 

• Use other barriers (e.g., disposable paper towels, paper napkins) when there is 

only limited contact with a patient’s respiratory secretions (e.g., to handle 

used tissues). Hand hygiene should be strongly reinforced in this situation. 

Gowns 

• Wear an isolation gown, if soiling of personal clothes or uniform with a 

patient’s blood or body fluids, including respiratory secretions, is anticipated. 

Most patient interactions do not necessitate the use of gowns. However, 

procedures such as intubation and activities that involve holding the patient 

close (e.g., in pediatric settings) are examples of when a gown may be needed 

when caring for pandemic influenza patients. 

128
• A disposable gown made of synthetic fiber or a washable cloth gown may be 

used. 

• Ensure that gowns are of the appropriate size to fully cover the area to be 

protected. 

• Gowns should be worn only once and then placed in a waste or laundry 

receptacle, as appropriate, and hand hygiene performed. 

• If gowns are in short supply (i.e., the demand during a pandemic could exceed 

the supply) priorities for their use may need to be established. In this 

circumstance, reinforcing the situations in which they are needed can reduce 

the volume used. Alternatively, other coverings (e.g., patient gowns) could be 

used. It is doubtful that disposable aprons would provide the desired 

protection in the circumstances where gowns are needed to prevent contact 

with influenza virus, and therefore should be avoided. There are no data upon 

which to base a recommendation for reusing an isolation gown on the same 

patient. To avoid possible contamination, it is prudent to limit this practice. 

Goggles or Face Shield 

In general, wearing goggles or a face shield for routine contact with patients with 

pandemic influenza is not necessary. If sprays or splatter of infectious material is likely, 

goggles or a face shield should be worn as recommended for standard precautions. 

Additional information related to the use of eye protection for infection control can be 

found at http://www.cdc.gov/niosh/topics/eye/eye-infectious.html. [Source: Supplement 4 

to the HHS Pandemic Influenza Plan] 

PPE for Special Circumstances 

PPE for Aerosol-Generating Procedures 

During procedures that may generate increased small-particle aerosols of respiratory 

secretions (e.g., endotracheal intubation, nebulizer treatment, bronchoscopy, suctioning), 

healthcare personnel should wear gloves, gown, face/eye protection, and a N95 respirator 

or other appropriate particulate respirator. Respirators should be used within the context 

of a respiratory protection program that includes fit-testing, medical clearance, and 

training. If possible, and when practical, use of an airborne isolation room may be 

considered when conducting aerosol-generating procedures. 

PPE for Managing Pandemic Influenza with Increased Transmissibility 

The addition of airborne precautions, including respiratory protection (an N95 filtering 

face piece respirator or other appropriate particulate respirator), may be considered for 

strains of influenza exhibiting increased transmissibility, during initial stages of an 

outbreak of an emerging or novel strain of influenza, and as determined by other factors 

such as vaccination/immune status of personnel and availability of antivirals. As the 

epidemiologic characteristics of the pandemic virus are more clearly defined, CDC will 

provide updated infection control guidance, as needed. 

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Precautions for Early Stages of Pandemic 

Early in a pandemic, it may not be clear that a patient with severe respiratory illness has 

pandemic influenza. Therefore precautions consistent with all possible etiologies, 

including a newly emerging infectious agent, should be implemented. This may involve 

the combined use of airborne and contact precautions, in addition to standard precautions, 

until a diagnosis is established. 

Caring for Patients with Influenza 

Healthcare personnel should be particularly vigilant to avoid: 

• Touching their eyes, nose or mouth with contaminated hands (gloved or 

ungloved). Careful placement of PPE before patient contact will help avoid 

the need to make PPE adjustments and risk self-contamination during use. 

Careful removal of PPE is also important. (See also: 

http://www.cdc.gov/ncidod/hip/ppe/default.htm.) 

• Contaminating environmental surfaces that are not directly related to patient 

care (e.g., door knobs, light switches) 

Hand Hygiene 

Hand hygiene has frequently been cited as the single most important practice to reduce 

the transmission of infectious agents in healthcare settings (see 

http://www.cdc.gov/handhygiene/pressrelease.htm) and is an essential element of 

standard precautions. The term “hand hygiene” includes both handwashing with either 

plain or antimicrobial soap and water and use of alcohol-based products (gels, rinses, 

foams) containing an emollient that do not require the use of water. 

• If hands are visibly soiled or contaminated with respiratory secretions, wash 

hands with soap (either non-antimicrobial or antimicrobial) and water. 

• In the absence of visible soiling of hands, approved alcohol-based products for 

hand disinfection are preferred over antimicrobial or plain soap and water 

because of their superior microbiocidal activity, reduced drying of the skin, 

and convenience. 

• Always perform hand hygiene between patient contacts and after removing 

PPE. 

• Ensure that resources to facilitate handwashing (i.e., sinks with warm and cold 

running water, plain or antimicrobial soap, disposable paper towels) and hand 

disinfection (i.e., alcohol-based products) are readily accessible in areas in 

which patient care is provided. For additional guidance on hand hygiene see 

http://www.cdc.gov/handhygiene/. 

Disposal of Solid Waste 

Standard precautions are recommended for disposal of solid waste (medical and nonmedical) that might be contaminated with a pandemic influenza virus: 

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• Contain and dispose of contaminated medical waste in accordance with 

facility-specific procedures and/or local or State regulations for handling and 

disposal of medical waste, including used needles and other sharps, and nonmedical waste. 

• Discard as routine waste used patient-care supplies that are not likely to be 

contaminated (e.g., paper wrappers). 

• Wear disposable gloves when handling waste. Perform hand hygiene after 

removal of gloves. 

Linen and Laundry 

Standard precautions are recommended for linen and laundry that might be contaminated 

with respiratory secretions from patients with pandemic influenza: 

• Place soiled linen directly into a laundry bag in the patient’s room. Contain 

linen in a manner that prevents the linen bag from opening or bursting during 

transport and while in the soiled linen holding area. 

• Wear gloves and gown when directly handling soiled linen and laundry (e.g., 

bedding, towels, personal clothing) as per standard precautions. Do not shake 

or otherwise handle soiled linen and laundry in a manner that might create an 

opportunity for disease transmission or contamination of the environment. 

• Wear gloves for transporting bagged linen and laundry. 

• Perform hand hygiene after removing gloves that have been in contact with 

soiled linen and laundry. 

• Wash and dry linen according to routine standards and procedures 

(www.cdc.gov/ncidod/hip/enviro/guide.htm). 

Patient-Care Equipment 

Follow standard practices for handling and reprocessing used patient-care equipment, 

including medical devices: 

• Wear gloves when handling and transporting used patient-care equipment. 

• Wipe heavily soiled equipment with an EPA-registered hospital disinfectant 

before removing it from the patient’s room. 

• Follow current recommendations for cleaning and disinfection or sterilization 

of reusable patient-care equipment. 

• Wipe external surfaces of portable equipment for performing x-rays and other 

procedures in the patient’s room with an EPA-registered hospital disinfectant 

upon removal from the patient’s room. 

Environmental Cleaning and Disinfection 

Cleaning and disinfection of environmental surfaces are important components of routine 

infection control in healthcare facilities. Environmental cleaning and disinfection for 

pandemic influenza follow the same general principles used in healthcare settings. 

[Source: Supplement 4 to the HHS Pandemic Influenza Plan] 

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Postmortem Care 

Follow standard facility practices for care of the deceased. Practices should include 

standard precautions for contact with blood and body fluids. 

EMS Infection Control Recommendations 

• Screen patients requiring emergency transport for symptoms of influenza. 

• Follow standard and droplet precautions when transporting symptomatic 

patients. 

• Consider routine use of surgical or procedure masks for all patient transport 

when pandemic influenza is in the community. (See mask guidance below.) 

• If possible, place a procedure or surgical mask on the patient to contain 

droplets expelled during coughing. If this is not possible (i.e., would further 

compromise respiratory status, difficult for the patient to wear), have the 

patient cover the mouth/nose with tissue when coughing, or use the most 

practical alternative to contain respiratory secretions. 

• Oxygen delivery with a non-rebreather face mask can be used to provide 

oxygen support during transport. If needed, positive-pressure ventilation 

should be performed using a resuscitation bag-valve mask. 91 

• Unless medically necessary to support life, aerosol-generating procedures 

(e.g., mechanical ventilation, nebulized breathing treatments) should be 

avoided during prehospital care. 

• Optimize the vehicle’s ventilation to increase the volume of air exchange 

during transport. When possible, use vehicles that have separate driver and 

patient compartments that can provide separate ventilation to each area. (See 

additional guidance below.) 

• Notify the receiving facility that a patient with possible pandemic influenza is 

being transported. 

• Follow standard operating procedures for routine cleaning of the emergency 

vehicle and reusable patient care equipment. 

The following information is from Interim Guidance on Planning for the Use of Surgical 

Masks and Respirators in Health Care Settings during an Influenza Pandemic92: 

Use of Surgical Masks and Respirators in Health Care Settings 

Surgical mask and respirator use is one component of a system of infection control 

practices to prevent the spread of infection between infected and non-infected persons. 

During an influenza pandemic, surgical masks and respirators—along with other forms of 

personal protective equipment (e.g., gloves, gowns, and goggles)—should be used by 

91 Stakeholder note: Oxygen delivery devices (e.g., masks for patients) are emerging in the equipment marketplace capable of high 

oxygen flow rates while providing containment and exhaled air and droplet particles through the use of an inline filter. These devices 

are commonly used in Canada. 92 Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Health Care Settings 

during an Influenza Pandemic. CDC, October, 2006. Available at: 

http://www.pandemicflu.gov/plan/healthcare/maskguidancehc.html 

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healthcare personnel in conjunction with Standard and Droplet Precautions, respiratory 

hygiene, cough etiquette, vaccination, and early diagnosis and treatment. 

Recommendations 

National Institute for Occupational Safety and Health (NIOSH)-certified respirators (N95 

or higher) are recommended for use during activities that have a high likelihood of 

generating infectious respiratory aerosols. 

• Aerosol-generating procedures (e.g., endotracheal intubation, nebulizer treatment, 

and bronchoscopy) performed on patients with confirmed or suspected pandemic 

influenza; 

• Resuscitation of a patient with confirmed or suspected pandemic influenza (i.e., 

emergency intubation or cardiac pulmonary resuscitation); and 

• Providing direct care for patients with confirmed or suspected pandemic 

influenza-associated pneumonia (as determined on the basis of clinical diagnosis 

or chest x-ray), who might produce larger-than-normal amounts of respirable 

infectious particles when they cough 

In the event of actual or anticipated shortages of N-95 respirators: 

• Other NIOSH-certified N-, R-, or P-class respirators should be considered in 

lieu of the N95 respirator. 

• If re-useable elastomeric respirators are used, these respirators must be 

decontaminated according to the manufacturer’s instructions after each use. 

• Powered air purifying respirators (PAPRs) may be considered for certain 

workers and tasks (e.g., high-risk activities). Loose-fitting PAPRs have the 

advantages of providing eye protection, being comfortable to wear, and not 

requiring fit-testing; however, hearing (e.g., for auscultation) is impaired, 

limiting their utility for clinical care. Training is required to ensure proper use 

and care of PAPRs. 

Planning assumptions and projections suggest that shortages of respirators are likely in a 

sustained pandemic. Therefore, in the event of an actual or anticipated shortage, planners 

must ensure that sufficient numbers of respirators are prioritized for use during the highrisk procedures. This will require careful planning as well as real-time supply monitoring 

to ensure that excess respirators are not held in reserve while healthcare personnel are 

conducting activities for which they would otherwise be provided respiratory protection. 

Conversely, excessive use of respirators could result in their unavailability for high-risk 

procedures. Decision guidance for determining respirator wear should consider factors 

such as duration, frequency, proximity and degree of contact with the patient. 

If supplies of N-95 (or higher) respirators are not available, surgical masks can provide 

benefits against large droplet exposure, and should be worn for all healthcare activities 

for patients with confirmed or suspected pandemic-influenza. 

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Guidance for Correct Use 

Respirator use should be in the context of a complete respiratory protection program in 

accordance with Occupational Safety and Health Administration (OSHA) regulations. 

Detailed information on respiratory protection programs, including fit test procedures, 

can be accessed at OSHA’s Respiratory Protection eTool 

(www.osha.gov/SLTC/etools/respiratory). Staff with responsibility for direct patient care 

should be medically cleared, trained, and fit-tested for respirator use. Training topics 

should include the following: 

• Proper fit-testing, wearing, and use of respirators 

• Safe removal of respirators 

• Safe disposal of respirators 

• Medical contraindications to respirator use 

Persons who wear surgical masks or respirators should be advised that: 

• Surgical mask or respirator use should not take the place of preventive 

interventions, such as respiratory etiquette and hand hygiene. 

• To offer protection, surgical masks and respirators must be worn correctly 

and consistently throughout the time they are used. 

• Wearing a surgical mask or respirator incorrectly, or removing or disposing 

of it improperly, could allow contamination of the hands or mucous 

membranes of the wearer or others, possibly resulting in disease 

transmission. 

• Proper surgical mask or respirator use and removal includes the following: 

o Prior to putting on a respirator or surgical mask, wash hands thoroughly 

with soap and water or use an alcohol-based hand sanitizer to reduce the 

possibility of inadvertent contact between contaminated hands and mucous 

membranes. 

o If worn in the presence of infectious persons, a respirator or surgical mask 

may become contaminated with infectious material; therefore, avoid 

touching the outside of the device to help prevent contamination of hands. 

o Once worn in the presence of a patient with patient with pandemic 

influenza, the disposable surgical mask or disposable N95 respirator 

should be removed and appropriately discarded. 

o After the surgical mask or respirator has been removed and discarded, 

wash hands thoroughly with soap and water, or use an alcohol-based hand 

sanitizer. 

o Further information about masks and respirators can be found at 

http://www.cdc.gov/ncidod/sars/respirators.htm and 

http://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/respsars.html 

#F. 

Additional information (see referenced sources) regarding ambulance ventilation 

Negative pressure isolation is not required for routine patient care of individuals with 

pandemic influenza. When possible, however, use vehicles that have separate driver and 

patient compartments that can provide separate ventilation to each area. Close the 

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door/window between these compartments before bringing the patient on board. Set the 

vehicle’s ventilation system to the non-recirculating mode to maximize the volume of 

outside air brought into the vehicle. If the vehicle has a rear exhaust fan, use it to draw air 

away from the cab, toward the patient-care area, and out the back end of the vehicle. 

Some vehicles are equipped with supplemental recirculating ventilation units that pass air 

through HEPA filters before returning it to the vehicle. Such units can be used to increase 

the number of [air changes per hour] (ACH)93,94. 

If a vehicle without separate compartments and ventilation must be used, open the outside 

air vents in the driver area and turn on the rear exhaust ventilation fans to the highest 

setting. This will create a negative pressure gradient in the patient area. 

93 Centers for Disease Control and Prevention. ONLINE. 2005. Public Health Guidance for CommunityLevel Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) Version 2 Supplement I: 

Infection Control in Healthcare, Home, and Community Settings Section IV. Infection Control for 

Prehospital Emergency Medical Services (EMS) CDC. Available: 

http://www.cdc.gov/ncidod/sars/guidance/I/index.htm [24 March 2007] 94 National Institute for Occupational Safety and Health. ONLINE. 1996. Health Hazard Evaluation Report 

95–0031–2601. NIOSH Hazard Evaluations and Technical Assistance Branch. Available: 

www.cdc.gov/niosh/hhe/reports/pdfs/1995-0031-2601.pdf [3 April 2007] 

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Appendix L - Cleaning and Disinfecting Strategies for

Environmental Surfaces in Patient-Care Areas 

Adapted from the 2003 CDC Guidelines for Environmental Infection Control in 

Health-Care Facilities. 

Source: Sehulster L, Chinn RY. Guidelines for environmental infection control in healthcare facilities. Recommendations of CDC and the Healthcare Infection Control Practices 

Advisory Committee (HICPAC) [Published errata appear in MMWR Recomm Rep 2003 

Oct 24;52(42):1025-6]. MMWR Recomm Rep 2003 Jun 6;52(RR-10):1-42. 

Rating Categories 

Recommendations are rated according to the following categories: 

• Category IA. Strongly recommended for implementation and strongly 

supported by well-designed experimental, clinical, or epidemiologic studies. 

• Category IB. Strongly recommended for implementation and supported by 

certain experimental, clinical, or epidemiologic studies and a strong theoretical 

rationale. 

• Category IC. Required by State or Federal regulation, or representing an 

established association standard. (Note: Abbreviations for governing agencies 

and regulatory citations are listed, where appropriate. Recommendations from 

regulations adopted at State levels are also noted. Recommendations from AIA 

guidelines cite the appropriate sections of the standard). 

• Category II. Suggested for implementation and supported by suggestive 

clinical or epidemiologic studies, or a theoretical rationale. 

• Unresolved Issue. No recommendation is offered. No consensus or 

insufficient evidence exists regarding efficacy.

1. Select EPA-registered disinfectants, if available, and use them in accordance with the 

manufacturer’s instructions. Category IB, IC (EPA: 7 United States Code [USC] § 136 et 

seq) 

2. Do not use high-level disinfectants/liquid chemical sterilants for disinfection of either 

noncritical instrument/devices or any environmental surfaces; such use is counter to label 

instructions for these toxic chemicals. Category IB, IC (FDA: 21 CFR 801.5, 807.87.e) 

3. Follow manufacturers’ instructions for cleaning and maintaining noncritical medical 

equipment. Category II 

4. In the absence of a manufacturer’s cleaning instructions, follow certain procedures. 

a. Clean noncritical medical equipment surfaces with a detergent/disinfectant. 

This may be followed with an application of an EPA-registered hospital 

disinfectant with or without a tuberculocidal claim (depending on the nature of the 

surface and the degree of contamination), in accordance with disinfectant label 

instructions. Category II 

b. Do not use alcohol to disinfect large environmental surfaces. Category II 

c. Use barrier protective coverings as appropriate for noncritical equipment 

surfaces that are 

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1) touched frequently with gloved hands during the delivery of patient 

care; 

2) likely to become contaminated with blood or body substances; or 

3) difficult to clean (e.g., computer keyboards). Category II 

d. Keep surfaces (e.g., floors, walls, crew seats, and countertops) visibly clean on 

a regular basis and clean up spills promptly. Category II 

1) Use a one-step process and an EPA-registered hospital-grade 

disinfectant/detergent designed for general housekeeping purposes in 

patient-care areas when a) uncertainty exists as to the nature of the soil on 

these surfaces [e.g., blood or body fluid contamination versus routine dust 

or dirt]; or b) uncertainty exists regarding the presence or absence of 

multi-drug resistant organisms on such surfaces. Category II 

2) Detergent and water are adequate for cleaning surfaces in nonpatientcare areas (e.g., administrative offices). Category II 

3) Clean and disinfect high-touch surfaces (e.g., doorknobs and handles, 

stretcher rails, light switches, and arm rests) on a more frequent schedule 

than minimal touch housekeeping surfaces. Category II 

4) Clean walls in patient-care areas when they are visibly dusty or soiled. 

Category II 

e. Do not perform disinfectant fogging in patient-care areas. Category IB 

f. Avoid large-surface cleaning methods that produce mists or aerosols or disperse 

dust in patient-care areas. Category IB 

g. Follow proper procedures for effective use of mops, cloths, and solutions. 

Category II 

1) Prepare cleaning solutions daily or as needed, and replace with fresh 

solution frequently according to facility policies and procedures. Category 

II 

2) Change the mop head at the beginning of the day and also as required 

by facility policy, or after cleaning up large spills of blood or other body 

substances. Category 

II 

3) Clean mops and cloths after use and allow drying before reuse; or use 

single-use, disposable mop heads and cloths. Category II 

Cleaning Spills of Blood and Body Substances 

1. Promptly clean and decontaminate spills of blood or other potentially infectious 

materials. Category IB, IC (OSHA: 29 CFR 1910.1030 §d.4.ii.A) 

2. Follow proper procedures for site decontamination of spills of blood or bloodcontaining body fluids. Category IC (OSHA: 29 CFR 1910.1030 § d.4.ii.A) 

a. Use protective gloves and other PPE appropriate for this task. Category IC 

(OSHA: 29 CFR 1910.1030 § d.3.i, ii) 

b. If the spill contains large amounts of blood or body fluids, clean the visible 

matter with disposable absorbent material, and discard the contaminated materials 

in appropriate, labeled containment. Category IC (OSHA: 29 CFR 1910.1030 § 

d.4.iii.B) 

c. Swab the area with a cloth or paper towels moderately wetted with disinfectant, 

and allow the surface to dry. Category IC (OSHA: 29 CFR 1910.1030 § d.4.ii.A) 

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3. Use EPA-registered hospital-grade disinfectants labeled tuberculocidal or registered 

germicides on the EPA Lists D and E (products with specific label claims for HIV or 

hepatitis B virus [HBV]) in accordance with label instructions to decontaminate spills of 

blood and other body fluids. Category IC (OSHA 29 CFR 1910.1030 § d.4.ii.A 

memorandum 2/28/97; compliance document CPL 2-2.44D [11/99]) 

4. An EPA-registered sodium hypochlorite product is preferred, but if such products are 

not available, generic versions of sodium hypochlorite solutions (e.g., household chlorine 

bleach) may be used. 

a. Use a 1:100 dilution (500–615 ppm available chlorine) to decontaminate 

nonporous surfaces after cleaning a spill of either blood or body fluids in patientcare settings. Category II 

b. If a spill involves large amounts of blood or body fluids, use a 1:10 dilution 

(5,000–6,150 ppm available chlorine) for the first application of germicide before 

cleaning. Category II 

Special Pathogens 

1. Use appropriate hand hygiene, PPE (e.g., gloves), and isolation precautions during 

cleaning and disinfecting procedures. Category IB 

2. Use standard cleaning and disinfection protocols to control environmental 

contamination during a pandemic influenza. Category IB 

a. Pay close attention to cleaning and disinfection of high-touch surfaces in 

patient-care areas (e.g., bedrails, equipment cabinets, drug boxes, 

monitor/defibrillators, armrests, door knobs and handles). Category IB 

b. Ensure compliance by staff with cleaning and disinfection procedures. 

Category IB 

c. Use EPA-registered hospital-grade disinfectants appropriate for the surface to 

be disinfected (e.g., either low- or intermediate-level disinfection) as specified by 

the manufacturers’ instructions. Category IB, IC (EPA: 7 USC § 136 et seq.) 

1). When contact precautions are indicated for patient care, use disposable 

patient-care items (e.g., blood pressure cuffs) whenever possible to 

minimize cross-contamination with multiple-resistant microorganisms. 

Category IB 

2). Follow these same surface cleaning and disinfecting measures for 

managing the environment of influenza patients. Category II 

3. Thoroughly clean and disinfect environmental and medical equipment surfaces on a 

regular basis using EPA-registered disinfectants in accordance with manufacturers’ 

instructions. Category IB, IC (EPA: 7 USC § 136 et seq.) 

4. Advise families, visitors, and patients about the importance of hand hygiene to 

minimize the spread of body substance contamination (e.g., respiratory secretions) to 

surfaces. Category II 

5. Do not use high-level disinfectants (i.e., liquid chemical sterilants) on environmental 

surfaces; such use is inconsistent with label instructions and because of the toxicity of the 

chemicals. Category IC (FDA: 21 CFR 801.5, 807.87.e) 

6. Clean surfaces that have been contaminated with body substances; perform low- to 

intermediate-level disinfection on cleaned surfaces with an EPA-registered disinfectant in 

accordance with the manufacturer’s instructions. Category IC (OSHA: 29 CFR 

1910.1030 § d.4.ii.A; EPA: 7 USC § 136 et seq.) 

138
7. Use disposable barrier coverings as appropriate to minimize surface contamination. 

Category II 

8. Use disposable, impervious covers to minimize body substance contamination to 

stretchers and surfaces when transferring or transporting bodies to morgue facilities. 

Category IB 

9. Use standard procedures for containment, cleaning, and decontamination of blood 

spills on surfaces as previously described (Environmental Services: II).967 Category IC 

(OSHA: 29 CFR 1910.1030 §d.4.ii.A) 

a. Wear PPE appropriate for a surface decontamination and cleaning task. 

Category IC (OSHA 29 CFR 1910.1030 §d.3.i, ii) 

b. Discard used PPE by using routine disposal procedures or decontaminate 

reusable PPE as appropriate. Category IC (OSHA 29 CFR 1910.1030 §d.3.viii) 

Post-Mortem Considerations 

There are a multitude of issues surrounding the handling of human remains during a 

pandemic however, infection control and decontamination measures are no different than 

with any other infectious disease process. A pandemic influenza death is a natural 

manner of death. Those who physically handle remains may be at risk of blood borne or 

body fluid exposure requiring universal precautions and proper training for handling the 

dead. Responders will need the knowledge and capability to identify PI event related 

deaths versus non PI event related deaths to ensure proper actions are taken at the scene. 

Additional information sources: 

Reynolds KA, Watt PM, Boone SA, Gerba CP. Occurrence of bacteria and biochemical markers on public 

surfaces. Int J Environ Health Res. 2005 Jun;15(3):225-34. 

Guidelines for Environmental Infection Control in Health-Care Facilities. MMWR June 6, 2003 / 

52(RR10);1-42. Centers for Disease Control and Prevention. Accessed December 2006 at 

www.cdc.gov/ncidod/dhqp/gl_environinfection.html 

Centers for Disease Control and Prevention. 2005. Public Health Guidance for Community-Level 

Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) Version 2 Supplement I: 

Infection Control in Healthcare, Home, and Community Settings Section IV. Infection Control for 

Prehospital Emergency Medical Services (EMS) retrieved March 24, 2007 at 

http://www.cdc.gov/ncidod/sars/guidance/I/index.htm . 

U.S. Northern Command and Department of Health and Human Services Fatality Management Pandemic 

Influenza Working Group Conference, White Paper: Scene Operations, to Include Identification, Medicolegal Investigation Protocols and Command and Control of Mass Fatalities Resulting from a Pandemic 

Influenza (PI) in the United States, September 2006 available at Joint Task Force Civil Support, 

www.jtfcs.northcom.mil/pages/WP_SceneOps(FINAL).pdf 

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Appendix M - Pandemic Influenza Resources 

This list, while not comprehensive, offers a starting point for obtaining information on 

pandemic influenza. Check regularly with local, State and Federal public health experts 

for additional guidance. 

International 

Avian Influenza Response from U.S. Agency for International Development 

www.usaid.gov/our_work/global_health/home/News/news_items/avian_influenza.html 

This site gives information on assistance provided to affected countries. 

Interim Guidance for U.S. Citizens Living Abroad 

www.cdc.gov/travel/other/avian_flu_ig_americans_abroad_032405.htm 

This site from the Centers for Disease Control and Prevention provides guidelines and 

recommendations about HPAI H5N1 for U.S. citizens living overseas. 

WHO Pandemic Preparedness 

www.who.int/csr/disease/influenza/pandemic/en 

This site defines an influenza pandemic, explains how a new influenza virus can cause a 

pandemic, presents the consequences of an influenza pandemic, explains the global 

surveillance systems and provides links to other pandemic plans from other nations. 

United States International Engagement on Avian and Pandemic Influenza 

www.state.gov/r/pa/scp/2006/72923.htm 

This fact sheet outlines United States actions to support avian influenza preparedness 

efforts in at least 53 countries, in collaboration with the World Health Organization 

(WHO), Food and Agriculture Organization (FAO), the World Organization for Animal 

Health (OIE) and other international and in-country partners. 

National 

Altered Standards of Care in Mass Casualty Events: Bioterrorism and Other Public 

Health Emergencies 

Agency for Healthcare Research and Quality Publication No. 05-0043 April 2005 

www.ahrq.gov/research/altstand/altstand.pdf 

Avian Influenza information from the Department of Agriculture 

www.usda.gov/wps/portal/usdahome?navtype=SU&navid=AVIAN_INFLUENZA 

This site supplies reports of efforts to protect the United States against highly 

transmissible forms of avian influenza, via trade restrictions, monitoring and other 

actions 

Avian Influenza information from the Centers for Disease Control and Prevention 

www.cdc.gov/flu/avian 

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This site presents information on the symptoms, treatment and complications of the 

disease, prevention and control, the types of influenza viruses, questions and answers on 

symptoms, vaccination and myths. 

Avian Flu information from the Environmental Protection Agency 

www.epa.gov/pandemicflu/ 

This site provides an overview of the Environmental Protection Agency’s actions. 

Avian Influenza information from the Infectious Diseases Society of America 

www.idsociety.org/Content/NavigationMenu/Resources/Avian_Pandemic_Flu/Avian_Pa

ndemic_Flu.htm

This site provides information on pandemic flu from the perspective of the IDSA, a 

specialty organization for scientists and healthcare professionals with an interest in 

infectious diseases. 

Avian Influenza Fact Sheet 

http://www.cdc.gov/flu/avian/gen-info/facts.htm 

Centers for Disease Control and Prevention (CDC) Interim Pre-pandemic Planning 

Guidance: Community Strategy for Pandemic Influenza Mitigation in the United 

States 

February 1, 2007 

http://www.pandemicflu.gov/plan/community/commitigation.html 

Emergency Planning: Pandemic from the Department of Education 

www.ed.gov/admins/lead/safety/emergencyplan/pandemic/index.html 

This site provides tools to assist with disseminating health information, planning for staff 

and student absences and maintaining a learning environment during a pandemic. 

Epi-X: The Epidemic Information Exchange 

www.cdc.gov/mmwr/epix/epix.html 

This Web-based communications network allows for information exchange among the 

CDC, State and local health departments, and other public health professionals. 

Ethical Guidelines in Pandemic Influenza 

Centers for Disease Control and Prevention 

February 2007 

www.cdc.gov/od/science/phec/panFlu_Ethic_Guidelines.pdf 

This document provides the ethical background used in formulating guidelines related to 

community mitigation strategies. 

Food and Drug Administration Pandemic Influenza WEB site: 

http://www.fda.gov/oc/op/pandemic/default.htm 

Guidance to Travelers 

http://www.cdc.gov/travel/other/avian_flu_ah5n1_031605.htm 

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Health and Human Services (HHS) Pandemic Influenza Plan 

November 2005 

www.hhs.gov/pandemicflu/plan 

HHS Pandemic Planning Updates 

Each report provides status on five key planning areas: monitoring and surveillance, 

vaccines, antiviral medications, State and local preparedness, and communications. 

Update III, November 13, 2006 

http://www.pandemicflu.gov/plan/pdf/panflureport3.pdf 

Update II, June 29, 2006 

http://www.pandemicflu.gov/plan/pdf/panflureport2.pdf 

Update, March 13, 2006 

http://www.pandemicflu.gov/plan/pdf/panflu20060313.pdf 

HEALTH AND HUMAN SERVICES Request for Information (RFI): Guidance for 

Prioritization of Pre-pandemic and Pandemic Influenza Vaccine 

http://aspe.hhs.gov/PIV/RFI/ 

Indian Health Services Pandemic Influenza Workbook -- A Planning Guide for 

American Indian/Alaska Native Communities (2006) 

http://www.ihs.gov/MedicalPrograms/epi/pi/documents/Pandemic_Influenza_Planni 

ng_Workbook.pdf 

Managing Anxiety in Times of Crisis 

http://mentalhealth.samhsa.gov/cmhs/managinganxiety/default.asp 

National Infrastructure Advisory Council (NIAC) 

The Prioritization of Critical Infrastructure for a Pandemic Outbreak in the United 

States-- Final Report and Recommendations by the Council 

January 16, 2007 

http://www.dhs.gov/xlibrary/assets/niac/niac-pandemic-wg_v8-011707.pdf 

National Vaccine Program Office 

www.dhhs.gov/nvpo/pandemics 

This site presents an historical overview of pandemics that occurred throughout the past 

century (Spanish influenza, Asian influenza and Hong Kong influenza), and three 

influenza scares (swine flu, Russian influenza and avian influenza). 

National Strategy for Pandemic Influenza 

Implementation Plan for the National Strategy for Pandemic Influenza 

http://www.pandemicflu.gov/plan/federal/index.html 

The National Strategy for Pandemic Influenza, issued by President Bush November 1, 

2005, guides our Nation's preparedness and response to an influenza pandemic, with the 

intent of (1) stopping, slowing or otherwise limiting the spread of a pandemic to the 

United States; (2) limiting the domestic spread of a pandemic and mitigating disease, 

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suffering and death; and (3) sustaining infrastructure and mitigating impact to the 

economy and the functioning of society. The Strategy charges the U.S. Department of 

Health & Human Services with leading the Federal pandemic preparedness. 

National Response Plan 

http://www.dhs.gov/xprepresp/committees/editorial_0566.shtm 

This Department of Homeland Security site contains a comprehensive all-hazards 

approach to enhance the ability of the United States to manage domestic incidents. The 

National Response Plan forms the basis of how the Federal Government coordinates with 

State, local and tribal governments and the private sector during incidents. 

Occupational Safety and Health Administration, U.S. Department of Labor 

http://www.osha.gov/Publications/OSHA3327.pandemic.pdf 

Guidance on preparing workplaces for an influenza pandemic. 

Office of Personnel Management, Human Capital Planning for Pandemic Influenza 

http://www.opm.gov/pandemic 

Pandemic Influenza Fact Sheet 

http://www.cdc.gov/flu/avian/gen-info/pandemics.htm 

Pandemic Influenza Preparedness, Response, and Recovery Guide for Critical 

Infrastructure and Key Resources 

www.pandemicflu.gov/plan/pdf/CIKRpandemicInfluenzaGuide.pdf 

This guide provides contingency planning process for a pandemic. Also provides 

business planners with sector-specific and common pandemic information planning 

variables keyed to escalating disaster phases. 

PandemicFlu.gov 

www.pandemicflu.gov 

The official U.S. government Web site for information on pandemic flu and avian 

influenza. 

Pandemic Influenza information from the Department of Veterans Affairs 

www.publichealth.va.gov/flu/pandemicflu.htm 

This site lists VA resources on pandemic flu. 

Pandemic Influenza Plan from the Department of Health and Human Services 

www.hhs.gov/pandemicflu/plan 

This site supplies guidance to national, State and local policymakers and health 

departments, outlining key roles and responsibilities during a pandemic and specifying 

preparedness needs and opportunities. 

Protecting the United States brochure from USDA 

www.usda.gov/documents/AvianFluBrochure.pdf 

This brochure describes two types of avian influenza and how the USDA is working with 

agencies nationally and internationally to protect the United States against avian 

influenza. 

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Strategic National Stockpile 

www.bt.cdc.gov/stockpile 

The site provides information on the availability and rapid deployment of life-saving 

pharmaceuticals, antidotes, other medical supplies, and equipment necessary to counter 

the effects of nerve agents, biological pathogens and chemical agents. 

Regional/Local 

American Bar Association – State and Local Government Law Section Checklist for 

State and Local Government Attorneys to Prepare for Possible Disasters 

www.abanet.org/statelocal/disaster.pdf 

CDC Cooperative Agreements on Public Health Preparedness 

www.bt.cdc.gov/planning/coopagreement 

This site provides information on State and local public health preparedness for and 

response to bioterrorism, other outbreaks of infectious diseases, and other public health 

threats and emergencies. 

Contact Information for State Departments of Agriculture, Wildlife and Public 

Health 

www.pandemicflu.gov/plan/states/statecontacts.html 

This site gives contact mail and phone contact information by State. When available, fax 

numbers and Web addresses are also provided. 

Local Health Department Guide to Pandemic Flu Planning 

www.naccho.org/topics/infectious/influenza/LHDPanFluGuide.cfm 

This guide from the National Association of County and City Health Officials is intended 

for local health departments (LHDs) to use as part of a multi-sector effort to coordinate 

planning for and response to a pandemic influenza outbreak. 

Pandemic Influenza information from the Association of State and Territorial Health 

Officials 

www.astho.org/templates/display_pub.php?pub_id=1383&admin=1 

This site provides access to information and resources for State pandemic planning 

meetings. 

Preparing for a Pandemic Influenza: A Primer for Governors and Senior State 

Officials 

www.nga.org/Files/pdf/0607PANDEMICPRIMER.PDF 

from the National Governors Association 

Read the National Governors Association report focused on the considerations States 

must make when developing policies in preparation for a potential pandemic. 

Providing Mass Medical Care with Scarce Resources: A Community Planning 

Guide 

www.ahrq.gov/research/mce 

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Designed for State, local, community and facility planners, this guide discusses ethical 

and legal issues, and considerations regarding prehospital care, hospital/acute care, 

palliative care, and alternative care sites. Chapter 8 is a 29-page case study for an 

influenza pandemic. 

State Pandemic Plans 

www.pandemicflu.gov/plan/states/stateplans.html 

This page provides access to all State pandemic plans that are currently available. 

State & Local Pandemic Influenza Planning Checklist 

www.pandemicflu.gov/plan/states/statelocalchecklist.html 

This site provides checklists and planning guides to help managers prepare for a 

pandemic. 

State Allocations of Antivirals 

www.pandemicflu.gov/plan/states/antivirals.html 

This site features a chart showing the individual State allocations of antivirals from the 

U.S. Department of Health and Human Services stockpile. 

Healthcare Resources 

Centers for Disease Control and Prevention (CDC) Interim Pre-pandemic Planning 

Guidance: Community Strategy for Pandemic Influenza Mitigation in the United 

States 

February 1, 2007 

http://www.pandemicflu.gov/plan/community/commitigation.html 

Development of a triage protocol for critical care during an influenza pandemic 

Canadian Medical Journal, (175-11), November 21, 2006 

By Michael D. Christian, Laura Hawryluck, Randy S. Wax, Tim Cook, Neil M. Lazar, 

Margaret S. Herridge, Matthew P. Muller, Douglas R. Gowans, Wendy Fortier, Frederick 

M. Burkle, Jr. 

Home Health Care Services Checklist 

www.pandemicflu.gov/plan/healthcare/healthcare.html 

This checklist identifies specific steps that home health care service providers can take 

now to prepare for a pandemic. 

Hospital Preparedness Checklist 

www.hhs.gov/pandemicflu/plan/sup3.html#app2 

This checklist can help State and local hospitals prepare for a pandemic. 

Long-Term Care and Other Residential Facilities Pandemic Influenza Planning 

Checklist 

www.pandemicflu.gov/plan/healthcare/longtermcarechecklist.html 

This checklist identifies key areas: a structure for planning and decision making, and a 

written plan with subplans. 

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Medical Offices and Clinics Pandemic Influenza Planning Checklist 

www.pandemicflu.gov/plan/healthcare/medical.html 

Specific steps are outlined in this checklist that medical offices and clinics, including 

outpatient care clinics, can take prepare for a pandemic. 

Modeling Community Containment for Pandemic Influenza: A Letter Report 

Committee on Modeling Community Containment for Pandemic Influenza 

http://www.nap.edu/catalog/11800.html 

Pandemic Influenza Toolkit 

www.cdc.gov/flu/pandemic/healthprofessional.htm 

Prepared by the Centers for Disease Control and Prevention (CDC), the toolkit provides 

resources and information for clinicians to use in discussing pandemic influenza with 

patients and providing care in case of a flu pandemic in the United States. 

Pandemic Flu Planning Guidance for MRC Units 

www.medicalreservecorps.gov/POUpdates/PandemicFluGuidance 

Read about the pandemic influenza planning guidance for Medical Reserve Corps (MRC) 

units that help identify specific activities MRC units can do now to prepare for a 

pandemic. 

Public Health Guidance for Community-Level Preparedness and Response to 

Severe Acute Respiratory Syndrome (SARS) Version 2 Supplement I: Infection 

Control in Healthcare, Home, and Community Settings 

Centers for Disease Control and Protection, January 8, 2004 

Outlines the infection control recommendations for prevention of SARS-CoV 

transmission in healthcare, household, and community settings. This and other SARS 

documents are online at www.cdc.gov/ncidod/sars 

The Agency for Healthcare Research and Quality has provided the following sites that 

may be helpful in the event of a pandemic: 

Development of Models for Emergency Preparedness: 

www.ahrq.gov/research/devmodels/ 

Standardized Hospital Bed Definitions: 

www.ahrq.gov/research/havbed/definitions.htm 

Emergency Preparedness Resource Inventory: 

http://www.ahrq.gov/research/epri 

Reopening Shuttered Hospitals to Expand Surge Capacity: 

www.ahrq.gov/research/shuttered/ 

Recommendations for Altered Standards of Care during a Mass Casualty Event: 

www.ahrq.gov/research/altstand/ 

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Computer Staffing Model for Disaster Preparedness Response: 

www.ahrq.gov/research/biomodel.htm 

Health Emergency Assistance Line and Triage Hub (HEALTH) Model: 

www.ahrq.gov/research/health 

Alternate Site Locator during Public Health Emergencies: 

www.ahrq.gov/research/altsites.htm 

Fire and EMS resources 

Avian Influenza information from the International Association of Fire Chiefs 

www.iafc.org/displaycommon.cfm?an=1&subarticlenbr=191 

This site gives firefighters key facts about avian influenza and influenza. 

Influenza Pandemic information from the International Association of Fire Fighters 

www.iaff.org/safe/content/Avian_Flu/Pan_Flu_Final.htm 

This informational bulletin for firefighters provides the basics on avian influenza and 

pandemic influenza. 

Emergency Medical Services and Non-Emergent (Medical) Transport 

Organizations Pandemic Influenza Planning Checklist 

www.pandemicflu.gov/plan/healthcare/emgncymedical.html 

EMS and medical transport organizations can use this checklist to help prepare for a 

pandemic. 

National Association of EMS Physicians 

www.naemsp.org 

NAEMSP offers a “Base Station Course” for EMS medical directors. This course is 

designed to be of use to all physicians who provide online medical direction to 

prehospital providers. It is a modular course that can be used in its entirety as the basis 

for a formal base station course or on a section-by-section basis to augment other 

educational programs and learning. 

Pandemic Influenza Planning Resources from the US Fire Administration 

www.usfa.dhs.gov/subjects/ems/pandemicflu/ 

This site provides planning resources to assist first responders in preparing for a national 

influenza pandemic. 

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Appendix N - Continuity of Operations Program

Elements 

According to the National Strategy for Pandemic Influenza: Implementation Plan,

95 there 

are 11 Continuity of Operations (COOP) program elements for which managers must 

prepare when planning for pandemic influenza. These elements apply to all types and 

sizes of EMS operations, and are essential parts of any pandemic influenza plan: 

• Planning 

. The foundation of a viable COOP program is the development and documentation of a 

COOP plan that, when implemented, will provide for the continued performance of an 

organization’s essential functions under all circumstances. In order to reduce the 

pandemic threat, a portion of the COOP plan’s objective should be to minimize the 

health, social, and economic impact of a pandemic on the United States. 

• Essential Functions 

Essential functions are those functions that enable organizations to provide vital services, 

exercise civil authority, maintain the safety and well being of the general populace, and 

sustain the economic base in an emergency. During a pandemic, or any other emergency, 

these essential functions must be continued in order to facilitate emergency management 

and overall national recovery. Within the private sector, essential functions can be 

regarded as those core functions, services, and capabilities required for sustaining 

business operations. 

Functions that are essential to EMS operations include: 

♦ Maintenance of a 911 call center and other ways for the public to access EMS; 

♦ A system to determine the caller’s problem(s); 

♦ A system to triage calls and designate appropriate medical response; 

♦ Maintenance of emergency vehicles and equipment; 

♦ Trained and available personnel to respond to calls; 

♦ Supporting legislation and regulations to enable EMS to function effectively; 

♦ Financial support to maintain a high-quality EMS system; 

♦ Medical direction and oversight; 

♦ Communications systems; and 

♦ Public education. 

• Delegation of authority 

Clearly pre-established delegations of authority are vital to ensuring that all 

organizational personnel know who has the authority to make key decisions in a COOP 

situation. Because absenteeism may reach a peak of 40 percent at the height of a 

pandemic wave, delegations of authority are critical. 

95 Homeland Security Council. 2006. National Strategy for Pandemic Influenza. Washington, DC at 

http://www.pandemicflu.gov/plan/federal/index.html 

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All EMS operations should already have clearly delegated authority under their medical 

director and in accordance with the incident command structure (ICS) and the National 

Incident Management System (NIMS). This authority should be maintained during 

pandemic influenza. 

• Succession planning 

An order of succession is essential to an organization’s COOP plan to ensure personnel 

know who has authority and responsibility if the leadership is incapacitated or 

unavailable in a COOP situation. Since an influenza pandemic may affect regions of the 

United States differently in terms of timing, severity, and duration, businesses with 

geographically dispersed assets and personnel should consider dispersing their order of 

succession. 

Leadership training should be provided for mid- and upper-level EMS supervisory staff 

to ensure that in case of major illness, injuries or deaths, there will be individuals who 

can take on the role of EMS medical director or leadership. The determination also 

should be made in advance regarding who in the organization would be able to adjust 

standard operating procedures and the scope of practice of emergency medical providers 

to the needs of the situation. 

• Alternate physical facilities 

The identification and preparation of alternate operating facilities and the preparation of 

personnel for the possibility of an unannounced relocation of essential functions and 

COOP personnel to these facilities is part of COOP planning. 

Because a pandemic presents essentially simultaneous risk everywhere, the use of 

alternative operating facilities must be considered in a non-traditional way. COOP 

planning for pandemic influenza will involve alternatives to staff relocation/co-location 

such as social distancing in the workplace through telecommuting, or other means. In 

addition, relocation and redistribution of staff among alternative facilities may reduce the 

chance of infection impacting centralized critical operations staff simultaneously. 

Alternate operating facilities impact a several aspects of EMS operations, including but 

not limited to: 

• 9-1-1 call center 

• Administrative offices 

• Crew quarters 

• Ambulance bays/garages/repair facilities 

• Emergency departments and alternate destinations 

• Effective communications 

The success of a viable COOP capability is dependent upon the identification, 

availability, and redundancy of critical communication systems to support connectivity of 

internal organizations, external partners, critical customers and the public. Systems that 

facilitate communication in the absence of person-to-person contact can be used to 

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minimize workplace risk for essential employees and can potentially be used to restrict 

workplace entry of people with influenza symptoms. 

EMS agencies are all too familiar with the failure of communications systems on 

emergency scenes, particularly when responders come from multiple agencies. 

Additionally, EMS relies on communications systems at multiple points in the emergency 

response process. EMS communication systems include: 

• Accepting communications in to a 9-1-1 center 

• Dispatching communications from a 9-1-1 center 

• Routing communications to between emergency operations centers 

• Receiving communications from field personnel to medical control 

• Coordination of communications within the field 

• Communication with special needs populations 

• Communication with destinations, such as hospitals, nursing homes 

• Emergency communication with the public (e.g., warning systems) 

EMS pandemic influenza planners must consider each of these communications systems 

and their capacities in terms of call volume, interoperability, redundancy etc. and 

determine how to ensure the effectiveness of these communication systems during 

pandemic influenza. 

Communication discipline is one of the keys to effective incident management, and 

ideally, these systems would be centralized through established ICS channels. There 

should also be a plan for backup or redundant communication strategies in case there are 

failures in primary communication methods. Similarly, other backup procedures for 

actions that can be taken when systems fail should be planned, tested in advance, and 

integrated into the planning process. 

• Business record-keeping 

Businesses should identify, protect, and ensure the ready availability of electronic and 

hardcopy documents, references, records, and information systems needed to support 

essential functions. Pandemic influenza COOP planning must also identify and ensure the 

integrity of vital systems that require periodic maintenance or other direct physical 

intervention by employees. 

EMS agencies rely on numerous business records and databases in order to maintain their 

continuity of operations, including but not limited to: 

• Patient records 

• Call records 

• Billing records 

• CAD data 

• Compliance data 

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EMS agencies must maintain these records in compliance with numerous Federal and 

local statutes, such as the Health Insurance Portability and Accountability Act (HIPAA) 

(if the EMS agency is a “covered entity” for purposes of HIPAA) and response time 

standards, which must be maintained during pandemic influenza, unless waived. 

EMS pandemic influenza planners must consider each of these records and database 

systems, both hardcopy and electronic, and determine how to maintain continuity of 

operations during pandemic influenza 

• Human capital 

State and local EMS planners should operate on the assumption that up to 40 percent of 

their staff may be absent for periods of about 2 weeks at the height of a pandemic wave, 

with lower levels of staff absent for a few weeks on either side of the peak. Absenteeism 

will increase not only because of personal illness or incapacitation but also because 

employees may be caring for ill family members, under voluntary home quarantine due to 

an ill household member, minding children dismissed from school, following public 

health guidance, or simply staying at home out of safety concerns. 

Each organization must develop, update, exercise, and be able to implement 

comprehensive plans to protect its workforce. Although an influenza pandemic will not 

directly affect the physical infrastructure of an organization, a pandemic will ultimately 

threaten all operations by its impact on an organization’s human resources. The health 

threat to personnel is the primary threat to continuity of operations during a 

pandemic. 

EMS agencies will face multiple challenges in maintaining their workforce during 

pandemic influenza. These challenges include but are not limited to: 

• Educating and training EMS personnel about influenza 

• Preventing EMS personnel from contracting influenza 

• Infection control, PPE and enforcement 

• Vaccination and administration of anti virals to EMS personnel 

• Sick leave policies during pandemic influenza 

• Return to work policies during pandemic influenza 

• Emotional and social support of EMS personnel 

Absenteeism 

Estimates of workforce absenteeism can be made using a free online tool from the 

Centers for Disease Control and Prevention. FluWorkLoss estimates the potential number 

of days lost from work due to an influenza pandemic. Users can change almost any input 

value, such as the number of workdays assumed lost when a worker becomes ill or the 

number of workdays lost due to a worker staying home to care for a family member. 

Users can also change the length and virulence of the pandemic so that a range of 

possible impacts can be estimated. 

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FluWorkLoss provides a range of estimates of total workdays lost, as well as graphic 

illustrations of the workdays lost by week and percentage of total workdays lost to 

influenza-related illnesses. It is available at www.cdc.gov/flu/tools/fluworkloss/. 

Absenteeism among the regular workforce may necessitate that EMS agencies consider 

temporary hiring of new personnel, such as retired or currently unemployed but qualified 

volunteer providers within the community and State and reserve military medical and 

nursing providers and other responders, as well as an expanded group of providers, such 

as veterinarians, dentists and dental auxiliary providers, pharmacists, and health 

professional students. 

In considering the best way to address workforce shortages during pandemic influenza, 

State and local EMS planners also should consider the potential for: 

• Modifying State certification and licensing requirements to allow out-of-State 

providers to practice on a temporary basis. 

• Modifying State regulations on a temporary basis to broaden scope of practice 

standards among various trained providers. 

• Reallocating providers from non-emergency care and non-emergency sites to 

emergency response assignments and from unaffected regions to affected 

regions (this will involve identifying skill sets of each practitioner group [e.g., 

paramedics, nurse midwives, etc.], so as to optimize reassignment potential). 

• Creating and training a pool of non-medical responders to support health and 

medical care operations. 

• Making adequate provisions to protect providers (and their families) who 

serve in mass casualty event situations to ensure their willingness to respond. 

• Developing systems for the advance registration and credentialing of 

clinicians to augment health care personnel needs during a mass casualty 

event. 

Pandemic influenza planners must determine which, if any, of these staffing 

contingencies might be appropriate in their service area and under what conditions. 

Decisions should be made under the supervision of the EMS Medical Director and in 

conjunction with State and local laws governing scope of practice, licensing and 

certification. 

• Training 

Testing, training and exercising of COOP capabilities are essential to assessing, 

demonstrating and improving the ability of organizations to execute their COOP plans 

and programs during an emergency. Pandemic influenza COOP plans should test, train, 

and exercise sustainable social distancing techniques that reduce person-to-person 

interactions within the workplace. [Refer to Chapter IV for additional guidance on justin-time EMS training.] 

• Devolution 

Devolution is the capability to transfer authority and responsibility for essential functions 

from an organization’s primary operating staff and facilities, to other employees and 

facilities, and to sustain operational capability under devolved authority for an extended 

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period. Because local outbreaks will occur at different times, have variable durations, and 

may vary in their severity, devolution planning may need to consider rotating operations 

between regional/field offices as a pandemic wave moves throughout the United States. 

• Reconstitution 

Reconstitution is the process by which an organization resumes normal operations. The 

objective during recovery and reconstitution after a pandemic is to expedite the return of 

normal services and operations as quickly as possible. Since a pandemic will not harm 

the physical infrastructure or facilities of an organization, and because long-term 

contamination of facilities is not a concern, the primary challenge for organizations after 

a pandemic will be the return to normal and bringing their systems back to full capacity. 

Logistics and Supplies 

Although logistics and supply management are not part of the COOP recommendations in 

the Implementation Plan, EMS agencies should make arrangements to ensure an adequate 

supply chain for equipment and supplies during pandemic influenza. 

Just-in-time inventory practices typical in many EMS agencies make healthcare 

operations particularly vulnerable to supply shortages during pandemic influenza. “The 

very rules of capitalism that make the US an ultra-efficient marketplace also make it 

exceptionally vulnerable in a pandemic,” according to The Wall Street Journal. 

Toronto EMS faced shortages of N-95 respirators during the SARS outbreak, and as a 

result is looking into stockpiling three months worth of medical supplies to prepare for 

pandemic influenza, according to Best Practices in Emergency Services.

96 Toronto EMS 

also has already put paper PPE on all its ambulances as well as outfitted each of its 

medics with their own fitted N-95 respirators and nitrile gloves. 

The National Strategy for Pandemic Influenza: Implementation Plan confirms that EMS 

agencies must plan for material management in their pandemic influenza plans. It states, 

“Healthcare facilities typically maintain limited inventories of supplies on-site and 

depend on just-in-time restocking programs. Replenishment of critical inventories is thus 

dependent upon an intact supply chain from manufacturing and distribution to 

transportation and receiving. During a pandemic there would be an increased demand for 

both consumable and durable resources. ... Competition for these resources at a time of 

increased demand could result in critical shortages.” 

Examples of Supplies and Equipment that May Be Scare during Pandemic 

Influenza 

• Consumable resources 

• Hand hygiene supplies (antimicrobial soap and alcohol-based, waterless hand 

hygiene products) 

• Disposable N95 respirators, surgical masks and procedure masks 

• Face shields (disposable or reusable) 

96 Simon Ostrow L. 2006 Pandemic Flu: Are You Ready?" Best Practices in Emergency Services, 9(5), 54­

55. 

153
• Gowns 

• Gloves 

• Facial tissues 

• Central line kits 

• Morgue packs 

• Ventilators 

• Respiratory care equipment 

• IV pumps 

Manufacturers and suppliers are likely to report inventory shortages because of the 

massive simultaneity of need and supply chains may also be disrupted by the effects of a 

pandemic on critical personnel. EMS agencies should make provision for these 

considerations in their planning efforts and consider stockpiling critical medical materiel 

individually or collaborating with other facilities to develop local or regional stockpiles 

maintained under vendor managed inventory systems. 

Financial Continuity 

Financial continuity is another area that is absent from the Federal COOP elements, but 

one which is important for State and local EMS planners to address. Preparing for and 

providing health and medical care during pandemic influenza could result in large 

financial losses for all involved organizations, if issues surrounding the financing of such 

preparation and care are not addressed. 

One potential source of disaster relief is the Stafford Act97 (Public Law 93-288). 

However, financing from the Federal Government must be supplemented by funds from 

other public as well as private organizations. 

In preparing a comprehensive plan, State and local EMS planners should include 

financial management experts from the participating organizations, such as hospital 

systems. In addition, formal mutual aid agreements or other contracts should be 

developed in advance to document relationships, expectations and requirements related to 

obtaining emergency reimbursements. 

On the patient side, issues of financial access, such as requiring proof of insurance, apply. 

This concern is closely related to legal issues of documentation for reimbursement. It is 

not likely that providers will be able to maintain documentation practices beyond what is 

considered minimally adequate to support treatment; altered standards of documentation 

for reimbursement purposes may have to be defined. 

The National Strategy for Pandemic Influenza: Implementation Plan addresses healthcare 

reimbursement when it states that more than one in four Americans receive health care 

coverage through Medicare, Medicaid, the State Children’s Health Insurance Program 

(SCHIP), the Veterans Health Administration, TRICARE, or other Federal programs. 

Ensuring access to, and timely payment for, covered services during a pandemic will be 

97 Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended by Public Law 93-288, 

June, 2006. 

154
critical to maintaining a functional health care infrastructure. It may also be necessary to 

extend certain waivers or develop incident-specific initiatives or coverage to facilitate 

access to care. 

However, the document cautions: “Pandemic influenza response activities may exceed 

the budgetary resources of responding Federal and State government agencies, requiring 

compensatory legislative action.” 

EMS planners will need to consider the cash flow and financial wherewithal to sustain 

operations for several months without adequate Federal or local reimbursement. 

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Appendix O - Special Needs Patients 

It is essential that plans for the delivery of health and medical care during pandemic 

influenza address caring for populations with special healthcare needs. These needs may 

vary from providing for alternate means of decontamination for babies and other nonambulatory persons, to having translators available, to providing mental health 

assessment resources within the healthcare setting. Involving organizations and services 

designed to serve groups with special needs under normal conditions may be a successful 

approach. 

Populations recognized as having special needs in a mass casualty event include but may 

not be limited to the following: 

Children. The unique physiology and wide variation in physical and cognitive 

development by age within childhood requires that triage personnel be trained in pediatric 

triage standards and other pediatric assessment protocols; family care and adult care be 

available; appropriately-sized supplies, equipment, and medication doses be available; 

and safe use of decontamination procedures be ensured. Provisions for treating children 

whose parents are not present and for treating parents who will not leave their children 

are important considerations. 

Persons with physical or cognitive disabilities. As under normal standards of care, 

provisions to accommodate the special disability-related needs of some persons are 

important aspects of the organization of care. These are likely to include issues of 

alternative and safe decontamination procedures, enhanced communication and issues 

involving informed consent. 

Persons with preexisting mental health and/or substance abuse problems. 

Preexisting mental health and substance abuse conditions are known to exacerbate an 

individual’s ability to cope with physical and emotional trauma. Provisions should be 

made for screening and direction to appropriate services as part of triage or other 

assessment protocols. 

Frail or immunocompromised adults and children. Individuals in these groups who 

are victims may require adjustments in treatment regimens and special monitoring, but 

these adjustments will be made within the context of any overriding goal to maximize 

lives saved. 

Persons wil limitied English proficiency. Local and regional planning may have to take 

into account the need for communication tools in languages other than English. Although 

printed materials of a general nature may be prepared in advance, printed materials and 

signs will not be an adequate response for those who cannot read any language. An 

additional challenge may be present if undocumented individuals fear discovery and 

reprisal if they come forward for health care in a mass casualty event. Involvement of 

156
formal and informal networks, organizations, and media outlets that serve persons with 

limited English proficiency is essential. 

Low socio-economic families. This population may provide a unique challenge to 

pandemic influenza planners because many hourly wage workers do not have the option 

of sick leave (should closing of schools be implemented) and many children depend on 

school as their main source for food and nutrition. Coordination with youth and social 

service agencies is important so that EMS workers are not confronted with underage 

children being left unattended without supervision and/or proper nutrition. 

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Appendix P – Other Legal and Regulatory Issues 

The National Strategy for Pandemic Influenza: Implementation Plan discusses the 

waiver and modification of certain legal requirements during pandemic influenza. It 

asserts, “Depending on the severity of a pandemic, certain requirements may be waived 

or revised to facilitate efficient delivery of health care services.” 

For example, the plan acknowledges that certain Emergency Medical Treatment and 

Active Labor Act (EMTALA), Medicare, Medicaid, State Children’s Health Insurance 

Program (SCHIP), and Health Insurance Portability and Accountability Act (HIPAA) 

requirements may be waived following a declaration of a public health emergency by the 

Secretary of HHS and a Presidential declaration of a major disaster or emergency. 

Some of the Federal, State and local laws and regulations that govern the delivery of 

health and medical care under normal conditions may need to be modified. These include 

laws to ensure access to emergency medical care; protect patient privacy and 

confidentiality of medical information; shield medical providers and other rescuers from 

lawsuits; govern the development and use of health and medical facilities; and regulate 

the number of hours health and medical providers can work as well as the conditions in 

which they work. Relevant laws include but are not limited to the following: 

• Emergency Medical Treatment and Active Labor Act (EMTALA) 

• Health Insurance Portability and Accountability Act (HIPAA) 

• Federal Volunteer Protection Act 

• Good Samaritan Law. 

Additional types of laws and regulations that relate to the delivery of health and medical 

care include: 

• Occupational Safety and Health Administration and other workplace 

regulations 

• Building codes and other facility standards 

• Publicly funded health insurance laws (including Medicare, Medicaid, and the 

State Children’s Health Insurance Program) 

• Laws pertaining to human subject research 

• Laws and regulations governing the use and licensure of drugs and devices. 

In developing a comprehensive plan for the delivery of health and medical care during 

pandemic influenza, it is also important to consider mechanisms to allow for legal, 

regulatory, or accreditation adjustments in the following areas: 

• Liability of providers and institutions for care provided under stress with 

less than a full complement of resources. The plan may have to provide for hold 

harmless agreements or grant immunity from civil or criminal liability under 

certain conditions. 

• Certification and licensing. Although it is important to ensure that providers are 

qualified, it is also important to have flexibility in granting temporary certification 

158
or licenses for EMS personnel and others who are inactive, retired or certified or 

licensed in other States. 

• Scope of practice. It may be necessary to grant permission to certain 

professionals on a temporary and emergency basis to function outside their legal 

scope of practice or above their level of training. The National EMS Scope of 

Practice Model and EMS stakeholders, however, stress the need for appropriate 

education, medical oversight and quality assurance of EMS providers, even 

during an emergency, to help assure patient safety. 

• Institutional autonomy. If organizations and institutions cede their authority in 

order to participate in a unified incident management system in a crisis, the plan 

may have to address the legal implications for those organizations. 

• Facility standards. Standards of care that pertain to space, equipment, and 

physical facilities may have to be altered in both traditional medical care facilities 

and alternate care sites that are created in response to the event. 

• Patient privacy and confidentiality. Provisions of HIPAA and other laws and 

regulations that require signed releases and other measures to ensure privacy and 

confidentiality of a patient’s medical information may have to be altered. 

• Documentation of care. Minimally accepted levels of documentation of care 

provided to an individual may have to be established, both for purposes of patient 

care quality and as the basis for reimbursement from third-party payers. 

• Property seizures. Provisions may have to be made to take over property, 

including facilities, supplies, and equipment for the delivery of care or to destroy 

property deemed unsafe. 

• Provisions for quarantine or mass immunization. The plan may have to 

address the establishment and enforcement of isolation, quarantine and mass 

immunization and provisions for release or exception. 

Any waivers granted are likely to be targeted to the affected area for a temporary and 

specified period of time and scope. In the case of a mass casualty event such as pandemic 

influenza that involves a communicable agent that moves from region to region, it will be 

important to have flexibility to extend or expand such waivers. 

159
Appendix Q – OSHA Guidance 

(Excepted from Occupational Safety and Health Administration. Pandemic Influenza 

Preparedness and Response Guidance for Healthcare Workers and Healthcare 

Employers. For updated information go to www.osha.gov 

Pre-Hospital Care and Patient Transport outside Healthcare Facilities 

During an influenza pandemic, patients will still require emergency transport to a 

healthcare facility. The following recommendations are designed to protect healthcare 

workers, including emergency medical services personnel, during pre-hospital care and 

transport. These recommendations can be instituted when patients are identified as having 

symptoms consistent with an influenza-like illness or routinely, regardless of symptoms, 

when pandemic influenza is in the community. 

160
Screen all patients for influenza-like 

illness.* 

If influenza is suspected, implement 

the following strategies: 

Without relying on patient screening, 

routinely implement the following 

strategies: 

Engineering Controls 

• Optimize the vehicle’s ventilation to 

increase the volume of air exchange 

during transport. The vehicle's ventilation 

system should be operated in the nonrecirculating mode and should bring in as 

much outdoor air as possible. 

• When possible, use vehicles that have 

separate driver and patient compartments 

that can provide separate ventilation to 

each area. In this situation, drivers do not 

require particulate respirators. 

• Optimize the vehicle’s ventilation to increase 

the volume of air exchange during transport. 

The vehicle's ventilation system should be 

operated in the non-recirculating mode and 

should bring in as much outdoor air as 

possible. 

• When possible, use vehicles that have separate 

driver and patient compartments that can 

provide separate ventilation to each area. In 

this situation, drivers do not require 

particulate respirators. 

Administrative Controls 

• Educate healthcare workers engaged in 

medical transport about the risks of 

aerosol-generating procedures. 

• Notify the receiving facility as soon as 

possible, prior to arrival, that a patient 

with suspected pandemic influenza 

infection is being transported to the 

facility and of the precautions that are 

indicated. 

• Minimize the opportunity for 

contamination of supplies and equipment 

inside the vehicle (e.g. ensure that all 

cabinetry remains closed during 

transport.). 

• Continue to follow standard infection 

control procedures, such as standard 

precautions, recommended procedures for 

waste disposal and standard practices for 

disinfection of the emergency vehicle and 

patient care equipment. 

• Educate healthcare workers engaged in 

medical transport about the risks of aerosolgenerating procedures. 

• Notify the receiving facility as soon as 

possible, prior to arrival, that a patient with 

suspected pandemic influenza infection is 

being transported to the facility and of the 

precautions that are indicated. 

• Minimize the opportunity for contamination 

of supplies and equipment inside the vehicle 

(e.g. ensure that all cabinetry remains closed 

during transport.). 

• Continue to follow standard infection control 

procedures, such as standard precautions, 

recommended procedures for waste disposal 

and standard practices for disinfection of the 

emergency vehicle and patient care 

equipment. 

Personal Protective Equipment 

• If tolerated by the patients, place a 

surgical mask on all patients with 

respiratory illness to contain droplets 

expelled during coughing. If this is not 

possible (i.e., would further compromise 

respiratory status, or is difficult for the 

patient to wear), have the patient cover 

the mouth and nose with a tissue when 

coughing, or use the most practical 

alternative to contain respiratory 

secretions. 

• Healthcare workers transporting patients 

with influenza-like illness should use a 

respirator (N-95 or better). If respirators 

are not available, healthcare workers 

should wear a surgical mask. 

• Consider routine use of surgical or procedure 

masks for all patients during transport when 

pandemic influenza is in the community. 

• Healthcare workers transporting patients 

should use a respirator (N-95 or better). If 

respirators are not available, healthcare 

workers should wear a surgical mask. 

*The Sentinel Provider Network definition of influenza-like illness is fever (>100°F or 37.8°C) and sore throat and/or 

cough in the absence of a known cause other than influenza. 

161
Appendix R – Suggested 9-1-1 & EMS

Activities/Readiness Steps Based on Different Phases of 

Pandemic Influenza 

Pandemic Phase 

(Based on WHO) 

Public Safety Answering 

Point (PSAP) 

Administrative Response 

EMS 

Administrative Response 

Interactions 

With Other Agencies 

Phase 3: Human 

infection(s) with a 

new subtype but no 

human-to-human 

spread, or at most 

rare instances of 

spread to a close 

contact. 

(The mindset should 

be focused on IF 

pandemic influenza 

comes to your area. 

In general, build 

good habits.) 

• Surveillance mode 

• Plan how PSAP can help 

local public health (PH) 

officials, Emergency Medical 

Services (EMS), and the 

Emergency Management 

Agency (EMA) monitor and 

prepare for a pandemic 

influenza 

• Plan for graded responses 

to Phase 4-6 as detailed 

below 

• Monitor the CDC and local 

public health information on 

a monthly basis to follow 

the course of current 

infections 

• Plan for scripting/protocol 

development and agency 

response in the event of 

evolution and transmission 

of the infection to your area 

• Plan for resource protection 

of assets in your jurisdiction 

• Staff education on 

pandemic influenza 

• Plan infection control and in 

the center 

• Plan for security and 

isolation for the center 

• Plan for facility quarantine 

and staging/transportation 

of ill employees 

• Plan for family support of 

PSAP staff 

• Inventory operational 

supplies and ensure 

adequate sources 

• Do table top exercises to 

test your assumptions 

focusing on decision-making 

and command structure 

(community wide) 

• Identify alternative work 

force options (retirees, past 

employees, other 

government employee 

groups) 

• Education on signs and 

symptoms of mental stress 

• Look at next generation 

technology to allow for 

remote communications 

• Surveillance mode 

• Plan how EMS can help local 

public health (PH) officials, 

Public Safety Answering Points 

(PSAP), and the Emergency 

Management Agency (EMA) 

monitor and prepare for a 

pandemic influenza 

• Complete CDC Emergency 

Medical Services and NonEmergency Medical Operations 

Check List available at 

www.pandemicflu.gov 

• Educate staff on pandemic 

influenza 

• Develop a comprehensive 

staged response considering 

the following: 

 Continuity of operations 

(COOP) when 40-60% of staff 

are ill or exposed—e.g 

alternate and/or flexible 

staffing plans 

• Supply chain disruption 

including identification of 

necessary supplies, purchase, 

storage and distribution 

• Housing, food and water etc 

for staff who must remain 

close to work 

• Develop plan for infection 

control 

• Develop plan for employee 

screening 

• Develop security plan 

• Develop protocols that 

address system needs related 

to fatality management 

• Plan and develop protocols for 

assessment, triage and 

transport with medical control 

with consideration to 

alternative care sites and 

modified response and 

treatment protocols for all 

patients including those with 

pandemic influenza 

• Participate in planning with 

EMS, public health officials 

and EMA for pandemic 

influenza 

• Work with community 

leadership to develop plans for 

medical call centers and/or 

• Local PH, PSAP, EMS, EMA to 

plan for when you will begin 

active surveillance for 

pandemic influenza patients 

• PSAP and EMS agency 

medical directors contact with 

local PH officials (discussions 

should center about if a 

pandemic influenza infection 

might occur in your area) 

• Law enforcement to discuss 

resource protection 

• Identify who is responsible for 

local hospitals to plan for 

patient overloads, minimal or 

no-responses to requests for 

service, alternative care sites, 

etc. PSAP needs to be 

informed. 

• Engage all suppliers and 

ensure they are planning for 

pandemic influenza 

• Engage with the organizations 

that are responsible for 

updating your dispatch or 

field protocols 

• Local Medical Examiner, PH, 

PSAP, and EMA to plan for 

handling potential surge of 

fatalities 

162
Phase 3: 

(continued) 

211 nonmedical public 

information points 

• Educate staff on prevention 

techniques 

•Develop security plan for 

facility, vehicles, and 

personnel 

• Participate in q

uarantine 

discussions with public health 

authorities-both for the public 

and for healthcare personnel 

who are exposed. Also, 

develop freedom of travel 

arrangements during 

restricted travel planning 

times 

• PPE level training and 

stockpile equipment 

• Plan for alternate supply lines 

during pandemic—“Just in 

time” supply lines may not be 

functional. Where will you get 

replacement supplies? 

• Mutual aid agreements—what 

will they (and you) honor? 

• Discuss with State leaders 

their resources in a pandemic 

and if there will be any help 

available from the State for 

you. Also, what are you 

expected to supply? 

• Plan for vaccination and/or 

prophylaxis of personnel and 

their families 

• Plan for supplying 

food/medicines/other needs of 

personnel who are 

quarantined 

• “Ju

st in time” training 

program development 

• Discuss the coordinat

ion of 

public information planning 

program—what and how are 

you going to tell the public 

when you are forced to curtail 

services? 

• Develop a plan to ensure 

consistent messages from 

public health officials, EMS, 

PSAPs with media 

coordination through the 

regional ICS system 

• Pat

ient tracking system in 

conjunction with PSAPs, public 

health officials, hospitals, Red 

Cross, etc. How are you going 

to track the patients? 

• Interop

erable communications 

plan 

• Plan to mod

ify operations 

according to level of severity 

of the pandemic 

• Fatality m

anagement 

• Continu

ity of operations 

planning (COOP) 

• Protoco

l development for field 

assessment and treatment 

based on latest information 

163
Phase 3: 

(continued) 

available from the CDC 

• Consider develop of plans for 

alternative transportation 

• Participate in planning or be 

aware of planning for 

alternate destinations 

• Consider protocols for nontransport 

• Develop a plan with PSAP for 

coordination of information to 

the field providers to address 

infection control related to 

pandemic influenza 

• Develop the working 

relationship with your local 

public health 

agencies/personnel 

• Revise transfer agreements 

and transfer protocols with 

health care (including skilled 

nursing and long term care) 

facilities and hospitals which 

reflect modified procedures to 

be used during a pandemic 

• Coordinate suggested referral 

policies or agreements with 

local home health agencies 

Phase 4: Small 

cluster(s) with limited 

human-to-human 

transmission but 

spread is highly 

localized, suggesting 

that the virus is not 

well adapted to 

humans. 

(The mind set is 

WHEN it will 

happen, not if. 

PSAPs have to 

prepare for worst 

scenario.) 

• Increased surveillance mode 

• Determine if there are any 

local EMS/public health 

surveillance tools used 

within their jurisdictions 

• Heightened awareness of 

the need to identify 

potential patients, protect 

the healthcare workforce, 

and to serve as another 

surveillance tool in the PH 

arsenal 

• Training staff to ask 

relevant questions should 

Phase 5 occur 

• Decision regarding how 

public information will be 

handled through the PSAP 

• Ensure information/ 

communication tools and 

methods of information in 

and out are consistent, 

reliable and up-to-date 

• Begin modified isolation 

procedures 

• Implement infection control 

measures 

• Full scale drills (include 

elected officials) 

• Anticipate need for expedited 

review and approval of 

treatment protocols with justin-time training based on case 

definition of the influenza 

patient 

• Need to participate and plan 

for alternate 

destinations/transportation 

modes 

• Engage with elected officials 

to plan executive orders that 

support PSAP and EMS needs 

during a pandemic 

• Reevaluate training needs for 

personnel on infection control 

and community mitigation 

efforts 

• Ensure medical 

countermeasures have been 

made available and/or 

administered to personnel per 

OSHA standards 

• Real-time supply monitoring 

to ensure that excess 

respirators are not held in 

reserve while healthcare 

personnel are conducting 

activities for which they would 

otherwise be provided 

respiratory protection 

• Decision guidance for 

determining respirator wear 

should consider factors such 

as duration, frequency, 

proximity and degree of 

contact with the patient 

• Begin modified isolation 

procedures 

• Local PH, PSAP, EMS, EMA 

planners (discussion should 

center on when a pandemic 

influenza infection might occur 

in your area) 

• More detailed discussions as 

detailed above in Phase 3 

• Agree with EMS and health 

leadership and other 

EMS/public safety responders 

what your protocol will be to 

notify responders that a 

potentially infected patient 

has called for help, what 

infection control measures 

they will use, and the protocol 

that all will follow in this 

instance 

• Engage mental health 

partners in your community to 

address post traumatic stress 

syndrome 

164
Phase 4 : 

(continued) 

• Are food and essential 

supplies available in stations 

to minimize the need for 

personnel to “shop” while on 

duty? 

• Plan with community agencies 

to support families of EMS 

personnel who may be 

quarantined and/or isolated 

due to exposure 

• Implement local plans on 

fatality management 

• Anticipate increased illness 

and absenteeism and 

implement flexible/alternate 

staffing plans to augment 

workforce 

• Diversion protocols may need 

to be suspended or modified 

to reflect facilities that are or 

are not receiving influenza 

patients 

Phase 5: Larger 

cluster(s) but humanto-human spread still 

localized, suggesting 

that the virus is 

becoming 

increasingly better 

adapted to humans 

but may not yet be 

fully transmissible 

(substantial pandemic 

risk). 

(Mind set: 

Implement 

aggressive 

infection control 

measures.) 

• Local surveillance mode 

should be at highest level 

• Caller questions modified as 

agreed by EMS medical 

direction and local public 

health authorities 

• Identify means to notify 

local EDs of a potentially 

infected patient 

• Monitor the CDC and the 

local PH sites every day 

• Preparation for providing 

public information— 

coordinate with (PIO) 

incident command structure 

to ensure appropriate public 

expectations of PSAP are 

appropriate 

• Coordinate plans of 

alternative care sites (when 

the public calls, what are 

you going to tell them?) 

• (No drills) 

• Aggressive infection control 

procedures put in place 

• Evaluate need for 

implementation of first level of 

plan 

• Local surveillance mode 

should be at highest level 

• Identify means to notify local 

EDs of a potentially infected 

patient 

• Monitor the CDC and the local 

PH sites every 4-7 days 

• Preparation for providing 

public information—coordinate 

with (PIO) incident command 

structure to ensure 

appropriate public 

expectations of PSAP are 

appropriate 

• Coordinate plans of alternative 

care sites 

• Aggressive infection control 

procedures put in place 

• Evaluate appropriateness of 

clinical procedures that 

increase the risk of 

dissemination of droplets or 

sputum 

• “Just in time” training 

program implemented 

• Discussion should center on 

when a pandemic influenza 

infection might occur in your 

area 

• Preparations for the first 

infected cases in your area 

should be almost complete 

• PSAP, EMS, PH and EMA 

discussions should occur 

regularly with Regional PSAP 

and EMS managers, elected 

officials, and law enforcement 

165
Phase 6: Pandemic: 

increased and 

sustained 

transmission in 

general population. 

• Continued monitoring of 

influenza cases 

• Caller questions and 

scripting should abandon 

the surveillance questions 

and shift to disaster 

scripting appropriate for 

local responses 

• Daily CDC and PH 

monitoring 

• Provide public information 

consistent with the local PH, 

EMS, and EMA message 

• Work with mental health 

professionals to deal with 

critical incident stress 

• Work with incident 

command structure to 

determine plans for hospital 

resources, alternative care 

centers and fatality 

management 

• Maintain close contact with 

public health leadership to 

facilitate activation of plan and 

communication to field 

providers 

• Daily CDC and PH monitoring 

• Implementation of modified 

triage and treatment protocols 

as needed 

• Implementation of modified 

staffing plans as needed 

• Monitor equipment and supply 

inventories closely 

• Provide public information 

consistent with the local PH, 

• PSAP, and EMA message 

• Work with mental health 

professionals to deal with 

critical incident stress 

• Work with incident command 

structure to determine plans 

for hospital resources, 

alternative care centers and 

fatality management 

• EOC and EMA activation 

probable 

• PSAP, EMS, PH, EMA 

interaction several times per 

day 

• Hospital or alternative care 

site coordinators can assist in 

destination decisions and 

facilitate bed exchange 

capabilities 

• Regional PSAP and EMS 

managers are essential 

contacts within the incident 

command system 

• Equipment and supply 

vendors who may be able to 

re-allocate supply assets to 

areas of greatest need 

Phase 6: 

(Recovery) 

• After action reports and 

evaluation (completed 

within two week period to 

prepare for next wave.) 

• Planning for the next phase 

• Prepare for continuing 

challenges with stress and 

mental health 

• Re-engage surveillance 

mode 

• After action reports and 

evaluation (completed within 

two week period to prepare 

for next wave.) 

• Ongoing communication with 

social support networks to 

help address personnel and 

family recovery needs 

• Establish re-supply lines and 

reorder inventory 

• Look externally to involve 

after action reports for entire 

community, involving PSAP, 

EMS, EM, PH, PIO and elected 

officials 

166
Appendix S – Participating Organizations and

Representatives

Administrative Team 

Elizabeth B. Armstrong, MAM, CAE (Project Director); Executive Director, National Association of 

State EMS Officials 

Kathy S. Robinson, RN, BS, FAEN, EMT-P (Principal Investigator); Program Advisor, National 

Association of State EMS Officials 

Fergus Laughridge, President, National Association of State EMS Officials 

John Becknell (Expert Writer); Best Practices in Emergency Services 

Keith Griffiths (Expert Writer); President, The RedFlash Group 

Lauren Simon (Expert Writer); Best Practices in Emergency Services 

National Stakeholders Group 

ORGANIZATION REPRESENTATIVE(S) 

Air and Surface Transport Nurses Association Jacqueline Stocking, RN 

American Academy of Pediatrics Paul Sirbaugh, DO 

American Academy of Pediatrics Joseph Wright, MD 

American Ambulance Association Ron Thackery 

American College of Emergency Physicians J. William Jermyn, DO 

American College of Emergency Physicians Art French, MD 

American College of Surgeons Jeffrey Hammond, MD 

American Public Health Association Mighty Fine, MPH 

Association of Air Medical Services Sam Cimone 

Association of Public Safety Communications Officials Yucel Ors 

Association of State and Territorial Health Officials Rick Buell 

Emergency Nurses Association Jan Ogar, RN 

International Association of Emergency Managers Dennis Sullivan 

International Association of Fire Chiefs Mary Beth Michos 

International Association of Fire Chiefs Jennie Collins 

International Association of Fire Chiefs Ron McGraw 

International Association of Fire Fighters Jonathan Moore 

International Association of Fire Fighters Ron Benedict 

International Association of Flight Paramedics Anthony Pellicone 

National Academy of Emergency Dispatch Gregory Scott 

National Association of State 9-1-1 Administrators Robert Oenning 

National Association of EMS Educators Angel Burba 

National Association of EMS Educators Robert Henderson 

National Association of EMS Physicians Russell MacDonald, MD 

National Association of EMS Physicians Jeffrey Lubin, MD 

National Association of EMTs Jerry Johnston 

National Association of EMTs Jennifer Frennette 

National Association of State EMS Officials Richard Alcorta, MD 

National Association of State EMS Officials Richard Rucker 

National Emergency Management Association Trina Sheets 

National Emergency Numbers Association Rick Jones, ENP 

National Emergency Numbers Association Dr. Bob Cobb 

National EMS Management Association Gary Wingrove 

National Native American EMS Association Charles Kmet 

National Registry of EMTs William E. Brown 

National Rural Health Association Gary Wingrove 

National Volunteer Fire Council Kenneth Knipper 

167
Federal Partners 

Agency for Healthcare Research and Quality Jennifer Todd 

Centers for Disease Control and Prevention Deborah Levy 

Department of Health and Human Services Sandy Bogucki, MD 

Department of Homeland Security Capt. Scott Middlekauff 

Department of Homeland Security Kenny Longfritz 

Department of Homeland Security Til Jolly, MD 

Department of Homeland Security Jon Krohmer, MD 

Department of Homeland Security Bob Sauer 

Department of Homeland Security Bob Weaver 

Department of Homeland Security Harry Watkins 

Department of Homeland Security Elizabeth Crafton 

Department of Homeland Security Rob Mooney 

Department of Veterans Affairs Carter Mecher, MD 

DHS/U.S. Fire Administration Rick Ziebart 

DHS/U.S. Fire Administration Marie Martinez 

Emergency Services Sector / Government Coordinating Council Gregory Bobel, MD 

Emergency Services Sector / Government Coordinating Council Michele Miller 

HRSA/ EMS-C Dan Kavanaugh 

HRSA/ EMS-C Tina Turgel 

HRSA/ EMS-C Karen Belli 

Indian Health Service Sid Caesar 

Indian Health Service Dean Ross 

NHTSA / Department of Transportation Dee Williams 

NHTSA / Department of Transportation Ed Mays 

NTIA/Department of Commerce Thomas Hardy 

NTIA/Department of Commerce William Belote 

NTIA/Department of Commerce Chris Algiere 

Special Thanks To: 

Kathy Adams-House (Meeting Facilitator); PerformTech 

Robert Bass, M.D.; (NASEMSO) Immediate Past President, Maryland State EMS Director 

Scott Bourn; American Medical Response 

Sharon Counterman; National Emergency Numbers Association 

Drew Dawson (Director); Office of EMS, National Highway Traffic Safety Administration 

Laura DeGrafft, (NASEMSO) Administrative Assistant 

Steve Delahousey; American Medical Response 

Sue Denston, (NASEMSO) Meeting Planner 

Laurie Flaherty; Office of EMS, National Highway Traffic Safety Administration 

Jenny Hansen; Office of EMS, National Highway Traffic Safety Administration 

Christopher Kahn, MD; Office of EMS, National Highway Traffic Safety Administration 

Pamela Kaufman; Association of Public-Safety Communications Officials 

Sharon Kelly; (NASEMSO) Executive Assistant 

Julie Krueger, MPH; (Project Coordinator) Office of EMS, National Highway Traffic Safety 

Administration 

Kurt Krumperman; Rural Metro 

Wendy Martin (Expert Writer); The RedFlash Group 

Katie Moran (President); PerformTech 

Amy Starchville, (NASEMSO) Contracts Manager 

Karen S. Thompson; (NASEMSO) Web Site Content Manager 

Barbara Tyeryar, (NASEMSO) Financial Assistant 

Melissa Trumbull; (NASEMSO) Program Manager 

Gamunu Wijetunge (Project Facilitator); Office of EMS, National Highway Traffic Safety Administration 

168

DOT HS 810 776


May 2007