Adapting Community Call Centers for Crisis 

Support: A Model for Home-Based Care and 

Monitoring 

Prepared for: 

Agency for Healthcare Research and Quality 

U.S. Department of Health and Human Services 

540 Gaither Road 

Rockville, MD 20850 

www.ahrq.gov

Contract No. 290-00-0014-12 

Prepared by: 

Denver Health, Denver, CO 

Investigators: 

Gregory M. Bogdan, Ph.D., Principal Investigator 

Deborah L. Scherger, RN, MS, Co-Investigator 

Anna M. Seroka, RN, Med, Co-Investigator. 

Jodi Watson, MPH 

Melinda Johnson, MAPP 

AHRQ Publication No. 07-0048 

September 2007 
Funding to support “Adapting Community Call Centers for Crisis Support: A Model for 

Home-Based Care and Monitoring” was provided by the U.S. Department of Health and 

Human Services' Office of the Assistant Secretary for Preparedness and Response 

through an Agency for Healthcare Research and Quality (AHRQ) contract to Denver 

Health (Contract No. 290-00-0014-12). 

The opinions expressed in this report are those of the authors and do not reflect the 

official position of AHRQ or the U.S. Department of Health and Human Services. 

This document is in the public domain and may be used and reprinted without permission 

except those copyrighted materials noted for which further reproduction is prohibited 

without the specific permission of copyright holders. 

Suggested Citation: 

Bogdan GM, Scherger DL, Seroka AM, Watson J, Johnson M. Adapting Community 

Call Centers for Crisis Support: A Model for Home-Based Care and Monitoring. 

Prepared by Denver Health under Contract No. 290-00-0014-12. AHRQ Publication No. 

07-0048. Rockville, MD: Agency for Healthcare Research and Quality. September 2007. 

ii 
Contents 

Executive Summary..................................................................................1 

Chapter 1. Final Products.........................................................................11 

 1. National Planning Scenarios Analysis Matrix.............................................11 

 2. Potential Health Call Center Capabilities for Four National Planning Scenarios...11 

 3. Suggested Elements for Public Health Information and Decision Support 

Hotlines: the Health Emergency Line for the Public (HELP) Model........................12 

 4. Interactive Response (IR) Applications...................................................12 

Chapter 2. Background............................................................................15 

Incorporating Health Call Centers Into Community Emergency Responses............15 

Addressing Public Concern....................................................................16 

HEALTH.........................................................................................16 

HELP.............................................................................................17 

Chapter 3. Methodology...........................................................................19 

Overall Objective................................................................................19 

Overall Strategy.................................................................................19 

Target Audiences................................................................................19 

Challenges for Preparedness...................................................................20 

Community Emergency Response Challenges..............................................22 

 Planning for Public Information Needs......................................................23 

Chapter 4. Results..................................................................................29 

1) Establish an advisory panel of subject matter experts to supplement our 

 expertise and provide assistance and guidance........................................29 

2) Develop scenarios for mass health emergencies, including chemical, 

 biological, radiological, nuclear, and explosive (CBRNE) events, and decide 

 which ones provide the best opportunity for home-management/ 

 shelter-in-place strategies.................................................................31 

3) Research existing models, protocols, and algorithms; develop and implement 

 a scenario-based model using poison control centers, nurse call lines, and 

 similar centers...............................................................................34 

4) Develop a mechanism to test and evaluate the model with a local exercise.......48 

Chapter 5. Recommendations.....................................................................57 

 Integration with Current Programs and Initiatives.........................................59 

 Public Health Communications and Education.............................................60 

 Special Needs Populations..........................................................................................61 

 Volunteer Use in Call Centers................................................................62 

 Public Information Partnerships..............................................................63 

 Model Utility and Adaptability...............................................................63 

References...........................................................................................65 

Figures 

Figure 1: How Do Health Call Centers Fit Into Emergency Responses?.........................15 

Figure 2: Percentage of Population Reported to Have Contacted a Call Center or 

 Hotline Related to Certain Health Events...................................................16 

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Figure 3: Checklist for Developing Health Information Content............................38 

Figure 4: Patient Dispositions From a Clinical Care Algorithm Software Program 

 That Many Nurse Advice Lines Would Use.................................................44 

Figure 5: Average Call Volume to HELP by Hour of the Day From July 22 to 

 September 7, 2003..............................................................................50 

Figure 6: The Five Common Product Appearances for 100 mg Doxycycline 

 Preparations......................................................................................54

Tables 

Table 1. Participating Subject Matter Experts...................................................30 

Table 2. Participating Federal Agency Representatives.......................................31 

Table 3. Mean Estimates of Influenza Impact From National Planning Scenarios.........41 

Appendixes 

Appendix 1. National Planning Scenarios Analysis Matrix...................................71 

Appendix 2. Potential Health Call Center Capabilities for Four National 

 Planning Scenarios........................................................................73 

Appendix 3. Suggested Elements for Public Health Information and Decision 

 Support Hotlines: the Health Emergency Line for the Public (HELP) 

 Model............................................................................................83 

Appendix 4. Developing an Interactive Response Tool: The HELP Model................103

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Executive Summary

Objective and Directives 

 This report describes the development, testing, and implementation of a model to 

enable community health call centers, such as poison control centers, nurse advice lines, 

and other hotlines, to support home-management and shelter-in-place approaches in 

certain mass casualty or health emergency events. To guide call centers in adapting to 

accommodate such emergencies, we developed four specific products: 

• A matrix of the Department of Homeland Security’s 15 National Planning 

Scenarios with potential call center response capabilities specified (Appendix 1). 

• For the four National Planning Scenarios for which call centers had the best 

capabilities, a detailed list of all the applicable capabilities (Appendix 2). 

• Suggested elements for public health information and decision support hotlines. 

(Appendix 3). 

• Four fully detailed interactive response applications that allow callers to use their 

touch-tone phones to automatically retrieve critical information during a public 

health emergency (Appendix 4). 

 These products were developed for the four specific planning scenarios but can be 

adapted to others as appropriate. Together, they cover the full range of capabilities that 

community health call centers can provide. 

 To develop these products, Denver Health responded to five specific directives. The 

results for each are summarized here. 

Results and Recommendations 

1. Establish an advisory panel of subject matter experts to 

supplement our expertise and provide assistance and guidance. 

 We convened a national advisory panel of 13 subject matter experts with backgrounds 

and experience in fields that we considered crucial to community and national response 

planning as it relates to health call centers. 

 In addition, we invited representatives from several key Federal agencies to 

participate, including the Department of Health and Human Services, Department of 

Homeland Security, and Department of Transportation, as well as the American Red 

Cross. Panelists and agency representatives convened at three advisory panel meetings 

and the final presentation meeting in Washington, DC. At these meetings, agency 

1 
representatives educated the panel and core team members on the current Federal 

response efforts under way and how this project would best integrate with or support 

those efforts. The core team described the potential response capabilities that community 

health call centers could provide in responding to specific scenarios and proposed 

strategies and resources for assisting them in such responses. The expert panelists 

provided guidance on the development of the strategies and resources and helped refine 

them for the greatest utility and exportability. 

2. Develop scenarios for mass health emergencies including 

chemical, biological, radiological, nuclear, and explosive 

(CBRNE) events and decide which ones provide the best 

opportunity for home-management/shelter-in-place strategies. 

 We used the Department of Homeland Security’s (DHS) National Planning Scenarios 

to ensure consistency with other preparedness and response efforts that are being 

developed. While these scenarios do not cover all possibilities for health emergencies, 

they do include a wide spectrum of disasters that communities could face. Though many 

other disaster scenarios have been developed, the DHS scenarios were developed with the 

participation of numerous Federal agencies. 

 We reviewed all 15 scenarios and determined which ones could benefit from use of 

the potential response capabilities of community health call centers. We then developed a 

matrix that lists each scenario, including expected casualties, infrastructure damage, 

evacuation/displacement of persons, sheltering, and victim care strategies. We focused 

development of our model on scenarios with the following characteristics: 

• The community infrastructure was expected to remain intact so that call centers 

would be operable. 

• Major public health outcomes would be involved. 

• The scenario had the potential for many “worried well” (those with little or no 

injury who could overwhelm health care delivery systems), who could benefit 

from home management or sheltering in place. 

 We determined that four biological related scenarios (Biological Attack–Aerosol 

Anthrax, Biological Disease Outbreak–Pandemic Influenza, Biological Attack–Plague, 

and Biological Attack–Food Contamination) afforded the best opportunity to involve all 

potential response capabilities for community health call centers. Furthermore, our team 

and the panel believed that many response capabilities for biological incidents could also 

be used to address the response needs of chemical, radiological, and natural disasters. The 

broader application of health call center response capabilities to meet the needs of all 15 

scenarios is discussed in this report. 

2 
3. Research existing models, protocols, and algorithms; develop 

and implement a scenario-based model using poison control 

centers, nurse call lines, and similar centers. 

 We researched whether there were proven or experimental models for health call 

center responses to the four selected scenarios or any closely related scenarios. Searches 

of the published literature, public health practices, and Internet resources produced only 

limited results related to our objective. Many local and State public health department 

Web sites provide flu vaccination clinic information, searchable by city name or zip code. 

A few health departments also had telephone information hotlines that used either 

standard recorded messages or live agents to provide specific clinic locations or general 

influenza information. We did not locate any operating examples of interactive automated 

telephone-based systems for providing information to or collecting information from the 

public during health emergencies. 

 We found published reports describing the use of call center capabilities for 

responding to health events relative to the four biological scenarios of interest: 

• An influenza hotline conducted a vaccination survey during an influenza season 

with a vaccine shortage. The hotline addressed questions from the public 

regarding vaccine availability, groups most at risk, and symptoms in order to 

reduce inquiries to physician offices and local health departments. The authors 

suggested that State health departments consider a hotline to educate the public 

regarding influenza vaccination and to follow up with callers who were advised 

to receive vaccination to improve compliance. 

• A health department in Canada provided SARS information to the public through 

a hotline and supported the management of more than 10,000 individuals placed 

in quarantine, mainly in their own homes. The hotline required more than 200 

health department staff to support its operations over a 3-month period. 

• A health department in the United States used videophones to monitor suspected 

SARS cases and their close contacts. Afterwards, the equipment was used to 

monitor patients with active and latent tuberculosis. 

• Health officials in Taiwan quarantined more than 130,000 people, mostly in their 

homes, for 10 to 14 days to prevent the transmission of SARS. Management of 

those in quarantine consisted of daily visits or telephone calls to review the 

person’s current health status, including temperature recordings and symptoms. 

• Four populations (Hong Kong, Taiwan, Singapore, and the United States) were 

surveyed about attitudes regarding the use of preventive measures to control the 

spread of a contagious disease. Support for any preventative measure decreased 

significantly if the condition of arrest for refusing to comply was added. The 

most favored methods of monitoring quarantine compliance were daily visits 

from health officials and periodic telephone calls. In the United States, the 

3 
majority of respondents favored home quarantine for themselves and their 

families. 

 These reports suggest that using the telephone to provide information and support 

disease control measures such as home quarantine would likely be favorably received by 

the public and would assist public health agencies in the management of such efforts. 

Indeed, our experiences in operating a health call center that provides poison and drug 

information and nurse triage recommendations suggest that the public will seek out such 

community resources during health emergencies. We developed the Health Emergency 

Line for the Public (HELP) program to provide information and decision support to the 

public related to health events in Colorado. 

 In this report, we provide the HELP model blueprint so that other health call centers 

can consider developing these response capabilities. We also present health call-centerbased information tools that use technology to better handle surges in demand, such as an 

Interactive Response (IR) system that allows callers to use their touch-tone phone to 

automatically retrieve information. 

 We focused the resource development on five health call center response capabilities: 

health information, disease/injury surveillance, triage/decision support, 

quarantine/isolation support, and outpatient drug information/adverse event reporting. We 

did not address the mental health assistance/referral capability as a specific health call 

center component, but included suggestions to reduce community anxiety and panic in 

the resources and strategies that we developed for the other five response capabilities. We 

assessed each response capability for: significance, applicability to scenarios, current 

examples, range of support technology, and staffing required. We then proposed 

resources and strategies for each capability. 

 Health Information. Use of health call centers could greatly augment mass risk 

communication messages and help to alleviate surges to health care systems. Our 

experience and that of others has shown that incidents generating public concern usually 

require robust mass risk communication strategies coupled with hotlines or other forums 

to assist those with further needs. Providing health information is applicable for all 

National Planning Scenarios; however, the best association of health call center expertise 

and community need is for: Aerosolized Anthrax, Pandemic Influenza Outbreak, Plague 

Outbreak, and Food Contamination. 

 We developed an instructional guide for community health call centers to develop a 

health information capability consistent with that of the HELP program (see Appendix 3, 

Suggested Elements for Public Health Information and Decision Support Hotlines).. We 

describe the components that we found to be essential for developing a standardized 

response capability. These components provide us with the platform onto which 

additional capabilities could be added to support outpatient health care and monitoring 

during public health emergencies. This response model for public health events includes 

providing consistent, accurate information, collecting and maintaining structured data to 

4 
characterize events and responses, and developing capability and capacity to adapt to 

other public health emergencies. 

 We also developed two applications for providing automated information to callers, 

especially important in events that could generate call volumes that surpass call center 

staff ability to answer calls. These two applications were developed for use with an IR 

system to allow callers to use their touch-tone phone to retrieve information. One IR 

application allows callers to get zip code-specific messages and was developed 

specifically for finding point-of-dispensing (POD) locations to get medications during an 

event requiring community prophylaxis. The Cities Readiness Initiative program of the 

Centers for Disease Control and Prevention (CDC) recommends POD mechanism 

development as a key element of readiness. The other IR application allows callers to 

navigate through a library of Frequently Asked Questions (FAQs) to retrieve information 

relative to their concern. Both applications ensure consistent and accurate information 

delivery: the same information is provided to every caller, every time. 

 Though the applications were developed for use with an IR system, they could be 

used without such technology. The call flows, decision trees, and message scripts could 

be used to guide call center staff in how to handle calls or could be used with other 

technology such as recordings and announcements to assist call center staff in managing 

higher call volumes. The POD application could be modified to provide any information 

based on zip codes, such as in evacuations, sheltering in place, snow cancellations, or 

mass vaccinations. 

 Disease/Injury Surveillance. Call centers that collect any health data could 

contribute to surveillance systems to quantify illness/injury (situational awareness) or to 

detect sentinel events or emerging health threats. Some health call centers may already 

analyze their own data to characterize their patient populations, while others may not 

realize the value of their data as it relates to a public health agency’s need for disease and 

injury surveillance. The National Planning Scenario with the best association between 

health call center expertise and community need for disease/injury surveillance was the 

Pandemic Influenza Outbreak scenario, though almost all of the other scenarios could 

benefit from using call centers to capture health data for disease or injury surveillance. 

 For example, the American Association of Poison Control Centers contributes to 

disease surveillance by transmitting data related to toxic substance exposures to the 

CDC’s BioSense program. That program is an initiative to develop a national 

biosurveillance capability that seeks to improve the Nation’s capabilities for disease 

detection, monitoring, and real-time situational awareness through access to existing data 

resources. 

 Appendix 3, Suggested Elements for Public Health Information and Decision Support 

Hotlines, discusses structured data collection and public health partnering for developing 

disease/injury surveillance capabilities. The POD and FAQ applications, besides 

providing health information, also can collect data that could be useful in surveillance, 

such as the zip codes entered by callers seeking information. 

5 
 Triage/Decision Support. Health call centers can assist with triage and decision 

support for health concerns and can alleviate surges to health care facilities, thereby 

reducing unnecessary hospital visits and associated health care costs. The National 

Planning Scenario with the best association between health call center expertise and 

community need for this capability was the Pandemic Influenza Outbreak scenario. 

However, almost all of the other scenarios could benefit from using call centers to assist 

with the triage and management of disease or injury, especially in preventing the 

“worried well” from overwhelming health care facilities. 

 Current examples of this capability include poison control centers that triage 

poisoning and provide exposure management support, and nurse advice lines that triage 

symptoms and provide symptom/disease management support. Both call center types 

provide such services with licensed clinical professionals on a daily basis, and this 

strengthens their credibility with the public. Research has shown that such centers reduce 

health care costs by preventing unnecessary emergency department visits and hospital 

admissions. Therefore, using these trusted call centers in health emergency situations 

should result in the same efficiencies and cost effective outcomes. 

 The HELP program does not use clinicians but provides disease and symptom 

information for the caller to use in making decisions for their own health care. Such an 

approach reduces the need to have clinicians—a finite resource that will be in high 

demand during any health emergency—on staff. For normal daily operations, trained 

information providers deliver scripted information and refer callers requiring exposure, 

symptom, or injury triage, as well as management support, to appropriate resources such 

as a poison center, nurse advice line, or health care provider. Using information providers 

to handle most public information needs prevents unnecessary calls to clinician-staffed 

lines so that they can continue to handle medical triage and management support calls. 

 Communities should consider the clinical recommendations they would use in the 

event of a major health emergency, such as pandemic influenza, that severely affects the 

health care delivery system. The health care delivery system and health care providers 

need to consider how they would handle a surge of sick patients in the face of increased 

demands on limited health care resources. A health call center needs to ensure that its 

recommendations are consistent with those of the rest of the health care delivery system 

and its health care providers. 

 Quarantine and Isolation Support. Health call centers are well suited to assist with 

monitoring or contacting those in quarantine and isolation, especially if they have 

appropriate guidance and resources. Research indicates public support for quarantine to 

control disease and for monitoring the status of those in quarantine by telephone. The two 

National Planning Scenarios involving infectious diseases (Pandemic Influenza Outbreak 

and Plague Outbreak) would potentially require the use of quarantine and isolation as 

disease control measures and could benefit from using call centers to support such 

measures. Future SARS and other infectious disease outbreaks would require planning 

and response capabilities similar to those for the influenza and plague scenarios. 

6 
 Telephones were used to monitor those in quarantine in the SARS outbreaks in 

Toronto and Taiwan, and less than one percent of those in quarantine developed 

symptoms or were noncompliant. Simply having a staff person contacting those in 

quarantine can attain this response capability, but larger numbers of people in quarantine 

will require more automated approaches for monitoring health status and compliance. We 

developed a Quarantine/Isolation (QI) Monitoring Application (see Appendix 4, 

Developing an Interactive Response Tool) that uses an IR system and frees staff to handle 

only those needing further attention, such as those developing symptoms or those who 

did not answer earlier calls. Since most in quarantine should require only periodic 

monitoring, automating much of that with the QI Monitoring Application could be of 

great utility. 

 The QI Monitoring Application automatically places calls to individuals in home 

quarantine to assess their current health status and reports on those that don’t answer so 

that further followup can be conducted. The application is part of an IR system that can 

initiate up to 12,000 calls in a ten-hour period. Though this application was developed for 

use with an IR system, it could be used without such technology. The call flows, decision 

trees, and message scripts could be used to guide call center staff in handling calls in a 

structured manner. The application could be adapted to other scenarios that might require 

contacting individuals by telephone for sheltering in place strategies. We recommend that 

public health agencies develop referral protocols and guidance for call center staff in 

handling situations in which a quarantined individual needs food, medication, or financial 

assistance. 

 Outpatient Drug Information/Adverse Event Reporting. The CDC’s Cities 

Readiness Initiative program requires that participating cities prepare plans for mass 

prophylaxis with Strategic National Stockpile assets. Depending on exposure, this 

program could result in thousands to millions of people being dispensed antibiotic 

medications. Health call centers can support these efforts by providing information about 

the incident and the supplied medications, as well as by collecting any potential adverse 

event reports. The two National Planning Scenarios involving agents that would be 

treated with antibiotics are Aerosolized Anthrax and Plague Outbreak, but other scenarios 

that involve either mass vaccinations (Pandemic Influenza Outbreak), wide-scale use of 

medications for treating radiation exposure (Nuclear Detonation, Radiological Dispersal 

Devices), or Food Contamination may also require this response capability. 

 Examples of health call centers providing this capability include the HELP program 

collecting adverse event information regarding smallpox vaccinations, many drug 

information centers collecting information for the FDA’s MedWatch reporting program, 

and poison control centers handling drug identification calls. 

 We have developed an application that would support mass prophylaxis with 

antibiotic drugs using an IR system. The Drug Identification (DI) Application assists 

callers in identifying dispensed drugs, provides information on how to take them, and 

describes potential adverse reactions. This would allow public health agencies to 

7 
concentrate on operating mass dispensing sites and health care providers to care for those 

that develop illness. Though this application was developed for use with an IR system, it 

could be used without such technology to guide call center staff in how to handle these 

calls. The application could be adapted to other scenarios that might require mass 

administration of medications or vaccinations and provision of relevant information. 

 

 Mental Health Assistance/Referral. Health call centers providing health 

information and support will help relieve anxiety and stress among the public, especially 

since many such centers are known and trusted resources within communities. All 15 of 

the National Planning Scenarios will likely result in varying degrees of community fear, 

panic, anxiety, and depression. Countless suicide prevention and counseling hotlines 

currently exist and are run by trained mental health staff. The National Suicide 

Prevention Lifeline provides a 24-hour toll-free service that routes callers to crisis centers 

across the country. Additionally, nurse advice lines are capable of handling patients with 

depression, and poison control centers regularly receive suicide and intentional harm 

calls. Health call center staff can be trained to identify callers that may benefit from a 

referral to community mental health resources. 

4. Develop a mechanism to test and evaluate the model with a 

local exercise. 

 The HELP model has been tested over 3 years of daily operations and in response to 

several major health events. The HELP model has made it possible for us to provide 

consistent, accurate, and up-to-date information during bioterrorism exercises and public 

health emergencies in partnership with the Colorado Department of Public Health and 

Environment. The HELP program provides a model for disseminating and collecting 

information that, to date, has involved handling more than 75,000 calls related to several 

major health events, including West Nile virus (WNV) and influenza outbreaks. The 

public’s demand for information during these events has required us to develop better 

strategies for delivering such services with limited staffing resources. 

 One strategy is to use initial announcements to relay the information most requested 

by callers to reduce their need to speak with staff. On average, 60 percent of callers listen 

to the recorded information and terminate the call, indicating that their concern was 

addressed with the announcement. This has remained fairly constant for a range of health 

events over the last 3 years. Additionally, recordings of other frequently requested 

information can be cycled to potentially answer callers’ questions while they are waiting 

to speak to staff. Many callers may get the information they require from those messages 

and no longer need to wait for assistance. This ensures that staff is assisting those that 

could not be helped easily by other means. Recordings can also refer callers to other 

information sources, such as the Internet, that they may opt to explore instead of waiting 

in queue. By reviewing the concerns of callers speaking with staff, managers can 

determine if additional information should be added to the initial announcement or queue 

messages, or disseminated by the media or other sources in hopes of meeting demand 

without call center staff involvement. 

8 
 The challenges we have encountered with surges in demand for HELP have led us to 

produce applications to better assist in providing information and supporting caller needs 

during health emergencies. Using technology such as an Interactive Response (IR) 

system has further improved our capacity for handling high call volumes. We have 

developed and tested four IR applications that we believe other community health call 

centers can use, as well: 

• Quarantine/Isolation (QI) Monitoring 

• Point of Dispensing (POD) Locations 

• Drug Identification (DI) 

• Frequently Asked Question (FAQ) Library 

 A prototype version of the QI Monitoring Application was tested in a rural user group 

(N=12) in conjunction with an influenza vaccination exercise in October 2005. The 

prototype application was revised to reflect many of the user suggestions. The revised 

and more fully developed QI Monitoring Application, along with the other three 

applications, were evaluated in an exercise in May 2006 in an urban user group (N=96) 

consisting primarily of local health personnel from 10 counties. The goal of the second 

exercise was to test the ability of the four IR applications either to initiate contact and 

determine health status of those in quarantine (QI Monitoring) or to effectively 

communicate key information to users calling into the four applications. 

 We met our overall exercise objectives, and we obtained excellent feedback to help us 

improve the tested applications. We also obtained important information on user 

acceptance of these IR applications. Although evaluations for all four applications were 

mostly favorable, it was apparent the FAQ Library application seemed more acceptable 

than the DI application, perhaps because the latter concerned medications that callers 

were asked to take. 

 The comments and evaluations of these applications should also help Public 

Information Officers in determining which ones may be acceptable for different events 

and in developing messaging strategies for those events. These results also suggest areas 

for potential community outreach efforts for public health agencies to create a more 

informed public. One lesson learned is that the applications will be only as good as the 

information that is developed for them and the means by which that information is 

provided to the public. 

5. Prepare a final report and recommendations. 

 This final report describes in detail areas described above: the model, the scenarios 

where the model could be used effectively at various levels of response, and a 

comparison of the model to other existing models. A brief summary of recommendations 

follows. 

9 
 To help the public make informed decisions and care for themselves during severe 

health events, such as disaster scenarios, we must plan ahead to develop strategies that 

will minimize or alleviate surge on health care delivery systems and accommodate those 

most in need. Helping community health call centers develop response capabilities 

through the models and applications in this report can increase their ability to support the 

public. 

 We believe, as determined, in conjunction with the advisory panel, that the four 

biological scenarios from the Department of Homeland Security National Planning 

Scenarios described above afford the best opportunity to involve most of the potential 

response capabilities for community health call centers. 

 The target audiences for the proposed scenario-specific models and applications are 

community health call centers that are established and trusted community resources, 

including: 

• Poison control centers. 

• Nurse advice lines. 

• Drug information centers. 

• Health agency hotlines. 

• Local/State/Federal public health agencies. 

 The resources that we have developed to support outpatient health care and monitoring 

during health emergencies with limited staffing will allow other health call centers to 

meet the challenges of surges in demand related to health events. These resources will 

provide the public with self-service support so that persons can make appropriate 

informed decisions about their health concerns. The basic call center infrastructure and 

essential elements of the HELP program are needed to support such strategies. 

 The HELP Model’s Interactive Response Tool and its four applications proposed in 

this report are not sole components but part of a comprehensive public information 

strategy that includes the use of mass media and community health call centers to support 

self-care, monitoring, appropriate referrals, situational awareness, and disease outbreak 

management and control. 

10 
Chapter 1. Final Products 

 This report describes the development, testing, and implementation of the Health 

Emergency Line for the Pubic (HELP)--a model to enable community health call centers, 

such as poison control centers, nurse advice lines, and other hotlines, to support homemanagement and shelter-in-place approaches in certain mass casualty or health 

emergency events. 

 The report presents four products, introduced here, to help community health call 

centers and public health and public safety agency planners adapt their call centers for 

surge response during a public health emergency. Following chapters provide the 

background, methodology, and results of the project as well as some recommendations. 

1. National Planning Scenarios Analysis Matrix 

 We reviewed the Department of Homeland Security (DHS) National Planning 

Scenarios and developed a matrix that summarizes the 15 scenarios for which emergency 

planners should develop response capabilities. Using the same set of scenarios will allow 

for a common language of response planning and capabilities development, so that best 

practices can be shared and adapted between agencies and localities. After summarizing 

each scenario, the matrix shows the six response capabilities that community health call 

centers can provide. The National Planning Scenarios Analysis Matrix lists each scenario 

and indicates which health call center capabilities correspond to the expected response 

needs of communities. 

 Call centers can use the matrix to determine whether they are prepared to provide 

response capabilities for the scenarios most likely to occur in the communities they serve. 

The matrix can help frame discussions among public health and public safety agency 

planners so that community health call centers can be integrated into planning and 

responses, both as a resource and as critical infrastructure. 

2. Potential Health Call Center Capabilities for Four 

National Planning Scenarios 

 We determined four National Planning Scenarios for which we determined that call 

centers had the best capabilities and developed a detailed list of all the applicable 

capabilities (Appendix 2). This document can assist call centers and public health 

agencies in determining the expected health needs for each scenario and selecting those 

for which they may want to plan. 

11 
3. Suggested Elements for Public Health Information 

and Decision Support Hotlines: the Health 

Emergency Line for the Public (HELP) Model 

 Appendix 3 describes many of the essential components of the HELP model. The 

HELP program serves as Denver Health’s operational platform for disseminating and 

collecting consistent, accurate, and up-to-date information, in partnership with public 

health agencies, during bioterrorism and other public health emergencies. The goal is to 

provide self-service information to the public so that they can make informed decisions 

about their health concerns. The structure and adaptability of the HELP model have 

allowed Denver Health to effectively respond to major health events, such as West Nile 

Virus (WNV) and influenza outbreaks. Community health call centers can use Appendix 

3 begin to develop similar capabilities within their existing infrastructure. 

 A more complete discussion of the requirements for general call center infrastructure 

(people, processes, and technology) can be found in the Health Emergency Assistance 

Line and Triage Hub (HEALTH) Model. The HEALTH model is discussed in Chapters 2 

and 3, and the full report is available at www.ahrq.gov/research/health/. 

 We strongly urge any call center attempting to provide these community services to 

do so in cooperation with the appropriate public health authority. That is, the authority 

that, by statute, is responsible for coordinating health and medical services following a 

major disaster or emergency or during a developing potential medical situation. 

Coordination with the health authority will help ensure overall consistency with other 

response measures in the community. 

4. Interactive Response (IR) Applications 

 Appendix 4 provides the blueprint for other call centers to develop similar capabilities 

within their own infrastructure and using their own equipment. It includes full details of 

the planning, analysis, design, implementation, and evaluation of the four IR applications 

that we developed: 

 

• Quarantine/Isolation (QI) Monitoring (outbound application). 

• Drug Identification (DI) (inbound application). 

• Point of Dispensing (POD) (inbound application). 

• Frequently Asked Question (FAQ) Library (inbound application). 

 An IR system with applications such as these allows callers to use their touch-tone 

phones to automatically retrieve information during a public health emergency. Since we 

had previously purchased an IR system, we designed the IR applications to use the 

available features of our equipment. We contracted with an IR consultant and developer 

12 
to oversee the development of the applications in accordance with our business 

requirements and specifications. The IR consultant developed the applications, provided 

administration and maintenance training for our internal technology staff, and assisted 

with modifications to the applications after testing in two exercises. Our internal 

technology staff made the appropriate programming changes to our telephone switch to 

support the IR applications. Through this process, our technology staff acquired some 

training on IR programming and can make certain modifications to the applications 

without requiring an IR consultant. 

 Call centers that have an IR system can contract with an IR consultant or use internal 

technology staff to program similar tools. Planners can review the Appendix 4 with 

internal technology staff to determine how best to develop the desired capabilities with 

available resources. Call centers that want to purchase an IR system can use the 

information in this appendix to help select equipment to meet their business needs and 

specifications. Call centers that cannot invest in such technology can still use the 

appendix to develop call handling procedures that their staff can use to provide the same 

capabilities to the public. 

 These four products were developed for the four specific planning scenarios but can 

be adapted to others as appropriate. Together, they cover the full range of capabilities that 

community health call centers can provide. 

13 
14 
Chapter 2. Background

Incorporating Health Call Centers Into Community 

Emergency Responses 

 The overall benefit to health call center involvement in a community emergency is 

depicted in Figure 1. Once an event occurs, media outlets (newspapers, television, radio, 

Internet) will devote much time and effort to reporting on it. The public will get needed 

information about the event from those media sources, but there will be limited 

opportunities to ask questions about how those events pertain to their individual 

circumstances. 

Figure 1. How Do Health Call Centers Fit Into Emergency Responses? 

 Health call centers (poison control centers, nurse advice lines, and health hotlines) 

have the expert and experienced staff to address the potential demand for more 

information with a range of approaches from recordings to speaking with a trained 

professional. By partnering with public safety and public health agencies, health call 

centers can provide information that is accurate, up-to-date, and consistent with official 

messages. Call centers can also collect information for use in situational awareness, from 

health concerns to the development of illness. 

Interactive

Response

Public will initially receive information from 

the mass media. 

Public Health/Public Safety agencies announce 

a health emergency. 

Information partners relay accurate, up-to-date, 

and consistent messages and collect data from 

the public. 

Poison Center Nurse Line Health Hotline 

Some percentage of 

the public will still have 

questions or concerns. 

Members of the public can 

also be called at home to 

monitor their current health 

status and be provided 

guidance and other 

resources. 

Recordings

15 
Addressing Public Concern 

 Public concern about an event and how it may affect individuals increases when it has 

potential health implications. Our previous research has shown that calls to health-related 

hotlines have ranged from less than 1 percent to 25 percent of the affected community’s 

adult population, depending on the nature of the event. Figure 2 depicts that concerns for 

emerging insect-borne disease outbreaks in Colorado and New York City (using hotline 

contacts as a percentage of the population) were much lower than concerns for an 

infectious disease outbreak primarily involving children in Florida.1-5

Figure 2. Percentage of Population Reported to Have Contacted a Call Center or Hotline 

Related to Certain Health Events 

Event Location - Issue

0

5

10

15

20

25

Florida -

Meningitis

Toronto -

SARS

Trenton -

Anthrax

NYC - 

WNV

Colorado - 

WNV

H

o

tlin

e

C

o

n

ta

cts

%( p

o

p

ula

tio

n)

 It has been demonstrated that the public perceives risk differently than public health 

professionals do.4,6 Experiences have shown that bioterrorism-related, child-focused, and 

newly emerging disease events, in particular, prompt people to contact call centers. 

Though it may be hard to predict the level of concern for any given health event, research 

in the field of risk communication indicates that certain risk perceptions increase levels of 

fear and concern. Covello et al, report that levels of concern tend to be most intense when 

the risk is perceived to be involuntary, inequitable, not beneficial, not under one’s 

personal control, associated with untrustworthy individuals or organizations, and 

associated with dreaded adverse, irreversible outcomes.4

HEALTH 

 The Rocky Mountain Regional Health Emergency Assistance Line and Triage Hub 

(HEALTH) model was developed as a partial solution to the public health 

16 
communications problems that were recognized in the aftermath of September 11, 2001 

and the concern about anthrax-laced letters distributed through the United States Postal 

Service. 

 The HEALTH model presents requirements, specifications, and resources needed for 

developing a public health emergency contact center that is highly integrated with public 

health agencies and that could minimize surges in the demand for health and event 

information during an emergency. The model was designed with medical contact centers 

(such as poison control centers and nurse advice lines) in mind as potential implementers, 

and as the appropriate repositories for the creation and maintenance of readiness for 

providing one-on-one health communication in a public health event. 

 To further assist other agencies in developing the capabilities and functions of this 

model, especially public health agencies, we created a HEALTH Contact Center 

Assessment Tool Set. The tool set is a Microsoft® Excel workbook that agencies can use 

to assess the potential demand they may face in a health emergency event and to 

determine the resources needed to address this demand. The tool set consists of seven 

simple checklists or spreadsheets, including: 

• Instructions. 

• Contact Surge Calculator. 

• Staffing-Resource Calculator. 

• Capital Expense Calculator. 

• Technology Expense Calculator. 

• Surge Options Matrix. 

• Glossary. 

 The HEALTH model incorporates the ability to provide one-on-one health 

information using the latest in technology to efficiently handle this demand through 

various communication modalities. The Rocky Mountain Regional HEALTH model 

report and tools are at www.ahrq.gov/research/health. 

HELP 

 Our poison center established the Health Emergency Line for the Public (HELP) pilot 

program in Colorado to provide information during bioterrorism and other public health 

emergencies. HELP originated as a pilot or proving ground for implementing some of the 

concepts and strategies that were developed in the HEALTH model. Since then, it has 

been continually developed and has responded to three major health events in Colorado: 

the deadliest WNV outbreak in the United States (2003), an influenza outbreak with early 

increased pediatric deaths (2003-2004), and an influenza outbreak during a vaccine 

shortage (2004-2005). The HELP program provides a model for disseminating and 

collecting information during health emergencies in partnership with a State health 

department. 

17 
 The HELP service was offered to the public in January 2003 to support a statewide 

smallpox vaccination program for health care volunteers in Colorado. The vaccination 

program finished in March 2003. The HELP program was then modified to provide 

WNV information to the public in anticipation of a second season of that outbreak in 

Colorado. Since July 22, 2003, a toll-free line has been available 24 hours a day, 

featuring current recorded messages and Web site referrals for more detailed information. 

Trained information providers are available from 7:00 a.m. to 11:00 p.m. daily to answer 

questions, collect demographic data, and provide referrals. Recordings are available in 

English and Spanish with additional translation services available for other languages. 

Information providers use FAQ scripts prepared by State health epidemiologists to 

explain symptoms, treatments, and prevention measures to callers. Evolving public 

concerns are identified, and applicable responses are developed within 48 to 72 hours. 

The HELP program has expanded information offerings to include additional topics such 

mold, influenza/pneumonia, anthrax/white powder, severe acute respiratory syndrome 

(SARS), hantavirus, tuberculosis, the human strain of avian influenza, and ricin. Other 

topics are added as information needs for the public and health providers are identified. 

 The HELP program provides the functional platform for piloting and testing other call 

center strategies, technology, and applications to efficiently provide information to the 

public in a health emergency. The technology infrastructure and requirements of the 

HELP program were described previously in the HEALTH model report. The essential 

elements that we have identified from the last 3 years of operating the HELP program 

service are addressed later in this report and in Appendix 3. 

18 
Chapter 3. Methodology 

Overall Objective 

 Our main objectives are 1) helping the public make informed decisions and care for 

themselves during health events, thereby alleviating their potential demands on health 

care delivery systems, and 2) assisting community health call centers with developing 

such response capabilities by employing strategies and models to provide support in: 

• Health information. 

• Disease surveillance. 

• Triage/decision support. 

• Quarantine and isolation support/monitoring. 

• Outpatient drug info/adverse event reporting. 

• Mental health support/referral. 

Overall Strategy 

 During any catastrophic event, the health care system will be overwhelmed with both 

the genuinely sick and the “worried well.” Communities need to use all resources 

available to them in order to prevent a complete breakdown in health care delivery that a 

large patient surge could precipitate. Community health call centers can serve a vital role 

in such response efforts if they are provided the appropriate tools and guidance. 

 The SARS outbreak in Toronto demonstrated how great public concern can be by the 

demand for information their hotline recorded—316,615 total calls over 3 months and a 

peak daily volume of 41,789 calls.2 Toronto Public Health was able to effectively use 

recorded information and up to 46 staff at a time for handling almost two-thirds of 

callers. However, a third of callers were not able to speak to a staffer at the time of their 

call, though they indicated the need to do so. This demonstrates that, despite the best 

efforts of a large and well-organized public health response, including a structured 

hotline capability, there were still challenges in meeting the information demands of the 

public. This project has produced resources and strategies that can guide health call 

centers to provide expanded services that can assist public health and health care agencies 

in an emergency. 

Target Audiences 

 Target audiences were health call centers selected based on the following criteria 

determined in the literature review: 1) pre-existing knowledge base/minimal 

19 
competencies, 2) existing connection to the public health network, 3) experience working 

within a care team framework, and 4) anticipated availability during a mass casualty 

event to perform the newly acquired cross-trained duties and competencies. 

 Health call centers identified as meeting the criteria include: 

• Poison control centers. 

• Nurse advice lines. 

• Drug information centers. 

• Health agency hotlines. 

• Local/State/Federal public health agencies. 

 The health call centers identified would likely be familiar with basic physiological 

responses to particular health threats due to a pre-existing knowledge and skills gained in 

their area of health care. In addition, the professionals employed by such centers would 

likely have prior experience in assessing patient status, problem-solving, and working 

with symptomatic patients over the phone. During any health emergency event, they 

would continue to provide regular services that help direct the appropriate patients to 

health care facilities. In addition, they could expand services to provide information and 

support related to the event, much of which could be handled with nonclinical staff. In 

this way, they could help with surge capacity and informing the public about health 

issues so that they can make informed decisions and care for themselves. 

Challenges for Preparedness 

 The 2004 Redefining Readiness Project from the Center for the Advancement of 

Collaborative Strategies in Health reported that approximately 60 percent of the public 

would not heed official instructions to get vaccinated during a smallpox outbreak, and 

that approximately 40 percent of the public would not heed official instructions to shelter 

in place during a dirty bomb incident.7

 These statistics can be alarming to preparedness 

planners who assume that the public will be compliant with government 

recommendations. However, it is informative to understand the reasons behind such 

statistics. 

 In the case of smallpox vaccination, 55 percent of respondents indicated that they 

would need more advice or information. They cited lack of worry about catching the 

disease, serious worries about what government officials would say or do, serious worries 

about the vaccine, and conflicting worries about catching the disease and getting sick 

from the vaccine. This is consistent with the actions of health and medical professionals 

who chose not to get vaccinated in the CDC’s Smallpox Vaccination Program, albeit 

without the actual presence of smallpox in the world. For those professionals, the risks of 

vaccination and the potential for adverse effects without a threat of the disease 

20 
contributed to their reluctance to participate in the program. However, most of these 

professionals would support targeted vaccinations as a strategy to stop an outbreak of 

smallpox—information that could help people to decide that they should get vaccinated 

during an outbreak. 

 In the case of sheltering in place during a dirty bomb incident, the major reasons for 

not following instructions involved concern for the safety of others (their children, family 

members, and pets). Having measures in place to assure the public that these others were 

being taken care of (school children were also sheltering in place) or were not at risk 

(pets kept indoors would be safe) would help them in complying with sheltering 

instructions. 

 These challenges can, in part, be alleviated by the use of community health call 

centers that can help provide needed information for people to make good decisions 

based on their individual concerns and situations. Call centers can not guarantee that 

everyone will comply with recommendations, but they can help people understand them 

and the risks or consequences of their choices. 

 The 2004 Redefining Readiness report further states that in regards to smallpox 

vaccination, “58 percent of the American people would find it extremely or very helpful 

if they could talk by telephone at no cost with someone they don’t know, who works for 

their local government, and who has been specially trained by the health department to 

give people information and advice about what to do in this situation. However, 

considerably more people (84 percent of the population) say they would find it extremely 

or very helpful to talk with someone they know well, who they are sure wants what is 

best for them, and who has been specially trained in advance to give people information 

and advice about what to do in this situation.” This suggests that call centers that are 

embedded in the community and familiar to the public should be well received when 

providing support during a health emergency. 

 Other encouraging findings come from a national survey conducted by the Harvard 

School of Public Health’s Project on the Public and Biological Security. Blendon et al. 

report that, when faced with a serious outbreak of pandemic flu, a large majority of 

Americans are willing to make major changes in their lives and cooperate with public 

health official recommendations. More than three quarters of Americans say they would 

cooperate if public health officials recommended that they curtail various activities of 

their daily lives for 1 month during a flu pandemic: 94 percent say that they would stay at 

home away from other people for 7 to 10 days if they were sick, and 85 percent say that 

they and all members of their household would stay at home for that period if another 

member of their household were sick. Therefore, providing support to individuals to 

enable them to remain at home and care for themselves could be critical.8

 In addition, helping the public make informed decisions and to care for themselves 

can alleviate their demands on health care delivery systems. A community health call 

center can provide general topic and event information, the most current public health 

messages, and appropriate information on personal and family protection for almost any 

21 
emergency that has a potential health impact. They can also provide the public with 

specific State and local health department guidelines, points of contact for referral 

agencies, and general health decision support and evaluation. 

 It is precisely this type of support that the public requests during an emergency. In our 

experiences during the influenza seasons of 2003-2004 and 2004-2005 in Colorado, 

public concerns centered on the unique challenges of each season. For example, in 2003-

2004 there were several pediatric deaths very early in the season that sparked fears in 

many parents. The most asked questions included “Where can my child get a flu shot?” 

“Where can I get a flu shot?” and “What are the symptoms of flu?” The most frequent 

call types during this season were information calls, followed by possible flu reports and 

calls from health care professionals requesting health department guidance documents. In 

the 2004/2005 season, there were concerns of vaccine shortage after a season that 

elevated influenza awareness in the public’s mind. The most asked questions this time 

included “Where can I get a flu shot?” “What is the status of the vaccine shortage?” and 

“What is FluMist?” Calls for information were the most frequent; however, calls from 

health care professionals requesting health department guidance documents and health 

departments updating our call center on current issues were the next highest. This shows 

that, as with community needs concerning a seasonal influenza, needs with similar health 

issues can change and systems need to be ready to handle those challenges. 

Community Emergency Response Challenges 

 After September 11, 2001 and the release of anthrax letters along the East Coast over 

the following weeks, our call center experienced a 10 percent increase in call volume 

related to these events, even though the affected communities were all in the Eastern 

portion of the country and our call center was in the Western portion. This phenomenon 

concerned us, because we did not know whether further terrorist attacks were on the 

horizon or if anthrax letters would surface in the communities that we serve. If such 

events were to occur, what would be the resultant public concern, and how would that 

affect our call volume? Would we be able to continue to provide the regularly needed 

services of poisoning information consultation and nurse triage recommendations? Or 

would these services be hindered by the public demand for information related to the 

current events? 

 

 We knew that call center responses about medical concerns from the public prevented 

unnecessary visits to health care facilities and reduced caller panic. The public would 

seek this type of expertise out if they again felt threatened by exposure to anthrax in their 

mail or if their environment was somehow contaminated by a terrorist attack. 

 Poison control centers are the classic resource for parents concerned about a 

potentially toxic exposure to their child. These centers have trained staff who are adept at 

calming parents while collecting information to assess an exposure. Most of the time, 

these exposures are not toxic and do not require further medical evaluation. According to 

the 2005 annual data from the American Association of Poison Control Centers, 74 

percent of calls to poison control centers are successfully managed in the home.9

 The 

22 
availability of such resources via telephone prevents approximately 1.8 million visits 

annually to physician offices and hospitals. As seasonal influenza patient influxes have 

demonstrated, the current health care delivery system would be challenged to 

accommodate this number of patients. 

 Nurse advice lines are another important resource for those who have health concerns 

and who are looking for guidance on what to do about those concerns. Seventy percent of 

callers to the Denver Health NurseLine complied with nurse recommendations, though 

that same percentage of callers had a different plan for health care in mind before 

calling.10 The trust that callers have for nurses, the information that nurses provide, and 

the nurses’ review of the patient’s options all contribute to this substantial change of 

behavior. 

 When planning for emergency responses, it seems wise to build on the expertise, 

credibility, and infrastructure of community health call centers. Expanding their 

capabilities to inform, educate, and assist the public with their health concerns can free 

the health care delivery system to most effectively use limited resources to provide care 

to those most in need. This approach can especially aid in handling those at low risk for 

injury or illness, who may have valid fears and concerns that, without a mechanism to get 

information, could lead them to overtaxed hospitals and health departments. 

 To begin developing this type of response capability, there community emergency 

planners and their response partners should consider four questions: 

• What would you do to handle a surge in public contacts during a public health 

emergency? 

• Could you adequately predict the potential volume of contacts? 

• How would you identify staff, facilities, and other resources for this need? 

• If you couldn’t handle this demand, who in your community could? 

 This report will address these issues to provide planners and response agencies with 

direction in answering these questions in ways that suit their communities’ needs. 

Planning for Public Information Needs 

 According to “Mass Medical Care with Scare Resources: A Community Planning 

Guide,” a 2007 publication by the Agency for Healthcare Research and Quality (AHRQ), 

the public requires clear messages and communications strategies to inform them about 

the status of the event and what actions they should take.11 To accomplish this during an 

event, it is important to have all potential communication partners involved, including 

public information officers (PIOs) from public safety agencies, public health agencies, 

hospitals and health care organizations, 911 dispatch centers, special information phone 

lines (211, 311, health call centers), and the media. 

 The National Incident Management System (NIMS) guidance outlines the 

organizational structure for enhancing the public communication effort by formation of a 

23 
Joint Information System (JIS) to provide the public with timely and accurate incident 

information and unified public messages.12 This system employs the Joint Information 

Center (JIC) to bring communicators such as the PIOs from various agencies together 

during an incident to develop, coordinate, and deliver unified messages. This helps to 

ensure that Federal, State, and local Governments are releasing the same information. 

While NIMS embraces the JIC/JIS concept, it leaves it to community planners to develop 

the processes, procedures, and systems for communicating timely and accurate public 

information during emergency situations. 

 Elements of a comprehensive public information strategy should include the use of: 

• Mass media to provide the public with information on preventive measures, home 

care management, and the appropriate time to seek health care services. 

• Community health call centers to reinforce mass messaging and to provide 

additional and more tailored information to individuals with questions and 

concerns, as well as to review these issues for their value as potential mass media 

messages. 

• Community health call centers to assist with outpatient (home care) monitoring 

and support, thereby helping to extend the reach of public health and health care 

systems into households. 

• Information collected by the call centers for situational awareness and disease 

outbreak management and control. 

 The CDC requires, in their Cooperative Agreement Guidance for Public Health 

Emergency Preparedness continuation grants for FY2006, that communities provide 

needed health and risk information to the public and key partners during a terrorism event 

or other emergencies. Target capabilities are to advise the public to be alert for clinical 

symptoms consistent with an attack agent, to disseminate health and safety information to 

the public, and to ensure that their public information line can simultaneously handle 

calls from at least 1 percent of the jurisdiction’s population or residences.13 

 So what would that mean for a community trying to meet such target capabilities? 

Let’s begin to address the questions that we posed above for community emergency 

response planners in context of the CDC target capability goal: 

 What would you do to handle a surge in public contacts during a public health 

emergency? 

 Many State and local health departments are beginning to develop plans and response 

capabilities for providing public information for pandemic influenza and other health 

emergencies. A recent thread on a Strategic National Stockpile Listserv indicated that 

public health agencies are planning a range of responses, including developing protocols 

and information resources, arranging for augmented staffing and volunteers, making 

24 
technology/infrastructure improvements, and partnering with established call centers. All 

of these are important measures and will be needed for developing any response 

capability. Public health or public safety agencies should reach out to health call centers 

in the community to learn about their capabilities and how they could assist in response 

efforts. Community health call centers should reach out to planners in emergency 

management or public health to learn about their needs and how they can be of 

assistance. Hopefully, the tools that we present in this report will be useful to all parties 

in developing the needed community response capabilities. 

 Could you adequately predict the potential volume of contacts and how would 

you identify staff, facilities, and other resources for this need? 

 The HEALTH Tool Set (www.ahrq.gov/research/health) can calculate call volumes 

given various parameters. For example, given a population of 4 million, the tool set first 

determines the approximate number of those most able to contact an information line (2.8 

million people age 15 years or older). Given a level of public concern at 1 percent and the 

communication means at 100 percent phone, the tool establishes a target capability goal 

(based on the CDC public information hotline goal of 1 percent) of 28,000 individuals or 

7,000 residences, assuming four people per residence. 

 Simultaneously serving that many people would require equal numbers of phone lines 

and staff. Such a capacity would be prohibitively expensive and impractical. Mass media 

messages and the Emergency Alert System would be better at addressing the most 

immediate concerns and needs of the public. 

 However, trying to accommodate that call volume over several days may be more 

realistic and practical, as people will naturally form questions and concerns over time as 

they process basic event information from media coverage and experience difficulties 

related to the event. Setting the event length from 1 to 5 days while keeping the call 

center operating for 18 hours each day (for example, from 6:00 a.m. to midnight, when 

most people are likely to call) estimates the staffing and phone lines required for handling 

the 1 percent call volume. The tool set is limited to assume that calls are equally spread 

over the duration of the event, but it does identify the relative numbers of staff and phone 

lines needed over time: 

Event Duration (Days) 1 2 3 4 5

Average Calls/Day 28,000 14,000 9,333 7,000 5,600 

Staffing (FTE) 354 181 123 93 76 

Phone Lines 401 213 148 116 95 

*These calculations assume that each caller speaks with an agent for an average call length of 293 

seconds, including after-call activities. 

 Operating such a call center is much more than just people and phone lines. It also 

takes facilities, technology and management experience for it to operate well. Again, the 

HEALTH Tool Set can help estimate costs for capital expenses (facilities, furniture, 

training, etc.) and technology expenses (computers, telephones, phone switches, etc.). If 

25 
an agency is starting without much infrastructure, the costs to build a call center can be 

substantial. The agency may find that unless it is going to operate such services 

continually, investment of such funds may be impractical. The HEALTH Tool Set also 

has a Surge Options Matrix—a series of questions to help users decide whether to 

develop a call center capacity or to seek other alternatives. 

If a particular agency could not handle this demand, who else in the community 

could? 

 There are usually a variety of call centers in any community that provide services 

such as customer relations and technical support—some may even be health related. 

These facilities may have the requisite capacity to handle large call volumes during an 

emergency, but if they are not involved in health services, they may lack staff who can 

handle health-related calls. It may be possible to develop partnerships with these nonhealth call centers for the use of their facilities during emergencies; however, staff may 

need to be supplied. Many other issues would need to be resolved in such arrangements: 

• Under what circumstances would the facility be available? Would that access be 

guaranteed? Would there be any limits on how long the facility could be used for 

a response (days, weeks, months)? 

• Would the facility have all the requisite equipment for the planned response 

capability? If not, could that equipment be stored onsite for when needed? If 

equipment is installed before an event, could the facility use it for their operations 

in the meantime? 

• Would there be opportunities for those expected to staff the center during an 

emergency to practice call handling before an event? Would they have access to 

that facility for such practice? Could there be periodic exercises to test the ability 

to mobilize resources and staff the facility? 

• Would the facility’s employees (since they are familiar with call center 

operations) be a potential staffing pool for a response? If so, could they be trained 

beforehand in how to handle health related calls? Would they be paid to 

participate in the response or would they be volunteers? What are the liability 

issues for using facility staff in either circumstance? 

• Are there any costs for facility “readiness” for a response? What would the costs 

be for using a facility during an event (direct cost reimbursement or daily usage 

fee)? For a prolonged response, would there be economic impacts to the facility’s 

business operations, and who would be responsible for those impacts? 

 This is just a partial list of issues that would have to be resolved. Many of these issues 

may not be a factor for those considering using community health call centers for 

providing response capabilities during an event. These call centers can include poison 

control centers, nurse advice lines, drug information centers, and public health hotlines, 

26 
among others. Since these community call centers deal with health-related calls every 

day, it should be easier for them to provide the needed capabilities under contract or in 

partnership with public health and public safety agencies. 

 It is likely that established health call centers would need additional resources only in 

equipment and staffing to provide services that are similar to those that they provide 

daily. In addition, these call centers have established relationships with the community 

that could help gain public trust in information from such sources. It is generally easier to 

expand the breadth of services that a trusted health call center provides normally than to 

convert a non-health call center to provide services that it normally does not. 

 The objective of this project is to provide some guidance, strategies, and resources for 

both community health call centers and the agencies planning for emergency event 

responses so that each understands how they can successfully develop the capabilities 

needed to meet the expected public needs for information and support. 

27 
28 
Chapter 4. Results 

 AHRQ assigned us five primary tasks to develop this model for adapting community 

health call centers to support outpatient health care and monitoring in a major health care 

crisis. We anticipate that this model will integrate with other community efforts by a 

variety of response agencies to address the specific needs of the public in certain health 

emergency scenarios. The goal of this project is to provide community health call centers 

with a tested model for responding to a health emergency and the resources to help 

inform and support the public.

1) Establish an advisory panel of subject matter experts 

to supplement our expertise and provide assistance 

and guidance. 

 We convened a national advisory panel of 13 subject matter experts (Table 1) that 

met at three advisory panel meetings held in Washington, DC. Panelists had backgrounds 

and experience in: 

• Public health and epidemiology. 

• Emergency preparedness planning, responses, and exercises. 

• Emergency call center services. 

• Nurse advice/triage and health decision algorithms. 

• Poison control centers and medical toxicology. 

• Health informatics. 

• Data and voice technology. 

• Victim services and mental health counseling. 

• Risk communication. 

• Law and public policy. 

29 
Table 1. Participating Subject Matter Experts 

Subject Matter Expert Agency 

David Pote, RS, REM San Luis Valley, CO 

Stephen P. Teret, JD, MPH The Johns Hopkins University Bloomberg School of Public Health 

Jane Shunney, RN Clark County Health District, NV 

Alicia Cronquist, RN, MPH Colorado Department of Public Health and Environment 

Diane J. Skiba, PhD, FAAN, FACMI University of Colorado Health Sciences Center 

Tracy Volkman, REHS Denver Public Health 

Robin Fudge Finegan, MA, MNM Finegan Flannigan and Associates 

Rocco Casagrande, PhD Gryphon Scientific, LLC 

Les Mortensen LVM Systems 

Thomas Glimp, MD, FAAEM Medcor, Inc. 

Rick Jones, ENP National Emergency Number Association 

Edward P Krenzelok, PharmD, FAACT, 

DABAT Pittsburgh Poison Center, Children's Hospital of Pittsburgh 

Donald M. Vickery, MD Demand Management Consultant 

 The panelists represented agencies and fields that were considered crucial to 

community and national response planning as it relates to community health call centers. 

They helped in reviewing our objectives, selecting appropriate disaster scenarios, and 

reviewing concepts for model and application development. Once application prototypes 

were developed, the panel reviewed exercise results and provided suggestions for 

improvement and exportability. 

 In addition, we invited representatives from several key Federal agencies and the 

American Red Cross to participate in panel meetings and the final presentation (Table 2). 

These representatives educated the panel and core team members about other Federal 

response efforts underway and how this project would best be able to integrate or support 

those projects. Agency representatives are listed in the table below. 

30 
Table 2. Participating Federal Agency Representatives 

Representative Agency 

Sally Phillips, RN, PhD 

AHRQ Public Health Emergency Preparedness 

Research Program 

Tom Sizemore, MD 

Department of Health and Human Services (HHS) Office 

of Preparedness and Emergency Operations 

Ann Knebel, RN, DNSc, FAAN HHS–Office of Preparedness and Emergency Operations

Ann E. Norwood, MD HHS Office of the Secretary 

Daniel Dodgen, PhD 

Substance Abuse and Mental Health Services 

Emergency Coordination 

Richard Hatchett, MD National Institute of Allergy and Infectious Diseases 

Suzi Gates, MPH 

Centers for Disease Control and Prevention (CDC) Office 

of Communications 

Carol Simon, BSN, PharmD 

CDC Coordinating Office for Terrorism Preparedness & 

Emergency Response 

Charles Magruder, MD, MPH CDC Information and Knowledge System Branch 

Dale Nordenberg, MD CDC National Center for Infectious Diseases 

Ellen Morrison 

Food and Drug Administration Office of Crisis 

Management 

Carol Hollis American Red Cross Emergency Coordination 

Dee Yeater American Red Cross Health Services 

Rick Davis American Red Cross Emergency Communications 

Dennis Atwood 

Department of Homeland Security Metropolitan Medical 

Response System 

2) Develop scenarios for mass health emergencies, 

including chemical, biological, radiological, nuclear, and 

explosive (CBRNE) events, and decide which ones 

provide the best opportunity for homemanagement/shelter-in-place strategies.

 We used the Department of Homeland Security’s National Planning Scenarios to 

assure consistency with other preparedness and response efforts.14 These 15 scenarios do 

not cover all possibilities for health emergencies; however, they do include a wide 

spectrum of disasters that communities could face. Although other potential disaster 

scenarios have been used for response planning, these 15 have been developed in a very 

structured manner and with participation of numerous Federal agencies. Using these 

scenarios will provide a common framework for sharing best practices and strategies. 

 We reviewed all 15 scenarios and determined the ones that could best benefit from 

the potential response capabilities of community health call centers. The six response 

capabilities that were assessed include: 

31 
• Health information. 

• Disease surveillance. 

• Triage/decision support. 

• Quarantine/isolation support. 

• Outpatient drug information/adverse event reporting. 

• Mental health assistance/referral. 

 We developed a matrix that lists each scenario and the expected casualties, 

infrastructure damage, and evacuations/displaced persons as presented in the executive 

summary for that scenario (see Appendix 1). We also provided the recommendations for 

evacuations, sheltering, and victim care strategies from the activated mission areas listed 

in the document. We determined which of the six potential response capabilities would 

be appropriate or practical for community health call centers to provide in each scenario. 

Each capability was then graded based on our experiences and the anticipated response 

needs of a community during such a disaster scenario using the following scale: 

• Capabilities that correspond best with expertise of health call centers and the 

expected response needs of a community. 

• Other capabilities that correspond with the expertise of health call centers and the 

expected response needs of a community. 

• Capabilities that may exist in health call centers though there may not be the 

response need in a community. 

• Capabilities that health call centers would need to refer to more appropriate 

resources within a community. 

• Capabilities that are not well-suited to community needs for this scenario. 

• Primarily a community response capability with which health call centers would 

need to integrate. 

 The scenario matrix indicates that a health call center’s capability to provide health 

information most frequently corresponds with the expected response needs of a 

community. The strongest association for this call center capability and community need 

occurs with the biological scenarios. However, providing health information would also 

be of benefit in almost all scenarios: nuclear, radiological, chemical, and natural 

disasters. For the remaining five call center response capabilities, the strongest 

associations with perceived community needs seem to correspond best with the 

32 
biological scenarios. Conversely, a technologically centered cyber attack seems the 

“weakest” scenario for benefiting from most of the response capabilities of a health call 

center. 

 Therefore, we decided to focus our model development on the biological scenarios 

since they involve large health impacts, have the potential for many “worried well,” and 

could benefit from home management of illness and sheltering in place strategies, and 

because community infrastructure could be expected to remain intact so that call centers 

would likely be able to operate. We determined, in conjunction with the advisory panel, 

that four of the biological scenarios afford the best opportunity to involve most of the 

potential response capabilities for community health call centers: 

• Biological attack – aerosol anthrax. 

• Biological disease outbreak – pandemic influenza. 

• Biological attack – plague. 

• Biological attack – food contamination. 

 In addition, we developed potential health call center capabilities for each of the four 

selected National Planning Scenarios (Appendix 2), which provide specific suggestions 

for each of the six health call center response capabilities. This document can assist call 

centers and public health agencies in determining the expected health needs for each 

scenario and selecting those for which they may want to plan. 

 This is not to imply that health call centers could not play an important role in 

responses to other scenarios, but rather that developing tools related to the response 

needs of these biological scenarios afforded the greatest potential for success. As the 

scenario matrix suggests, the resultant applications and response strategies could then be 

assessed for applicability or modification to address the response needs of other 

scenarios. For example, a surveillance application for influenza or plague reports could 

be adjusted to capture chemical or radiological agent illness reports. 

 Our assessment also suggested that, while mental health assistance and referral is a 

capability that all scenarios would likely need, it is primarily a community response 

capability in which health call centers would play a supportive role. Therefore, we did 

not specifically develop an application for this capability but instead considered how to 

incorporate sensitivity to community emotions, stress, and anxiety that a major disaster 

will exacerbate. 

33 
3) Research existing models, protocols, and algorithms; 

develop and implement a scenario-based model using 

poison control centers, nurse call lines, and similar 

centers. 

 To better develop our community health call center model and tools, we first 

researched available information on existing models, protocols, and algorithms for 

community communication strategies related to the four biological scenarios. 

 In the fall of 2005, we searched www.PubMed.gov (medical and scientific literature), 

www.Google.com (Internet), and www.CDC.gov (public health practice and guidance) 

Web sites to locate information. We used subject keywords (biological attack, disease 

outbreak, anthrax, aerosol anthrax, inhalation anthrax, plague, pneumonic plague, 

influenza, pandemic influenza, food contamination) in combination with each of these 

focusing keywords (surveillance, triage, quarantine, isolation, mental health, prophylaxis, 

side effects, adverse events, clinical algorithms). Results from these searches were 

reviewed to find existing models of call center strategies for community communication 

and support. 

 The searches revealed only limited results related to model development. We did, for 

example, identify many city and State public health department Web sites providing 

influenza vaccination clinic information that were searchable by using either city name or 

zip code (California15, Minnesota16, Georgia17, Massachusetts18). A few included a 

telephone information hotline as well (San Diego19, Oregon20). We did not locate any 

States using interactive automated telephone-based systems, but some did have either 

noninteractive recorded messages or a person on the line providing specific clinic 

location or general influenza information. Some Web sites simply forwarded the user to 

the CDC Web site for general influenza information. 

 A report by Cartter et al. described the Connecticut influenza hotline and how it 

conducted a vaccination survey during the 2004-2005 influenza season when there was a 

vaccine shortage. The hotline addressed questions from the public regarding vaccine 

availability, which groups were most at risk, and influenza symptoms in order to reduce 

inquires to physicians and local health departments. The authors suggested that State 

health departments consider a hotline to educate the public regarding influenza 

vaccination and to follow up with callers who were advised to receive vaccination in 

order to improve compliance.21

 A few reports were related to severe acute respiratory syndrome (SARS) surveillance 

strategies using telephones or call centers: 

• Toronto Public Health, in addition to providing SARS information to the public 

through their hotline, also used this resource to support the management of 13,291 

individuals who were placed in quarantine, mainly in their own homes. Of that 

34 
number only 0.1 percent were issued an enforceable quarantine order after initial 

noncompliance.2

 

 

• Kuhles reported using videophones to monitor seven suspected SARS cases and 

their close contacts. Afterwards, the videophones were used to monitor patients 

with active and latent tuberculosis. The videophones enabled local health 

department staff to visually assess the patient’s condition during each call.22

• Lee et al. reported on the experience in Taiwan of using quarantine to prevent 

transmission of SARS. From late February to mid June 2003, more than 131,000 

people were placed in quarantine for 10 to 14 days; most were placed in home 

quarantine during the months of April and May. Management of those in 

quarantine consisted of daily visits or telephone calls to review the person’s health 

status including temperature recordings and symptoms. The quarantine was 

considered very successful with only 0.2 percent fined for violation of quarantine 

rules.23

• Blendon et al. reported results of a survey conducted in four populations (Hong 

Kong, Taiwan, Singapore, and the United States) concerning attitudes about 

quarantine in a public health emergency. Respondents were asked if they 

supported the use of three preventive measures to control the spread of a 

contagious disease: requiring everyone to wear a mask in public, requiring 

everyone to have their temperature taken to screen for illness before entering 

public places, and quarantining people suspected of having been exposed to the 

disease. The percentage of people favoring any measures in any population 

ranged from 44 percent to 99 percent; the highest mean favorable response 

occurred for quarantine. However, support for all measures decreased 

significantly if the condition of arrest for refusing to comply was added. 

Respondents were also asked about their preferences for monitoring compliance 

during quarantine and were most in favor of a daily visit from a health official 

followed by periodic telephone calls. The least favored methods of monitoring 

were more intrusive measures such as periodic video screening, electronic 

bracelets, and stationed guards. In the U.S., more than 70 percent of respondents 

favored home quarantine for themselves and their family as opposed to a separate 

facility.24

 These results suggested to us that using the telephone to provide information and 

support disease control measures like home quarantine would likely be favorably 

received by the public and would assist public health agencies in the management of such 

efforts. We therefore proceeded with the use of the HELP model as a platform for a wide 

range of call center based health information strategies on which we could explore the 

use of an Interactive Response (IR) system to automate certain of those functions to 

better handle surges. 

35 
We developed tools for the five response capabilities mentioned earlier: 

• Health information. 

• Disease/injury surveillance. 

• Triage/decision support. 

• Quarantine/isolation support. 

• Outpatient drug information/adverse event reporting. 

 This section will review each response capability and propose scenario-based 

strategies for using community health call centers, including: 

 

• Significance of the response capability. 

• Applicability of the capability to the National Planning Scenarios. 

• Current examples of the capability. 

• Range of technology to support the capability. 

• Staffing required to deliver the capability. 

• Our proposed resources and strategies for the capability. 

Health Information 

 Significance. Use of health call centers could greatly augment mass risk 

communication messages and help alleviate surges to health care systems. Our 

experience and that of others has shown that incidents that generate public concern 

usually require robust mass risk communication coupled with hotlines or other forums to 

assist those with further needs.5 

 Scenarios. Of the 15 National Planning Scenarios, we identified applicability for this 

health information capability in all scenarios, with the best association of health call 

center expertise and community need for Aerosolized Anthrax, Pandemic Influenza 

Outbreak, Plague Outbreak, and Food Contamination. 

 Current Examples. Current examples of health information capabilities include 

those provided by poison control centers, nurse advice lines, drug information centers, 

many public health agency hotlines (often single issue focused or developed ad hoc to 

address a certain event), and our HELP program. 

36 
 Technology. Basic telephone technology is required to provide health information 

capability and could consist of a single phone line with a recording or a live agent. 

Accommodating larger call volumes requires additional phone lines, a telephone switch 

that can support simultaneous announcements, automated call distribution, call 

management software, and even additional equipment, such as an IR system to allow 

callers to retrieve information by voice or by touch-tone entries. The HEALTH model 

report describes much of the technology that an advanced call center that expects to 

handle significant call volume should consider.5 

 Staffing. Delivering health information requires trained information providers—

individuals who have been trained in customer service, operating telephones and other 

equipment, and the topical content. Clinicians are not required (and would be 

overqualified) for this capability unless a call center is being considered for providing 

assessment or management of a caller’s health concern or medical condition. 

 Proposed Resources. Appendix 3, Suggested Elements for Public Health 

Information and Decision Support Hotlines, offers instructions that a community health 

call center can use to develop health information capabilities that are similar to the HELP 

program. The model describes the essential components for developing a standardized 

response capability and provided us with the platform onto which additional capabilities 

could be added to support outpatient health care and monitoring during public health 

emergencies. This model for responding to public health events includes providing 

consistent and accurate information, collecting and maintaining structured data to 

characterize events and responses, and developing capability and capacity to adapt to 

other public health emergencies. Issues that are important to the creation of standardized 

responses are call-handling procedures, call center infrastructure/technology issues, 

creation of toll-free lines with up-to-date recordings, integration of related Web sites, 

training for information providers, defining referral procedures, quality control and 

quality assurance practices for maintaining consistent and accurate information delivery 

and reporting protocols. 

 We strongly urge a call center attempting to provide health information during an 

emergency to do so in cooperation with the public health authority that is, by statute, 

responsible for coordinating health and medical services in response to public health and 

medical care needs following a major disaster or emergency. Coordination with the 

health authority will help ensure overall consistency with other response measures. 

Figure 3 shows the process that we used to draft, review, and approve health information 

content. The messages on various health topics in some of the applications in this report 

were developed in concert with State health department epidemiologists. They should not 

be viewed as absolutes, and any call center planning to use the message contents should 

first have them reviewed by its own public health agency. 

37 
Figure 3: Checklist for Developing Health Information Content 

1) Develop message or FAQ content. 

9 Determine topic. 

9 Determine question(s) to be addressed. 

9 Review available information. 

9 CDC Web site and printed materials. 

9 State/local health department Web sites and printed materials. 

9 Internet search engine (i.e. Google, Yahoo). 

9 Prepare draft questions and answers (keep wording at 3rd grade level 

and under). 

9 Submit drafts to State/local epidemiologists responsible for approval. 

9 Once approved, add information content as appropriate. 

9 FAQ: enter into searchable format with keywords, and load into 

system used to manage information resources. 

9 Message: record message and incorporate into call flow(s) where 

appropriate. 

9 Determine if need to translate content into other languages. 

2) Train staff on content, and monitor for consistent use. 

9 Use quality assurance/quality control methods to assure consistency 

among staff (case review, listening in, role playing). 

 We have developed two applications for providing automated information to callers, 

which is especially important in events that could generate increased call volumes that 

surpass a call center’s staffing capacity. The two applications were developed for use 

with an IR system so that callers can retrieve information using a touch-tone phone. Both 

ensure consistent and accurate information delivery: the same information is provided to 

every caller, every time. These applications are summarized below and described fully in 

Appendix 4, Developing an Interactive Response Tool. 

 POD Application. The CDC’s Cities Readiness Initiative program 

(www.bt.cdc.gov/cri/) recommends Points of Dispensing as a key element of readiness 

and response. This IR application will provide inbound callers with locations for drug 

dispensing sites in their county based on the caller’s zip code. The caller can choose 

between English and Spanish. The application also can provide an individual message for 

each zip code within a county to allow for relaying customized information. Finally, the 

application can report on how many callers select each message option. 

 FAQ Library Application. The FAQ Library Application can disseminate health 

department-approved, up-to-date, consistent, and accurate information to the public and 

health care providers. This IR application allows callers to navigate through a library of 

FAQs to retrieve information relative to their concern. Callers can choose to speak to an 

information provider. The information providers use the same FAQs to answer caller 

questions. The application provides reports on how many callers selected each message 

option and on the zip codes entered. An initial bulletin announcement can be activated to 

38 
provide emergency or seasonal information prior to callers being prompted for their zip 

code. 

 Although these applications were both developed for use with an IR system, they 

could be used without such technology. The call flows, decision trees, and message 

scripts could be used without technology to guide call center staff in how to handle calls 

and what information to provide. Or these applications could be used with other 

technology such as recordings and announcements to assist call center staff in managing 

higher call volumes. Both applications could be adapted to other scenarios than those for 

which they were originally designed. The POD application could be modified to provide 

any information to be delivered based on a zip code designation for such events as 

evacuations, sheltering in place, snow cancellations, or mass vaccinations. The FAQ 

application could have any topics loaded into it for callers to retrieve. 

Disease/Injury Surveillance 

 Significance. Call centers that collect any health data could contribute to surveillance 

systems for reporting illness/injury (situational awareness), for detection of sentinel 

events, or for emerging health threats. Some health call centers may already analyze their 

own data to characterize their patient populations or to identify health issues as they 

emerge. Others may not realize the value of their data as it relates to a public health 

agency’s need for disease and injury surveillance. 

 Scenarios. Of the 15 National Planning Scenarios, the one with the best association 

between health call center expertise and community need for this capability was 

Pandemic Influenza Outbreak, though almost all the other scenarios could benefit from 

using call centers to capture health data related to disease or injury surveillance. 

 

 Current Examples. A current example of a health call center contributing to disease 

surveillance is the HELP program and its experiences in identifying sentinel events such 

as hantavirus and tuberculosis cases, as well as supplying weekly geo-coded data on selfreported cases of influenza/pneumonia, mold exposures, and WNV-related dead bird 

reports. The American Association of Poison Control Centers also transmits data related 

to toxic substance exposures to the CDC’s BioSense program 

(www.cdc.gov/biosense/files/BioSense_Overview_Handout9-06.pdf), whose objective is 

to improve the Nation’s capabilities for disease detection, monitoring, and real-time 

situational awareness through access to existing data from health care organizations 

across the country. Some individual poison centers25 and nurse advice lines26 have also 

analyzed their data as part of syndromic surveillance programs. Drug information centers 

that collect information on adverse drug events related to medical products contribute 

data to FDA’s MedWatch reporting program (www.fda.gov/medwatch/). 

 Technology. Besides the call center technology mentioned previously for providing 

health information capability, a data collection system would be required for a disease 

and injury surveillance capability. Such data collection systems could range from forms 

or databases in software applications such as Microsoft Excel and Access that are 

39 
designed to capture specific data to more advanced data collection applications that are 

marketed to health call centers for managing their operations. Statistical analysis 

capabilities would require the use of commercial software applications such as Microsoft 

Excel, SAS, or SPSS. Call centers could perform analysis themselves, or they could 

provide the data to public health or other agencies for analysis. 

 Staffing. In addition to information providers who are trained to collect data, 

statisticians and/or data analysts would be needed to perform and interpret analyses. 

 Proposed Resources. Appendix 3, Suggested Elements for Public Health 

Information and Decision Support Hotlines, discusses structured data collection and 

public health partnering for developing disease surveillance capabilities. The POD and 

FAQ library IR applications described above that provide health information also can 

collect zip code data that could be useful in surveillance, such as which zip codes are 

entered for callers seeking information related to WNV in humans or for callers seeking 

antibiotic medication dispensing locations. 

Triage/Decision Support 

 Significance. Health call centers can assist with triage and decision support for health 

concerns. These support services can alleviate surges to health care facilities and thereby 

reduce associated health care costs that occur with hospital visits. 

 Scenarios. Of the 15 National Planning Scenarios, the Pandemic Influenza Outbreak 

had the best association between health call center expertise and community need. 

However, almost all the other scenarios could benefit from using call centers to assist 

with the triage and management of disease or injury, especially in preventing the 

“worried well” from overwhelming health care facilities. 

 Current Examples. Current examples of call center capabilities with triage and 

decision support include poison control centers that triage poisoning and provide 

exposure management support and nurse advice lines that triage symptoms and provide 

symptom/disease management support. The fact that these call center types provide 

services by licensed professionals (nurses, pharmacists, physicians) lends public 

credibility to the capabilities. Research has shown that a nurse advice line can affect 

patient behavior and facilitate the most appropriate use of health care resources.10 Poison 

control centers save an estimated $6.50 for every dollar invested in their operation.27 By 

preventing unnecessary emergency department visits and hospital admissions through 

poisoning management support and consultations, they reduce use of expensive 

diagnostic testing, inappropriate use of antidotes, and lengthy hospital admissions. 

Therefore, using these same call centers in health emergency situations should result in 

the same efficiencies and cost effectiveness outcomes. 

 The HELP program does not normally provide symptom, disease, or exposure 

management and, therefore, does not need to be staffed by clinicians. It does, however, 

provide disease and symptom information that supports the public in making informed 

40 
decisions about their health care. For normal daily operations, HELP is staffed with 

trained information providers who deliver scripted information and refer callers requiring 

exposure, symptom, or injury triage, as well as management support, to appropriate 

resources such as a poison center, nurse advice line, or a health care provider. Another 

value of the HELP program providing health information to the public in an emergency 

event is preventing unnecessary calls to clinician-staffed lines and allowing them to 

appropriately handle medical triage and management support calls. However, the HELP 

program could be staffed with clinicians to provide triage or symptom management 

support for an emergency event, if needed. An example of this occurred when clinicians 

were needed to support a statewide smallpox vaccination program.28 

 Technology. In addition to the call center technology and the data collection systems 

mentioned previously, clinicians require proven and stable software programs. These 

programs should be secure and HIPPA-compliant, and they should include embedded 

triage and decision support algorithms; support for the necessary health, medical, and 

drug information; and appropriate documentation and storage of collected data, 

recommendations, and information. For information providers solely providing 

information that supports the caller in making an informed decision about their health 

concerns, the same call documentation is appropriate and beneficial. Call recording is 

essential, as it ensures quality assurance and quality control, supports staff training, and 

serves as a durable record of call content. 

 Staffing. Depending on the service provided, trained information providers and/or 

clinicians such as nurses, pharmacists, physicians, nurse practitioners, or physician 

assistants may be needed to staff the call center. 

 Proposed Resources. We are not proposing a specific resource beyond the delivery 

of health information by information providers to allow callers to make the most 

appropriate decision for their health concerns. However, we are suggesting that 

communities consider the clinical recommendations they would use in the event of a 

major health emergency that severely impacts the health care delivery system, such as 

pandemic influenza (Table 3). 

Table 3. Mean Estimates of Influenza Impact From National Planning 

Scenarios15 

Health Outcomes 15% GRA* 35% GRA* 

Fatalities 87,000 207,000 

Hospitalizations 314,400 733,800 

Outpatients Visit 18.1 million 42.2 million 

Self-care Ill 21.3 million 49.7 million 

*GRA = gross rate of attack; the percentage of US population with a clinical case of influenza. 

 A community may need to adjust standards of care in its planning for handling the 

increased patient demands from a pandemic or severe influenza outbreak. For more 

41 
information, review the AHRQ publication, Mass Medical Care with Scarce Resources: 

A Community Planning Guide (http://www.ahrq.gov/research/mce/). Health care delivery 

systems and health care providers need to consider how they would handle increased 

volumes of sick patients, many of whom will not necessarily benefit from direct 

evaluations, in the face of increased demands on limited health care resources. A health 

call center would need to ensure that its recommendations to callers were consistent with 

those of the rest of the health care delivery system and its health care providers. The 

following example includes some information that a call center may consider using as 

part of a home care management strategy. 

 Information for Patients. The language presented here is meant to be a discussion 

starter for communities to begin planning for handling the increased patient demands that 

could result from a pandemic or severe influenza outbreak. This language is not meant to 

be used as presented but rather, should be used by health care providers to strategize how 

they would handle increased volumes of sick patients, many of whom will not necessarily 

benefit from direct evaluations in the face of increased demands on limited health care 

resources. As part of such a strategy, clinical care algorithm dispositions may need to be 

reviewed and potentially revised. 

• Influenza is a viral illness that causes muscle aches and pains, as well as 

respiratory symptoms ranging from cough, fever, and sore throat to severe 

respiratory distress. 

• Almost everyone has experienced influenza at some point in their lives; it is 

most likely to occur in the winter when viruses are more easily spread from 

person to person. 

• The human strain of avian influenza is expected to result in more people 

having severe respiratory symptoms than is usual for other types of influenza. 

• Just as with other types of influenza, there is not any specific treatment 

available. 

• In most cases, rest, fluids, and over-the-counter medications that help to lessen 

your symptoms are all that is needed. 

“You have indicated that you have some of the symptoms of influenza but are not 

experiencing the most severe symptom, respiratory distress or breathing 

difficulty. That is very good. It is likely that your symptoms will not worsen, and 

home care will be all that is required. Because there is no specific treatment for 

influenza, medical care is only a benefit for those who are in severe respiratory 

distress and require assistance in breathing. Therefore, unless you are having 

substantial difficulty in breathing, there will be no benefit in going to the hospital 

or the doctor’s office. Another advantage of staying home is that you avoid the 

spread of influenza that occurs in these settings. You could be exposed to 

influenza or, if you have influenza, you may expose others to the disease.” 

42 
Home health care measures should include: 

• Rest. (Help your body’s immune system to fight off the flu by getting lots of 

rest.) 

• Fluids. (Drink plenty of fluids to keep hydrated.) 

• Over-the-counter medicine. (Pain relievers, decongestants, and fever reducers 

can help lessen many influenza symptoms and give you some relief.) 

• Temperature. (Monitor your temperature periodically.) 

• Food. (Your body needs food to replenish the energy used to fight off 

influenza.) 

Monitor yourself. (If any of these symptoms occur, contact us or seek medical 

care): 

• Shortness of breath or difficulty breathing. 

• Confusion or seizures. 

• Inability to retain fluids and keep hydrated. 

If your health status changes, you can always call us back to be re-evaluated and 

get further recommendations. 

 As an example, Figure 4 below contains a listing of possible patient dispositions that 

clinical care algorithm software programs can recommend when used by nurse advice 

lines. Many of these recommendations are conservative and tend to refer patients to 

health care providers for in-person clinical evaluation. This conservative approach helps 

to assure that potentially significant medical conditions receive the appropriate diagnostic 

testing and clinical followup. However, in a severe health emergency such as pandemic 

influenza, community health care resources could be overwhelmed and require more 

judicious use of limited health care resources. In such a scenario, alternative dispositions 

and recommendations may be needed, especially those supporting home care 

management, if appropriate, to help alleviate demands on the health care delivery system. 

Another consideration is directing patients with non-influenza signs and symptoms to 

specific facilities to reduce the potential for disease spread among patients. 

43 
Figure 4: Patient Dispositions From a Clinical Care Algorithm Software 

Program That Many Nurse Advice Lines Would Use 

Nurse Advice Line Recommendation Pandemic Event Recommendation 

-Homecare 

-Provide home/self care 

-Instructed in self care 

-Information or advice only Consider revising these 

dispositions as part 

-Homecare with follow up PRN of community pandemic 

influenza response measures; 

-Homecare with appt in 2 weeks explore alternatives such as 

-Call HCP within 24 hours increasing homecare guidance 

-Call or see HCP within 2 weeks to reduce referrals to other 

-Call or see HCP within 24 hours HCPs. 

-Call or see HCP within 3 days 

-See HCP within 72 hrs 

-See HCP within 24 hrs 

-See HCP within 4 hrs These dispositions require more 

-Care required within 4 hrs immediate action and should 

Activate EMS 911 continue to be directed to 

-See in ED immediately appropriate HCPs; consider 

specific locations to direct these 

patients to. 

*PRN= according to need (from the Latin "pro re nata"); HCP=health care provider; EMS=emergency 

medical system; ED=emergency department. 

Quarantine/Isolation Support 

 Significance. Health call centers can assist with monitoring and supporting patients in 

quarantine and isolation. Several reports are published of managing and monitoring by 

telephone those placed in quarantine for SARS.2,21-23 Other research has indicated public 

support of the use of quarantine to control disease and for monitoring the status of those 

in quarantine by telephone.24 The Seattle/King County Advanced Practice Center offers 

a toolkit for “Planning & Managing for Isolation & Quarantine”

(www.isolationandquarantine.com) to assist in proactively planning for and managing the 

implementation of large-scale isolation and quarantine. They suggest establishing a 

public health hotline and call center for public inquiries and caution: 

“In an emergency situation, focus on your expertise. Do not try to reinvent 

yourself or your organization by taking on something outside of what you 

know. Admit where your expertise ends and find the community 

organizations with whom you can partner to acquire their expertise for the 

response.” 

44 
 Community partners such as health call centers are well suited to assist with 

monitoring or contacting those in quarantine and isolation, especially if they had 

appropriate guidance and resources. 

 Scenarios. Of the 15 National Planning Scenarios, only the two scenarios involving 

infectious diseases, Pandemic Influenza Outbreak and Plague Outbreak, would 

potentially require the use of quarantine and isolation as disease control measures and 

could benefit from using call centers. Though SARS outbreak is not one of the DHS 

scenarios, SARs and other infectious diseases would require planning and response 

capabilities similar to those for influenza and plague scenarios. 

 Current Examples. Telephones were used to monitor those in quarantine in the 2003 

SARS outbreaks in Toronto2

 and Taiwan.23 Public health departments around the 

country currently use quarantine and isolation measures with tuberculosis patients, and in 

Nassau, NY, they use videophones to monitor patient status and compliance.22 The CDC 

Division of Global Migration and Quarantine also has field stations at certain airports 

when suspected infectious persons are identified on airplanes inbound to the United 

States.29 

 Technology. Basic telephone technology is required to initiate periodic calls to those 

assigned to home quarantine by public health agencies. Simply having a staff person 

place calls on a single phone line can attain this response capability. As larger numbers of 

people are placed in quarantine, additional personnel and phone lines are needed to 

manage them. As the number of those in quarantine reaches into the thousands (as in the 

Toronto and Taiwan experiences), an IR system would be beneficial in automating those 

periodic calls, recording those who answered and their reported health status, transferring 

people who needed further attention to staff, and reporting those that did not answer 

within the specified attempts for followup. 

 Staffing. Trained information providers could manage quarantine monitoring and 

provide assistance and referrals according to established public health agency protocols. 

Agencies like the American Red Cross could be used to help support those in quarantine 

by delivering food or other supplies. 

 Proposed Resource. We have developed the Quarantine/Isolation Monitoring 

Application to support quarantine and isolation monitoring strategies, which would use 

an IR system. The application would free staff to handle only callers needing further 

attention, such as those developing symptoms or those who could not be reached 

(potentially noncompliant with quarantine). In the Taiwan SARS experience, 113,132 

people were quarantined with only 133 (0.1 percent) having suspect or probable disease 

diagnosis. Of the 108 who were tested, only 21 were SARS positive via polymerase chain 

reaction. Only 286 persons (0.2 percent) were fined for violation of quarantine. This 

demonstrates that less than 1 percent of those in quarantine needed much more than 

periodic monitoring. Automating much of that monitoring with a tool such as the QI 

45 
Monitoring Application could be very useful. This application is summarized here and 

fully described in Appendix 4, Developing an Interactive Response Tool. 

 QI Monitoring Application. The QI Monitoring Application has the capability to 

automatically place outbound calls to individuals in home quarantine/isolation to assess 

their current health status. The application calls the quarantined person at specified times, 

provides messages in English or Spanish identifying the purpose of the call, requires the 

person to select an option that reflects his or her current health status (using temperature 

as a decision point), transfers him or her to an information provider for assistance if 

indicated, and provides information about who to call if he or she needs assistance before 

the next monitoring call. 

 Though this application was developed for use with an IR system, it could be used 

without such technology. The call flows, decision trees, and message scripts could guide 

call center staff in how to handle calls and what information to provide. The application 

could be adapted to other scenarios that might require telephoning individuals, such as 

sheltering in place strategies or followups to vaccinations. Public health agencies may 

want to develop referral protocols and guidance for call center staff in handling situations 

in which a quarantined individual needs food, medication, or financial assistance. 

Outpatient Drug Information/Adverse Event Reporting 

 Significance. The CDC’s Cities Readiness Initiative program requires that 

participating cities prepare plans for mass prophylaxis with Strategic National Stockpile 

assets. Depending on the potential for exposure, this could result in thousands or millions 

of people being dispensed antibiotic medications. Health call centers can support these 

efforts by providing information about the incident and the supplied medications, as well 

as collecting any potential adverse event reports. 

 Scenarios. This response capability primarily is applicable for the two National 

Planning Scenarios involving agents treated with antibiotics: Aerosolized Anthrax and 

Plague Outbreak. Other scenarios that involve either mass vaccinations (Pandemic 

Influenza Outbreak) or wide-scale use of medications for treating radiation exposure 

(Nuclear Detonation, Radiological Dispersal Devices) or potentially Food Contamination 

may also require this response capability. 

 Current Examples. The HELP program has collected adverse event information 

regarding smallpox using the Vaccine Adverse Event Reporting System (VAERS) form 

fields (vaers.hhs.gov/).28 In addition, drug information centers collect information for the 

FDA’s MedWatch reporting program (www.fda.gov/medwatch/), as well as handling 

drug information and identification calls. Poison control centers have much experience in 

handling drug identification calls, which comprise 61 percent of their non-exposure 

calls.9

 

 Technology. In addition to the call center technology and data collection systems 

mentioned previously, staff would require drug identification resources such as online 

46 
searchable databases such as Drugs.com (www.drugs.com/pill_identification.html) and 

RxList.com (www.rxlist.com/interact.htm) or commercial database IDENTIDEX System 

(www.micromedex.com/products/identidex/). MedWatch and VAERS form data fields 

could be incorporated into data collection systems or paper forms could be completed. 

 Staffing. Trained information providers could manage providing drug identification 

assistance to the public. Clinicians would be more appropriate for collection of adverse 

drug or vaccine event reports. 

 Proposed Resource. We have developed the Drug Information (DI) Application to 

support mass prophylaxis with antibiotic drug strategies using an IR system. The IR 

system application would assist callers in the identification of the drug they were given 

and provide them with information on how to take it and its potential adverse reactions. 

The application would allow public health agencies to concentrate on operating mass 

dispensing sites and allow health care providers to care for those who are ill. This 

application is summarized here and fully described in Appendix 4. 

 DI Application. The DI Application allows callers to identify medications based on 

the appearance of the antibiotic drugs that are being dispensed at POD locations during a 

public health emergency. The callers are given clear directions from menu messages and 

can repeat messages or drug descriptions. This application accommodates one language 

selection (English), but it could be modified for additional language selections. 

 Though this application was developed for use with an IR system, it could be used 

without such technology. The call flows, decision trees, and message scripts could be 

used without technology to guide call center staff in how to handle calls and what 

information to provide. The application could be adapted to other scenarios that might 

require mass administration of medications or vaccinations and to provide relevant 

information. 

Mental Health Assistance/Referral 

 Significance. Call centers providing health information and support will help to 

relieve anxiety and stress among the public, but some callers may need further assistance. 

Call center staff can assist these callers by referring them to community mental health 

resources. 

 Scenarios. Most of the 15 National Planning Scenarios will result in varying degrees 

of community fear, panic, anxiety, and even depression. 

 Current Examples. Countless suicide prevention and counseling hotlines currently 

exist and are run by trained mental health staff. The National Suicide Prevention Lifeline 

provides a 24-hour toll-free service that routes callers to crisis centers across the country 

(www.suicidepreventionlifeline.org/). Additionally, nurse advice lines are capable of 

handling patients with depression. Poison control centers regularly receive suicide and 

intentional harm calls. 

47 
 Technology. Besides the call center technology and the data collection systems 

mentioned previously, staff would require protocols and referral resources to access 

agencies providing counseling and mental health services. 

 Staffing. Information providers would not necessarily be trained in assessing mental 

health concerns but could adequately provide referral assistance with training. Clinicians 

trained in identifying mental health warning signals would be an integral resource for 

assisting such callers. 

 Proposed Resources. No specific resources are proposed. However, it is 

recommended that good risk communication principles be used for handling callers who 

are anxious or under stress.4

 Call center staff should be trained on how to handle calls 

from those under stress. The Kansas Department of Health and Education developed 

phone bank operator training that includes communications protocols, techniques, and 

role playing for a variety of health emergencies.30 The CDC also offers good disaster 

mental health resources (www.bt.cdc.gov/mentalhealth/). 

 It is recommended that call centers review the content of their recordings and FAQs 

to determine if they can be improved to reduce caller anxiety. Using a voice for 

recordings that is pleasant and that mentions appropriate reassurances such as “there will 

be adequate supplies of medications for everyone” will help to alleviate caller anxiety. 

Following unpleasant information with positive statements also can help in many 

situations. The Center for Risk Communication (www.centerforriskcommunication.com) 

provides information on communication methods for high concern, high stress, or 

emotionally charged issues based on behavioral-science research and practice. 

4. Develop a mechanism to test and evaluate the model 

with a local exercise. 

HELP Model Testing 

 The HELP model has been tested in more than 3 years of daily operations and 

response to several major health events. The HELP model has made it possible for us to 

provide consistent, accurate, and up-to-date information during bioterrorism exercises 

and public health emergencies in partnership with the Colorado Department of Public 

Health and Environment. HELP served as a proving ground for the implementation of 

some HEALTH concepts and strategies. Since its launch, the HELP program has 

continually developed as it responded to three major health events in Colorado: the 

deadliest WNV outbreak in the United States (2003), an influenza outbreak with early 

increased pediatric deaths (2003/2004), and an influenza outbreak during a vaccine 

shortage (2004/2005).26,28 The HELP program provides a model for disseminating and 

collecting information that, to date, has involved handling more than 75,000 calls related 

to several health events and outbreaks. 

 The first test of the HELP model occurred on the day the program began daily 

operations to support a WNV outbreak in Colorado. The service began answering 

48 
telephone calls at 7:00 a.m., and a press release announcing the first human case of WNV 

in the State occurred within the next few hours. State health department staff handled up 

to 1,000 calls regarding WNV the previous year (first year of the outbreak in the State) 

and expected several times that number during the second year of the outbreak because of 

its greater potential to result in human disease. However, the 12,500 calls over the next 3 

months were much more than expected. During the same period, human WNV cases 

surpassed 2,500, and human deaths totaled 47. Figure 5 depicts the average call volumes 

to HELP by hour of the day for the initial 7 weeks. During that time, call volumes 

averaged greater than 1,500 calls weekly and 220 calls daily, with peak call volumes of 

2,229 in 1 week, 524 in 1 day, and 178 in 1 hour. These call volumes accurately reflected 

the public’s demand for information, since all 96 channels (individual phone lines) 

dedicated to HELP were never all used at once. If that were to occur, additional callers 

would have received a busy signal, and we would have no means to determine the 

number of callers that could not get through. 

 The drivers for these call volumes involved both the status of the outbreak in the 

news each day (number of human cases and deaths) and the time of day that such news 

was disseminated by the media. As Figure 5 shows, hourly spikes in call volume were 

related to times of television newscasts, usually featuring the HELP toll-free phone 

number as part of the news crawler during updates. Therefore, we began to staff up for 

certain hours to better accommodate those volume surges. Staffing was usually limited to 

no more than four information providers at a time (the number that our funding from the 

State health department could support). Therefore, we used our initial announcement to 

relay the most requested information to alleviate a caller’s need to speak with staff. On 

average, 60 percent of callers listened to the recording and then terminated the call; the 

remaining 40 percent chose to remain on the line to speak with a staff person. This 

indicated to us that most callers were having their concern addressed with recorded 

information; otherwise they would have waited in queue to speak with a staff person 

(those waiting at least 6 seconds past end of recording were counted as those needing to 

speak with staff). It is important to keep announcements and recordings reasonable in 

length—less then 30 seconds and only sparingly up to 1 minute. The average of 60 

percent of callers having their concern addressed by the initial announcement has 

remained fairly constant over the last 3 years and for a range of health events. 

49 
Figure 5: Average Call Volume to HELP by Hour of the Day From July 22 to 

September 7, 2003 

0

200

400

600

800

1000

1200

1400

Number of Calls

7:00 9:00 11:00 1:00 3:00 5:00 7:00 9:00

Hour of Day

Hotline in morning newpaper

Morning TV news 

report 

featuring hotline

Afternoon TV news 

featuring hotline

 A strategy to assist those waiting in queue (which has at peak times reached up to 20 

callers with some waiting up to 30 minutes) is to cycle recordings of other frequently 

requested information in hopes of answering their questions while they are waiting. Many 

callers may get the information they require from those messages and no longer need to 

wait for assistance. This ensures that staff is assisting those who could not be helped 

easily by other means. The recordings can also refer callers to other information sources 

(such as the Internet) that they may opt to explore instead of waiting in queue or 

investigate first before calling back. We have found this most effective for inquiries about 

finding flu vaccination sites that could be easily located via a Web site. We typically 

cycle a recording stating, “We are experiencing high call volumes at this time; please 

consider calling back at another time,” for those in queue for more than a few minutes. 

Callers appreciate being kept informed about wait times, and technology that estimates 

queue times for callers can be used. 

 Assuming that messaging will work for a majority of callers, the number of staff and 

phone lines required to deliver information to the same number of callers can be 

50 
decreased. Here is the example that we used for calculating the resources needed to 

handle 28,000 callers depending on an event lasting from 1 to 5 days. 

Event Duration (Days) 1 2 3 4 5 

Average Calls/Day 28,000 14,000 9,333 7,000 5,600 

Staffing (FTE) 354 181 123 93 76 

Phone Lines 401 213 148 116 95 

The more callers who can be handled effectively with messaging strategies, the fewer 

staff and phone lines will be needed (good recorded messages can deliver information 

consistently and at a constant rate). 

Event Duration (Days) 1 2 3 4 5 

Agent Calls/Day 11,200 5,600 3,733 2,800 5,600 

Message Calls/Day 16,800 8,400 5,600 4,200 3,360 

Staffing (FTE) 146 76 52 40 33 

Phone Lines 174 95 68 54 45 

These calculations assume that only 40 percent of callers speak with an agent for an average call length of 

293 seconds, including after call activities; the remainder receive only messages/recordings. 

 Furthermore, by reviewing the concerns of callers speaking with staff, managers can 

determine if additional information should be added to the initial announcement, added to 

queue messages, or disseminated by the media or other sources in hopes of meeting 

demand without call center staff involvement. 

 All of these strategies for providing information to the greatest number of callers with 

limited resources greatly assisted us in handling the call volumes related to the 2003/2004 

influenza season. From November 17, 2003 to January 31, 2004, HELP received almost 

24,000 calls with peak call volumes of 7,145 weekly, 2,565 daily, and 345 hourly. During 

influenza seasons, many callers are trying to locate vaccination sites. We have 

successfully referred callers with Internet access to a Web site that they can easily use to 

find these locations in Colorado. We provided the direct URL address in our initial 

announcement to off-load many callers to this resource. Our information providers use 

the same Web site to assist callers in finding vaccination locations. The announcement 

content seemed to be effective, since those who waited to speak to staff for that reason 

prefaced it by saying “Sorry, I know I could use the Internet, but I do not have access.” A 

reporter doing an influenza story showed viewers how to locate vaccination sites using a 

computer on the air and assisted in reducing the overall HELP call volume almost 

immediately. Partnering with media can greatly assist in providing the most requested 

information and reducing the demand on hotlines during events. 

IR Applications Evaluation 

 It is the challenges we encountered with surges in demand to HELP that led us to 

develop and test the four IR applications. Appendix 4 provides the full details of the two 

51 
exercises used to evaluate the applications. This is a brief summary of those exercises and 

user feedback about improving each application:

• Quarantine/Isolation (QI) Monitoring. 

• Point of Dispensing (POD) Locations. 

• Drug Identification (DI). 

• Frequently Asked Question (FAQ) Library. 

 Quarantine/Isolation Monitoring. A prototype version of the QI Monitoring 

Application was tested in 12 rural volunteers who served as “isolation cases” in 

conjunction with an influenza vaccination exercise in October 2005. Data were collected 

in the volunteers and entered into the State health department’s Outbreak Management 

System. 

 The application was revised to reflect many of the user suggestions. In an exercise in 

May 2006, the revised and more fully developed QI Monitoring Application and the other 

three applications were evaluated in an urban user group consisting primarily of local 

health personnel from 10 counties. The goal of the second exercise was to test the ability 

of the four IR applications either to initiate contact and determine health status of those in 

quarantine or to effectively communicate key information to users calling in to the 

applications. 

 An issue realized from this exercise was that the application could not guarantee 

quarantine compliance. Even if someone answered the application during every calling 

period, there was no way to prevent another person from answering on behalf of the 

person in quarantine. Requiring entry of data to specific prompts like “last 4 digits of 

social security number” would not guarantee the identity of the person who answered, as 

almost any identifying information could be shared with another. Adding confirmatory 

prompts would make the application more complicated and could result in more people 

finding it difficult to use while being in compliance. Agencies using home quarantine 

strategies could consider certain qualifications for individuals to reduce undetected 

circumvention, such as requiring a land line (and not a cell phone) for contact and 

agreeing to have call forwarding features disabled. Therefore, it will be important to 

develop effective risk communication messages to the public and adequate support for 

those in quarantine to assure good overall compliance. Public health agencies will find it 

difficult to monitor individuals in home quarantine without strategies to reduce the need 

for staff. This application monitored up to 70 percent of quarantined persons 

demonstrating compliance with few personnel resources. The QI Monitoring Application 

(or some similar monitoring strategy) will permit limited staff resources to concentrate on 

obviously noncompliant individuals and those with additional needs or to manage the 

myriad of other response actions required in a health emergency. 

52 
 The second version of the QI Monitoring Application required the person answering 

the call to indicate their most current temperature reading as an objective means to 

monitor their health status. The public health departments helping to design this exercise 

believed that providing a thermometer to everyone in quarantine would be realistic and 

would help to identify those potentially developing signs of illness. Those selecting the 

option for a temperature reading of less than 100oF were considered well but also were 

given an option to select if they needed to speak to someone. Those selecting the option 

for a temperature reading equal to or greater than 100o

F or who indicated difficulty in 

taking their temperature were transferred to the HELP service for assistance. For testing 

results of the second version, see Appendix 4. 

 Concern was raised about whether this application could work for everyone, 

including the elderly and those with special needs. It was never our intention that the 

application could work for everyone, rather that it could work for most. It would be at the 

discretion of public health agencies coordinating quarantines to decide which individuals 

this application could assist in monitoring, thereby freeing resources to monitor those 

with additional or special needs. 

 Drug Identification (DI). The DI Application was tested to determine how effective 

such an application would be to assist the public in identifying antibiotic drugs that may 

be dispensed during certain public health events. The underlying challenge is that more 

than one brand of the same medication will be distributed to the same household during 

an emergency, and each may have a different appearance. For example, there are several 

manufacturers of doxycycline. Figure 6 contains the five different appearances of 100 mg 

doxycycline preparations that are contained in local and national stockpiles. This IR 

application offers a self-service alternative for callers to correctly identify drugs by type 

(capsule or tablet), shape, color, and imprints rather than calling their doctor or 

pharmacist. The application can identify, in addition to doxycycline, ciprofloxacin and 

Levaquin, which are other antibiotic drugs in many local stockpiles. 

53 
Figure 6. The Five Common Product Appearances for 100 mg Doxycycline 

Preparations 

 Product A Product B Product C 

 Product D Product E 

 

 Point of Dispensing (POD) Locations. The POD application was tested to determine 

if callers entering their 5-digit zip code could get correct POD locations in a self-service 

manner. This application could be modified to provide any zip-code-specific information 

and to ensure: 

• Consistent, accurate information based on zip code. 

• Collection of zip code data to characterize events (situational awareness—caller 

locations and the potential need for more media messaging). 

• Expanded capacity for handling surges since calls are handled without personnel. 

• Support for mass prophylaxis/immunizations, evacuations, or sheltering in place 

information. 

 Volunteers were assigned to evaluate this application by calling a toll-free number, 

entering a 5 digit zip code, and recording that zip code and the location they were given

on an evaluation form. We received all evaluations back (100 percent return rate), and all 

recorded the correct POD location for their entered zip code. 

 Frequently Asked Question (FAQ) Library. The FAQ Library Application was 

tested to evaluate the ability of users to navigate a library of messages and to obtain 

desired information. Our HELP program uses this library for handling callers after hours 

with great success by allowing self-service information delivery that is consistent and 

accurate. The application collects entered data to characterize the information needs of 

the public (the entered zip code for situational awareness—identifying public information 

54 
needs and where to target them). The application is able to expand capacity for handling 

surges and is capable of adapting to different events. 

 We met our overall exercise objectives and obtained excellent feedback to improve 

the tested applications. We also obtained important information on user acceptance for 

these IR applications. Although evaluations were mostly favorable for all four 

applications, the FAQ Application seemed more acceptable than the DI Application 

(perhaps because the latter concerned medications to be taken). The comments and 

evaluations of these applications should help public information officers in determining 

which ones may be acceptable for different events and in developing messaging 

strategies. These results also suggest areas for potential community outreach efforts for 

public health agencies to create a more informed public. One lesson learned is that the 

tools will be only as good as the information that is developed for them and how it is 

provided to the public. 

55 
56 
Chapter 5. Recommendations 

 In reviewing disaster scenarios for expected community needs, it becomes clear that 

we must help the public make informed decisions and care for themselves during severe 

health events. It is only with such strategies that we can hope to alleviate many potential 

demands on health care delivery systems and to accommodate those most in need. 

Assisting community health call centers to develop certain response capabilities is a part 

of that overall strategy. By employing the scenario-specific models and tools in this 

report, health call centers can increase their ability to support the following areas: 

• Health information. 

• Disease surveillance. 

• Triage/decision support. 

• Quarantine and isolation support/monitoring. 

• Outpatient drug information/adverse event reporting. 

• Mental health support/referral. 

 As this report has illustrated, four of the Department of Homeland Security National 

Planning Scenarios afford the best opportunity to involve most of the potential response 

capabilities for community health call centers: 

• Biological attack – aerosol anthrax. 

• Biological disease outbreak – pandemic influenza. 

• Biological attack – plague. 

• Biological attack – food contamination. 

 This does not imply that health call centers could not play an important role in 

responses to other scenarios; rather, that developing tools related to the response needs of 

these four biological scenarios affords the greatest potential for success. 

Poison control centers, nurse advice lines, drug information centers, health agency 

hotlines and local/State/Federal public health agencies were chosen as target audiences 

for the proposed scenario-specific models and applications because they are familiar with 

basic physiological responses to particular health threats due to the knowledge and skills 

gained in their area of health care. The professionals employed by such centers have 

experience in assessing patient status, problem-solving, and working with symptomatic 

patients over the phone. During any health emergency, these centers could continue to 

57 
provide regular services while expanding services to provide information and support 

related to the event. Much of the expansion of services could be handled with nonclinical 

staff. In this way, these centers could help with surge capacity and informing the public 

about health issues so that they can make informed decisions and care for themselves. 

 It seems wise to build on the expertise, credibility, and infrastructure of community 

health call centers when planning for emergency responses. Expanding their capabilities 

to inform, educate, and assist the public with their health concerns can free the health 

care delivery system to most effectively use their limited resources to provide care to 

those most in need. This approach can especially aid in handling those at low risk for 

injury or illness, who may have valid fears and concerns that, without a mechanism to get 

information, could lead them to overtaxed hospitals and health departments. 

 This does not guarantee compliance with official recommendations, but it should help 

the public to understand the risks or consequences of their choices. However, call centers 

that are embedded in the community and familiar to the public should be well received 

when providing support during a health emergency. 

 Call centers attempting to provide the community services described here should do 

so in cooperation with the public health authority that, by statute, is responsible for 

coordinating health and medical services in response to public health and medical care 

needs following a major disaster or emergency, or during a developing potential medical 

situation. This coordination with the public health authority will help to ensure 

consistency with other response measures. 

 The model and tools proposed in this report should be used as part of a 

comprehensive public information strategy that includes the use of: 

• Mass media to provide the public with information on preventive measures, home 

care management, and the appropriate time to seek health care services. 

• Community health call centers to reinforce mass messaging and to provide 

additional and more tailored information to individuals with questions and 

concerns, as well as to review these issues for their value as potential mass media 

messages. 

• Community health call centers to assist with outpatient (home care) monitoring 

and support, thereby helping to extend the reach of public health and health care 

systems into households. 

• Information collected by the call centers for situational awareness and disease 

outbreak management and control. 

 In an emergency, the public may view hospitals as “safe havens”—places to go for 

food, shelter, protection, and medical attention. However, particularly in the event of a 

transmissible infectious disease in which hospitalized patients represent the sickest 

58 
patients in the community, the concept of hospitals as “safe havens” may not be 

applicable. It may become more advantageous to manage and support the public in their 

homes with the assistance of health call centers. Community response planners will need 

to reinforce the concept of the home as a “safe haven” in their risk communication 

strategies and develop measures to support this concept in all aspects of their planning 

efforts. The possibility that some rudimentary degree of medical care will need to be 

delivered in the home setting should be included in public preparedness and education 

campaigns. 

Integration With Current Programs and Initiatives 

 The concept of using community health call centers, the proposed model, and the IR 

applications fits well within programs and initiatives at the State and Federal levels. Such 

response resources can easily fit within the National Incident Management System 

(NIMS) that provides a consistent nationwide template to enable all government, privatesector, and nongovernmental organizations to work together during domestic incidents. 

 By working within the NIMS framework and coordinating with local authorities, 

health call centers can ensure that the public receives accurate, coordinated information, 

helping to decrease panic and calls to emergency management. In the same manner, call 

centers can participate in ongoing operations, such as quarantine and isolation 

management or Strategic National Stockpile support, as part of the multi-agency 

coordination system, a combination of facilities, equipment, personnel, procedures, and 

communications integrated into a common framework for coordinating and supporting 

incident management. 

 Federal and State Governments have set forth several requirements to be prepared for 

a disaster, including pandemic influenza. In Homeland Security Presidential Directive 8: 

National Preparedness, there are 36 essential capabilities on the Target Capabilities List 

(TCL) that various levels of government should develop and maintain.31 Among those 

TCLs is the requirement to strengthen medical surge and mass prophylaxis capabilities. 

Included in the National Preparedness Goal is supporting medical target capabilities for 

medical surge, such as isolation and quarantine.32 The proposed model and IR 

applications provide support for these efforts by allowing residents to identify and locate 

their point of dispensing (POD) location for mass prophylaxis and providing a 

mechanism to track and monitor patients in isolation and quarantine in order to assist 

public health agencies. 

 The State of Colorado, like many others, has a quarantine and isolation component in 

its pandemic influenza plan. The Pandemic Influenza Annex to the Colorado Department 

of Public Health and Environment Internal Emergency Response Implementation Plan 

gives the authority to isolate or quarantine persons, groups of people, or buildings in 

Colorado, and at the recommendation of the Governor’s Expert Emergency Epidemic 

Response Committee, to limit or close public gatherings and restrict the movement of 

people.40 Containment strategies range from those affecting individuals (e.g., isolation of 

patients) to measures that affect groups or entire communities (e.g., monitoring of 

59 
contacts, cancellation of public gatherings). Guided by the current epidemiological data, 

State and local public health officials will implement the most appropriate of these 

measures to maximize the impact on influenza transmission and to minimize the impact 

on individual freedom of movement. The HELP program is included in the plan as a 

means to gather surveillance data for situational awareness and to support efforts to 

monitor those individuals placed in isolation or quarantine. Using the proposed IR 

applications will aid in providing this response capability. 

Public Health Communications and Education 

 The National Association of County and City Health Officials has some timely 

recommendations to prepare for pandemic influenza. First is to engage the community 

and bring all stakeholders together in a way that makes sense. An essential piece to 

preparing any community for a public health emergency is involving stakeholders in the 

planning. Community members need to be heard, and if they feel that their views are not 

only being considered but also incorporated into the planning process, they will be more 

likely to support whatever plan is created. Second is to empower people to do their own 

planning. Third is to establish excellent lines of communication, the key to education 

about and awareness of any public health issue. These recommendations support the 

concept of health call centers and their use of IR technology to communicate with the 

public: 

“Dissemination and sharing of timely and accurate information with the health 

care community, the media, and the general public will be one of the most 

important facets of the pandemic response. Advising the public in actions they 

can take to minimize their risk of exposure or actions to take if they have been 

exposed, will reduce the spread of the pandemic and may also serve to reduce 

panic and unnecessary demands on vital services.”33

 The National Governors Association also stresses the importance of public 

communications in order to build a trusted relationship with the response community and 

enhance the public’s understanding of pandemic influenza. Responses to pandemic 

influenza must provide for effective communication to the public to minimize negative 

behaviors, accentuate positive actions, and limit the psychosocial and psychological 

impact of imposing public health measures that include movement restrictions. These 

messages should be developed and trained and trusted messengers should be selected 

now.34 For this reason, established and community-embedded health call centers are a 

good fit to partner with public health agencies to provide such communications. 

 A major goal of public health education messages is to ensure that the public has the 

knowledge to protect itself. Prevention and infection control are the first line of defense, 

but there are other education topics as well. Dispelling rumors keeps the public properly 

informed and less prone to panic because of misinformation. Public health authorities 

have the responsibility to explain the rationale behind disease control measures, to 

explain why these measures are necessary, and to ensure that information is current and 

that messages do not contradict one another.35 Health call centers can partner with public 

60 
health agencies to relay such information to the public in a consistent, accurate, and upto-date manner. 

 In “Components of Effective Disaster Public Education and Information,” (December 

2005) a working group of the Emergency Management Accreditation Program 

emphasizes the correlation between effective public education and coordinated, effective 

disaster response and recovery outcomes. The report outlines steps for creating 

comprehensive and understandable public education messages so that residents can be 

better informed and better prepared. The report notes that, “Federal and State 

Governments must support local capabilities to provide effective public education and 

information through continuity of authority, emphasis, message, and language, as local 

and State public education and information have a direct impact on successful outcomes 

in a disaster.”36 It is such local capabilities that health call centers have to offer the 

governments and communities they serve.

 Blendon et al. reported that most Americans favor the use of quarantine as a weapon 

against contagious diseases like SARS and pandemic influenza but are far less 

comfortable with strict enforcement and monitoring measures. While 76 percent of 

Americans surveyed said that they favor quarantining those potentially exposed to serious 

contagious diseases, only 42 percent supported a compulsory quarantine under which 

those who refused to comply could be arrested. However, 75 percent of those surveyed 

would favor periodic telephone calls to monitor those in quarantine.24 This suggests that a 

quarantine strategy using a health call center and a tool such as the QI Monitoring 

Application would be favorable to most Americans and likely to experience good 

compliance. 

 The HELP model, which has become established in the community and is used on a 

daily basis, can be a resource for times of disaster, giving people the risk-based messages 

that include how to care for themselves and their families in order to mitigate a threat. 

The various call flows are designed to give reassurance as well as direction and 

information on the appropriate response measures. Such information can substantially 

change the behavior of the caller. Our report on the Denver Health NurseLine 

demonstrated that 70 percent of patients complied with nurse advice line 

recommendations, though the same percentage had a different plan for their health care 

prior to calling.10 Patients who called were already aware of a need for information and 

were receptive to changing their behavior based on the information they received. It is 

not unlikely that the same behavioral changes would be seen in an emergency situation 

with persons contacting a health call center and perhaps even those receiving information 

via an IR system. 

Special Needs Populations 

 Special needs populations will need customized forms of contact during an 

emergency. The proposed IR applications take into consideration some special needs 

communities, in particular the Spanish-speaking population. By developing most of the 

IR applications to accommodate both English and Spanish, a majority of callers will have 

61 
the option to use such strategies to get information on the disaster. Depending on a 

community’s demographics, it may want to offer additional language options for callers. 

Planners will need to determine if there will be sufficient demand to have announcements 

recorded in a particular language or to have those callers speak with a staff person using a 

translation service. The vision impaired will also likely find it easy to retrieve 

information via their telephone rather than from printed materials or the Internet. Many 

call centers have relied on TTY/TDD technology to communicate with the hearing 

impaired, though text messaging and e-mail communications are becoming more 

prevalent. The IR applications do not support TTY/TDD, and those callers would need to 

interact with a staff person to get information. The use of toll-free numbers should enable 

those without a phone in their home, a cell phone, or without even their own residence to 

call from any public phone at no cost. 

Volunteer Use in Call Centers 

 Volunteers can assist health call centers in responding to public inquiry. The 

volunteers would need to have a vested interested in the community and be able to think 

on their feet, work under pressure, and answer the questions. To find these individuals, a 

call center can look to established volunteer groups, church organizations, or recognized 

nongovernment organizations like the Salvation Army or the American Red Cross. 

Planners who choose to use health care workers to staff a call center may want to look for 

volunteers through the Health Resources Services Administration (HRSA) Emergency 

Systems for Advance Registration of Volunteer Health Professionals program that each 

State is developing. An important caveat made by HRSA is that these individuals will 

need to identify themselves to callers as volunteers helping the State.37

 When using volunteers in a call center, it is best to be aware of the legal implications 

of volunteer use in a disaster situation. Good Samaritan statutes are laws enacted by 

various States that protect health care providers and other rescuers from being sued when 

they are giving emergency help to a victim. The rescuer has to use reasonable, prudent 

guidelines for care during the response. Under such laws, the assistance must be 

voluntary, the person receiving the help must not object to being helped, and the rescuer’s 

actions must be a good-faith effort to help.38 

 The Federal Volunteer Protection Act provides that no volunteer of a nonprofit 

organization or governmental entity shall be liable for harm caused by an act or omission 

of the volunteer on behalf of the organization or entity if the volunteer meets certain 

requirements.39 It is very important to note that this Federal law preempts State laws to 

the extent that such laws are inconsistent, except that it does not preempt any State law 

that provides additional protection from liability relating to volunteers or to any category 

of volunteers in the performance of services for a nonprofit organization or government 

entity. Health call centers that use volunteers should contact their legal counsel to ensure 

that their use is in compliance with applicable laws, that volunteers are covered under 

their liability insurance for such use, and that volunteers are properly trained for such 

activities. 

62 
Public Information Partnerships 

 Public information partnerships between health call centers and public health 

agencies prove that together they can meet the expected needs of communities during 

health emergencies including: improving information support and surge capacity, 

expanding surveillance signals, and collecting data for situational awareness. These 

partnerships help meet the new demands on public health agencies, increasing their 

response capabilities and access outside of the 9:00 a.m. to 5:00 p.m. work day, handling 

rapidly evolving information while maintaining control, and enabling members of the 

public to care for themselves and their families by supplying the information to help them 

make decisions. 

 The need for such partnerships will remain constant or potentially increase, since 

public health events will continue to occur. These events will require effective, 

structured, and coordinated systems for providing public information and support as part 

of the response. The HELP model has been proven to be a cost-effective, efficient, 

reliable, and adaptable component of Colorado’s readiness response model for any public 

health emergency. The HELP model offers the promise for similar response capabilities 

for other community health call centers working in partnership with their public health 

agencies. These community resources will likely have robust infrastructure to serve as 

strong platforms that can incorporate the proposed tools and adapt them as needed. 

Model Utility and Adaptability 

 This model and the IR applications were applied locally and statewide, but they could 

potentially be adapted for interstate and Federal use. There may be legal risk implications 

for clinical personnel using decision support and triage strategies across State lines. The 

National Council of State Boards of Nursing (www.ncsbn.org) is working to secure 

mutual recognition of nurse licensure across States that may help with this issue. 

However, a larger issue concerns the coordination of messages across various levels of 

government to ensure consistency and public trust. It may be difficult for public health 

and safety agencies across all levels of government to agree on specific strategies and 

develop unified messages. It may be easier to develop response resources such as the 

HELP model and IR applications on a statewide or smaller scale to avoid the difficulties 

in regional and national coordination. Planners at various levels of government should 

consider this challenge in their planned application of such resources. 

 The model and applications that we have developed are largely informational in 

nature and can be delivered easily with trained nonclinicians or can be automated. 

However, the applications should all be employed with sufficient back-up support such as 

the HELP platform so that users can always get the proper assistance. 

 In our experience, it has been valuable to have systems and processes that can be 

adjusted to the changing needs of emerging public health events. This has included the 

ability to: 

63 
• Rapidly change FAQ content and public health messages. 

• Handle surge responses through a variety of mechanisms 

o Using recordings/announcements 

o Using an interactive response system with interactive response 

applications 

o Partnering with media to deliver information 

o Having trained ancillary staff. 

• Learn from experiences. 

 Some of the lessons learned from more than 3 years of operating the HELP program 

include: 

• Call volume is driven by the event and media attention—anticipate call volume 

surges related to morning, afternoon, and evening news broadcasts. 

• Media organizations are willing to assist with disseminating information, 

including hotline numbers regularly displayed in television news crawlers. 

• Adaptation to include the latest local and State health department messages is 

necessary to meet both public health and public needs. 

• Surveillance, though not an intended purpose of the program, became an 

important function due to the utility of structured data collection (situational 

awareness) and the ability to identify emerging issues (sentinel event detection). 

 Operating a public informational resource requires the ongoing need to adapt, 

reassess, and improve. There always will be further challenges to address: 

• Testing the IR applications in various community groups (non-English speakers, 

seniors) and determining if there are any issues with their use. 

 

• Improving public messages and FAQ information content. 

• Determining other information and tools for meeting the needs of health 

emergency events. 

64 
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directive 8: national preparedness. 

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onalPreparednessGuidance.pdf. 

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rimNationalPreparednessGoal_03-31-

05_1.pdf. 

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education and information working 

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(EMAP). Available at: 

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67 
68 
Appendixes 

69 
70 
Casualties Infrastructure Damage Evacuations/Displaced Persons Evacuation and Shelter Victim Care Health Information Disease/ Injury Surveillance Triage/ Decision Support Quarantine and Isolation Support Outp

Inf

Even

1

Nuclear Detonation - 10 Kiloton Improvised Nuclear Device

This scenario postulates a 10-kiloton improvised nulear device (IND) detonation

in a large metropolitan area.

Hundreds of thousands

Total destruction within radius of 0.5 to 3 miles

100,000 seek shelter in safe areas (decontamination required for all before entering shelters); 250,000 told

to shelter-in-place as plume moves across region; 1 million+ self-evacuatefrom major cities.

Evacuation and/or sheltering of downwind populations required. Actions

needed: monitor/ decontaminate evacuees, protect schools and day care facilities, provide shelter/reception facilities.

Decontamination and both short-term and long-term treatment; hospitals overwhelmed; level of care may be lowe

than normally expected

2

Biological Attack - Aerosol Anthrax

Dispersal of the anthrax takes place in a densely populated urban city with a significant commuter workforce. The exposed population will disperse widely before the incident is detected.

13,000 fatalities and injuries

Minimal, other than contamination

25,000 seek shelter (decontamination required); 10,000 instructed to shelterin-place; 100,000 self evacuate out of affected areas

Evacuation and treatment will be required; provide warnings to the population-at-large and the population-a

risk; need to notify people to shelter-inplace and/or evacuate 

Care to the ill must be provided and should include disbursing PEP/vaccinations and establishing treatment/distribution centers

3

Biological Disease Outbreak - Pandemic Influenza

Pandemic Influenza strikes locations across the country. All entities must use pre-existing resources. Available medical supplies will be distributed as available. Health care systems will not be able to activate MOUs with neighboring locales.

15% attack rate: 87,000 fatalities; 300,000 hospitalizations

None

No evacuation required; shelter-inplace or quarantine instructions given to certain highly affected areas

Evacuations not necessary; quarantine has not typically been used with much success to stop the spread of influenza 

Antiviral drugs for treatment of most ill; ventilators may be necessary for many; at-home care and OTC medications for most 

4 Biological Attack - Plague

Pneumonic plague is released into three main areas of a major metropolitan city. Included is rapid dissemination to distant locations through foreign and domestic travel.

6,000 illnesses, unknown fatalities None

No evacuation needed; shelter-inplace or quarantine to certain highly affected areas; possible large-scale self-evacuation from affected communities

Transport and treatment of some vicitms

will be required; self-quarantine through shelter-in-place may be instituted 

Treatment or prophylaxis with ventilators

and antibiotics, as well as information measures to prevent spread of disease; advanced treatment for those with pneumonia 

5 Chemical Attack - Blister Agent

A light aircraft sprays chemical agent YELLOW into a packed college football stadium. The agent directly contaminates the stadium and the immediate surrounding area, and generates a downwind vapor hazard.

150 fatalities, 70,000 hospitalizations

Minimal 

More than 100,000 evacuated; 15.000

seek shelter in immediate area (decontamination required)

Evacuation and/or sheltering of downwind populations in a 360 degree arc around release site required until contained

Decontamination for tens of thousands of people and short-term and long-term medical treatment

6

Chemical Attack - Toxic Industrial Chemicals

Grenades and IEDs cause significant explosions at at fixed facility petroleum refineries. Simultaneously multiple cargo

containers at a nearby port explode aboard or near several cargo ships with resulting fires.

350 fatalities; 1,000 hospitalizations

50% of structures in area of explosion

10,000 evacuated; 1,000 seek shelter in safe areas; 25,000 insturcted to temporarily shelter-in-place as plume moves across region; 100,000 selfevacuate out of region

Evacuation/sheltering/protection of downwind populations will be required

Injuries to be treated will include traumaburns, smoke inhalation, severe respiratory distress, seizures, and/or comas; short- and long-term treatment will be required, as well as decontamination

7

Chemical Attack - Nerve Agent

Sarin vapor is released into the ventilation systems of three large commercial office buildings in a metropolitan area. The agent kills 95% of the people in the buildings, and kills or sickens many of the

first responders. In addition, some of the agent exits through rooftop ventilation stacks, creating a downwind hazard.

5,700 fatalities (95% of building occupants); 300 injuries

Minimal, other than contamination

Temporary shelter-in-place instructions are given for 50,000 people in adjacent buildings

Evacuation/sheltering/protection of downwind populations will be required; large numbers of worried well swamping

the medical system

Decontamination and monitoring of individuals as they are allowed to leave their buildings; hundreds will require hospital treatment

8

Chemical Attack - Chlorine Tank Explosion

 Using a low-order explosive a storage tank man-way is ruptured, releasing a large quantity of chlorine gas downwind o

the site. Secondary devices are set to impact first responders.

17,500 fatalities; 10,000 severe injuries; 100,000 hospitalizations

Immediate explosion area and

metal corrosion in areas of heavy exposure

100,000 instructed to temporarily shelter-in-place as plume moves across region; 50,000 evacuated to shelters in safe areas; 500,000 selfevacuate out of region

Evacuation/sheltering/protections of downwind populations will be required

Injuries to be treated will include respiratory difficulty or severe distress and trauma; short- and long-term treatment may be required

9

Natural Disaster - Major Earthquake

A 7.2-magnitude earthquake, with a subsequent 8.0 earthquake following, occurs along a fault zone in a major metropolitan area of a city, greatly impacting a six-county region with a population of approximately 10 million people.

1,400 fatalities; 18,000 hospitalizations

150,000 buildings destroyed; 1 million buildings damaged

300,000 homes destroyed; 250,000 seek shelter in safe areas; 250,000 self evacuate the area

Structural engineers inspect critical buildings, bridges, freeways, waste facilities, etc; inspection teams deployed to inspect hundreds of homes for safe habitability

Activation of task forces for delivery of mass care and health and medical services; temporary housing strategies considered

10

Natural Disaster - Major Hurricane

A Category 5 hurricane hits a Major Metropolitan Area (MMA). Sustained winds are at 160 mph with a storm surge greater than 20 feet above normal. Massive evacuations are required. Certain low-lying escape routes are inundated by water anywhere from 5 hours before the eye of the hurricane reaches land.

1,000 fatalities; 5,000 hospitalizations

Buildings destroyed, large amounts of debris

1 million evacuated; 150,000 seek shelter in safe areas; 200,000 homes destroyed

State and local officials have time to execute evacuation plans; roads leading from the area are overwhelmed and massive traffic jams hinder the evacuation efforts; need to provide for temporary shelter and interim housing; permanent housing support will also be required 

Medical assistance; shelter and temporary housing assistance; emergency food, water and ice provision; sanitary facility provision

11

Radiological Attack - Radiological Dispersal Devices

Dirty bombs contating cesium chloride (CsCl) are detonated in three separate, but regionally close, moderate-to-large cities.

180 fatalities, 270 hospitalizations, 20,000 needing decontamination

Structures affected by blast, up to 0.5 square mile of contamination

Evacuation of 100,000 downwind will be required after plume has passed, a localized area will need to be relocated

until area is cleaned up.

Sheltering and/or evacuation of downwind populations will be required and must occur quickly; hospitals inundated by 50,000 "worried well"

Decontamination of injuried persons prior to hospital admission; superficial decontamination needed for most; shortand long-term followup for injured

12

Explosives Attack - Bombing Using Improvised Explosive Devices

Improvised explosive devices (IEDs) to detonate bombs at a sports arena, parking lot, and underground transportation. More IEDs detonated in the lobby of the nearest hospital emergency room (ER).

100 fatalities; 450 hospitalizations

Structures affected by blast and fire

Evacuation of immediate area around each explosion results in approximately 5,000 people seeking shelter in safe areas.

Evacuation is required as well as additional threat assessment; area must be cordoned

Injuries range from "walking wounded" to multiple systems trauma, burns, some fatalities; potential loss facilities at target hospital will require other facilities to receive all patients from blast sites 

13

Biological Attack - Food Contamination

Ground beef is tainted in California with an agent, following retail distribution, the tainted ground beef is in three cities.

500 fatalities; 650 hospitalizations; 1,800 illnesses

None None Not Applicable

Victim care will require diagnosis and treatment of affected population and distribution of prophylaxis for potentially exposed populations

Potential Health Call Center Response Capab

Appendix 1. National Planning Scenarios Analysis Matrix

Scenario 

Number

Executive Summary Mission Areas Activated

Scenario Title Scenario Description
Casualties Infrastructure Damage Evacuations/Displaced Persons Evacuation and Shelter Victim Care Health Information Disease/ Injury Surveillance Triage/ Decision Support Quarantine and Isolation Support Outp

Inf

Even

Potential Health Call Center Response Capab

Scenario 

Number

Executive Summary Mission Areas Activated

Scenario Title Scenario Description

14

Biological Attack - Foreign Animal Disease (Foot & Mouth)

Farm animals at specific locations are infected with hoof and mouth disease. None Huge loss of livestock None Not Applicable

It will be necessary to euthanize and dispose of infected and exposed animals; impact on farmers and farm communities should be considered

15 Cyber Attack

In a cyber attack, credit-card processing facilities are hacked and numbers released to Internet, causing mass credit card cancellation, nationwide failure of ATMs; also payroll and pension malfunctions.

None Cybernetworks None Not Applicable Economic assurance

Capabilites that may exist in health call centers though there may not be a great response need in the community.Capabilities that health call centers would need to refer to more appropriate resources within the community.Primarily a community response capability that health call centers would need to integrate with.Capabilities that correspond best with the expertise of health call centers and the expected response needs of the community. These capabilities are addressed within this task order with proposed strateUtilizing general informational messages distributed by government and community leaders via the media (i.e. public service announcements, radio bulletins, television "crawlers", Emergency Alert Systnumber of the public.

Mass Risk 

Communication

Other capabilities that correspond with the expertise of health call centers and the expected response needs of the community.Recognizing individuals with mental health needs, providing referrals to community resources where appropriate and incorporating any post-event government agency directives (i.e. surveying commun

Mental Health Assistance/Referral

Grading Scale for Scenarios and Health Call Center Response Capabilities

Scenarios identified as most applicable for integration with health call center capabilities and that are specifically addressed in this task order.Utilizing clinical algorithms or decision trees to support the management of caller reported symptoms. There are varying levels of clinical decision support depending upon the scope of practice of the pealso include non-clinicians providing information to callers to allow them to make their own healthcare decisions.

Triage/Decision 

Support

Providing drug information including pill identification and collection of adverse drug events, especially needed with large-scale prophylaxis or immunization without standard medical supervision (i.e. C

Outpatient Drug 

Information/Adverse 

Event Reporting

Monitoring the compliance, health status and resource needs of those assigned to home quarantine and isolation. Quarantine and Isolation Support

Quarantine applies to people who have been exposed to a contagious illness and may be infected but are not yet ill. Separating exposed people and restricting their movements is intended to stop the sp

be highly effective in protecting the public from disease.Isolation is the separation and restriction of movement of ill people to stop the spread of that illness to others. People in isolation may be cared for in their homes, in hospitals or at designated health car

Health Information Providing disaster and/or disease information to the public during and after the crisis. This information is provided to the public and providers to support their ability to care for themselves and others.

Collecting specific data or utilizing already established databases to identify disease/illness/injury, emerging health trends or sentinel events. Disease/Injury Surveillance

Capabilities that are not well-suited to expected community needs for this scenario.

Definitions for Potential Health Call Center Response Capabilities
Appendix 2. Potential Health Call Center 

Capabilities for Four National Planning Scenarios 
1. Biological Attack-Aerosol Anthrax1-3 

Health Information Capabilities 

• Recorded messages provide information on areas where attack has occurred, 

symptoms of inhalation anthrax, and incubation period. 

• Inform the public about how inhalation anthrax is contracted and the low risk 

of contracting the illness from an infected person. 

• Provide prophylaxis information for infected and non-infected individuals. 

• Provide information about the course of the illness and the risk period for 

exposure in areas where attack has occurred. 

• Provide information on the differences between inhalation, cutaneous, and 

gastrointestinal anthrax. 

Disease/Injury Surveillance Capabilities 

• Monitor number of calls reporting malaise, fever, cough, nausea, and 

vomiting. Other symptoms may include drenching sweats, dyspnea, chest 

pain, and headache.

• Document demographic information and place of travel for previous 7 days to 

help identify point of exposure.

• Identify suspicious cases and rule out influenza/pneumonia or other causes of 

related symptoms.

• Report data to local, State, and Federal health agencies as appropriate.

Triage/Decision Support Capabilities 

• Identify symptoms and rule out influenza/pneumonia or other causes of 

related symptoms. Differentiation is best identified by lack of nasal 

congestions/runny nose as seen in influenza like illness (ILI) or bloody and 

watery sputum that is indicative of pneumonic plague. Symptoms of 

inhalation anthrax include:

- Malaise - Sore throat - Nausea 

- Vomiting - Fever - Sweats 

- Dyspnea - Headache - Cough 

- Chest pain

• Recommend and/or refer for medical treatment cases with the above 

symptoms. Note: infection of inhalation anthrax cannot be ruled out if 

symptoms remit for a few days—in these instances it is important to 

encourage the caller to seek a medical evaluation and antibiotic therapy.

• Individuals who were in the area of the attack and are asymptomatic should be 

encouraged to seek medical attention for prophylactic treatment.

74 
Quarantine/Isolation Support Capabilities 

• There are no data suggesting patient-to-patient transmission of inhalational 

anthrax, so quarantine and isolation strategies are not likely to be needed. 

• Consider monitoring people taking prophylaxis to determine if disease 

symptoms develop or if there are issues with drug therapy compliance.

Outpatient Drug Information/Adverse Event Reporting 

Capabilities 

• Antibiotic therapy is necessary for individuals in high-risk groups who 

develop fever or evidence of systemic disease.

• Doxycycline, penicillin, and ciprofloxacin are the preferred antibiotics for the 

treatment of inhalation anthrax. It has been recommended by the CDC that a 

combination of two or three antibiotics may be necessary in persons with 

inhalation anthrax, giving the individual a greater chance of survival.

• Monitor for the possibility of allergic type reactions to antibiotics and 

encourage individuals to seek medical treatment prior to stopping therapy. 

Other complaints by individuals undergoing antibiotic therapy may include 

gastrointestinal tract intolerance.

• Antibiotic therapy is suggested to last 60 days, however spores may remain 

latent following discontinuation and patients should be instructed to report any 

flu-like symptoms immediately.

• Collect and report all adverse events to the local and State health departments 

and the FDA, as applicable.

Mental Health Assistance/Referral Capabilities 

• Provide support for individuals who are taking prophylaxis.

• Help individuals cope with escalating fear, anxiety, and grief.

• Help infected groups or individuals deal with stigmatization and/or 

discrimination when perceived as a source of contagion.

2. Biological Disease Outbreak-Pandemic Influenza3-10 

Health Information Capabilities 

• Recorded message provides information on infection control measures such as 

hand hygiene and contact precautions.

• Provide information on general symptoms of ILI and factors that may 

contribute to the development of a novel influenza virus.

• Inform about populations at increased risk for contracting ILI, symptoms that 

may or may not be present in young children or the elderly, nature and 

severity of influenza outbreak, and indications of either seasonal or novel 

virus.

75 
• Inform individuals with ILI symptoms to remain at home and separated from 

family members for 5 days after symptoms remit.

• Provide vaccination and antiviral information and locations.

Disease/Injury Surveillance Capabilities 

• Monitor number of calls reporting ILI symptoms and their demographic 

information.

• Collect travel, occupation, and personal contact information of individuals 

reporting ILI to determine the potential for a novel influenza outbreak. 

Important questions should include:

 Travel to areas affected by avian influenza viruses in poultry

 Direct contact with poultry

 Close contact with persons suspected or confirmed novel influenza 

virus

 Occupational exposure to novel influenza via agriculture, health care, 

or laboratories

• Conduct data collection including:

 Number of contacts that the infected individual has had

 Relationship of contact

 Nature of time in contact

 Whether contacts were vaccinated or on antiviral medications

 Number of contacts that have become ill or have been ill

 Number of days between symptom onset and reporting

• Report data to local, State, and Federal health agencies as appropriate.

Triage/Decision Support Capabilities 

• Identify symptoms, number of days with symptoms, and possibility of novel 

influenza outbreak. (Incubation time for seasonal influenza is generally 1 to 4 

days. Incubation time for novel influenza is unknown; however, conservative 

estimates indicate 10 days between time of exposure and symptoms.)

• Individuals with symptoms who have indicated possible exposure to novel 

influenza virus (e.g. infected poultry, travel to areas affected by avian 

influenza, contact with individuals infected with novel influenza, or 

occupational exposure) should be directed to seek medical treatment. 

• Identify early signs and symptoms of influenza that suggest need for medical 

evaluation:

 - Rhinorrhea - Conjunctivitis - Chills 

 - Rigors - Myalgia - Headache 

 - Diarrhea

• Identify individuals with underlying chronic illnesses that may or may not 

have symptoms indicative to ILI (such individuals may or may not have a 

fever and children may often present with GI symptoms such as vomiting 

and/or diarrhea).

76 
• Advise individuals to self-monitor and, if symptoms occur or become worse, 

to contact hotline for further treatment guidance.

• Direct infected individuals to the appropriate level of care based on symptoms 

and potential contacts.

• Minimize the number of individuals seeking treatment at hospitals or clinics 

that are overwhelmed, and limit contact between infected and non-infected 

individuals.

Quarantine/Isolation Support Capabilities 

• Assess progression or regression of symptoms, and identify needs of 

quarantined and isolated individuals.

• Facilitate and help with early detection of symptoms in individuals who are 

quarantined, limiting the time between symptom onset and isolation. 

• Provide passive and active monitoring to quarantined or isolated individuals 

based on symptom level.

• Daily phone contact between hotline and quarantined/isolated individual for 

symptom evaluation.

• Assess the need for direct medical attention.

Outpatient Drug Information/Adverse Event Reporting 

Capabilities 

• Antiviral treatment may be necessary for individuals infected with novel 

influenza, persons they have been in contact with, and persons considered 

high-risk (post-exposure prophylaxis may last for 10 days).

• Antiviral medication indicated for novel influenza include:

o Amantadine

o Rimantadine

o Oseltamivir

o Zanamivir

• There is a greater possibility of antiviral resistance with amantadine and 

rimantadine (both are better suited for pre-exposure prophylaxis). Side effects 

of these antiviral medications can include:

o Central Nervous System (CNS): nervousness, anxiety, insomnia, 

difficulty concentrating, lightheadedness and potentially delirium, 

hallucinations, agitation, and seizures in severe instances.

o Gastrointestinal (GI) System: nausea and anorexia

• Both oseltamivir and zanamivir are more effective and lack antiviral 

resistance, as well as have fewer side effects:

o Oseltamivir can have GI side effects

o Zanamivir can cause bronchospasm and is contraindicated in 

individuals with underlying chronic respiratory disease

• Oseltamivir and influenza vaccine can be administered concurrently.

• Collect and report all adverse events to the local and State health departments 

and the FDA, as applicable.

77 
Mental Health Assistance/Referral Capabilities 

• Provide support for quarantined/isolated individuals.

• Help individuals cope with escalating fear, anxiety, and grief.

• Help infected groups or individuals deal with stigmatization and/or 

discrimination when perceived as a source of contagion.

3. Biological Attack-Plague11,12 

Health Information Capabilities 

• Recorded messages provide information on areas where attack has occurred, 

symptoms of pneumonic plague, incubation period, and contact precautions.

• Provide prophylaxis information for infected and non-infected individuals. 

Asymptomatic individuals at risk for developing illness include:

o Household members of infected individuals

o Health care and laboratory workers

o First responders

o Patient transporters

o Coworkers

o Friends

• Provide information about the course of the illness and the risk period for 

exposure in areas where attack has occurred.

• Provide information on the differences between bubonic and pneumonic 

plague.

Disease/Injury Surveillance Capabilities 

• Monitor number of calls reporting fever, cough, dyspnea, bloody or watery 

sputum, or rapidly progressing symptoms of pneumonia or 

bronchopneumonia.

• Document demographic information and place of travel or contact for the past 

6 days (important to note locations to identify if endemic exposure is 

possible). 

• Identify suspicious cases, and work to rule out influenza or inhalation anthrax.

• Monitor for reports of illness in areas not known to have enzootic infections.

• Report data to local, State, and Federal health agencies as appropriate.

Triage/Decision Support Capabilities 

• Identify symptoms, and rule out influenza or inhalation anthrax. 

Differentiation is best identified by bloody and watery sputum in individuals 

with pneumonic plague. Other symptoms include fever, weakness, rapidly 

developing pneumonia with shortness of breath, chest pain, cough, sometimes 

bloody and watery sputum, nausea, vomiting, and abdominal pain.

78 
• Recommend medical treatment in all cases with the above symptoms, 

especially those who have been in contact with infected individuals or in the 

area of the attack over the past 6 days.

• Identify individuals who have been in contact with infected persons who 

currently do not have symptoms, and recommend prophylaxis treatment.

• Provide information to reduce contact precautions.

Quarantine/Isolation Support Capabilities 

• Assess symptoms of individuals who are being treated for pneumonic plague 

for progression or regression of symptoms such as with daily phone contact.

• Assess symptoms of individuals who are being treated with antibiotics and are 

asymptomatic to identify development of symptoms.

• Monitor quarantined and isolated individuals until they have received at least 

48 hours of antibiotic treatment and they have shown clinical improvement.

• Assess the need for direct medical attention.

Outpatient Drug Information/Adverse Event Reporting 

Capabilities 

• Antibiotic treatment should begin within 24 hours of the first symptoms.

• Doxycycline and ciprofloxacin are available in the oral form, and 

streptomycin and gentamicin are available intravenously.

• There is a possibility of allergic type reactions to these antibiotics, in which 

case the person should seek medical treatment prior to stopping therapy.

• Other complaints by individuals undergoing antibiotic therapy may include 

gastrointestinal tract intolerance.

• Collect and report all adverse events to the local and State health departments 

and the FDA, as applicable.

Mental Health Assistance/Referral Capabilities 

• Provide support for quarantined/isolated individuals.

• Help individuals cope with escalating fear, anxiety, and grief.

• Help infected groups or individuals deal with stigmatization and/or 

discrimination when perceived as a source of contagion.

4. Biological Attack-Food Contamination13

Health Information Capabilities 

• Recorded messages provide information on food contamination and its 

potential source, as well as symptoms that may develop.

• Provide prophylaxis or treatment information if available.

79 
Disease/Injury Surveillance Capabilities 

• Monitor number of calls reporting unusual symptoms, and document locations 

where the individuals have eaten.

• Document and classify symptoms in order to better identify the type of agent.

• Help to develop strategies for diagnosis based on symptoms.

• Report data to local, State, and Federal health agencies as appropriate.

Triage/Decision Support Capabilities 

• Identify symptoms and use diagnostic strategies to determine the nature of the 

illness.

• Make recommendations and/or referrals for medical treatment.

• Depending on the type of agent, advise individuals to self-monitor and, if 

symptoms occur or become worse, to contact hotline for further treatment 

guidance.

Quarantine/Isolation Support Capabilities 

• Depending on the agent, quarantine or isolation may be necessary; however, 

most agents do not pose a threat of infection through person-to-person contact.

Outpatient Drug Information/Adverse Event Reporting 

Capabilities 

• Medical treatment will vary based on the agent used in the attack.

• Collect and report all adverse events to the local and State health departments 

and the FDA, as applicable.

Mental Health Assistance/Referral Capabilities 

• Provide support for quarantined/isolated individuals.

• Help individuals cope with escalating fear, anxiety, and grief.

• Help infected groups or individuals deal with stigmatization and/or 

discrimination when they are perceived as a source of contagion.

80 
References 

1. Marano N. COCA conference call 

summaries and slides: anthrax (March 

16, 2004). 

http://www.bt.cdc.gov/coca/summaries/

anthrax031604.asp. Accessed February 

5, 2007. 

2. Inglesby TV, O’Toole T, Henderson 

DA, et al. Anthrax as a biological 

weapon 2002: Updated 

recommendations for management. 

JAMA. 2002 287(17):2236-52. 

3. United States Department of Health and 

Human Services. Public health guidance 

for state and local partners: community 

disease control and prevention. 

Supplement 8:S3-S16, 2005. 

4. United States Department of Health and 

Human Services. Public Health 

Guidance for State and Local Partners: 

Clinical Guidelines. Supplement 5:S2-

S29, 2005 

5. United States Department of Health and 

Human Services. Public Health 

Guidance for State and Local Partners: 

Healthcare Planning. Supplement 3:S2-

S24, 2005 

6. United States Department of Health and 

Human Services. Public Health 

Guidance for State and Local Partners: 

Infection Control. Supplement 4:S3-

S13, 2005 

7. United States Department of Health and 

Human Services. Public Health 

Guidance for State and Local Partners: 

Public Health Communications. 

Supplement 10:S2-S15, 2005 

8. United States Department of Health and 

Human Services. Public Health 

Guidance for State and Local Partners: 

Pandemic Influenza Surveillance. 

Supplement 1:S2-S15, 2005 

9. United States Department of Health and 

Human Services. Public Health 

Guidance for State and Local Partners: 

Antiviral Drug Distribution and Use. 

Supplement 7: S2-S18, 2005 

10. Centers for Disease Control and 

Prevention. Antiviral Agents for 

Influenza: Side Effects and Adverse 

Reactions. 

http://www.cdc.gov/flu/professionals/tr

eatment/side-effects.htm <Accessed 

February 5, 2007> 

11. Inglesby TV. Dennis DT. Henderson 

DA. Bartlett JG. Ascher MS. Eitzen E. 

Fine AD. Friedlander AM. Hauer J. 

Koerner JF. Layton M. McDade J. 

Osterholm MT. O’Toole T. Parker G. 

Perl TM. Russell PK. Schoch-Spana M. 

Tonat K. Plague as a Biological 

Weapon: Medical and Public Health 

Management. Journal of the American 

Medical Society. 283(17):2281-2290, 

2000 

12. Centers for Disease Control and 

Prevention. Frequently Asked 

Questions About Plague. 

http://www.bt.cdc.gov/agent/plague/faq.

asp <Accessed February 5, 2007 

13. Centers for Disease Control and 

Prevention. Infectious Disease 

Information: Food-Related Diseases. 

http://www.cdc.gov/ncidod/diseases/foo

d/illness.htm <Accessed February 5, 

2007> 

81 
Appendix 3. Suggested Elements for Public Health 

Information and Decision Support Hotlines: The 

Health Emergency Line for the Public (HELP) Model
Contents 

Introduction ............................................................................................................................... 85

Goals and Lessons Learned ....................................................................................................... 86 

Elements of a Telephone Information and Decision Support System....................................... 88 

Call Handling Requirements and Support Services ........................................................ 88 

Service Levels.................................................................................................................. 89 

Service Users................................................................................................................... 90 

Multipurpose/Multifunction Support Services................................................................ 91 

Use of Recordings and Other Information Resources.........................................93 

Use of Call Center Technology ....................................................................................... 94 

Information Topics and Content...................................................................................... 94

 Staff Training and Quality Control..............................................................95 

 Data Collection and Reporting....................................................................97 

Adaptability and Utility................................................................................................... 98

Appendixes 

 Appendix 3-A. Sample FAQ from West Nile Virus Library....................................100 

 Appendix 3-B. Sample Report Items and Data Graphs..........................................101 

 84
Introduction 

 The Rocky Mountain Regional Health Emergency Line for the Public (HELP) program 

provides a model for disseminating and collecting information in health emergencies. In our 

experience, the basic call center infrastructure and elements of HELP are needed to support the 

tools described in this report. This appendix describes those HELP elements so that similar 

capabilities can be developed within existing community health call centers to support outpatient 

health care and monitoring during public health emergencies. A more complete discussion of the 

requirements for call center infrastructure (people, processes, and technology) can be found in 

the Health Emergency Assistance Line and Triage Hub (HEALTH) model report on the Agency 

for Healthcare Research and Quality Web site (www.ahrq.gov/research/health/). 

 85
Goals and Lessons Learned 

 The HELP program objectives, which we developed with our public health partners include: 

 

• Developing a standardized and prepared response to public health events. 

• Providing consistent, accurate information. 

• Collecting and maintaining structured data to better characterize events and responses. 

• Developing capability and capacity to adapt to other public health emergencies. 

 Essential components for a standardized and prepared response include: 

• Call handling procedures. 

• Call center infrastructure/technology. 

• Toll-free lines with up-to-date recordings. 

• Integrated Web site. 

• Trained information providers. 

• Defined referral procedures. 

• Consistent, accurate information delivery. 

• Structured data collection and reporting. 

 In our experience with operating health/medical call centers and responding to health 

emergency events, we learned a number of valuable lessons: 

• Structured upfront planning is essential. 

• All call center staff should have a basic understanding of the flow of information. 

• Systems need to be flexible to: 

o Meet any challenges or unexpected questions and requests for information, 

o Update/change the information provided as new data becomes available, 

o Adapt to unpredictable and changing call volumes, 

 86
o Provide additional trained staff when call volumes increase. 

• A formal and timely communications process must be in place that includes constant 

reviews and revisions of the information so that only the most current and correct 

information is provided to callers. 

 The last lesson relates to quality control mechanisms that will ensure the success and 

continual improvement of hotline services, as well as provide the call center with the capability 

to provide specialized information customized to the health event. 

 In planning for future events, it is clear that data collection must be sensitive so that it can: 

• Identify special populations and capture the needs of those populations. 

• Be flexible enough to address those needs. 

 Summary: Call centers are a valuable resource in providing consistent and accurate 

information not only to the general public but also to health care providers, as well as between 

health care providers and health departments. The goal is to develop a program that can provide 

much-needed support for those affected, those with concerns (worried well), and those 

professionals managing the incident. 

 87
Elements of a Telephone Information and Decision 

Support System 

Call Handling Requirements and Support Services 

Authorization and Liability 

 Call flow processes, scripting, and the prepared responses to frequently asked questions 

(FAQs) should be approved by the appropriate agency (i.e. public health department) or other 

client. These must be carefully followed during call delivery. Adding unapproved information or 

personal opinions creates liability for the persons delivering the service, for the contact center 

itself, and for the client agency. 

 If call center personnel (licensed professionals or information providers) have a processrelated concern arising from the scripts or decision trees when speaking to a caller, they are to 

contact supervisors immediately. If the information specialist or clinician handling a call has any 

concern or is uncomfortable with how the call resolved, they should report the call identification 

number, date and time of the call, person handling call, and situation/concerns to a supervisor or 

to quality assurance personnel. 

Security, Confidentiality, and Compliance 

 All caller information should be treated as confidential and shared only with call center and 

client agency employees for whom it is appropriate. It should be determined whether it is 

necessary to comply with any provisions of the Health Insurance Portability and Accountability 

Act (HIPPA). If the client agency is a public health entity, or if the call center is involved in 

responding to a community emergency, there may be exemptions from HIPPA 

(www.cdc.gov/od/science/regs/privacy/index.htm). 

 To safeguard patient health information and confidentiality, do not send e-mails or online 

reports that contain caller identification information unless the content is encrypted. Also 

consider collecting non-sensitive information. For example, collecting only a caller’s zip code 

and county reduces the amount of information to collect and thereby shortens call times, while 

still allowing staff to answer questions, supply information, and report situational awareness 

information to the state health department (i.e. the top information requests by county). This 

minimal information approach also reduces any potential barriers for callers who may not feel 

comfortable providing names, addresses, phone numbers, and other identifying information. 

 However, callers may be comfortable supplying additional identifying information, 

depending on the situation. If a caller’s questions cannot be addressed immediately (for example, 

the information is not available and a response request must be e-mailed to a State 

epidemiologist) callers can be given the option to supply contact information so they could be 

called back with a response. Also, if they were reporting an incident, such as a dead bird during a 

West Nile Virus outbreak, they might supply location information (at least cross streets) to allow 

for geo-coding of data. 

 88
Summary 

 It is important to determine what the data needs are for either providing information to or 

collecting information from the public to allow for adequate disease outbreak management and 

situational awareness for the specific incident being addressed. 

Service Levels 

 A two-level service system was developed to respond to the needs of different clients and 

incidents. Level 1 involves only basic information collection and dissemination, while Level 2 

involves more advanced clinical triage or decision support. We have developed our platform to 

provide Level 1 service and use information providers only (unlicensed staff). We have the 

capability to expand to Level 2 service if the client or incident requires by bringing in clinical 

staff. However, in many incidents there may be a lack of clinical professionals available to 

handle calls; therefore, we chose to concentrate on Level 1 service that information providers can 

deliver. 

* Level 2 that includes clinicians such as nurses providing decision support for the public and providers 

will require pre-designed protocols/clinical decision trees specific to the event. 

1. Level 1 Service 

– Recorded information on current 

event status 

– Information Providers give approved 

content through FAQ’s 

– Data collection as required by client 

– Reporting and data analysis as 

required by client 

2. Level 2 Service 

– Recorded information on current 

event status 

– Information Providers give 

approved content through FAQ’s 

– Decision support for public with 

suspected related symptoms* 

– Decision support for providers 

treating public* 

Delivery Method 

– Telephone 

– Web site 

– Information Providers 

– Registered Nurses* 

Delivery Method 

– Telephone 

– Web site 

– Information Providers 

 89
Summary 

 Planners should first determine the type of service level that they intend to provide and then 

staff appropriately. It is then important to establish the precise services that are needed before 

developing the support systems and procedures for them to properly function. 

Service Users 

 It is helpful to determine the expected potential service users and to begin to forecast what 

their needs may be. Though we intended to provide services to primarily the general public, we 

found there were many other service users that we had not anticipated, and we had to develop 

resources in order to meet their needs. The following figure demonstrates the different user 

groups we have identified from operating the HELP program.

Summary 

 Planning for specific user groups will help in the development of appropriate 

resources and information; however, planners should be prepared to adapt services to 

new user groups as situations require. 

Public Health Care

Providers

HELP Clinics Schools

 

Health 

Agencies

Hospitals 

 and EDs 

 90
Multipurpose/Multifunction Support Services 

 It is also important to know the scope of the services that the call center will provide. 

A hotline can be constructed that addresses only a single topic/incident or one that could 

handle multiple topics. It may be best to begin providing services for a few topic areas 

and then to gradually increase topic areas over time (see figure below for an example of 

expanded services). 

Caller Contact Center

Smallpox West Nile 

Virus SARS

Recorded

Information Recorded

Information

FAQ’s

Resources

Information

Support

Recorded

Information

FAQ’s

Resources

Public 

Health 

consultation

Centralized Data Collection

Reporting

Public Public 

Health

Provider

Public

Information 

Specialists

Public 

Health

Database Public Health

Next Public 

Health Issue

 91
An example of a more detailed call handling flow for West Nile Virus calls is shown 

below. The expected needs for both the public and public health professionals were 

accounted for and appropriate information resources or referrals were put in place. 

 

Summary

 A single hotline can be configured to provide information and support for a variety of 

events. It may be better to establish one emergency hotline that can be customized to 

various events and gain support from the public and health care professionals than to try 

to promote a new hotline for every new event. 

 92
Use of Recordings and Other Information Resources 

 Once service levels, scope of services, service providers, and call flows are 

determined, it becomes important to consider ways to help handle anticipated call 

volumes. In non-emergency events it may be easy to have staff answer every call. 

However, in any type of health event that generates some public concern, call volumes 

may rapidly increase, especially if media organizations become engaged; it becomes 

difficult to staff so that every call is answered and there are no call queues. 

 Up-front messages can provide the most requested information of the day to satisfy 

the greatest number of callers with a fixed complement of staff. Be careful to keep the 

length of upfront messages acceptable to callers (generally no more than 1 minute), or 

they get frustrated with the inability to speak to someone in a timely manner. 

 We have tracked call times to make sure that the majority of callers do listen to 

messages and then hang up (indicating to us that they received answers to their questions) 

instead of waiting in queue (indicating they still have unanswered questions). For those 

that opt to remain in queue, we cycle other frequently requested information after 1 

minute to try to answer their questions before reaching the staff. That ensures that the 

staff is really assisting those who could not be helped easily by other means. Callers also 

can be referred to other information sources (such as the Internet) that they may opt to 

explore instead of waiting in queue or to investigate first before calling back. It is 

important that Web addresses are easy for the caller to jot down from the message (i.e. 

www.cohelp.us). Internet resources with more complicated addresses can then be 

accessed from the supplied Web address via links. This avoids difficulty with trying to 

capture complex Web addresses (i.e. www.cdphe.state.co.us/dc/Influenza/index.html). 

 Messages and recordings provide many advantages: 

• Insure consistent, accurate information delivery on every call. 

• Deliver the most urgent public health messages. 

• Allow for customized messages to address most frequent concerns and issues. 

• Reduce the need to speak with a staff person. 

• Assist with call volume surges. 

• Direct callers to Internet resources for information. 

Summary 

 Remember that every call that can be handled by a recorded message or referred to 

the Internet reduces the need for staffing during peak call volumes. 

 93
Use of Call Center Technology 

 Call center technology can improve call handling efficiency and assist with call 

volume surges. Examples of such technology are: 

• Automatic Call Distribution (ACD) functionality, which insures that calls are 

evenly distributed among available call handling staff and reduces any delays in 

answering calls. 

 

• Call management software, which can be used to monitor call length times, 

queues and wait times, abandonment rates, and other call metrics (these metrics 

are important for both understanding what callers are experiencing and to help 

manage staff in the call center). 

• Interactive Response (IR) technology to allow callers to access information using 

their touch tone phones or even voice commands and thereby increase their ability 

to self-service their needs. This is used extensively in banking and airline 

industries. Examples of four such applications that we have developed for 

addressing anticipated needs in certain public health emergencies are detailed in 

Appendix 4, Developing an Interactive Response Tool. 

Summary 

 In operating a call center, it is important to consider available technology for 

increasing call handling efficiencies and understanding call metrics. 

Information Topics and Content 

 It is important to determine the specific topic areas on which information will be 

provided. We have worked in partnership with public health agencies to determine these 

topic areas and have required that an epidemiologist approve all information content 

before using it. This helps to ensure consistency with broader public health response 

messages and efforts. Topic areas could include: 

-Smallpox -Ricin 

-West Nile Virus -Mold 

-Influenza/Pneumonia -Avian Flu 

-Anthrax -White Powder 

-Tuberculosis -SARS 

-Hantavirus 

 

 94
Besides determining the topics, it is also important to determine the information subtypes 

to be offered, such as: 

• General information. 

• Public health messages (personal/family protection, health department messages 

and points of contact). 

• Provider guidelines and treatment information. 

 The process of determining these subtypes helps anticipate specific questions for 

which the public may need answers. Developing information resources in the format of 

FAQs and their answers works very well (see Appendix 3-A at the end of this appendix 

for an example). The FAQs can be assigned key words so they can be quickly referenced 

during a call. We have also found that having a process for “Information Not Available” 

is important. For such calls it is important to have a notification protocol to alert the 

appropriate health department contact so they can evaluate whether a FAQ or other 

resource is needed with the expectation of an answer within 72 hours. 

 Referral protocols can also be important information resources. Since the HELP 

program is staffed with information providers, they are instructed to refer callers with 

certain health issues to other resources: callers requiring symptom management are 

referred to their health care provider or a nurse advice line, and callers reporting a 

potentially toxic exposure are referred to a poison control center. 

Summary 

 Determine information topics to be addressed and then what information content is 

needed. Consider having all content approved first by appropriate public health agencies. 

Be prepared to add additional information as the situation and need dictates. Develop the 

appropriate referral protocols to direct callers to other resources, as needed. 

Staff Training and Quality Control 

 It is important to provide call center staff with the appropriate tools and training for 

them to deliver the expected service level. The skill profile for staff depends on the actual 

level of service they are required to provide and may also depend on the nature of the 

event. 

 In our experience, Level 1 service can be provided with Information Providers (those 

with some familiarity of health concepts, such as teachers, paramedics, veterinary 

technicians, medical/nursing students). Level 2 service would require licensed clinicians 

(such as nurses, pharmacists, physicians), who would be expected to provide health care 

assessment and advice. 

 95
 We suggest developing a standardized training program for staff that includes the 

following three components: 

• Customer service/communication skills—to prepare staff for answering calls from 

people who have different abilities for processing information, a range of emotions 

regarding health concerns, and special needs (such as translation services for nonEnglish speakers and TDD/TTY services for the hearing impaired). Important skills 

to teach are active listening to help callers identify their specific concerns while 

demonstrating empathy and respect. Crisis listening skills may be needed to help staff 

identify callers with signs of mental distress who could benefit from counseling 

resources and referrals. 

• Technology skills—to teach staff to operate telephones and information management 

software. Utilizing software that guides staff through a call in a standardized manner, 

prompting them for required information, will help to simplify training in this area. 

• Content education—to prepare staff to provide the appropriate information in a 

conversational manner and at a level that the caller can comprehend. Requiring staff 

to first listen to live calls and to have them role play as callers can help their training. 

 We developed a training program that includes 3 hours of didactic and 3 hours of 

practical call handling for all new personnel. The 6-hour time frame seemed reasonable 

for circumstances that would require a quick staffing ramp up to address an emergency. 

We have pre-trained certain individuals (such as existing administrative personnel) and 

provided them limited call handling experience to give us a resource for potential surges 

in call volume. We have also had staff attend Web casts and in-person trainings related to 

specific health topics for their continued training. Affording staff the opportunity to 

promote the HELP program to the public and professional groups at conferences has 

resulted in increased staff satisfaction. 

 It is important to have active quality assurance/quality control (QA/QC) 

procedures in place both to monitor the services being provided and to provide feedback 

to staff. Such procedures can help to quickly identify if calls are not being handled 

properly and staff need further training. QA/QC procedures can include recorded call 

reviews (or “listening in” to live calls), peer review of call documentation, and 

mechanisms for staff to provide feedback and suggest improvements. 

Summary 

Develop a staff training program that is consistent with expectations for service delivery 

and can be used to accommodate staffing ramp ups related to emergencies. Training 

should include components for communication skills, technology skills, and content 

education. An active QA/QC program helps to assure consistent service delivery and to 

provide staff feedback for ongoing improvement. 

 96
Data Collection and Reporting 

 As important as it is to provide information to the public and health care providers, it 

is equally important to provide data related to an event, including the most common 

concerns, the origin of calls, and the specific information that callers are reporting. This 

data can help in the overall management of a health emergency and may be useful to 

public health agencies. They may be used to create additional or clearer messages for 

public information campaigns through various media outlets or to better understand 

whether disease control measures are effective (i.e. situational awareness). 

 For call data to be useful, it must be collected in a structured manner and then be 

reported in a consistent and reliable manner. The first step is to choose a commercial 

software application that has the ability to accommodate data entry and management 

requirements, preferably in a structured manner that leads staff step-wise through call 

data collection. In our experience, important call data elements include but are not limited 

to: 

• Call volumes (calls per hour, day, week). 

• Number of callers who listened to recorded information only. 

• Number of calls handled by a live agent. 

• Calls abandoned (caller hung up without listening to recorded information). 

• Caller demographics (zip code, county, city). 

• Caller contact info (phone number or e-mail, if needed to provide followup). 

• Call type (WNV, influenza, other topics). 

• Call reason (information, report case, provider information). 

• Health info provider (listing of FAQs used). 

• Surveys (dead bird reports, vaccine adverse events reporting system). 

 Ideally, the software should be able to assist in information resource management 

(such as maintaining and quickly accessing FAQ libraries or State/local health 

department notification and referral protocols). As stated previously, we established an 

“Information Not Available” protocol which requires that the appropriate health 

department contact is notified and our software application accommodates this 

notification automatically. 

 97
 The software should also be able to generate reports and export data files for 

transmission to the appropriate agencies or clients. An example of the components of 

reports generated for our public health partners include: 

• Call metrics (call volume, call times, call disposition). 

• Caller demographics (zip code, county, city). 

• Call types (WNV, influenza and other topics). 

• Information delivered (specific FAQs and counts of requests).. 

• Customizations (“Information Not Available” requests, out-of-state calls). 

• Surveillance signals (based on call center experiences). 

o Sentinel alerts (such as any “white powder” calls or health topics not covered). 

o Trends in public concerns (comparisons to previous reporting periods). 

 We have found it extremely useful to export and transmit survey data (such as dead 

bird reports or self-reported illness of influenza/pneumonia that can be geo-coded) to a 

recipient for conversion to maps for use in situational awareness and disease control 

strategies. A few sample data reports items and graphs from typical reports are presented 

in Appendix 3-B at the end of this appendix. 

Summary 

 We do not endorse any specific software application but urge call centers to choose a 

solution that affords them the data entry, information resource management, and 

reporting capabilities they require. Agreed upon reporting schedules and processes should 

be developed with expected report recipients to ensure timely and useful information 

exchange. 

Adaptability and Utility 

 In our experience, it has been valuable to have systems and processes that can be 

adjusted to the changing needs of emerging public health events. This has included the 

ability to: 

• Rapidly change FAQ content and public health messages. 

• Handle surge responses through a variety of mechanisms: 

o Use of recordings/announcements. 

 98
o Partnering with media to deliver information. 

o Having trained ancillary staff. 

• Learn from experiences. 

 Some of the lessons learned from more than 3 years of operating the HELP program 

include: 

• Call volume is driven by the event and media attention—anticipate call volume 

surges related to morning, afternoon, and evening news broadcasts. 

• Media organizations are willing to assist with disseminating information; for 

example, regularly including hotline numbers in television news crawlers. 

• Adaptation to include the latest local and State health department messages are 

necessary to meet both public health and public needs. 

• Surveillance, though not an intended purpose of the program, became an important 

function due to the utility of structured data collection (situational awareness) and 

ability to identify emerging issues (sentinel event detection). 

 Such partnerships between community health call centers and public health agencies 

prove that together we can meet the expected needs of communities during health 

emergencies, including: improving information support, improving surge capacity, 

expanding surveillance signals, and data collection for situational awareness. These 

partnerships help realize the new demands on public health agencies—increasing their 

response capabilities and access outside of the 9 a.m. to 5 p.m. work day, handling 

rapidly evolving information while maintaining control, and enabling the public to care 

for themselves and their families by supplying the information for them to make 

decisions. 

Summary 

 The need for such partnerships will remain constant and potentially increase since 

public health events will continue to occur. These events will require effective, 

structured, and coordinated systems for providing public information and support as a 

component of a cost-effective, efficient, reliable, and adaptable response. 

 99
Appendix 3-A. Sample FAQ from West Nile Virus Library 

Personal Protection (PPFAQ1): How can I protect myself from West Nile virus? 

9 The best way to protect you and your family is to limit mosquito exposure. 

9 Limit outside activity around dawn and dusk when mosquitoes feed. 

9 Wear protective clothing such as lightweight long pants and long sleeve shirts when 

outside. 

9 Apply insect repellant to exposed skin when outside. Repellents with DEET are effective 

but should be applied sparingly. 

9 Make sure that doors and windows have tight- fitting screens. Repair or replace screens 

that have tears or holes in them. 

9 Drain and prevent formation of all standing water. Stock permanent ponds or fountains 

with fish that eat mosquito larvae. 

9 Change water in birdbaths or wading pools and empty flowerpot saucers of standing 

water at least once a week. 

9 Remove items that could collect water such as old tires, buckets, empty cans, and food 

and beverage containers. 

 100
Appendix 3-B. Sample Report Items and Data Graphs 

Total Calls = 36,361 

 Smallpox = 193 

60%

40% Calls handled

by agent

Calls handled

by message

 WNV = 12,555 (2,850 Dead Bird Reports) 

 Influenza/Pneumonia/Mold = 23,613 

Influenza Seasons Comparison 

 2003 (10-01-03 to 02-28-04) 2004 (10-01-04 to 02-28-05) 

Total Calls: 7110 7385 

Top Call Types: Information Call Information Call 

Possible Flu Health Professional 

Health Professional State Health Dept Alert 

Top 3 FAQs: Where can my child get a flu shot? Where can I get a flu shot? 

Where can I get a flu shot? Vaccine Shortage Statement 

What are the symptoms of the flu? What is FluMist? 

Surveillance Map of Dead Bird Reports During West Nile Virus Outbreak - 2004 

 101
Appendix 4. Developing an Interactive Response 

Tool: The HELP Model
104
105

Contents 

1.0 Introduction....................................................................................... 107

 1.1 Planning Phase......................................................................... 108 

 1.2 Analysis Phase........................................................................ .109 

 1.3 Design Phase........................................................................... 109 

 1.4 Implementation Phase..................................................................110 

 1.5 Evaluation Phase....................................................................... 111 

2.0 Interactive Response Tool Planning Document.............................................. 113 

 2.1 System Business Value.....................................................................113 

 2.2 Goals..................................................................................... 113 

 2.3 Roles and Responsibilities.............................................................114 

 2.4 Objectives............................................................................... 115 

 2.5 Feasibility Analysis.................................................................... 115 

 2.6 Resources and Timeline................................................................116 

3.0 Interactive Response Tool Business and Functional Requirements (Analysis) 

 Document...........................................................................................117 

 3.1 Business Requirements................................................................117 

 3.2 Functional Requirements..............................................................119 

4.0 Interactive Response Tool Design Document.................................................123 

 4.1 Quarantine/Isolation Monitoring Application.......................................123 

 4.2 Drug Identification Application.......................................................129 

 4.3 Point of Dispensing Application......................................................138 

 4.4 Frequently Asked Question (FAQ) Library Application...................................148 

5.0 Interactive Response Tool Implementation Document......................................195 

 5.1 Testing....................................................................................197 

 5.2 Training.................................................................................197 

 5.3 Migration................................................................................198 

 5.4 Success Measures......................................................................198 

6.0 Interactive Response Tool Evaluation Document.............................................201 

 6.1 San Luis Valley Region Exercise....................................................201 

 6.2 North Central Region Exercise.......................................................203 

 6.3 Evaluation Summary..................................................................210 

 6.4 Future Research................................................................................................210 

Appendixes 

 Appendix 4-A. Case/Contact Investigation Form..................................................211 

 Appendix 4-B. QI Monitoring Call Log...................................................... ..213 

 Appendix 4-C. DI Evaluation Form..............................................................217 

 Appendix 4-D. POD Evaluation Form...........................................................219 

 Appendix 4-E. FAQ Library Evaluation Form..................................................221 
106
107

1.0 Introduction 

 We used a project methodology-driven approach (illustrated in Figure 1) in developing this 

Interactive Response (IR) Tool. By adhering to best practices standards, this project methodology can 

save time, money, and resources by adhering to step-by-step processes from planning through 

evaluation to maximize benefit and minimize risk. Each phase of the project should result in 

documentation to adequately capture the knowledge exchange and most appropriate decisions. 

Planning Analysis Design Implementation Evaluation 

Figure 1. Project Methodology Phases 

 The following reviews the five phases and the strategies we employed in each to develop an IR 

solution for providing the most beneficial and efficient support for health call center services during 

public health emergencies. These IR solution requirements were largely formed from our call center 

experiences in responding to public health events and the types of services we anticipate being needed 

for responding to specific scenarios. This same project methodology can be utilized to replicate this IR 

solution and its applications within another call center environment, to adapt them to other scenarios, 

or to use similar applications with other technology or much reduced technology (such as developing 

call handling algorithms for use by call handling personnel). The importance of this tool and the IR 

solution described is to provide a framework for other health call centers to develop the needed 

capabilities for responding to events in their own communities. 
108

1.1 Planning Phase 

Planning Analysis Design Implementation Evaluation 

• Identify Business Goals and 

Objectives 

• Establish Selection or Steering 

Committee 

• Establish Project Team 

• Define Roles and Responsibilities 

• Conduct a Feasibility Study 

• Determine Resources Needed

 The planning phase identifies why a technology solution such as IR should be implemented and 

determines how the project team will implement it. During this phase, the system’s business value to 

the organization is identified (e.g. improve care, lower costs, increase profits). The problem or goal is 

defined as well as how the technology can serve as a solution for the problem. The goal(s) for the 

solution should align with the organization’s goals. A selection or steering committee is then 

established to represent the organization’s decision-makers and key stakeholders. This group 

ultimately makes the selection decision and provides oversight for integration of the new technology 

into the organization. A project team is established and is responsible for understanding the 

technology, knowing of any associated restrictions on it, understanding the impact of any decisions on 

other technology within the organization, making decisions for the overall good of the application of 

the technology, and becoming the key resource for the application once implemented. The project team 

manages all aspects of the project through the planning, analysis, design, implementation, and 

evaluation phases. A feasibility study guides the selection of the system by determining the 

opportunities and limitations of the proposed technology, whether its applications will address the 

identified problems and if the organization should proceed. The feasibility study also identifies the 

objectives of the system, costs, benefits, value of the system, and the scope of the project. The 

expected deliverable from the planning phase is the Planning Document (see Section 2 beginning on 

page 113). 
109

1.2 Analysis Phase 

Planning Analysis Design Implementation Evaluation 

• Answer Technology/System Questions 

o Who will use it? 

o What will it do? 

o Where will it be used? 

o When will it be used? 

• Focus Analysis on User Needs 

• Assess Current Systems, Improvement Opportunities & Needed New System 

Functions 

• Determine Functional Specifications

 The analysis phase answers the questions of who will use the technology/system, what capabilities 

it will have, and where and when it will be used. The project team assesses the current systems, 

identifies improvement opportunities, and determines the functions that the new technology/system is 

to perform. The focus of this phase is on the users of the technology/system and their needs. The 

project team determines functional specifications through conducting interviews and/or gathering data 

from planners, operations staff and end-users. The expected deliverable from the analysis phase is the 

Business and Functional Requirements (Analysis) Document (see Section 3 beginning on page 117). 

1.3 Design Phase 

Planning Analysis Design Implementation Evaluation 

• Determine Technology/System Software & Hardware 

Specifications 

• Determine User Interfaces 

• Determine Forms and Reports 

• Determine Needed Applications, Programs, Databases & Files 

• Use Existing Product or Design New Product

 The design phase determines how the technology/system will operate in terms of hardware, 

software, and within any network infrastructure; user interfaces, forms and reports; and the 

applications, programs, databases, and files needed. During this phase it is determined whether the 

technology/system will accomplish the work through either selecting an existing product or designing 
110

a new product. The expected deliverable from the design phase is the Design Document (see Section 4 

beginning on page 123).

 The Design Document contains four applications (inbound and outbound) that address specific 

capabilities that we determined would be needed during certain scenarios. These applications should 

increase efficiency and reduce personnel support for providing services to communities experiencing 

health emergencies: 

• Quarantine/Isolation (QI) Monitoring Application (outbound application). 

• Drug Identification (DI) Application (inbound application). 

• Point of Dispensing (POD) Application (inbound application). 

• Frequently Asked Question (FAQ) Library Application (inbound application). 

1.4 Implementation Phase 

Planning Analysis Design Implementation Evaluation 

• Build or Purchase Technology/System 

• Test Solution 

• Training Staff and Users 

• Develop Migration Plan which includes a 

conversion plan and change management plan 

• Develop Success Measures 

• Go Live

 The implementation phase includes building or purchasing the technology/system, testing and 

piloting it, training staff, migration into an active environment, and then going live. During this phase, 

the technology solution undergoes comprehensive testing by first the project team and then other users. 

This allows for both coarse and fine-tuning to validate that the design meets the requirements and 

objectives. The overall implementation plan is developed and followed, appropriate users are included 

in the process, realistic time frames are established, and communication is highlighted. Depending on 

the environment of your call center, you may want to consider utilizing change management strategies 

and training to create a positive environment for learning and change among the staff impacted by the 

implementation. In addition, criteria for measuring success will be developed. The expected 

deliverable from the implementation phase is the Implementation Document (see Section 5 beginning 

on page 195). 
111

1.5 Evaluation Phase 

Planning Analysis Design Implementation Evaluation 

• Describe and Assess Performance 

• Review & Discuss Results 

• Make Required Improvements

 The evaluation phase describes and assesses the overall performance of the technology/system 

once it has been piloted and used. An evaluation methodology is developed and the results are 

disseminated, reviewed, and discussed so that the feedback can be utilized for technology/system 

improvements. The expected deliverable from the evaluation phase is the Evaluation Document (see 

Section 6, beginning on page 201). 

 The Evaluation Document contains our experiences with testing the QI Monitoring Application in 

two instances: 1) a rural community exercise with an early version of the application, and 2) an urban 

area exercise with a more developed version of the application. Both exercises contributed to 

improvements of the application so that it is ready for actual usage in an emergency. 
112
113

 2.0 Interactive Response Tool Planning Document 

 The Health Emergency Line for the Public (HELP) pilot program in Colorado, established by the 

Rocky Mountain Regional poison center to provide information during bioterrorism and other public 

health emergencies, provides a model for disseminating and collecting information in health 

emergencies in partnership with a State health department. While developing better strategies and 

means for managing call volume surges without sacrificing customer care, we identified the following 

capabilities: 

• Respond to large influx of call volume during public health events. 

• Assist quarantined persons during health emergency events. 

• Assist health departments in distributing drugs in emergency events by providing the locations of 

dispensing centers. 

• Have a fixed footprint within our call center preventing the need to expand our physical space in 

responding to increased call volumes. 

• Increase our ability to respond rapidly to customer needs. 

• Fit into our operating budget without excessive increases in technology costs prior to and during an 

emergency or disaster. 

 Our key objective was to develop a model that community health call centers could implement to 

support outpatient health care and monitoring in a major public health event. 

2.1 System Business Value 

 Though the applications are intended for use during a disaster, we anticipate there will be ways to 

use the applications on a day-to-day basis. Any of the anticipated applications (drug identification, 

quarantine and isolation monitoring, etc.) could be adapted for non-emergency use. Because our center 

primarily provides services via the telephone, we are always looking for ways to be more efficient. 

Any way for us to more effectively and judiciously use personnel time, matching the right resource to 

the right need, is of benefit to our call center. Development of IR applications has the potential for 

freeing staff from information relating duties that could be automated (such as recordings of locations 

by entering zip codes) and allowing them to focus on tasks better suited to their training and expertise 

(such as assisting with clinical decision support of callers with health concerns). 

2.2 Goals 

 Our goal was to develop, implement, and test a model to enable call centers (such as poison control 

centers, nurse advice lines, and other hotlines) to support home management/shelter-in-place 

approaches in certain mass casualty or health emergency events. We developed strategies, protocols, 

and algorithms to respond to specific scenarios. We believe that the resulting applications can help us 
114

meet the goals of our mission without negatively affecting our customers. In order to both align with 

the organizational goals and achieve the desired business values, the solution must: 

• Address the pertinent issues related to a public health event. 

• Handle surges of call volumes without increasing our current physical facilities. 

• Assist with delivering services without minimal increases in staffing (especially during a health 

pandemic event). 

• Not adversely affect our customer service. 

2.3 Roles and Responsibilities 

 A steering committee must be selected that represents the organization’s decision-makers and key 

stakeholders. This committee ultimately makes the selection decisions and provides oversight for 

integration of the new technology into the organization. In order to make sure that the needs across our 

center were being met and that project merged with our existing technology, we chose the following 

responsibility areas to serve on the steering committee: 

Contracts, Finance, Call Center Administrative Director, Research Director, Poison Center Program 

Manager, HELP Supervisor, Business Technology Manager, Information Systems (IS) Manager, 

Telecommunications Engineer, and Project Manager. 

From this group a project team was selected (see list below) to manage all aspects of the project 

through the planning, analysis, design, implementation, and evaluation phases. Additionally, the 

project team had the following overall responsibilities: 

• Understanding the technology being researched and any associated restrictions. 

• Understanding the impact of any decisions on other technology within the organization. 

• Making decisions for the overall good of the application of the technology. 

• Becoming the key resource for the application of the technology once implemented. 

 Further specific responsibilities for each project team member are: 

Research Director 

• Principal Investigator—Has overall responsibility for seeing project through completion

Poison Center Program Manager 

• Key stakeholder—Assures project can integrate with established operations and meets business 

needs 

Business Technology Manager 

• Key stakeholder—Coordinates telecommunication/information systems services support and 

provides input regarding telephone programming, call management, and reporting 
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Project Manager 

• Assists Principal Investigator with managing all aspects of project, including coordination of pilot 

tests, documentation, and interface with technical staff 

Telecommunications Engineer 

• Coordinates information technology components of project, including vendor evaluation/selection 

process, ensuring the system conformation to our technology standards, testing and maintaining 

call routing, voice equipment, and related services 

Information Systems (IS) Manager 

• Primary contact for database and reporting support, ensures the system conforms to IS standards, 

coordinates IS support services 

Outside Technology Vendor 

• Understands the needs of the organization, its current infrastructure and resources, and provides a 

cost-effective technology solution with capability for modifications and refinements 

2.4 Objectives 

1. Implement IR solution applications within the budget and time table established. 

2. Identify and evaluate four important public health event scenarios that will serve as examples for 

utilization of IR technology applications. 

3. Identify the application requirements for each chosen scenario. 

4. Identify all processes and procedures necessary to incorporate into applications. 

5. Create call flow designs for the applications. 

6. Develop the beta versions of the applications. 

7. Create an implementation plan and testing strategies for the applications. 

8. Pilot test applications in up to two exercises. 

9. Review and evaluate testing results and modify applications accordingly. 

10. Complete all documentation of application development and testing. 

11. Provide health agencies with a tool that describes the process for developing and implementing an 

IR solution for managing needs of the public during health events, and provide guidance of how to 

utilize such a tool depending upon their available resources. 

2.5 Feasibility Analysis 

 A feasibility analysis guides the selection of the technology/system by determining the 

opportunities and limitations of the proposed technology, whether its applications will address the 

identified problems, and if the organization should proceed. The feasibility analysis also identifies the 

objectives of the system, its costs, benefits and value, and the scope of the project. We used a 

categorical scale (poor, fair, good, excellent) to judge our Information Technology departments’ 

familiarity with each of these feasibility components, as well as how well the system will ultimately be 

accepted by its users and incorporated into the ongoing operations of the organization with limited 

disruption. 
116

2.6 Resources and Timeline

Human 

Total project hours include exploring the problem, developing the applications, testing and refining 

the applications and then developing the tool for others to understand the process. Just application 

development or adaptation of the developed applications would take significantly less time. 

Hardware 

• Costs of hardware (for example, an IR system), if any. 

Application Development and Administration 

• Internal Information Technology (IT) Group—Administer new IR applications. 

• External IR Consultant—Develop IR applications and train IT group in their operations. 

Timeline for New Applications 

 The timeframes listed do not necessarily occur in series; many can be done concurrently while 

other milestones are in progress. There also may be delays between milestones due to other demands 

on the responsible person(s) and the resources they require to support them. The approximate times 

required for each of the five project phases are: 

• Planning – 4 weeks 

• Analysis – 2 weeks 

• Design – 4 weeks 

• Implementation – 34 weeks 

• Evaluation (Modification) – 16 weeks 

Note: In actuality, the evaluation phase including modifications begins during the implementation 

phase, continues through testing and is ongoing through operations based upon user experiences and 

feedback. 
117

3.0 Interactive Response Tool Business and Functional 

Requirements (Analysis) Document 

 Based upon our understanding of our call center’s interactive response (IR) technology, it has the 

ability to facilitate automated information dissemination and collection to callers using touch tone 

telephones. During a health emergency event it will likely be necessary to increase the ability to 

provide appropriate information to communities without the benefits of increased human resources. 

Therefore, we decided to explore the potential application of our IR system to assist us in responses to 

certain scenarios and the health needs we anticipate. We present this IR solution as a model that could 

efficiently and effectively handle surges related to certain public health emergencies, without 

compromising current medical information and triage advice services, for consideration. 

 The purpose of this section is to provide the business requirements and technical specifications for 

an IR solution and its applications as a model for other community health call centers. The information 

contained in this requirements document is an example of the steps that any call center would take to 

either replicate this IR solution within their technology environment or to adapt this solution for 

another purpose. This document should serve as a guide for determining the specific requirements and 

identifying key criteria to be applied towards the final design of an IR solution (hardware and/or 

applications). This document can also be used for determining specific requirements for nontechnology solutions for the same capabilities within a call center (such as development of call 

handling procedures for call center staff to provide the information). 

 This document is intended for medical or public health community call centers and their technical 

personnel. This document could be useful for public health agencies that may want to develop such 

capabilities for responding to events and it could assist them in discussions with their community 

health call centers partners. 

3.1 Business Requirements 

 Business requirements and benefits to be realized with the strategic deployment of the proposed IR 

solution and its applications are outlined below: 

• The IR solution must be capable of operating multiple applications based on the identified needs 

of the public in the event of a health emergency. This IR solution and its applications will 

address current gaps in response and preparedness efforts faced by many jurisdictions for 

meeting the increased surge capacity demands on the health care delivery system that terrorism, 

accidents, disease outbreaks, and natural disasters could cause. This IR solution should assist in 

providing the public with adequate information to make educated decisions about perceived 

health concerns via telephone, potentially lessening the demand for evaluations at health care 

facilities. 

• The implemented IR solution should support the following applications: 

o Point of Dispensing (POD) Application: The POD Application will disseminate 

information in a public health emergency to enable inbound callers to receive locations 

for drug dispensing sites specific to their county, based on the zip code that the caller 

enters. The callers dialing into the POD Application should be given clear directions 

from the menu messages to be able to repeat any message or the location of the drug 

dispensing sites. Callers should also be given a choice to select another zip code after 

getting information for their first entered zip code. The POD Application will be 
118

designed to accommodate two language selections (English and Spanish) that the caller 

will select at the beginning of the call. The POD Application will also provide reporting 

on how many callers selected each of the available message options. The POD 

Application will be required to have the ability to provide an individual message for 

each zip code within a county to allow for the greatest potential for relaying customized 

information. 

o Drug Identification (DI) Application: The DI Application will allow inbound callers to 

obtain self-service identification for the different appearances of antibiotic drugs that are 

being dispensed at POD sites during a public health emergency. The callers should be 

given clear directions from the menu messages and be able to repeat messages or 

descriptions of the identified drug. The caller should also have the ability to identify 

more than one drug appearance per call or to repeat messages. The application should 

have messages that refer callers to other resources if they cannot utilize the self-service 

application or the drug appearance is not included as an option (this could be modified to 

automatically transfer them to an information provider for assistance). This application 

will be designed to accommodate one language selection (English), however future 

programming changes may be needed for additional language selections that the caller 

will select at the beginning of the call (just as with the other three applications). The DI 

Application will also provide reporting on how many callers selected each of the drug 

identification options. The DI Application should be able to accommodate options for all 

expected antibiotic drug appearances that are to be distributed. 

o Quarantine/Isolation (QI) Monitoring Application: The QI Monitoring Application 

should have the capability to automatically place outbound calls to individuals in home 

quarantine/isolation to assess their current health status. The directions given to the 

quarantined person by the application should be clear the person should have the ability 

to repeat a message. The application will be designed to accommodate two language 

selections (English and Spanish) that the call recipient will select at the beginning of the 

call. The application will call the quarantined person at specified time periods, provide 

them messages identifying the purpose of the call, require them to select an option that 

reflects their current health status (transferring them to an information provider for 

assistance if needed) and provide them information about who to call if assistance is 

needed before the next monitoring call. If a person does not answer a call upon the first 

attempt, the application will initiate a second call attempt within a defined time period. If 

the second call attempt goes unanswered, the application will flag this person as noncompliant. The QI Monitoring Application will also provide reports on compliance so 

follow ups can be made by appropriate agencies. 

o Frequently Asked Question (FAQ) Library Application: The FAQ Library Application 

will disseminate up-to-date, consistent and accurate information approved by health 

department epidemiologists to the public and health care providers from a searchable 

library of FAQs. Callers dialing into this application should be able to select desired 

information with discernable directions from the application including maneuverability 

throughout the menus. Also callers should have the ability to select an option to speak 

with an Information Provider, if needed. The application will provide reports on how 

many callers selected all message options. 
119

• The IR solution and its applications should be implemented without affecting daily patient care 

business. 

• The IR solution should be implemented with adequate trunking capacity (call volume capacity) 

incorporated; thus minimizing delay to disseminate information to the general public. The key 

to handling call surges effectively during a health emergency is that consistent and accurate 

information be disseminated to inform the greatest number of callers with minimal staffing 

levels. 

• The IR solution should be implemented such that the telephone switch (e.g. for our center an 

Avaya S8700 PBX) is the primary contact point to the public switched telephone network 

(PSTN). This configuration allows the proper resource to handle the call most effectively and 

thereby benefits from the other call handling capabilities of the telephone switch. 

3.2 Functional Requirements 

 The following functional requirements have been identified for an IR solution within our call 

center infrastructure. It is not necessary that other call centers create an IR solution with all the same 

specifications, but we recommend considering them in the development process. 

Technical Specifications 

 The proposed IR solution was developed and implemented using the following hardware and 

software: 

Platform 

• Avaya IR version 2.0 on a Sun Microsystems Blade 150 running Solaris UNIX software. 

• Real Speak version on separate windows server Dell Power-Edge 2850 Intel Xeon Processor at 2.8 

GHZ/2MB Cache; Operating System = Windows Server 2003 R2 Standard Edition. Memory= 

1GB DDR2 400MHz. 

o The Real Speak solution will be used in future application modifications to have the IR play 

back to caller text file as speech, utilizing licensed channels to provide 6 simultaneous 

instances of either English or Spanish text-to-speech connections. 

• Microsoft SQL 2000 is used to create tables for the IR to access for either playing back text records 

in voice or pulling records from tables directing the IR to call phone numbers. The IR also updates 

tables on the SQL server with record status for reporting purposes. 

Diagram of the implemented IR solution is shown below: 
120

P o in t to P o in t T 1

(2 4 c h a n n e ls )

A v a y a IR

V e rs io n : 2 .0 

Avaya S8700

C M 2 .0

Four T 1s

(9 6 c h a n n e ls )

T e x t T o S p e e c h S e rv e r

W ith R e a l S p e a k

LAN

D a ta

LAN

M ic ro s o ft S Q L 2 0 0 0

D a ta

L o c a l/L o n g D is ta n c e 

N e tw o rk C lo u d

Integration 

• The IR solution should be capable of integrating with existing telephone switch. 

 

• The IR solution should be capable of integrating within existing LAN and allow more than one 

user to log into the system at a time. 

• The IR solution should have the ability to operate multiple applications simultaneously (POD, DI, 

QI Monitoring and FAQ Library applications) without compromising current call traffic. 

• This IR solution should be “self-contained” and easy to administer. 

Functionality 

• The IR solution should be capable of a minimum of 24 T1 channels and should have the flexibility 

to expand to 96 channels without the need of purchasing another IR system (expandability of the 

IR system should be cost effective). 

 

• The IR solution should have the ability to organize, backup, and save applications and operating 

system files to the LAN as well as to external media for off-site storage. 

• The IR solution should have an easy reporting method to retrieve calls from a given application in 

a fast and efficient manner. Search criteria are items such as, but not limited to which application 

was selected by caller, call center the call may flow out to, date of call, time of call, and duration of 

call. 

• The IR solution should be a validated system. All documentation of the systems operations should 

be proven to work PRIOR to the installation of said system as well as afterwards. Furthermore, the 

system should not lose archived recorded announcements. Refer to the following link for questions 

regarding validated system: http://www.fda.gov/cdrh/comp/guidance/938.pdf. 
121

• The IR solution should have alarm and alarm reporting capabilities such as (but not limited to) 

audible alarms, e-mail notification, dialing out for assistance (SOS System), and 24 X 7 

service/support. 

• The IR solution should have built-in redundancy such that no information is lost during an alarm or 

if a system failure event were to occur. 

• The IR solution should be capable of unique login identification along with the capability of user 

rights (allowing only certain access to system for some logins and more access for other logins - 

allowing running of multiple applications). 

• The IR solution should have an audit mechanism to track of who has logged into system and their 

actions which ideally can be printed out or exported to a file (HIPAA Compliance). 

• The IR solution should be compatible with current LAN and System Applications (implementing 

this solution should not cause other Windows-based applications to fail). 

Performance 

• The IR solution should be capable of meeting the Telecommunications Standard of five nine 

availability; the system must be fully functional 99.999 percent of the time, maintenance time 

excepted. 

• The IR solution should be capable of having more than one user logged into the system for 

listening to or modifications to applications from different channels at the same time. 

• The IR solution should be capable of operating multiple different applications in different call 

centers using different criteria; flexibility for changing business needs. 

• The IR solution should be capable of archiving and retrieving records for future research in an 

efficient manner. 

• The IR solution should have reporting capabilities with standard output formats that allow for 

sharing without special software. 

Scalability 

• The IR system should have built-in capacities for additional applications and other “Right to Use” 

ports that may be required for further expansion (such as speech-to-text or speech recognition). 

Ease of Use 

• The IR solution should be easy to use and maintain for both day-to-day monitoring as well as 

implementing new applications to serve evolving business needs. It is strongly suggested that the 

system be capable of rapidly receiving changes to announcements or a specific application in order 

to meet the changing needs during an emergency. Furthermore, the administrators of this system 
122

must have the capability of monitoring the progress of said changes to ensure that needs are being 

met. 

• The vendor of the IR solution should provide on-site training for systems administrators as well as 

on-site training for all initial users of the IR solution. Training will empower systems 

administrators to operate and maintain the system and its applications and to explore their 

adaptation for other uses. User training will empower supervisors and call center management to 

run reports as well as collect and review data from caller interactions with applications to analysis 

operational effectiveness. 

Security 

• The IR system should be capable of segmenting users to certain levels of access within the system 

including ability to set up user objects/rights. 

• The IR solution should integrate with current Windows security user objects within the LAN. 

Manageability 

• Ideally, a call center would have the ability to perform remote administration duties on the IR 

solution in case staff members cannot physically access the facility; the solution should have the 

ability to allow technicians to remotely access the device and manage all functions as if physically 

at facility. 
123

4.0 Interactive Response Tool Design Document 

 We chose to use the Department of Homeland Security’s National Planning Scenarios to assure 

consistency with other preparedness and response efforts that are being developed. While these 

scenarios do not cover all possibilities for health emergencies, they do include a wide spectrum of 

disasters that communities could face. Though there are many other potential disaster scenarios that 

have been developed, these scenarios have been developed in a very structured manner and with 

participation of numerous Federal agencies. 

 We reviewed all 15 scenarios and determined which could benefit from utilization of the potential 

response capabilities of community health call centers. We then developed a matrix that lists each 

scenario including expected casualties, infrastructure damage, evacuation/displacement of persons, 

sheltering and victim care strategies. In addition, we determined the necessary potential community 

health call center responses. The six potential response capabilities for community health call centers 

include providing health information, disease surveillance, triage/decision support, quarantine/isolation 

support, outpatient drug information/adverse event reporting and mental health issues. 

 We decided to focus our model development on scenarios that: involved great health impacts, had 

potential for many “worried well” (those with little or no injury that could overwhelm health systems), 

could benefit from home management/sheltering in place strategies, and included intact community 

infrastructure so that call centers would be able to operate. It was determined that the four biological 

related scenarios (Biological Attack – Aerosol Anthrax, Biological Disease Outbreak – Pandemic 

Influenza, Biological Attack – Plague, Biological Attack – Food Contamination) afforded the 

opportunity to involve all six potential response capabilities for community health call centers. 

 The resulting applications are for Quarantine and Isolation (Q/I) Monitoring, Drug Identification 

(DI), Point of Dispensing (POD), and Frequently Asked Questions (FAQ) Library. 

4.1 Quarantine/Isolation Monitoring Application 

 The QI Monitoring Application should have the capability to automatically place outbound calls to 

individuals in home quarantine/isolation to assess their current health status. The directions given to 

the quarantined person should be clear and the person should have the ability to repeat a message. The 

application will be designed to accommodate two language selections (English and Spanish) that the 

call recipient will select at the beginning of the call. The application will call the quarantined person at 

the specified time periods, provide messages identifying the purpose of the call, require the person to 

select an option that reflects their current health status (transferring them to an information provider for 

assistance if needed), and provide information about who to call if assistance is needed before the next 

monitoring call. If a person does not answer a call upon the first attempt, the application will initiate a 

second call attempt within a defined time period. If the second call attempt goes unanswered, the 

application will flag this person as non-compliant. The QI Monitoring Application will also provide 

reports on compliance to further follow-ups can be made by appropriate agencies. Future scope 

changes will include ability to dial out 12,000 calls during a ten-hour period (requiring ten 

simultaneous outbound calls on IR). 

 The following application was the results of modifications following exercises with the San Luis 

Valley Region Exercise, October 2005 and the North Central Region Exercise, May 2006. 
124

Initiate Application 

CallStatus 

= “N” or 

“R” ?

Read Record CallStatus

Application Data Flow

Get Next Record

(see Call Record Table)

Read Record CallStatus

All 

Records 

Called?

NEXT RECORD

QUIT

Yes

No

No

Go To

CALL_OUT

Page 2

CallCount 

> 1

Set CallCount = 0

CallCount = 

CallCount + 1

Yes

No

SLEEP 15 Minutes

Yes

NOTE: Each record will have 

a CallStatus of the following:

N = Not Called

A = Answered by Person

R = Retry

H = House Call Required

D = DNR (Done)

Yes
125

Update Record in Table 

with

CallCount & CallStatus

Dial 

<PhoneNumber>

Greeting Announcement 5000: “This is 

the Quarantine Monitoring System. 

Mensaje. For English, press 1. Para 

Espanol, marke el 2.”

Answered?

Set CallStatus = “R”

Set CallStatus = “A”

Disconnect Call

CALL_OUT

Go To

NEXT 

RECORD

Page 1

No

Yes

 or other digit

2 If no entry 

repeat 

5000 twice

Yes

ENGLISH

SPANISH

CallCount 

< 2 ?

Set CallStatus = “H”

No

No 

Response

And Time 

Out

2 #

Set CallStatus = “D”

1

Transfer to HELP 

Information Providers

5006 – “Please hold 

while we connect your 

call to the HELP 

Information Providers. 

They will collect 

information about your 

elevated temperature 

and any other 

symptoms you may be 

experiencing.

5002 – “If you need any 

assistance or would like to speak 

with an Information Provider 

please press 1. Otherwise, thank 

you for your participation in the 

regional quarantine program. 

Your compliance ensures the 

health of those around you. If you 

need assistance in the future, 

please call HELP directly at 1-

800-XXX-XXXX. Good Bye.” 

3

Transfer to HELP 

Information Providers

5017 – “Please hold 

while we connect your 

call to the Information 

Providers. They will 

assist you with any 

temperature reading 

issues.”

Set CallStatus = 

“D”

Transfer to HELP 

Information Providers

Set CallStatus = 

“D”

1

HELP Announcement (English) 5013:

“This is HELP contacting <name> during your 

quarantine period. When placed in quarantine, 

you were requested to take your temperature 

every 12 hours. Please locate your most recent 

temperature reading.” 

Temp Menu Announcement (English) 5014:

“If your temperature is 100 degrees or above, 

please press 1. If your temperature is less than 

100 degrees, please press 2. If you do not have 

your temperature reading or cannot take your 

temperature, please press 3. To repeat this 

message press #.”

Hang Up Call

Begin 

Spanish Call 

Flow

 Page 3

1

QI Main Call Flow (English)

Nothing 

Pressed

Please note if the CallStatus = R, 

the application will call back in 15 

minutes.

Page 2

NOTE: Each record will have

a CallStatus of the following:

N = Not Called

A = Answered by Person

R = Retry

H = House Call Required

D = DNR (Done)
126

Set CallStatus = “A”

QI 2nd Language Call Flow (Spanish)

NOTE: All messages are the 

same as for English but 

recorded in Spanish

Page 3

NOTE: Each record will have 

a CallStatus of the following:

N = Not Called

A = Answered by Person

R = Retry

H = House Call Required

D = DNR (Done)

Begin 

Spanish Call 

Flow

HELP Announcement (Spanish) 5013:

“This is HELP contacting <name> during your 

quarantine period. When placed in quarantine, 

you were requested to take your temperature 

every 12 hours. Please locate your most recent 

temperature reading.” 

Temp Menu Announcement (Spanish) 5014:

“If your temperature is 100 degrees or above, 

please press 1. If your temperature is less than 

100 degrees, please press 2. If you do not have 

your temperature reading or cannot take your 

temperature, please press 3. To repeat this 

message press #.”

Update Record in Table 

with

CallCount & CallStatus

Set CallStatus = “R”

Disconnect Call

Go To

NEXT 

RECORD

Page 1

Yes CallCount 

< 2 ?

Set CallStatus = “H”

No

No 

Response

And Time 

Out

# 2

Set CallStatus = “D”

1

Transfer to HELP 

Information Providers

5006 – “Please hold 

while we connect your 

call to the HELP 

Information Providers. 

They will collect 

information about your 

elevated temperature 

and any other 

symptoms you may be 

experiencing.

5002 – “If you need any 

assistance or would like to speak 

with an Information Provider 

please press 1. Otherwise, thank 

you for your participation in the 

regional quarantine program. 

Your compliance ensures the 

health of those around you. If you 

need assistance in the future, 

please call HELP directly at 1-

800-XXX-XXXX. Good Bye.” 

3

Transfer to HELP 

Information Providers

5017 – “Please hold 

while we connect your 

call to the Information 

Providers. They will 

assist you with any 

temperature reading 

issues.”

Set CallStatus = 

“D”

Transfer to HELP 

Information Providers

Set CallStatus = 

“D”

1

Hang Up Call

Nothing 

Pressed

Please note if the CallStatus = R, 

the application will call back in 15 

minutes.
127

Announcements

Greeting Announcement 5000: "This is the Quarantine Monitoring System. Mensaje. For 

English, press 1. Para Espanol, marke el 2."

HELP Announcement 5013: "This is HELP contacting <name> during your quarantine period. 

When placed in quarantine, you were requested to take your temperature every 12 hours. 

Please locate your most recent temperature reading." 

Temp Menu Annoucement 5014: "If your temperature is 100 degrees or above, please press 1. 

If your temperature is less than 100 degrees, please press 2. If you do not have your temperature 

reading or cannot take your temperature, please press 3. To repeat this message press #."

Temperature >100 Announcement 5006: "Please hold while we connect your call to the HELP 

Information Providers. They will collect information about your elevated temperature and any 

other symptoms you may be experiencing."

Temperature <100 Announcement 5002: "If you need any assistance or would like to speak 

with an Information Provider please press 1. Otherwise, thank you for your participation in the 

regional quarantine program. Your compliance ensures the health of those around you. If you 

need assistance in the future, please call HELP directly at 1-800-XXX-XXXX. Good Bye." 

Transfer to Information Provider Announcement 5017: "Please hold while we connect your 

call to the Information Providers. They will assist you with any temperature reading issues."

Page 4

NOTE: All messages should be recorded for both English and other language (Spanish)
128

Call Record Table (Example)

CallCount Name PhoneNumber CallStatus

0 John Doe 5555551234 N

0 Jane Smith 5555557890 N

0 Pete Black 5555553456 N

0 Kelly Green 5555552345 N

0 Jack Black 5555557654 N

0 Bill Blue 5555553465 N

0 Nancy White 5555550098 N

Record Table file is loaded into database before each calling period. 

SQL Table format for Quarantine (csv):

“<CallCount>”,”<Name>”,”<PhoneNumber>”,”<CallStatus>”

CallCount Name PhoneNumber CallStatus

1 John Doe 5555551234 D

1 Jane Smith 5555557890 D

1 Pete Black 5555553456 D

1 Kelly Green 5555552345 D

1 Jack Black 5555557654 D

1 Bill Blue 5555553465 R

1 Nancy White 5555550098 R

After 1st run thru Table, everyone except Bill and 

Nancy answered call and provided a response

CallCount Name PhoneNumber CallStatus

1 John Doe 5555551234 D

1 Jane Smith 5555557890 D

1 Pete Black 5555553456 D

1 Kelly Green 5555552345 D

1 Jack Black 5555557654 D

2 Bill Blue 5555553465 D

2 Nancy White 5555550098 H

After 2nd run thru Table, Bill answered and provided 

a response but Nancy did not

Report would be generated that indicates that Nancy 

requires a house call, and the other 6 people are 

being successfully monitored by application

Page 5
129

4.2 Drug Identification (DI) Application 

Drug Identification (DI) 

Application Contents

DI Main Call Flow (English) 1 

CIPRO Flow 2

LEVA Flow 3

DOXY Flow 4

DOXY Cap Flow 5

DOXY Tab Flow 6

General and Ciprofloxacin Announcements 7

Levaquin and Doxycycline Announcements 8

Introduction 

 The DI application will allow inbound callers to obtain self-service identification for the different 

appearances of antibiotic drugs that are being dispensed at POD sites during a public health emergency. 

The callers should be given clear directions from the menu messages and be able to repeat messages or 

descriptions of the identified drug. The caller should also have the ability to identify more than one drug 

appearance per call or to repeat messages. The application should have messages that refer callers to other 

resources if they cannot utilize the self-service application or the rug appearance is not included as an 

option (if it could be modified to automatically transfer them to an information provider for assistance). 

This application will be designed to accommodate one language selection (English). However, future 

programming changes may be need for additional language selections that the caller will select at the 

beginning of the call (just as with the other three applications). The DI application will also provide 

reporting on how many callers selected each of the drug identification options. The DI application should 

be able to accommodate options for all expected antibiotic drug appearances that are to be distributed.
130

DI Main Call Flow (English)

Toll-Free #: 800-XXX-5029

Greeting Announcement 5000: “Thank you for calling the Pill Identification Line.”

Page 1

2

Pill Imprint Menu Announcement 5020: “Does your pill have an imprint or some 

writing on it? Please press 1 for yes or 2 for no.”

1 2

Cipro, Levaquin, Doxy Menu Announcement 5004: “If your pill is 

imprinted on one side with the letters C-I-P-R-O please press 1.....L-E-VA-Q-U-I-N, please press 2......another imprint, please press 3.”

Not One of the Pills Announcement 5018:

“This pill doesn’t fit the description of the 

medications that are currently being 

distributed..... Goodbye.”

Hang Up

Greeting Announcement 5000: “Thank you 

for calling the Pill Identification Line.” 1 3

CIPRO 

FLOW

LEVA 

FLOW

DOXY 

FLOW

Main 

Menu

Intro Announcement 5001: “This automated pill Identification service is only 

intended for the medications being distributed in your community for ..........” No Selection

If no entry repeat 5020 

twice

No Selection

If no entry repeat 5004 

twice
131

CIPRO Flow

Cipro Announcement 5006: “You have indicated your pill has the imprint C-I-P-RO...........For dosing information, please press 1. For side effects, please press 2. 

To return to the main menu, please press 9”

Cipro Dosing Announcement 5023:

“Adults need to take 1 Cipro tablet 

every 12 hours......... “ 

Page 2

1

No Selection

9

To Repeat Announcement 5002: “To repeat 

this message press #, to return to the main 

menu, press 9.”

2

#

Cipro Side Effects Announcement 5029:

“Side effects for Cipro include upset 

stomach, vomiting, ..... “ 

9

Hang Up

#

Main 

Menu

Not One of the Pills Announcement 5018:

“This pill doesn’t fit the description of the 

medications that are currently being 

distributed..... Goodbye.”

Greeting Announcement 5000: “Thank 

you for calling the Pill Identification Line.”

If no entry repeat 5006 

twice

No Selection If no entry repeat 5002 

twice

Main 

Call 

Flow
132

LEVA Flow

Levaquin Announcement 5008: “You have indicated your pill has the imprint L-EV-A-Q-U-I-N...........For dosing information, please press 1. For side effects, 

please press 2. To return to the main menu, please press 9”

Levaquin Dosing Announcement 5021

“Adults need to take 1 Levaquin tablet 

every 24 hours.....“ 

Page 3

1

No Selection

9

To Repeat Announcement 5002: “To repeat 

this message press #, to return to the main 

menu, press 9.”

2

#

Levaquin Side Effects announcement 5030

“Side effects for Levaquin include diarrhea, 

nausea, headache..... “ 

#

9

Main 

Menu

Hang Up

Not One of the Pills Announcement 5018:

“This pill doesn’t fit the description of the 

medications that are currently being 

distributed..... Goodbye.”

Greeting Announcement 5000: “Thank 

you for calling the Pill Identification Line.”

If no entry repeat 5008 

twice

No Selection If no entry repeat 5002 

twice

Main 

Call 

Flow
133

DOXY Flow

Page 4

1

Doxycycline Menu Announcement 5009: “Is your pill a blue, oblongshaped capsule with either .........Press 1 for yes or press 2 for no.”

2

Hang Up

2

1

Doxycycline Menu Announcement 5012:

“Is your pill a brownish, round-shaped 

tablet.......Press 1 for yes or press 2 for no.”

No Selection If no entry repeat 5009 

twice

Not One of the Pills Announcement 5018:

“This pill doesn’t fit the description of the 

medications that are currently being 

distributed..... Goodbye.”

Greeting Announcement 5000: “Thank you 

for calling the Pill Identification Line.”

DOXY 

Cap 

Flow

DOXY 

Tab 

Flow

No Selection

If no entry repeat 5012 

twice

Main 

Call 

Flow
134

DOXY Cap Flow

Doxycycline Blue Menu Announcement 5011: “You have indicated your pill is a 

blue oblong-shaped capsule........For dosing information, please press 1. For side 

effects, please press 2. To return to the main menu, please press 9”

Doxycycline Dosing Announcement 5015:

“Adults need to take 1 doxycycline capsule 

every 12 hours as directed..... “ 

P

1

age 5

2 9

#

Doxycycline Side Effects Announcement 5016:

“Side effects for doxycycline include upset 

stomach, vomiting, diarrhea,..... “ 

9

Hang Up #

Main 

Menu

No Selection If no entry repeat 5011 

twice

Not One of the Pills Announcement 5018:

“This pill doesn’t fit the description of the 

medications that are currently being 

distributed..... Goodbye.”

Greeting Announcement 5000: “Thank you 

for calling the Pill Identification Line.”

To Repeat Announcement 5002: “To repeat 

this message press #, to return to the main 

menu, press 9.”

DOXY 

Flow

No Selection If no entry repeat 5002 

twice
135

DOXY Tab Flow

Page 6

1

No Selection

9

2

#

9

#

Main 

Menu

Doxycycline Brown Menu Announcement 5013: “You have indicated your pill is a 

brown round-shaped tablet......For dosing information, please press 1. For side 

effects, please press 2. To return to the main menu, please press 9”

DOXY 

Flow

Doxycycline Dosing Announcement 5015:

“Adults need to take 1 doxycycline capsule 

every 12 hours as directed..... “ 

Doxycycline Side Effects Announcement 5016:

“Side effects for doxycycline include upset 

stomach, vomiting, diarrhea,..... “ 

To Repeat Announcement 5002: “To repeat 

this message press #, to return to the main 

menu, press 9.”

No Selection If no entry repeat 5002 

twice

Hang Up

If no entry repeat 5011 

twice

Not One of the Pills Announcement 5018:

“This pill doesn’t fit the description of the 

medications that are currently being 

distributed..... Goodbye.”

Greeting Announcement 5000: “Thank you 

for calling the Pill Identification Line.”
136

Greeting Announcement 5000: “Thank you for calling the Pill Identification Line.” 

Intro Announcement 5001: “This automated pill identification service is only intended for the medications being 

distributed in your community for illness prevention by public health agencies. In order for you to use this service, you 

must have the pill in front of you. You will need to read the letters and numbers on the pill and answer a few questions. 

If you cannot read the letter and numbers on the pill yourself, please have someone assist you with this before 

proceeding. This service cannot help you identify other medications. For identification of other medications, you should 

hang up and contact your local pharmacy or poison center.” 

Pill Imprint Menu Announcement 5020: “Does your pill have an imprint or some writing on it? Please press 1 for yes 

and 2 for no.”

Not One of the Pills Announcement 5018: “This pill does not fit the description of the medications that are currently 

being distributed for illness prevention. Please contact your pharmacist or poison center for further assistance. Good 

Bye.” 

Cipro, Levaquin, Doxy Menu Announcement 5004: “If your pill is imprinted on one side with the letters C-I-P-R-O, 

please press 1. If your pill is imprinted on one side with the letters L-E-V-A-Q-U-I-N, please press 2. If your pill has 

another imprint, please press 3.”

Page 7

Cipro Announcement 5006: “You have indicated that your pill has the imprint C-I-P-R-O. Your pill is an antibiotic 

called Cipro. For dosage Information, please press 1. For side effects, please press 2. To return to the main menu, 

please press 9.”

Cipro Side Effects Announcement 5029: “Side effects for Cipro include upset stomach, vomiting, diarrhea, fatigue, 

dizziness or headache. If you have problems with any of these symptoms, tell your doctor. Less common side effects

include pain in arms or legs, changes in vision, restlessness, ringing in the ears, or mental changes. If any

of these symptoms occur, call your doctor right away. Severe allergic reactions are very rare. Signs of an allergic 

reaction include rash, itching, swelling of the tongue, hands or feet, fever, or trouble breathing. If any of these symptoms 

occur, call your doctor right away.”

Cipro Dosing Announcement 5023: “Adults need to take 1 Cipro tablet every 12 hours as directed. A child’s dose 

depends on body weight. Give the medicine to your child as directed by the doctor. It is best to take Cipro 2 hours 

before or after a meal with at least one large glass of water. However, if an upset stomach occurs, Cipro may be taken 

with food. Avoid dairy products such as milk and yogurt for at least 3 hours before and after taking the medicine. If you 

take vitamins or antacids such as Tums or Maalox, take them 6 hours before or 2 hours after taking Cipro. If you miss a 

dose, start again taking one tablet every 12 hours. Do not take 2 pills to make up for the missed dose. Finish all your 

pills, even if you feel okay, unless your doctor tells you to stop. If you stop taking this medicine too soon, you may 

become ill.”

To Repeat Announcement 5002: “To repeat this information, please press the # sign. To return to the main menu, 

please press 9.” 

General & Ciprofloxacin Announcements 
137

Levaquin Dosing announcement 5021: “Adults need to take 1 Levaquin tablet every 24 hours as directed. Safety of 

Levaquin in children has not been established and therefore should only be used for children under the direction of your 

doctor. Take Levaquin with or without food, but avoid taking Levaquin within two hours of taking antacids like Tums or 

Maalox, iron tablets, zinc, ulcer medications like Sucralfate or the antiretroviral medication Videx. If you are diabetic, 

please consult your doctor before taking Levaquin. Pregnant or breastfeeding women should consult their doctor before 

taking Levaquin. If you miss a dose, start again taking 1 pill every 24 hours. Do not take 2 pills to make up for the 

missed dose. Finish all your pills, even if you feel ok, unless your doctor tells you to stop. If you stop this medication 

too soon, you may become ill.”

 Levaquin Side Effects Announcement 5030: “Side effects for Levaquin include diarrhea, nausea, headache, muscle 

aches, blurred vision, heartburn, and constipation. Serious side effects include high or low blood sugar or allergic 

reactions. If any of these symptoms occur, contact your doctor right away.”

Page 8

Levaquin Announcement 5008: “You have indicated that your pill has the imprint L-E-V-A-Q-U-I-N. Your pill is an 

antibiotic called Levaquin. For dosage Information, please press 1. For side effects, please press 2. To return to the 

main menu, please press 9.”

Levaquin & Doxycycline Announcements 

Doxycycline Side Effects Announcement 5016: “Side effects for doxycycline include upset stomach, vomiting, or 

diarrhea. If you have problems with any of these symptoms, tell your doctor. Less common side effects include dark 

urine, yellowing of the eyes or skin, sore throat, fever, unusual bleeding or bruising, fatigue, white patches in the 

mouth. If any of these symptoms occur, call your doctor right away. Allergic reactions to doxycycline are rare. Signs of 

an allergic reaction are rash, itching, swelling of the tongue, hands or feet, fever, and trouble breathing. If any of these 

symptoms occur, call you doctor right away.”

Doxycycline Dosage Announcement 5015: “Adults need to take 1 doxycycline tablet every 12 hours as directed. A 

child’s dose depends on body weight. Give the medicine to your child as directed by the doctor. Take doxycycline with 

food and at least one full glass of water. Avoid taking antacids (like Tums or Maalox), cholestyramine (like Questran), 

colestipol (like Colestid), dairy products (like milk or yogurt) or vitamins 3 hours before or after taking doxycycline. If 

you miss a dose, start again taking 1 pill every 12 hours. Do not take 2 pills to make up for the missed dose. Finish all 

your pills, even if you feel okay, unless your doctor tells you to stop. If you stop this medication too soon, you may 

become ill.”

Doxycycline Blue Menu Announcement 5011: “You have indicated your pill is a blue oblong-shaped capsule with 

either Z-2-9-8-5 or D-A-N-5-4-4-0 printed on it. This pill is an antibiotic called doxycycline. Doxycycline is spelled D-OX-Y-C-Y-C-L-I-N-E. For dosage information, please press 1. For side effects, please press 2. To return to the main 

menu, please press 9.”

Doxycyline Menu Announcement 5012: “Is your pill a brownish, round-shaped tablet with either “Z-3-6-2-6” or “D-AN-5-5-5-3” printed on it? Press 1 for yes or press 2 for no.”

Doxycycline Menu Announcement 5009: “Is your pill a blue, oblong-shaped capsule with either “Z-2-9-8-5” or “D-A-N5-4-4-0” printed on it? Press 1 for yes or press 2 for no.”

Doxycycline Brown Menu Announcement 5013: “You have indicated your pill is a brown round-shaped tablet with 

either Z-3-6-2-6 or D-A-N-5-5-5-3 printed on it. This pill is an antibiotic called doxycycline. Doxycycline is spelled D-OX-Y-C-Y-C-L-I-N-E. For dosing information, please press 1. For side effects, please press 2. To return to the main 

menu, please press 9.”
138

4.3 Point of Dispensing (POD) Application

 The Point of Dispensing (POD) application will disseminate information in a public health 

emergency to enable inbound caller to receive locations for drug dispensing sites specific to their 

county, based on the zip code that the caller enters. The callers dialing into the POD application should 

be given clear directions from the menu messages to be able to repeat any message or the location of 

the drug distribution sites. Callers should also be given a choice to select another zip code after getting 

information for their first entered zip code. The POD application will be designed to accommodate two 

language selections (English and Spanish) that the caller will select at the beginning of the call. The 

POD application will also provide reporting on how many callers selected each of the message options. 

The POD application will be required to have the ability to provide an individual message for each zip 

code within a county to allow for the greatest potential for relaying customized information.
139

POD Main Call Flow (English)

Toll-free #: 800-XXX-5028

Greeting Announcement: (English/Spanish) 5026 – “Thank you for calling the 

Point of Distribution Assistance Line.” 5027 – “To proceed in English, press 1. To 

proceed in Spanish, please press 2.”

Zip Code in 

Table?

Y

Collect 5 Digit Zip Code after Announcement (English) 5028

“This is an automated service to identify how to obtain the medications 

currently being dispensed.....please enter your five digit zip code.“ 

Page 1

Out of Area Zip Code Announcement 

(English) 5024:

“The zip code you have provided is not within 

the affected area ...” Caller is prompted to 

hang up unless they need to speak to an 

Information Provider.

See Zip Code Table, Cross County 

Announcements (English) XXXX: 

"You have entered a zip code which crosses 

into more than one county. If you live in ....." 

1

See POD Messages by County 1 or 2 

(English) xxxx:

Specific In Area Zip Code Announcement (English) 

5022: 

“The zip code you have provided is within the affected 

area...” 

Await entry of five 

digit zip code

N

Does Zip Code 

cross into more 

than 1 county?

Y

N

Check Zip 

Code (See Zip 

Code Table) 

If no entry repeat 5028 twice, then 5007 - “Sorry 

we can no longer process your call, good bye.”

No Selection

If no entry repeat 5026 & 5027 

twice, then 5011 - “You will need to 

speak to an information provider”, 

then 5002 - “Please hold while I 

transfer your call”

No Selection

Route Call to 

Information 

Provider

Hang Up

2

Route Call to 

Information Provider

Hang Up

5035 - “To repeat this message press #, to 

enter a new zip code press 9.” If no selection, 

repeat 5035 twice, then 5004 – “Thank you 

for calling. Goodbye.”

#

9

Pg 2

Out of Area Zip Code Announcement (English) 

5024:

“The zip code you have provided is not within the 

affected area ...” Caller is prompted to hang up unless 

they need to speak to an Information Provider.

In Area

Out of Area

Route Call to 

Information Provider
140

POD 2nd Language Call Flow (Spanish)

Page 2

Y

From Pg 1

Spanish 

route

NOTE: All messages are the same 

as for English but recorded in 

Spanish

Zip Code in 

Table?

Y

Collect 5 Digit Zip Code after Announcement (Spanish) 5028

“This is an automated service to identify how to obtain the medications 

currently being dispensed.....please enter your five digit zip code.“ 

Out of Area Zip Code Announcement 

(Spanish) 5024:

“The zip code you have provided is not within 

the affected area ...” Caller is prompted to 

hang up unless they need to speak to an 

Information Provider.

See Zip Code Table, Cross County 

Announcements (Spanish) XXXX: 

"You have entered a zip code which crosses 

into more than one county. If you live in ....." 

See POD Messages by County 1 or 2 

(Spanish) xxxx:

Specific In Area Zip Code Announcement (Spanish) 

5022: 

“The zip code you have provided is within the affected 

area...” 

Await entry of five 

digit zip code

N

Does Zip Code 

cross into more 

than 1 county?

N

Check Zip 

Code (See Zip 

Code Table)

If no entry repeat 5028 twice, then 5007 - “Sorry 

we can no longer process your call, good bye.”

No Selection

Hang Up

Route Call to 

Information Provider

Hang Up

5035 - “To repeat this message press #, to 

enter a new zip code press 9.” If no selection, 

repeat 5035 twice, then 5004 – “Thank you 

for calling. Goodbye.”

#

9

Out of Area Zip Code Announcement (Spanish) 

5024:

“The zip code you have provided is not within the 

affected area ...” Caller is prompted to hang up unless 

they need to speak to an Information Provider.

In Area

Route Call to 

Information Provider
141

Example of Zip Code Tables and Announcements 

 The table below shows examples of zip code listings for Denver and environs with the number of 

the recorded announcements that would be given for each county. Examples of announcements for 

different zip codes follow the zip code listings. 
142

Zip Code Table (Part 1)

Page 3

ZIP 

CODE CITY 1st COUNTY 2nd COUNTY 3rd COUNTY 4th COUNTY

XCOUNTY 

MESSAGE#

AFTER #5022, WILL TRANSFER 

TO POD MESSAGE #

80001 ARVADA JEFFERSON 5509

80002 ARVADA JEFFERSON 5509

80003 ARVADA ADAMS JEFFERSON 5006 1=5500, 2=5509

80004 ARVADA JEFFERSON 5509

80005 ARVADA JEFFERSON 5509

80006 ARVADA JEFFERSON 5509

80007 ARVADA JEFFERSON 5509

80010 AURORA ADAMS ARAPAHOE 5008 1=5500, 2=5501

80011 AURORA ADAMS ARAPAHOE 5008 1=5500, 2=5501

80012 AURORA ARAPAHOE 5501

80013 AURORA ARAPAHOE 5501

80014 AURORA ARAPAHOE DENVER 5016 1=5501, 2=5505

80015 AURORA ARAPAHOE 5501

80016 AURORA ARAPAHOE 5501

80017 AURORA ARAPAHOE 5501

80018 AURORA ARAPAHOE 5501

80019 AURORA ADAMS 5500

80020 BROOMFIELD ADAMS BOULDER BROOMFIELD JEFFERSON 5005 1=5500, 2=5502, 3=5023, 4=5509

80021 BROOMFIELD BROOMFIELD JEFFERSON 5021 1=5503, 2=5509

80022 COMMERC E C ITY ADAMS 5500

80024 DUPONT ADAMS 5500

80025 ELDORADO SPRGS BOULDER 5502

80026 LAFAYETTE BOULDER 5502

80027 LOUISVILLE BOULDER 5502

80028 LOUISVILLE BOULDER 5502

80030 WESTMINSTER ADAMS 5500

80031 WESTMINSTER ADAMS JEFFERSON 5006 1=5500, 2=5509

80033 WHEAT RIDGE JEFFERSON 5509

80034 WHEAT RIDGE JEFFERSON 5509

80035 WESTMINSTER ADAMS 5500

80036 WESTMINSTER ADAMS 5500

80037 COMMERC E C ITY ADAMS 5500

80038 BROOMFIELD BOULDER 5502

80040 AURORA ADAMS 5500

80041 AURORA ARAPAHOE 5501

80042 AURORA ADAMS 5500

80044 AURORA ARAPAHOE 5501

80045 AURORA ADAMS 5500

80046 AURORA ARAPAHOE 5501

80047 AURORA ARAPAHOE 5501

80101 AGATE ADAMS ELBERT 5013 1=5500, 2=5507

80102 BENNETT ADAMS ARAPAHOE ELBERT 5033 1=5500, 2=5501, 3=5507

80103 BYERS ARAPAHOE 5501

80104 CASTLE ROC K DOUGLAS 5506

80105 DEER TRAIL ADAMS ARAPAHOE 5008 1=5500, 2=5501

80106 ELBERT DOUGLAS ELBERT 5030 1=5506, 2=5507

80107 ELIZABETH ELBERT 5507

80108 CASTLE ROC K DOUGLAS 5506

80109 CASTLE ROC K DOUGLAS 5506

80110 ENGLEWOOD ARAPAHOE DENVER 5016 1=5501, 2=5505

80111 ENGLEWOOD ARAPAHOE 5501

80112 ENGLEWOOD ARAPAHOE DENVER DOUGLAS 5014 1=5501, 2=5505, 3=5506

Note: Message 5023 is for certain residents of Broomfield County who are to get medications via the US Postal Service

Includes Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, Elbert, Gilpin, and Jefferson Counties 

Note: Any 5 digit number not contained in these tables will get message #5024 (Out of Area Zip Code Announcement)
143

Zip Code Table (Part 2)

Includes Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, Elbert, Gilpin, and Jefferson Counties 

Note: Any 5 digit number not contained in these tables will get message #5024 (Out of Area Zip Code Announcement)

Page 4

ZIP 

CODE CITY 1st COUNTY 2nd COUNTY 3rd COUNTY 4th COUNTY

XCOUNTY 

MESSAGE#

AFTER #5022, WILL TRANSFER 

TO POD MESSAGE #

80113 ENGLEWOOD ARAPAHOE 5501

80116 FRANKTOWN DOUGLAS 5506

80117 KIOWA ELBERT 5507

80118 LARKSPUR DOUGLAS 5506

80120 LITTLETON ARAPAHOE DOUGLAS 5019 1=5501, 2=5506

80121 LITTLETON ARAPAHOE 5501

80122 LITTLETON ARAPAHOE 5501

80123 LITTLETON ARAPAHOE DENVER JEFFERSON 5032 1=5501, 2=5505, 3=5509

80124 LITTLETON DOUGLAS 5506

80125 LITTLETON DOUGLAS JEFFERSON 5031 1=5506, 2=5509

80126 LITTLETON DOUGLAS 5506

80127 LITTLETON JEFFERSON 5509

80128 LITTLETON JEFFERSON 5509

80129 LITTLETON ARAPAHOE DOUGLAS 5019 1=5501, 2=5506

80130 LITTLETON DOUGLAS 5506

80131 LOUVIERS DOUGLAS 5506

80134 PARKER DOUGLAS ELBERT 5030 1=5506, 2=5507

80135 SEDALIA DOUGLAS 5506

80136 STRASBURG ADAMS ARAPAHOE 5008 1=5500, 2=5501

80137 WATKINS ADAMS ARAPAHOE 5008 1=5500, 2=5501

80138 PARKER ARAPAHOE DOUGLAS ELBERT 5018 1=5501, 2=5506, 3=5507

80150 ENGLEWOOD ARAPAHOE 5501

80151 ENGLEWOOD ARAPAHOE 5501

80155 ENGLEWOOD ARAPAHOE 5501

80160 LITTLETON ARAPAHOE 5501

80161 LITTLETON ARAPAHOE 5501

80162 LITTLETON JEFFERSON 5509

80163 LITTLETON DOUGLAS 5506

80165 LITTLETON ARAPAHOE 5501

80166 LITTLETON ARAPAHOE 5501

80201 DENVER DENVER 5505

80202 DENVER DENVER 5505

80203 DENVER DENVER 5505

80204 DENVER DENVER 5505

80205 DENVER DENVER 5505

80206 DENVER DENVER 5505

80207 DENVER DENVER 5505

80208 DENVER DENVER 5505

80209 DENVER DENVER 5505

80210 DENVER DENVER 5505

80211 DENVER DENVER 5505

80212 DENVER ADAMS DENVER JEFFERSON 5012 1=5500, 2=5505, 3=5509

80214 DENVER DENVER JEFFERSON 5029 1=5505, 2=5509

80215 DENVER JEFFERSON 5509

80216 DENVER ADAMS DENVER 5010 1=5500, 2=5505

80217 DENVER DENVER 5505

80218 DENVER DENVER 5505

80219 DENVER DENVER 5505

80220 DENVER DENVER 5505

80221 DENVER ADAMS DENVER 5010 1=5500, 2=5505

80222 DENVER ARAPAHOE DENVER 5016 1=5501, 2=5505

80223 DENVER DENVER 5505
144

 8

Announcements

Page

Announcements

Gre e ting Announce m e nt 5026: "Thank you for calling the P oint of Distribution A ssistance 

Line." (repeat m essage in Spanish)

Gre e ting Announce m e nt 5027: "To proceed in English, press 1. To proceed in Spanish, 

please press 2." (Italics in Spanish)

Colle ct 5 Digits Announce m e nt 5028: “This is an autom ated servic e to identify how to obtain 

the m edications currently being dispens ed in the Denver M etropolitan area by public health 

agenc ies for diseas e prevention. If you live or work in the Denver M etropolitan A rea by using a 

touc h tone phone, pleas e enter your five digit zip c ode. “ 

Out of Are a Zip Code Announce m e nt 5024: “The zip code y ou have provided is not within the 

affec ted area and y ou will not need to take any m edications at this tim e. B y entering the area 

where drugs are being distributed, you m ay needless ly increas e your chance of expos ure. 

Please understand that public health agencies are getting drugs to people with the highest 

likelihood of exposure first. Giving drugs to people who do not need them will slow down the 

distribution proces s. If you feel that you m ay still have been exposed, please wait on the line for 

the firs t available inform ation provider to ass is t y ou. Otherwis e please hang up." 

In Are a Zip Code Announce m e nt 5022: “The z ip c ode you have provided is within the affected 

area and you m ay need to take antibiotics to prevent illness. The following are instructions to 

receive your m edic ations for y ou and y our fam ily m em bers." 

Spe cia l USPS Announce m e nt 5023 (Broom fie ld 80020 only): "People in this zip code will be 

having m edic ations delivered to their hom es by the US P os tal S ervice. These drugs will arrive in 

the nex t 24-48 hours. Y ou will not need to do any thing else but wait for their arrival. If after this 

am ount of tim e you have not received your m edic ations or if y ou need additional m edications, 

pleas e contac t B room field P ublic Health at 303-XXX-XXXX."

5002: "P lease hold while I trans fer your call."

5004: "Thank you for calling. Goodbye."

5007: "Sorry we can no longer process your call."

5011: "Y ou will need to speak to an inform ation P rovider."

5015: "P ress 1 to repeat this this inform ation, press 9 to end the c all."

5035: "To repeat this m essage press #, to enter a new zip code press 9."
145

Page 9

County County Messages (for any zip code within that county) Zip Codes entirely 

within:

Zip Codes that cross 

into:

Adams

5500: Your zip code indicates you are in Adam s County. Tri 

County Health Departm ent officials are distributing antibiotics to 

the Adam s County population at Blake Com m unity College, 

located at 1234 West 100th Avenue in Blake. This location is 

between Pena and Sheridan Boulevards on West 100th 

Avenue. All Points of Distribution are well stocked with plenty of 

m edications for everyone, and all Points of Distribution are 

open 24 hours. You m ay push # to repeat this m essage.

80019, 80022, 80024, 

80030, 80035, 80036, 

80037, 80040, 80042, 

80045, 80229, 80233, 

80241, 80260, 80601, 

80602, 80603, 80614, 

80640, 80642, 80643, 

80654, 80701

80003, 80010, 80011, 

80020, 80031, 80101, 

80102, 80105, 80136, 

80137, 80212, 80216, 

80221, 80230, 80234, 

80247, 80249

Arapahoe

5501: Your zip code indicates you are in Arapahoe County. Tri 

County Health Departm ent Officials are distributing antibiotics 

to the Arapahoe County population at Lionsville High School, 

located at 2743 South Maple Street in Lionsville. This location 

is four blocks east of South Pennsylvania and Highland Avenue. 

All Points of Distribution are well stocked with plenty of 

m edications for everyone, and all Points of Distribution are 

open 24 hours. You m ay push # to repeat this m essage.

80012, 80013, 80015, 

80016, 80017, 80018, 

80041, 80044, 80046, 

80047, 80103, 80111, 

80113, 80121, 80122, 

80150, 80151, 80155, 

80160, 80161, 80165, 

80166, 80233

80010, 80011, 80014, 

80012, 80105, 80110, 

80112, 80120, 80123, 

80129, 80136, 80137, 

80138, 80222, 80231, 

80236, 80247

Boulder

5502: Your zip code indicates you are in Boulder County. 

Boulder County Health Departm ent Officials are distributing 

antibiotics to the Boulder County Population at Em m itsville High 

School, located at 8725 Jeannie Road in Em m itsville. This 

location is on the corner of Fresno Street and Jeannie Road, 

after Highway 119 becom es Jeannie Road. All Points of 

Distribution are well stocked with plenty of m edications for 

everyone, and all Points of Distribution are open 24 hours. You 

m ay push # to repeat this m essage.

80025, 80026, 80027, 

80028, 80038, 80301, 

80302, 80303, 80304, 

80305, 80306, 80307, 

80308, 80309, 80310, 

80314, 80321, 80322, 

80323, 80328, 80329, 

80455, 80466, 80471, 

80481, 80501, 80502, 

80503, 80504, 80510, 

80513, 80516, 80533, 

80540, 80544

80020, 80403

Broomfield

5503: Your zip code indicates you are in Broom field County. 

Broom field Health and Hum an Services Officials are 

distributing antibiotics to the Broomfield County population at 

the Broom field County Fairgrounds, located at 234 Presston 

Street in Broomfield. This location is one block east of Main 

Street and East 8th Avenue. All Points of Distribution are well 

stocked with plenty of m edications for everyone, and all Points 

of Distribution are open 24 hours. You m ay push # to repeat 

this m essage. 

No zips entirely in 

Broomfield County

80020, 80021, 80234 

Note: 80020 will get 

special message 5023 

about USPS delivery

Clear Creek

5504: Your zip code indicates you are in Clear Creek County. 

The Clear Creek County Public Health Nursing Service is 

distributing antibiotics to the Clear Creek County population at 

Westm inster Middle School, located at 234 Highway 103 in 

Westm inster. This location is south of Interstate 70 and 

Highway 9 on Highway 107. All Points of Distribution are well 

stocked with plenty of m edications for everyone, and all Points 

of Distribution are open 24 hours. You m ay push # to repeat 

this m essage.

80436, 80438, 80444, 

80452, 80476

80439

POD Messages by County 1
146

County County Messages (for any zip code within that county) Zip Codes entirely 

within:

Zip Codes that cross 

into:

Denver

5505: Your zip code indicates you are in Denver County. 

Denver Public Health Officials are distributing antibiotics to 

the Denver County population at the Denver Metroplex, 

located at 1653 E. Washington in Denver. This location is 

five blocks east of Bannock and Louisiana. All Points of 

Distribution are well stocked with plenty of medications for 

everyone, and all Points of Distribution are open 24 hours. 

You may push # to repeat this message.

80201, 80202, 80203, 

80204, 80205, 80206, 

80207, 80208, 80209, 

80210, 80211, 80217, 

80218, 80219, 80220, 

80223, 80224, 80237, 

80238, 80239, 80243, 

80244, 80246, 80248, 

80250, 80251, 80252, 

80255, 80256, 80257, 

80259, 80261, 80262, 

80263, 80264, 80265, 

80266, 80270, 80271, 

80273, 80274, 80275, 

80279, 80280, 80281, 

80285, 80290, 80291, 

80292, 80293, 80294, 

80295, 80299

80014, 80110, 80112, 

80123, 80212, 80214, 

80216, 80221, 80222, 

80226, 80227, 80231, 

80232, 80235, 80236, 

80247, 80249 

Douglas

5506: Your zip code indicates you are in Douglas County. Tri 

County Health Department Officials are distributing 

antibiotics to the Douglas County population at Our Lady of 

Loretto High School, located at 3448 Walker Drive in Castle 

Rock. This location is south of the intersection of Highway 47 

and Front Street. All Points of Distribution are well stocked 

with plenty of medications for everyone, and all Points of 

Distribution are open 24 hours. You may push # to repeat 

this message. You may push # to repeat this message.

80104, 80108, 80109, 

80116, 80118, 80124, 

80126, 80130, 80131, 

80135, 80163 

80106, 80112, 80120, 

80125, 80129, 80134, 

80138

Elbert

5507: Your zip code indicates you are in Elbert County. 

Elbert County Health Department Officials are distributing 

antibiotics to the Elbert County population at Kiowa 

Elementary School, located at 563 Pawnee Avenue in Kiowa. 

This location is north on Ute Avenue from Suwanee Street. 

All Points of Distribution are well stocked with plenty of 

medications for everyone, and all Points of Distribution are 

open 24 hours. You may push # to repeat this message. 

80107, 80117, 80808, 

80828, 80830, 80831, 

80832, 80833, 80835

80101, 80102, 80106, 

80134, 80138

Gilpin

5508: Your zip code indicates you are in Gilpin County. 

Jefferson County Health Department Officials are distributing 

antibiotics to the Gilpin County population at the Coors 

Memorial High School, located at 234 Highland Ave in 

Golden. This location is south on Highland from Golden 

Gate Canyon Road. All Points of Distribution are well stocked 

with plenty of medications for everyone, and all Points of 

Distribution are open 24 hours. 

80422, 80427, 80474 80403

Jefferson

5509: Your zip code indicates you are in Jefferson County. 

Jefferson County Health Department Officials are distributing 

antibiotics to the Jefferson County population at Dinasaur 

Ridge Middle School, located at 1118 NW 41st Ave in 

Golden. This location is southwest of Highway 6 and Parson 

Street on 41st Avenue. All Points of Distribution are well 

stocked with plenty of medications for everyone, and all 

Points of Distribution are open 24 hours. 

80001, 80002, 80004, 

80005, 80006, 80007, 

80033, 80034, 80127, 

80128, 80162, 80215, 

80225, 80228, 80401, 

80402, 80419, 80425, 

80433, 80437, 80453, 

80454, 80457, 80465, 

80470

80003, 80020, 80021, 

80031, 80123, 80125, 

80212, 80214, 80226, 

80227, 80232, 80235, 

80439
147

Cross County Announcements

Cross County Announcements Specific County 

Info Message

5034 “You have entered a zip code which crosses into m ore than one county . If you live in Adam s 

County, press 1. If you live in Arapahoe County, press 2. If you live in Denver County, press 3." 1=5500, 5=5501, 3=5505

5033 “You have entered a zip code which crosses into m ore than one county . If you live in Adam s 

County, press 1. If you live in Arapahoe County, press 2. If you live in Elbert County, press 3." 1=5500, 2=5501, 3=5507

5008 “You have entered a zip code which crosses into m ore than one county . If you live in Adam s 

County, press 1. If you live in Arapahoe County, press 2." 1=5500, 2=5501

5005 “You have entered a zip code which crosses into m ore than one county . If you live in Adam s 

County, press 1. If you live in Broom field County, press 2. If you live in Boulder County, press 3. If you 

live in Jefferson County, press 4." 

1=5500, 2=5502, 3=5023, 

4=5509

5009 “You have entered a zip code which crosses into m ore than one county . If you live in Adam s 

County, press 1. If you live in Broom field County, press 2." 1=5500, 2=5503

5012 “You have entered a zip code which crosses into m ore than one county . If you live in Adam s 

County, press 1. If you live in Denver County, press 2. If you live in Jefferson County, press 3." 1=5500, 2=5505, 3=5509

5010 “You have entered a zip code which crosses into m ore than one county . If you live in Adam s 

County, press 1. If you live in Denver County, press 2." 1=5500, 2=5505

5013 “You have entered a zip code which crosses into m ore than one county . If you live in Adam s 

County, press 1. If you live in Elbert County, press 2." 1=5500, 2=5507

5006 “You have entered a zip code which crosses into m ore than one county . If you live in Adam s 

County, press 1. If you live in Jefferson County, press 2." 1=5500, 2=5509

5014 “You have entered a zip code which crosses into m ore than one county . If you live in Arapahoe 

County, press 1. If you live in Denver County, press 2. If you live in Douglas County, press 3." 1=5501, 2=5505, 3=5506

5032 “You have entered a zip code which crosses into m ore than one county . If you live in Arapahoe 

County, press 1. If you live in Denver County, press 2. If you live in Jefferson County, press 3." 1=5501, 2=5505, 3=5509

5016 “You have entered a zip code which crosses into m ore than one county . If you live in Arapahoe 

County, press 1. If you live in Denver County, press 2." 1=5501, 2=5505

5018 “You have entered a zip code which crosses into m ore than one county . If you live in Arapahoe 

County, press 1. If you live in Douglas County, press 2. If you live in Elbert County, press 3." 1=5501, 2=5506, 3=5507

5019 “You have entered a zip code which crosses into m ore than one county . If you live in Arapaho 

County, press 1. If you live in Douglas county, press 2." 1=5501, 2=5506

5020 “You have entered a zip code which crosses into m ore than one county . If you live in Boulder 

County, press 1. If you live in Gilpin County, press 2." 1=5502, 2=5508

5021 “You have entered a zip code which crosses into m ore than one county . If you live in Broom field 

County, press 1. If you live in Jefferson County, press 2." 1=5503, 2=5509

5025 “You have entered a zip code which crosses into m ore than one county . If you live in Clear Creek 

County, press 1. If you live in Jefferson County, press 2." 1=5504, 2=5509

5029 “You have entered a zip code which crosses into m ore than one county . If you live in Denver 

County, press 1. If you live in Jefferson County, press 2." 1=5505, 2=5509

5030 “You have entered a zip code which crosses into m ore than one county . If you live in Douglas 

County, press 1. If you live in Elbert County, press 2." 1=5506, 2=5507

5031 “You have entered a zip code which crosses into m ore than one county . If you live in Douglas 

County, press 1. If you live in Jefferson County, press 2." 1=5506, 2=5509

Page 11
148

4.4. Frequently Asked Question (FAQ) Library Application 

 The FAQ Library application will disseminate up-to-date, consistent, and accurate information 

approved by health department epidemiologists to the public and health care providers from a 

searchable library of FAQs. Callers dialing into this application should be able to select desired 

information with discernable directions from the application including maneuverability throughout the 

menus. Also, callers should have the ability to select an option to speak with an Information Provider, 

if needed. The application will provide reports on how many callers selected all message options. 

Callers dialing into this application will hear the initial greeting then will hear a special bulletin 

announcement if recorded prior to being prompted for their zip code. The special greeting 

announcement is built into the application so emergency or seasonal announcements can be easily 

changed by an administrator dialing in with a special access code and selecting the appropriate 

announcement. 
149

Incoming Call

Check for 

Special 

Bulletin Msg

No

Yes

<Special Message 1>

Retrieve 

Bulletin Board 

Message

Message 5004 -

“Please enter your 

5-digit zip code”

Zip Code Menu

Message 5000 -

“Welcome to the 

automated HELP 

Information Line”

Match County 

in Zip_Codes 

flat file

Go To 

Symptoms 

Main Menu

(Page 2)

NOTE: Bulletin Board 

Message can be activated 

(See Administration of 

Bulletin Messages, page 

45)

NOTE: Zip code will be 

stored in report as ** if 

no match is found

Page 1

Update 

Custom 

Report

Initial Menu
150

1

West Nile Virus

Symptoms - Main Menu

Go To 

West Nile 

Virus

(page 3)

Note: /set Conv_data 

field = “0” indicating caller 

reached Main Menu but 

did not select a Topic

2

Mold

3

Hantavirus

4

All Other Topics

Go To 

Topic 4

(page 42)

Go To 

Hantavirus

(page 37)

Go To 

Mold

(page 32)

Message 5006=For information about West Nile Virus, press 1.

Message 5007=For information about Mold, press 2.

Message 5008=For information about Hantavirus, press 3.

Message 5009=For all other topics press 4

Page 2
151

West Nile Virus

Message 5011=For information about WNV in humans press 1. 

Message 5012=For information about insect repellents and mosquito control press 2. 

Message 5013=For information about WNV in birds press 3. 

Message 5014=For information about WNV in other animals including pets press 4.

Message 5015=You may speak to a Health Information Provider at any time by pressing 0.

1

West Nile Virus in 

Humans

Go To 

West Nile 

Humans

(page 4)

2

Insect Repellents 

& Mosquito 

Control

3

West Nile Virus in 

Birds

4

West Nile in 

Animals

Go To 

West Nile 

Animals 

(page 27)

Go To 

West Nile 

Birds

(page 22)

Go To 

Insect 

Repellents

(page 9)

Page 3

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152

West Nile Humans

Message 5027=For information about the incubation period of WNV press 1.

Message 5028=For information about the symptoms of WNV press 2.

Message 5029=For information about WNV and immunity to future infection press 3.

Message 5030=For information about tests press 4.

1

Incubation Period

Go To 

Incubation 

Period

(page 5)

2

Human Symptoms

3

Future Immunity

4

Tests

Go To 

Tests

 (page 8)

Go To 

Future 

Immunity

(page 7)

Go To 

Human 

Symptoms 

(page 6)

Page 4
153

Incubation Period

Message 5031

The incubation period is usually 3 to 14 days for West Nile Virus. Once bitten by a mosquito 

there is no way to prevent getting the virus. The best protection is prevent getting mosquito 

bites in the first place by wearing insect repellent containing DEET.

A mosquito bite that is red and swollen does not mean that it is more likely to be from an 

infected mosquito. It is the a result of your body’s allergic reaction to the mosquito’s saliva, 

which was injected into you when you were bitten.

Most mosquitoes are not infected, so it is unlikely that the mosquito that bit you was capable of 

transmitting the virus. No action should be taken unless you develop symptoms.

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154

Human Symptoms

Message 5032

80% of people who become infected with West Nile Virus will not develop any symptoms.

20% will develop West Nile fever: fever, headache, and body aches. Occassionally, the person will develop a 

skin rash on the trunk of the body and swollen lymph glands. This illness lasts several days and person gets 

better without any treatment.

1 in 150 persons that get infected with WNV will develop a more severe form of the disease.

The symptoms include headaches, high fever, neck stiffness, muscle weakness or tremors, stupor, 

disorientation, coma, convulsions and paralysis. This can cause permanent brain damage or death. If you 

are experiencing these more severe symptoms you should see your medical provider.

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155

Future Immunity

Message 5033

If you have been tested positive for having had WNV, it is assumed immunity will be life-long; however, it 

may wane in later years. 

If you were not tested for WNV, then you should consider yourself susceptible and take precautions. 

There are hundreds of viruses that circulate in the state and can cause identical symptoms. Thus you 

can not accurately diagnose WNV infection by symptoms or history of mosquito bites. It requires a blood 

test.

Also other mosquito-borne viruses are out there, although fairly rare. The bottom line is take precautions 

if mosquitoes are biting you.

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156

Tests

Message 5034

If you develop symptoms such as high fever, confusion, muscle weakness, and severe headaches, you 

should see your doctor. Your dotcor can order any tests he/she feels are necessary. 

Your physician will draw a blood sample and send it to a commercial or pulic health laboratory for testing.

The WNV tests are effective and accurate. The WNV tests are effective and accurate. Initial tests are 

usually followed with back-up tests to confirm WNV infection. 

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157

Insect Repellents

1

Use of repellents

Go To 

Use Of 

Repellents

(page 10)

2

Breeding Habitats

3

Larvacide

4

Mosquitoes all 

other

Go To 

Mosquitoes 

All Other

 (page 21)

Go To 

Larvacide

(page 20)

Go To 

Breeding 

Habitats 

(page 15)

Message 5035 = For information about Insect Repellents and their use press 1.

Message 5036 = For information about Mosquito breeding habitats press 2.

Message 5037 = For information about larvacide press 3. 

Message 5038 = For all other information about mosquitoes press 4.

Page 9
158

Use of Repellents

1

Containing DEET

Go To 

Containing 

DEET

(page 11)

2

Percentage DEET

3

Repellent Applied

4

How Often Applied

Go To 

Health Dept 

DEET 

(page 14)

?

Go To 

Repellent 

Applied

(page 13)

Go To 

Percentage 

DEET

(page 12)

Message 5038 = For information about insect repellent containing DEET and its use with infants and children press 1.

Message 5039 = For information the about protection time and percentage of DEET press 2.

Message 5040 = For information how often insect repellent should be applied press 3.

Message 5041 = For information about how often insect repellent should be applied press 4. 

Message 5015 = You may Speak to a Health Information provider at any time by pressing 0.

Page 10

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159

Containing DEET

Message 5042

According to the Academy of Pediatrics, repellents containing 10% to 30%

DEET can be used for children 2 mos. Infants should be kept away from mosquitoes.

Apply it to your own hands and then run them on your child.

Avoid children’s eyes and mouth and use it sparingly around their ears.

Do not apply repellent to children’s hands. Children may put their hand in their mouths.

Do not allow young children to apply insect repellent to themselves. Have an adult do it for them.

Keep repellents out of reach of children.

Do not apply repellent to skin under clothing. If repellent is applied to clothing, wash treated clothing 

after use.

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160

Percentage DEET

Message 5043

You want to choose a repellent that provides the maximum amount of protection for the amount of time 

that you will be outdoors. A higher percentage of DEET should be used if you are will be outdoors for 

several hours while a lower percentage of DEET can be used if time outdoors will be limited.

A product containing 23.8% DEET will provide an average of 5 hours of protection from mosquito bites.

A product containing 20% DEET will provide an average of 4 hours of protection.

A product with 6.65% DEET will provide an average of 2 hours of protection.

Products with 4.75% DEET and 2% Soybean oil are both able to provide roughly 1 and half hours 

protection.

Option to return to main menu, option to return to topics or option to speak to a Health Information 

Provider.

Virus will not develop any symptoms.

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161

Repellent Applied

Message 5044

You want to choose the repellent that provides the maximum amount of protection for the amount of time 

that you will be outdoors. A higher percentage of DEET should be used if you will be outdoors for several 

hours while a lower percentage of DEET can be used if tie outdoors will be limited.

A product containing 23.8% DEET will provide an average of 5 hours of protection from mosquito bites.

A product containing 20% DEET will provide an average of 4 hours of protection from mosquito bites.

A product with 6.65 % DEET will provide an average of 2 hours of protection from mosquito bites.

Products with 4.75% DEET and 2% soybean oil were both able to provide roughly 1 and 1 half hours of 

protection. 

Sweating, swimming, or getting wet can wash off repellent so reapplication of the repellent may be 

needed. 

If you are not being bitten, it is not necessary to re-apply repellent.

Concentrations above 30% do not provide extra protection.

You may speak to a Health Information provider at any time by pressing 0.

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162

Health Dept DEET

Message 5046

The Health Dept. recommends repellents with DEET because it is the most studied and most 

effective insect repellent available. Non-DEET repellents product do provide some 

protection from mosquito bites. Studies show that these products do not provide the same 

level or length of protection. 

A soybean-oil based product has been shown to provide some protection for a period of time 

similar to a product with a low concentriation of DEET (4.75%).

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163

Breeding Habitats

1

Habitat Definition

Go To 

Habitat 

Definition 

(page 16)

2

Reducing Habitat

3

Public Habitat

4

Habitat All Other

Go To 

Habitat

All Other

(page 19)

Go To 

Public 

Habitat

(page 18)

Go To 

Reducing 

Habitat

(page 17)

Message 5047 = For information on what is a mosquito breeding habitat press 1. 

Message 5048 = For information on how you can reduce mosquitoes on your property press 2. 

Message 5049 = For information about the breeding habits on public property or someone else’s property press 3. 

Message 5050 = For all other information about mosquito breeding habitats press 4. 

Message 5015 = You may speak to a Health Information Provider at any time by pressing 0.

Page 15

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Habitat Definition

Message 5051

Anything that can hold standing water for 4 to 7 days is a mosquito breeding habitat. For 

example, flower pots, pet food and water dishes, birdbaths, swimming pool covers, buckets, 

barrels, cans, clogged rain gutters, discarded tires, wheelbarrows, leaky air conditioner hoses, 

tarps, plastic garden sheeting, ponds, ditches, plant saucers, puddles, equipment, barbecue 

grills, toys, boats, canoes, and trash.

Any container that can hold water should be emptied at least every 4 to 7 days.

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Reducing Habitat

Message 5052

Empty containers that hold water, such as bird baths or plant saucers every 4 to seven days.

Stock your ponds with mosquito eating fish such as Koe or Fathead minnows which can be 

purchased commercially at private fish hatcheries.

These fish are only recommended for ornamental ponds that do not empty into natural streams 

or other bodies or water. 

For ponds that empty into natural waters, contact the Division of Wildlife District office in your 

area to see what types of fish, like trout, are acceptable in your area.

Use larvacide in your pond. Several larvacide options exist.

Remove excess vegetation around the pond perimeter which mosquito larvae use for shelter.

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Public Habitat

Message 5053

Mosquito-breeding sites, such as large areas of standing water, can be reported to the 

mosquito control program or local health department in your area. 

Mosquito Control programs must follow rules and regulations regarding where and what type of 

mosquito control they can do. They may or may not be able to treat the site depending on 

whether it is within the control , district boundaries, on private property or in a protected area 

that cannot be treated.

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Habitat All Other

Message 5054

To find more information about the Mosquito Control program in your area, go to 

www.fightthebitecolorado.com. Click on State Health Department West Nile Virus Homepage 

located on the right hand side of the page. Click on List of Commercial Pesticide Applicators in 

Colorado – under Professional Information and Resources and then Information for Local 

Health Departments. You will find your information there or you can press 0 and one of our 

Health Information Providers will assist you.

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Larvacide

1

Go To 

(page TBD )

234

Note: This topic message is under development but up to 4 menu choices have been allocated 

to it (TBD = To Be Determined).

Message 5056 =

Message 5057 = 

Message 5058 = 

Message 5059 =

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(page TBD )

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(page TBD )

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(page TBD)

Page 20

Message 5060

TBD

Message 5061

TBD

Message 5062

TBD

Message 5063

TBD
169

Page 21

Mosquitoes All Other

1

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(page TBD )

234

Note: This topic message is under development but up to 4 menu choices have been allocated 

to it (TBD = To Be Determined).

Message XXXX =

Message XXXX = 

Message XXXX = 

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(page TBD )

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(page TBD )

Go To 

(page TBD)

Message XXXX

TBD

Message XXXX

TBD

Message XXXX

TBD

Message XXXX

TBD
170

West Nile Birds

Message 5064 = For information about how birds get and transmit WNV press 1.

Message 5065 = For information about whether your bird bath or bird feeder is contributing to WNV in birds press 2. 

Message 5066 = For information about symptoms a WNV infected bird will display press 3.

Message 5067 = For information about whether you will be exposed to the virus by handling a dead bird press 4.

1

Bird Transmittal

Go To 

Bird 

Transmittal

(page 23)

2

Bird Feeders

3

Bird Symptoms

4

Dead Birds

Go To 

Dead Birds

 (page 26)

Go To 

Bird 

Symptoms

(page 25)

Go To 

Bird Feeders 

(page 24)

Page 22
171

Bird Transmittal

Message 5068

First, mosquitoes acquire the virus when they feed on infected birds. The virus then starts 

replicating in the salivary glands of the infected mosquito. The mosquito then spreads the virus 

to other birds when the mosquito feeds. 

It is also believed that scavenger birds, like crows and magpies, and raptors (eagles, hawks 

and owls) can be infected from eating infected animals.

Since birds do not become ill for several days, it is possible for them to travel a considerable 

distance and help spread the disease as other mosquitoes feed on them. 

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Bird Feeders

Message 5069

It is unknown whether WNV can be transmitted from bird feed or water contaminated with 

droppings from an infected bird. 

There are other diseases, such as salmonella, that can be transmitted by contaminated bird 

feed and water. Feeding birds brings many birds into close contact and increases the risk of 

disease transmission.

Feeding should be reduced or stopped in the summer. If not, bird feeders and baths should be 

cleaned and disinfected at least every 5 to 7 days.

Bird excrement can be cleaned up with soap and water and then allowed to air dry. For 

surfaces that might come in contact with food, table tops, grills, and bird feeders a disinfectant 

should be applied after cleaning with soap and water. Be sure to wash hands after cleaning up 

any animal droppings or handling dead birds.

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Bird Symptoms

Message 5070

Over 225 species of birds in the United States have died due to WNV. Bird die-offs are an 

indicator of the virus circulating in the area. But, bird die-offs can be due to other diseases, 

such as salmonella.

Birds infected with WNV may be unable to fly, appear disoriented, stagger or be unbalanced, 

slow to move when approached or lying motionless.

Many things can cause similar symptoms in birds, only testing can tell if the bird is infected. 

There is no way to tell from if a bird died from WNV by looking at it. Only a lab test can tell.

The test can only be done on certain types of birds. However, the State Department of Health 

tracks all bird die-offs during West Nile Virus season. If you have found a dead bird please 

push 0 to speak with one of our Health Information Providers and file a Dead Bird Report.

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Dead Birds

Message 5071

There is no evidence that of the virus being transmitted directly from bird to human. However, 

persons should avoid contacting dead birds with their bare hands. Gloves, shovel, or plastic 

bags should be used to handle the carcasses.

Three lab workers have been infected while dissecting infected bird carcasses for testing. In all 

three cases the lab workers suffered cuts or needle stick from contaminated scalpels or 

needles.

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West Nile Animals

Message 5072 = For information about WNV and cats and dogs press 1. 

Message 5073 = For information about horse vaccine press 2.

Message 5074 = For information about vaccination and foals press 3. 

Message 5075 = For information about horse symptoms and testing press 4.

1

Cats and Dogs

Go To 

Cats and 

Dogs

(page 28)

2

Horse Vaccine

3

Foal Vaccine

4

Horse Symptoms

Go To 

Horse 

Symptoms

 (page 31)

Go To 

Foal Vaccine

(page 30)

Go To 

Horse 

Vaccine 

(page 29)

Page 27
176

Cats and Dogs

Message 5076

WNV in pets is probably common but actual illness in dogs and cats if very rare. Dogs and cats 

can get the virus from a mosquito but it is extremely unlikely that that your dog or cat will 

develop a disease from WNV. 

If you pet does is ill, contact your veterinarian.

You can protect your pet from mosquitoes by bringing it indoors during dawn and dusk when 

mosquitoes are actively feeding.

If you are going to use insect repellent on your animals, consult your veterinarian first. Make 

sure the insect repellent is safe for use on animals. Insect repellent and bringing them indoors 

will prevent other diseases besides WNV.

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177

Horse Vaccine

Message 5077

WNV is very dangerous for horses. Once a horse becomes ill about one third of the animals 

die or need toe put to sleep. 

Fortunately, there is a vaccine for horses. Get them vaccinated for WNV. The vaccine series 

consists of two doses of vaccine 3 -6 weeks apart, then annual boosters. The vaccine is 94% 

effective. 94 out 100 horses will be protected from illness if infected.

Check with local veterinarians to get the vaccine. It should be administered in early spring.

Prevent exposure to mosquitoes. Reduce mosquito breeding areas, keep animals in screened 

stalls during mosquito-feeding times. Use air curtains in barns and stalls to keep flying insects 

out, conduct mosquito control.

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Foal Vaccine

Message 5078

In high-risk areas, foals born from mares not previously vaccinated, may be vaccinated 

beginning at 6-8 weeks of age. If the mare did receive the vaccine prior to foaling, it is 

recommended starting at 3 to 4 months of age.

In low risk areas, foals from vaccinated mares may be started a 5–7 months of age, while 

foals from non-vaccinated mares can be started at 3 to 4 months of age.

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Horse Symptoms

Message 5079

Infected horses show symptoms of that include a lack of coordination, stumbling, weakness of 

limbs, muscle tremors or paralysis. If you notice symptoms you should consult your 

veterinarian.

A simple blood test is used to determine if the horse has been infected WNV. The specific test 

is an ELISA IgM antibody capture. ELISA stands for enzyme linked immunoosorbent assay.

The test is very accurate in detecting infections. Normally the test will be positive within 1 to 2 

days of the animal becoming ill.

Treatment for a WNV infected horse includes supportive care consistent with standard 

veterinary practices for animals with viral infections.

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Mold

Message 5016 = For general information about mold in the home press 1, 

Message 5017 = For information about how to clean up mold press 2, 

Message 5018 = For information about testing for mold press 3, 

Message 5019 = For information about symptoms of mold exposure press 4,

Message 5015 = You may speak to a Health Information Provider at any time by pressing 0.

1

Mold in the Home

Go To 

Mold Home

(page 33)

2

Mold Cleanup

3

Mold Testing

4

Mold Exposure

Go To 

Mold 

Exposure 

(page 36)

Go To 

Mold Testing 

(page 35)

Go To 

Mold 

Cleanup

(page 34)

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Mold Home

Message 5080

There is always some level of mold and the amount varies by location. Molds enter your home 

through doorways, windows, ventilation systems or they are carried into the home by being 

attached to a person or object.

Molds will grow whenever conditions are right. They require moisture and organic material in 

order to grow and gradually destroy whatever they grow on by digesting the material.

The Colorado Department of Public Health and Environment has Mold Informational materials 

that can be mailed to you. If you would like these mailed to you please press 1; if your would 

like to speak with one of our health information provider, press 0.

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Mold Cleanup

Message 5081

If you can see or smell mold, you likely have a problem and should take steps to clean your 

home for mold.

Whether you can clean the mold yourself or need to hire a contractor depends on the size of the 

problem. Small areas, usually less than 10 feet by 10 feet, may be able to be handled by the 

homeowner or maintenance staff using personal protective equipment. For larger areas, it is 

advisable that an experienced professional contractor be used.

Non-porous moldy items can be cleaned using protective equipment such as gloves, a mask, 

and eye protection. Porous items such as sheetrock, carpeting, and wood, needs to be 

removed. 

The Colorado Department of Public Health and Environment has Mold Clean-Up Informational 

materials that can be mailed to you. If you would like these mailed to you please press 1; if your 

would like to speak with one of our health information provider press 0.

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183

Mold Exposure

Message 5083

Daily exposure to some molds is common without necessarily causing harm. Mold spores can 

cause harm when they are present in large numbers and people inhale the spores. 

For some people, a relatively small amount of mold spores can trigger an asthma attack or lead 

to other health problems. For others the symptoms may only occur when exposure levels are 

much higher. Children, especially infants less than one year, should not be exposed to moldy, 

water damaged environments.

Symptoms occur from inflammation, allergy or infection from molds. Allergic reactions are the 

most common and symptoms include:

· Respiratory problems, such as wheezing, difficulty breathing and a shortness of breath

· Nasal and sinus congestion

· Eye irritation

· Dry, hacking cough

· Nose or throat irritation

· Skin rashes or irritation

If you have been exposed to mold and are feeling sick, you should consult a medical 

professional. You should tell the physician about your symptoms and about when, how and for 

how long you were exposed.

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Mold Testing

Message 5082

The state does not provide testing services and public health agencies seldom provide the service. 

Going to private contractors to get your home tested as a first step is not recommended because air 

sampling for mold can be expensive. There are few available standards for judging what is an 

acceptable quantity of indoor molds. 

If you feel you are at the point you want to invest in air sampling you can find them in your local phone 

book. The State Department of Public Health and Environment has a listing of Contractors at 

www.cdphe.state.co.us/dc/envtox This list is not provided as an endorsement of these contractors. It is 

a listing of contractors who do mold testing in the state of Colorado.

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direct your call to a 

Health Information 

Provider”
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Hantavirus

Message 5020 = For general information about Hantavirus disease and symptoms press 1, 

Message 5021 = for information on how to clean up mouse nests and droppings safely press 2, 

Message 5022 = for information of prevention of Hantavirus press 3 

Message 5023 = to obtain a free brochure on Hantavirus press 4

Message 5015 = you may speak to a Health Information Provider at any time by pressing 0

1

Hantavirus 

General

Go To 

Hantavirus 

General 

(page 38)

2

Hantavirus 

Cleanup

3

Hantavirus 

Prevention

4

Hantavirus 

Brochure

Hantavirus 

Brochure 

(page 41)

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Hantavirus 

Prevention

(page 40)

Go To 

Hantavirus 

Cleanup

(page 39)

Currently Disconnected

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direct your call to a 

Health Information 

Provider”
186

Hantavirus General

Message 5084

Hantavirus is a serious respiratory disease that is carried by certain rodents, primarily deer 

mice, and is passed to humans through contact with infected urine, droppings or saliva. It is 

extremely serious, with a high fatality rate. 

The incubation period varies widely, but ranges from 1-6 weeks, with an average of 1 -2 weeks.

The early symptoms include fever, headache, and muscle pain, severe abdominal, joint and 

lower back pain, nausea and vomiting.

A cough and shortness of breath usually develops 1 to 5 days after the onset of symptoms. 

The primary symptom of Hantavirus is difficulty in breathing due to fluid build-up in the lungs. 

This can quickly progress to respiratory failure.

Currently there is no effective drug treatment for Hantavirus. Early admission to the hospital 

where monitoring, treatment of symptoms, and good supportive therapy can be provided is 

important.

If you have had exposure to rodents and experience symptoms mentioned above, you should 

see your medical provider. It would be helpful to mention the exposure to your physician. A 

quick diagnosis helps the physician take appropriate measures.

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187

Hantavirus Cleanup

Message 5085

Listen to the Prevention message for information about eliminating rodents.

Get rid of rodents in and around the home.

Air out rodent infested buildings at least 30 minutes before cleaning. Do not sweep off dry vacuum 

rodent contaminated surfaces which may stir up the dust and allow potentially contaminated dust to be 

breathed in. Spray contaminated surfaces with bleach solution. The bleach solution should be made 

up of 1 cup bleach to 1 gallon of water. Allow it to sit for 5 to 10 minutes before cleaning it with a mop 

or wet vacuum. Wear gloves. 

In heavily rodent infested areas or situations where ventilation and/or wet clean-up can not be 

effectively done, use a face mask with HEPA filter.

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Hantavirus Prevention

Message 5086

Seal holes and cracks 1⁄4 inch or larger with steel wool, metal sheeting hardware cloth, or 

patching plaster. Insure weather seals under doors are tight and screens are in good repair.

Eliminate food and water sources. Store pet food and bird seed in metal containers. Feed 

animals only as much as they will consume at one time. Feed only in the daytime and remove 

food and water at night. Clean up spilled feed and seed. Keep garbage in containers with tight 

lids. Do not feed rodents. Limit possible nesting sites. Rodents like hiding places.

Indoors use snap traps with peanut butter and oatmeal. Spray carcasses with bleach solution. 

Bleach solution is made of 1 cup bleach to 1 gallon of water. Let it soak 10 minutes. Use 

rubber gloves when handling the carcasses. Place carcass in bag and in outdoor trash. 

Outdoors you can use snap traps, multi-catch traps or poisons.

Keep grass and vegetation trimmed low. Store firewood up off the ground to prevent burrowing 

underneath. 

Store hay, woodpiles and equipment 100 feet away from the buildings if possible.

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Hantavirus Brochure

Message 5087

A free brochure with information about Hantavirus and Rodent Prevention is available from the 

Colorado Department of Public Health and Environment. If you would like one sent to you 

please call toll free 1-800-XXX-XXXX.

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1

General Topic 1

Other Topics

Submenu 1

2

General Topic 2

3

General Topic 3

Submenu 2 Submenu 3

4

Topic 4 submenu 4

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Submenu 3

1

Message 5094

2

Message 5095

3

Message 5096

4

Message 5097

Note: This topic message is under development but up to 4 menu choices have been allocated 

to it (TBD = To Be Determined).

Message XXXX =

Message XXXX = 

Message XXXX = 

Message XXXX =
191

Message 5024 = To repeat this information, press #

Message 5025 = To return to the Main Menu, press 9.

Message 5026 = To speak with a Health Information Provider, press 0

Repeat or Return Menu

Go To 

<CameFrom>

Menu

Check 

CameFrom Field

Go To 

Symtoms 

Main Menu 

(page 2)

Page 43

Note: If a caller does not 

make a selection from any 

menu, within a set period of 

time they will be prompted to 

select one of these three 

options

0

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# 9
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Incoming Call from 

Hidden Prompt 

Message 

Record 

Mode

Message 5000 =

Welcome to the Special Bulletin 

board administration application

Check for 

Active = 

“Y”

Yes

No

Message 5004 =

“There is currently 

no active 

message.”

Set Active = 

“N”

Message 5005 =

“The message is 

now de-activated.”

Message 5022 =

“You may choose between messages 2-9 

in the pre-recorded list. By selecting 

option 2-9, you will hear the message as 

it is recorded. After you have heard the 

message, you can then press 1 if you 

choose to activate it. Please enter your 

option now.”

Go To 

PreRecorded 

Menu

 (Page 46) 1 2

Special Message = 1

Message 5025 =

“Please speak your message 

after the tone. When you are 

finished, press #.”

Message 5006 =

Please enter password

Password 

valid?

No

Disconnect 

Call

Message 5007 =

The password you 

entered is not valid.

Yes

Go To 

Message 

Record Cont 

(Page 45)

Note: Entering “*8” at the initial menu on page 1, 

will activate this script. A password is used for 

script security.

Page 44

Main Menu

Message 5002 =

“To activate a special bulletin board message press 1”

Message 5003 =

“To de-activate the current special bulletin board 

message press 2”

Activation Menu

Message 5009 =

“To record a special bulletin board message press 1”

Message 5010 =

“To use a prerecorded message, press 2”

2

1

2

1

Activation Menu

Message = 5011

“To hear the current recording, press 1”

Message = 5012

“To de-activate the current special bulletin board 

message, press 2”

Administration of Bulletin Messages
193

Message 5025= “Please speak 

your message after the tone. 

When you are finished, press #.”

Go To 

Main Menu 

(Page 44)

Message Record Cont

Copy Temp 

Phrase into 

Message #1

Message = 5026

“Your message will now be played back:”

Set Active = 

“Y”

Message 5032 =

“The message is now activated.”

Message 

Record 

Mode

Go To 

Main Menu 

(Page 44)

Page 45

Bulletin Message = 1

(Currently not recorded)

Message 5027 = If you are happy with this message, press 1.

Message 5028 = To re-record, press 2.

Message 5024 = To return to the Main Menu, press 9

1 29
194

Pre-Recorded Menu

Go To 

Main Menu

 (Page 1)

1

Message 5023:

“To activate the message, press 1.”

Message 5024:

“To return to the Main Menu, press 9.”

2 3 4 5 6 7 8 9

Set Active = 

“Y”

“The message is 

now activated.”

9

Go To 

Main Menu

 (Page 1)

< Selected Message # >

Page 46
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5.0 Interactive Response Tool Implementation Document 

The implementation phase includes building or purchasing the technology/system, testing and 

piloting it, training staff on it, migration of it into an active environment, and then going live. During 

this phase, the technology solution undergoes comprehensive testing first by the project team and 

internal users and then by external users. This allows for both coarse and fine tuning to validate that 

application designs meet the requirements and objectives. The implementation plan should incorporate 

appropriate users in the process, establish realistic time frames for tasks, provide adequate opportunity 

for feedback, and establish criteria for measuring success. Depending on the environment of your call 

center, you may consider using change management strategies to create a positive environment for 

learning and change among the staff impacted by the implementation. Our project team was 

responsible for ensuring that each component of the implementation phase was addressed following 

their clearly defined roles and responsibilities. 

Building the Technology Solution 

 Since we previously purchased an IR system, our first task was to build a technology solution 

utilizing this equipment. This included development of the IR applications and making programming 

changes to the telephone switch to support IR application functionality. We contracted with an IR 

consultant and developer to oversee the development of the applications in accordance with our 

business requirements and specifications. The IR consultant developed the applications, provided 

administration and maintenance training for our Information Technology (IT) group and assisted with 

modifications to the applications after testing. Our IT group made the appropriate programming 

changes to our telephone switch to support the IR applications. 

Implementing the Solution 

 The following is a project time line for the implementation milestones, the responsible person(s), 

and the timeframe for completion. The implementation phase occurs after completion of the planning, 

analysis, and design phases (approximately 6 to 8 weeks). The timeframes listed do not necessarily 

occur in series; many can be done concurrently while other milestones are in progress. There also may 

be delays between milestones due to other demands on the responsible person(s) and the resources they 

require to support them. 
196

The following table outlines the major implementation milestones for the four applications 

(approximately 34 weeks to complete): 

Milestone Responsible Person(s) Timeframe 

Develop IR applications IR Consultant 8 weeks 

Test IR applications on IR consultant 

system (test environment) 

IR Consultant 4 weeks 

Internal testing of QI Monitoring 

application prototype 

Telecommunications 

Engineer/Project Manager 

2 weeks 

1st External testing of QI Monitoring 

application prototype 

Telecommunications 

Engineer/Project Manager 

4 weeks 

Install applications on IR system Telecommunications 

Engineer/IS Manager 

2 weeks 

Record messages and announcements for 

all IR applications 

Telecommunications 

Engineer 

2 weeks 

Internal testing and validation of all four 

applications 

Telecommunications 

Engineer/IS Manager 

2 weeks 

2nd External testing of all applications Project Manager 4 weeks 

Train IT group to administer and 

maintain applications 

Telecommunications 

Engineer 

2 weeks 

Adjust and refine applications and their 

recorded messages 

Telecommunications 

Engineer 

4 weeks 

Document application designs and 

administration procedures 

Telecommunications 

Engineer 

4 weeks 
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5.1 Testing 

 We used an iterative testing approach that included four cycles of testing: 1) technology testing 

(external testing by the IR consultant and internal IT group testing), 2) internal testing by our call 

center staff, 3) external testing by a rural user group, and 4) external testing by an urban user group. 

This testing approach gave ample opportunities to validate that the applications function as required 

and that any difficulties in using the applications were identified and addressed (user acceptance 

testing). These testing cycles are already included in the overall implementation timeline in the 

previous section. Total time for testing required approximately 16 weeks to complete. 

5.2 Training 

 The training strategy for this project was to ensure that the general public with a touch tone 

telephone should be able to navigate through these IR applications and have a positive overall 

experience. 

 In a testing environment, we could not convey instructions through the media or other channels that 

we would use in an actual emergency situation. Therefore, we had to incorporate clear directions for 

users within the applications themselves so that there would be a high probability of user acceptance. 

Some of the directions that were incorporated into the applications include: 

• An option to connect to an information provider (live person) when there is an appropriate need 

or if the user gets lost within the application 

• An option to repeat a message so that the user can hear it again to fully capture the information 

being relayed 

• An option to utilize the application again (such as with POD and DI applications) so they do 

not have to call again to enter a different response 

• An option to return to the main menu (such as with FAQ Library application) so they can get 

answers to more than one question they may have 

 There is always a trade off with devoting time at each step in an IR application with providing 

instructions in addition to the critical messages, so a balance in providing good guidance while keeping 

callers moving through the application has to be achieved. Testing of applications with user groups is 

one of the best ways to determine that balance. 

 It would be best to incorporate clear instructions into the QI application; however, we would still 

recommend public health agencies develop an instruction sheet for quarantine that includes what is 

expected of those in quarantine, what they should expect during the quarantine period, and what 

resources to contact for anticipated difficulties in maintaining quarantine (food, medications, finances, 

etc.). 
198

5.3 Migration 

 The migration plan has both a technical and a business component. The technical component 

(conversion plan) describes how the new system will be installed and where applicable, how data in 

the previous system will move to the new system (this does not apply for this technology solution). 

Installation of the IR technology solution and the steps involved were discussed in previous sections. 

The business component includes a change management plan that helps users understand the change 

and motivate them to adapt to the changes. 

 The change management plan for this effort began early in the process and continued throughout 

the project. The project team, steering group and external advisory panel represented the key 

stakeholders and users that the technology system would impact. We focused on communication and 

feedback throughout the process to ensure members understood the costs and benefits for the 

organizations involved and end user groups, our plan for implementing the technology solution, how 

we would measure success, and the feedback process for continuous improvement. The iterative 

testing strategy provided a feedback loop for participants and users to identify what worked and what 

did not work so that appropriate changes could be made to the applications. These ultimately should 

result in applications that are well designed, efficiently deliver the required capabilities and do so in a 

manner that is effective and acceptable to the user. 

5.4 Success Measures 

 It is critical to develop criteria for measuring success of any technology under development. 

Measures may include ease of use, successful installation, accurate programming performance, system 

security, accurate reporting, database accessibility, hardware and software reliability and 

maintainability. Success measures should reflect the essential criteria that the organization expects the 

solution to have. Success measures for the entire project included those for the management and 

development of call center applications to support outpatient health care and monitoring in a major 

public health event. For the tool itself and the applications developed, the measures of success were the 

following: 

• Project completed within allotted timeframe and budget. 

• Project goal met – developed IR applications that community health call centers could implement. 

• IR applications developed within available IR technology/system. 

• IR applications addressed the anticipated response needs for the users. 

• IR applications were designed for a high probability of user acceptance (good user ratings for the 

following eight criteria): 

o Directions given by the IR were easy to follow. 

o Recorded voice on the IR was easy to understand. 

o Recorded voice on the IR went at a proper speed. 

o Recorded voice on the IR was at a proper volume. 

o User satisfied with experience using the IR. 
199

o User had a positive opinion of the IR. 

o User would trust receiving supportive contact or information via an automated system like the 

IR during a public health event, User would accept receiving supportive contact or information 

via an automated system like the IR during a public health event. 

Each of the above criteria and the measurements and feedback received from testing will be reviewed 

in the Evaluation Document below.
200
201

6.0 Interactive Response Tool Evaluation Document 

6.1 San Luis Valley Region Exercise 

 The San Luis Valley Region is made up of six rural counties located in the Southwest of Colorado. 

Most of public health agencies in the valley only have one or two public health nurses assigned to 

them. The total census population for the region is 48,000 but population can increase to greater than 

75,000 in the summer months. We decided to test a prototype version of the QI Monitoring application 

in conjunction with a planned influenza vaccination exercise in this rural area. 

Exercise Design 

 In order to test the vaccination plans that would be used during a disease outbreak, such as for 

pandemic influenza, public health nursing services in the six counties in the San Luis Valley conducted 

free flu shot clinics beginning on Saturday, October 15, 2006. The exercise began with a fictitious 

health emergency being declared. Area clinics were opened and flu shots were provided to the public 

to test the ability of the local public health agencies to respond to this staged incident. As part of the 

response, each county public health nursing service also practiced the ability of its staff to isolate ill 

persons and to quarantine people who have been exposed to ill individuals. 

A series of questions was asked before each person was admitted to the vaccination clinic to segregate 

out those who were already ill and may need to be quarantined. A “Yes” answer to any of the 

following questions was sufficient for the person to be assigned to home quarantine: 

• Do you have a fever now? 

• Do you have body aches now? 

• Do you have a new cough or new sore throat? 

• Have you been around someone who has the flu or the above symptoms? 

Methodology 

 Two citizens in each county, a total of 12, volunteered to be mock “isolation cases” and help test 

the QI Monitoring application. Data on individuals to be placed into isolation were collected (see 

sample Case/Contact Investigation Report Form – Appendix 4-A) and faxed to the Regional 

Epidemiologist who entered them into the State Health Department’s Outbreak Management System. 

Data were transferred twice each day (prior to start of calling periods) as a flat file to test our ability to 

utilize this for directing the QI Monitoring application to call people. We were also provided the list of 

all mock cases and their contact information to verify that the application received the complete list 

and made the appropriate calls. The Quarantine/Isolation (QI) Monitoring application called the 12 

volunteers identified for quarantine and isolation during the exercise to check on their status (whether 

they answered the provided phone number) two times (calling periods) per day for 2 to 4 days. 

Results 

 The application was able to utilize the received flat files for contacting volunteers prior to each 

calling period. There was difficulty in reaching one person who had a telephone number that blocked 

solicitation calls (they also use IR systems). This was disabled to permit receipt of calls from the IR 
202

system. Otherwise the application successfully dialed all listed phone numbers. All 12 volunteers 

successfully interacted with IR application (call registered as answered by a person) at least once 

during their quarantine. Four of the volunteers answered the IR application calls within 1 or 2 attempts 

for all calling periods. The Regional Epidemiologist was notified whenever a volunteer had not 

answered for two consecutive calling periods, signifying a need for a home visit. This occurred for 8 of 

the volunteers who failed to answer the IR application calls within 2 attempts for two to four 

consecutive calling periods. 

• Total number of calling periods for all 12 volunteers = 74. 

o # Calling periods with calls answered with 1 attempt = 38 (51 percent). 

o # Calling periods with calls answered with 2 attempts = 14 (19 percent). 

o # Calling periods without calls answered with 2 attempts = 22 (30 percent). 

• Notifications to Regional Epidemiologist (2 consecutive calling periods without an answer) = 

14. 

 The feedback from volunteers and exercise organizers suggested several potential improvements 

for the QI Monitoring application (followed by our assessment of each suggestion): 

• Have the option to repeat messages. (Such an option was added). 

• Call up to three times during an hour to attempt contact. (Application could be programmed to 

call as many times per day as needed.) 

• IR system should recognize telephone prefixes and call the appropriate county health agency 

when someone does not answer. (This is not possible with the IR system.) 

• Recorded voice should speak slower. (Recordings updated with best “voice” for speed, clarity, 

tone and volume.) 

• If cell phone is called, integrate GPS information to insure the person is still at home. (This is 

not possible with the IR system.) 

• IR should give a phone number to call back on if the person cannot wait to speak to someone. 

(It is important that the quarantined person complete calls when received, but the application 

does provide an announcement of a direct number to use if assistance is needed afterwards.) 

• Cancel call forwarding feature to limit calls to a land line telephone at the person’s home. (This 

would require cooperation of telephone service provider and be subject to applicable laws.) 

• Provide an electronic link between State Health Department and the call center to transfer case 

or contact data. (A flat file was used to export list of contacts to make prior to each calling 

period – it is a manual process for loading this file into the application.) 

 There were also suggestions for public health agencies using this application: 

• Have someone make at least one home visit during the home quarantine or isolation period. 
203

• Develop protocols for children. 

• Develop protocols for more than one case or contact at the same location. 

• Provide an information sheet to home quarantine or isolation candidates explaining: 

o What to expect. 

o What to do in certain instances. 

o What not to do. 

o Who to call if you need help. 

Summary 

 There were several key lessons learned from the San Luis Valley Region Exercise. In a pandemic 

influenza or other infectious disease (i.e. SARS) scenario, home quarantine or isolation may be an 

important, early component of the public health response. With effective risk communication 

messages to the public and adequate support for those in quarantine, we expect a good percentage of 

compliance. Small public health agencies (and perhaps larger agencies) will have difficulty keeping 

track individuals in home quarantine or isolation. This will require extensive personnel resources 

without the benefit of a system like the IR and the QI Monitoring application (or some similar 

monitoring strategy). In this test the application was able to monitor up to 70 percent of the 

quarantined persons which demonstrated compliance with little personnel resources. This may help 

public health agencies free up resources to focus on non-compliant individuals or manage the myriad 

of other response actions required. 

6.2 North Central Region Exercise 

 The North Central Region (NCR) consists of 10 counties in the Denver metropolitan area with a 

population of 2.7 million people. The geography of the NCR ranges from mountainous rural to 

suburban foothills to urban plains areas. The NCR was established by Colorado as a Homeland 

Security region. The NCR is participating in the Cities Readiness Initiative (CRI) with the goal of “get 

pills into people within 48 hours using every method available to save as many lives as possible.” The 

antibiotic medications the CRI is preparing to distribute will come from local caches as well as the 

Strategic National Stockpile (SNS), if necessary. 

Exercise Design 

 The goal of the NCR Exercise was to test the ability of the four IR applications to initiate contact 

and effectively communicate key information to users. In addition to a more fully developed version 

of the QI Monitoring application, public health volunteers also tested the Drug Identification (DI), 

Point of Dispensing (POD) and Frequently Asked Question (FAQ) Library applications. Up to ten 

volunteers from each county participated in the exercise beginning on May 2, 2006. A total of 96 

volunteers tested the QI Monitoring application, with approximately one third assigned to test one of 

the three other applications. The goals for testing each application were: 

• QI Monitoring: initiate contact and assess health status of individuals in quarantine reflective of 

their assigned “health” scenario. 
204

• DI: provide accurate pill identification based upon supplied drug photo. 

• POD: provide accurate location for drug distribution based upon entered zip code. 

• FAQ Library: to provide accurate information that was retrievable by the user about an 

assigned health concern. 

Evaluation Methodology 

 Unlike the first exercise in the San Luis Valley, this exercise was strictly scripted so that we could 

evaluate IR application accuracy as well as how the user assessed the applications upon a set of eight 

criteria. Volunteers were provided a call log (see Appendix 4-B) to record their experiences with the 

QI Monitoring application. An additional evaluation form was used to record the answers from their 

use of one of the three assigned other applications (Appendices 4-C – 4- E). The volunteers evaluated 

the QI Monitoring and other assigned application on specific aspects using a 5-point scale (5 = 

Strongly Agree, 4 = Agree, 3 = Undecided, 2 = Disagree, 1 = Strongly Disagree). The eight criteria 

used to evaluate each IR application were: 

• Directions given by the IR were easy to follow. 

• Recorded voice on the IR was easy to understand. 

• Recorded voice on the IR went at a proper speed. 

• Recorded voice on the IR was at a proper volume. 

• User satisfied with experience using the IR. 

• User had a positive opinion of the IR. (This criteria was tailored to a specific question about 

each application.) 

• User would trust receiving supportive contact or information via an automated system such as 

the IR during a public health event. 

• User would prefer to receive supportive contact or information via an automated system such as 

the IR versus a person during a public health event 

 The QI Monitoring application attempted to contact all volunteers during two call periods (9:00am 

– 11:00am and 2:00pm – 4:00pm) each day for two consecutive days. Each volunteer was assigned one 

of four “health” scenarios so we could determine, once contacted, if the QI Monitoring application 

correctly reported a person’s health status. 

 The following is an example “health” scenario: 

“You are a 65-year-old man who has been quarantined since May 1st and is expecting to receive 

automated calls verifying your health status on May 2nd and May 3rd. You begin experiencing 
205

symptoms including body aches and fever above 100oF on the afternoon of May 3rd. You will be 

contacted by the IR for your health status and should respond according to the following: 

• May 2nd - morning: Temperature <100oF (no assistance needed)May 2nd - afternoon: 

Temperature <100o

F (no assistance needed)May 3rd - morning: Temperature <100oF (no 

assistance needed). 

• May 3rd - afternoon: Temperature >100oF (assistance needed) 

 Volunteers returned call logs after the exercise and their evaluations of the applications and 

comments were reviewed to determine if any modification would be needed. 

Results 

 We received 93 evaluations (97 percent return rate); 88 evaluations were completed representing 

92 percent of volunteers. The results for each application will be discussed in the following sections. 

Quarantine/Isolation (QI) Monitoring 

 The modified version of this application was again able to utilize a flat file for contacting 

volunteers. A problem was encountered during the first calling period with dialing three long distance 

numbers. The application was quickly modified to allow for long distance dialing (“1” added to front 

of long distance numbers) for the three remaining calling periods. Otherwise the application 

successfully dialed all listed phone numbers for all calling periods. All but two volunteers 

successfully interacted with IR application (call registered as answered by a person) at least once 

during their quarantine. Fifty-nine (61 percent) of the volunteers answered the IR application calls 

within 1 or 2 attempts for all calling periods: 20 answered for three periods, 14 for two periods, and 1 

for just one period. Four times a person made a mistake in the language selection (and could not go on 

to select a health status – instructions what to do if this occurs could be provided upon enrollment). A 

county public health contact was notified whenever a volunteer had not answered for two consecutive 

calling periods, signifying a need for a home visit. This occurred for 15 of the volunteers who failed to 

answer the IR application calls within 2 attempts for two to four consecutive calling periods. 

• Total number of calling periods for all 96 volunteers = 382. 

o # Calling periods with calls answered with 1 attempt = 278 (72 percent). 

o # Calling periods with calls answered with 2 attempts = 45 (12 percent). 

o # Calling periods without calls answered with 2 attempts = 59 (15 percent). 

• Notifications to Regional Epidemiologist (2 consecutive calling periods without an answer) = 

19. 

 The majority of volunteers indicated favorable scores (4 or 5) for seven of the eight criteria used to 

assess the QI Monitoring application (n=88): 
206

• Directions given by the IR were easy to follow – 99 percent (mean score 4.6, median score 5.0). 

• Recorded voice was easy to understand – 99 percent (mean score 4.7, median score 5.0). 

• Recorded voice went at a proper speed – 98 percent (mean score 4.6, median score 5.0). 

• Recorded voice was at a proper volume – 97 percent (mean score 4.7, median score 5.0). 

• Satisfied with experience using the IR – 93 percent (mean score 4.6, median score 5.0). 

• Had a positive opinion of the IR – 93 percent (mean score 4.6, median score 5.0). 

• Would trust receiving supportive contact via an automated system like the IR during a public 

health quarantine – 88 percent (mean score 4.3, median score 5.0). 

 The only criteria not scored favorably by a majority of users concerned their preference in 

receiving health department contact from an automated system versus speaking to a live person: 43 

percent with scores 4 or 5, mean score 3.4 and median score 3.0. 

 In hindsight we thought we should have asked users to assess if it would be acceptable to receive 

supportive contact from an automated system during public health quarantine. Indeed some of the 

comments received from users seemed to indicate that the IR would be acceptable for use during such 

an emergency. One comment raised the question whether this application could work for everyone. It 

was never our intention that this application could work for everyone. It would be at the discretion of 

public health agencies coordinating quarantine efforts to decide which individuals this application 

could assist in monitoring – the goal being that many individuals could be supported by this approach. 

That would reduce the overall number of individuals requiring personnel to monitor them, so those 

resources could concentrate on special needs cases. 

• “Much faster automated...was on hold 11 to 12 minutes awaiting to speak to a live person – a 

reasonable time frame – but this will dramatically increase during a true emergency, using up 

cell phone batteries, increasing public anxiety, and overtaxing responders.” 

• “Prefer a real person, but this was easy to understand.” 

• “If an actual emergency occurred, I wouldn't mind being called by IR as long as I could get to a 

live person if my questions weren't answered.” 

• “But will it work for everyone? Especially the very elderly living with relatives.” 

Drug Identification (DI) 

 This application was tested to determine how effective it would be in assisting the public in 

identifying antibiotic drugs that may be distributed during certain public health events. The underlying 

challenge is that multiple medications will be distributed to the same household during an emergency 

and not all of them will look the same. For example there are multiple manufacturers of doxycycline, 

all of which are contained in the local and SNS stockpiles. Rather than calling their doctor or 

pharmacist to question them about these medications, this IR application offers a self-service 

alternative. 
207

 Thirty volunteers were assigned to evaluate this application. Rather than provide the actual 

medication, they were provided pictures of both sides of one of the doxycycline drugs, asked to 

identify it with the application and record the answer on an evaluation form (see Appendix 4-C). We 

received completed evaluations from 26 volunteers (83 percent return rate) assigned to test this 

application. A total of 24 (92 percent) correctly identified the pictured drug: 22 identified it as 

doxycycline, 2 identified it as an antibiotic, 1 did not provide an answer and 1 indicated that the color 

of the pictured drug did not match any of the options (a printer issue – see comment below). 

• “The prompt asked for a brown pill not pink with this imprint.” 

 To increase the ability of callers to correctly identify drugs, the application includes drug type 

(capsule, tablet), drug shape, drug color and drug imprint for identification. In a real event, this caller 

could have been routed to an Information Provider for assistance (an option that could be added to the 

application) or directed to another resource. 

 The majority of volunteers indicated favorable scores (4 or 5) for seven of the eight criteria used to 

assess the DI application (n=26): 

• Directions given by the IR were easy to follow – 96 percent (mean score 4.6, median score 5.0). 

• Recorded voice was easy to understand – 88 percent (mean score 4.5, median score 5.0). 

• Recorded voice went at a proper speed – 85 percent (mean score 4.3, median score 5.0). 

• Recorded voice was at a proper volume – 92 percent (mean score 4.5, median score 5.0). 

• Trust automated system to correctly identify drug – 77 percent (mean score 4.2, median score 4.5). 

• Satisfied with experience using the IR – 73 percent (mean score 4.2, median score 5.0). 

• Would trust receiving information via an automated system like the IR during a public health 

emergency – 77 percent (mean score 4.2, median score 4.5). 

 The only criteria not scored favorably by a majority of users concerned their preference in 

receiving health department information from an automated system versus speaking to a live person: 

42 percent with scores 4 or 5, mean score 3.4 and median score 3.0. Again, we thought we should 

have asked users to assess if it would be acceptable to receive information about medications from an 

automated system during public health emergency. Indeed one of the comments received from users 

seemed to indicate that the IR would be acceptable for use during such an emergency. 

• “Talking to a real person is always comforting but this system did work well.” 

 Other comments identified improvements for the application including recorded messages (spelling 

out drug names, using better voice for recording) and an option to identify more than one drug 

appearance per call. We made the appropriate modifications to the application to address these 

suggestions. 

• “I could not understand the name of the medication. Need to pronounce it better and slower. 

Spelling it would help.” 
208

• “It would be nice to be able to identify more than one pill per call if there is potential for family 

members to have different products. I wouldn’t want to listen to the introduction more than 

once” 

Point of Dispensing (POD) 

 This application was tested to determine if zip code specific messages could assist users with 

getting POD locations where drugs are being distributed. The application allows users to call and 

receive very specific messaging according to their entered 5 digit zip code. This application provides 

self-service information delivery where messages could be modified for a variety of events besides 

mass drug dispensing. Major application benefits include: 

• Provides consistent, accurate information dependent upon entered zip code. 

• Collects zip code data to characterize events (situational awareness – where are callers from 

and should more media messaging be used). 

• Expands capacity for handling surges since calls are handled without personnel. 

• Adaptable to any emergency where zip code specific messaging is needed including shelter in 

place strategies. 

• Supports mass prophylaxis/immunizations. 

Thirty-six volunteers were assigned to evaluate this application. Callers were instructed to enter a 5 

digit zip code, record that zip code and the location they were given on an evaluation form (see 

Appendix 4-D). We received all 36 evaluations back (100 percent return rate) and all recorded the 

correct POD location for their entered zip code. 

 The majority of volunteers indicated favorable scores (4 or 5) for seven of the eight criteria used to 

assess the POD application (n=36): 

• Directions given by the IR were easy to follow – 83 percent (mean score 4.3, median score 

5.0)Recorded voice was easy to understand – 92 percent (mean score 4.4, median score 5.0). 

• Recorded voice went at a proper speed – 81 percent (mean score 4.1, median score 4.0). 

• Recorded voice was at a proper volume – 92 percent (mean score 4.4, median score 5.0). 

• Information received was accurate based upon entered zip code – 94 percent (mean score 4.6, 

median score 5.0). 

• Satisfied with experience using the IR – 86 percent (mean score 4.4, median score 5.0). 

• Would trust receiving information via an automated system like the IR during a public health 

emergency – 86 percent (mean score 4.4, median score 5.0). 

 The only criteria not scored favorably by a majority of users concerned their preference in 

receiving health department information from an automated system versus speaking to a live person: 

47 percent with scores 4 or 5, mean score 3.5 and median score 3.0. Again, we thought we should 

have asked users to assess if it would be acceptable to receive information about POD locations from 

an automated system during public health emergency. 
209

 Comments identified improvements for the application including recorded messages (using better 

voice for recording, providing major intersections to locations, eliminating confusing words) and an 

option to repeat location messages. We made the appropriate modifications to the application to 

address these suggestions. 

• “I had to play the message several times to hear the location - still not sure what the name of 

the stadium was.” 

• “Need ‘directions to location’ option. I really liked the message about 'plenty of antibiotics' 

and impression that people would be taken care of properly.” 

• “Speak at different speeds for different parts of the message. Eliminate words like prophylaxis 

which don't help most callers.” 

Frequently Asked Question (FAQ) Library 

 This application was tested to evaluate the ability of users to navigate a library of messages and to 

obtain the desired information. Our HELP program uses this library for handling calls after hours and 

with great success. One of the benefits of the FAQ Library application is allowing self-service 

information delivery that is consistent and accurate. The application collects structured data to 

characterize the information needs of the public (situational awareness – what are public information 

needs and should media messaging be used for them). The application has the ability to expand 

capacity for handling surges and is capable of adapting to different events. 

 Thirty volunteers were assigned to evaluate this application. Callers were instructed to call, obtain 

the answer to the question they were assigned and record the answer on an evaluation form (see 

Appendix 4-E). We received 28 completed evaluations (93 percent return rate): 27 (96 percent) 

provided correct answers to one of the following assigned questions: 

• What is the incubation period for West Nile Virus in humans? 

• What are the symptoms of mold exposure? 

• How do I know if I have West Nile Virus? 

 The one incorrect entry gave mold-growing conditions instead of symptoms of mold exposure. 

 The majority of volunteers indicated favorable scores (4 or 5) for all eight criteria used to assess 

the FAQ Library application (n=28): 

• Directions given by the IR were easy to follow – 96 percent (mean score 4.6, median score 

5.0)Recorded voice was easy to understand – 96 percent (mean score 4.6, median score 

5.0)Recorded voice went at a proper speed – 82 percent (mean score 4.1, median score 4.0). 

• Recorded voice was at a proper volume – 100 percent (mean score 4.7, median score 5.0). 

• Able to easily navigate through the options to find information – 100 percent (mean score 4.7, 

median score 5.0). 

• Satisfied with experience using the IR – 100 percent (mean score 4.7, median score 5.0). 

• Would trust receiving information via an automated system like the IR during a public health 

emergency – 93 percent (mean score 4.5, median score 5.0). 
210

• Would prefer receiving information via an automated system versus a live person during a public 

health emergency – 57 percent (mean score 3.7, median score 4.0). 

 This application received the most favorable evaluations from users. However, the lowest rating 

again concerned the preference in receiving health department information from an automated system 

versus speaking to a live person. The responses suggest that most users would find it acceptable to 

retrieve information from an FAQ library during public health emergency. Comments identified 

improvements for the application including recorded messages (using better voice for recording, 

eliminating confusing words), an option to repeat messages and an option to return to the main to 

answer another question. We made the appropriate modifications to the application to address these 

suggestions. 

• “I felt that the symptoms were listed very quickly. IR needs to slow down just a little bit, 

otherwise very good!” 

• “He went too fast to write it all down However, if I was calling to see if I had the symptoms, I 

would know what I was listening for and would probably not write all of them down.” 

• “When you get to the answer you are looking for your only option was to repeat the message or 

start all over again. Could you also provide an option to go to the West Nile Virus main 

menu?” 

• “Need way to slow down or pause recording when listing things, otherwise too much info too 

fast.”

6.3 Evaluation Summary 

 Exercise objectives were met and we obtained excellent feedback to help us improve the tested 

applications. We also obtained important information on what the user acceptance was for these IR 

applications. Although there were mostly favorable evaluations for all four applications, it was 

apparent the FAQ Library application seemed more acceptable than the DI application (perhaps 

because the latter concerned medications to be taken). The comments and evaluations of these 

applications should help Public Information Officers in determining which ones may be acceptable for 

different events and in developing messaging strategies. These results also suggest areas for potential 

community outreach efforts for public health agencies to create a more informed public. One lesson 

learned is that the applications will only be as good as the information that is developed for them and 

how it is provided to the public.

6.4 Future Research 

 These IR applications have yet to be tested with vulnerable and at risk populations (Spanishspeakers, seniors, etc). Such testing may be necessary to determine if some groups would respond as 

positively to the IR applications as the test groups did. Additional research will be needed to 

determine other information and resource needs for the public and how to provide them health 

emergency events. 
211

Appendix 4-A. Case/Contact Investigation Report Form 

San Luis Valley Region Pandemic Influenza Exercise 

Case/Contact Investigation Report Form 

(Fill in the blanks and circle all that apply. Please complete form as completely as possible.) 

Report Date: ___/___/_____ (mm/dd/yyyy) 

Report Time: ___:___am/pm 

*Diagnosis: Influenza Case → (must have fever (>100o

F), plus cough or sore throat) 

 (circle) Influenza Contact (must be household member of a case in the past 5 days) 

*If an Influenza Case, Illness Onset Date: ___/___/_____ (mm/dd/yyyy) 

*#Last Name: _________________ (use alias from inject form if this is an inject case) 

*#First Name: _________________ (use alias from inject form if this is an inject case) 

*#Birth Date: ___/___/_____ (mm/dd/yyyy) 

*Sex: (circle) Female Male 

Race: (circle) Unknown American Indian/Alaskan Native 

 White Pacific/Hawaiian 

 Asian Black Other 

Ethnicity: (circle) Unknown Hispanic Not Hispanic 

Residence Information: Street Address City County ZIP 

 *#Address 1: 

 Address 2: 

Phone Numbers: 

 *#Home: _ _ _ - _ _ _ - _ _ _ _ *Work: _ _ _ - _ _ _ - _ _ _ _ 

 *Mobile _ _ _ - _ _ _ - _ _ _ _ 

*Household Members: Name (Last, First) Birth Date Phone 

 Member 1: ____________, __________ ___/___/______ ___-___-____ 

 Member 2: ____________, __________ ___/___/______ ___-___-____ 

 Member 3: ____________, __________ ___/___/______ ___-___-____ 

 Member 4: ____________, __________ ___/___/______ ___-___-____ 

 (Use additional forms as needed for other household members) 

Case Notes or Comments: 

Person filling out this form (please print): ___________________________ 

Please Fax this form ASAP to Regional Epidemiologist at XXX-XXX-XXXX or call XXX-XXX-XXXX 
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213

Appendix 4-B. QI Monitoring Call Log 

North Central Region Exercise 

Quarantine/Isolation (QI) Monitoring Call Log 

An Interactive Response (IR) system is an automated tool commonly used throughout the business community 

to disseminate information and provide guidance to the public without requiring enormous amounts of 

manpower. If you have ever called a utility company or bank and were asked by a recorded voice to “press 1, 

press 2, or press 3” based on your needs, you have used an IR. 

Public Health Preparedness Officials realized that this technology could be incredibly useful to help address 

community needs in case of a quarantine and isolation scenario, or as a method to disseminate zip-code based 

information regarding Points of Distribution (POD) sites for mass prophylaxis. To develop this, the RMPDC 

purchased an IR system for use through its COHELP program as a tool to assist in the delivery of information 

during a public health emergency, while lowering the impact of increased call volume on our call center staff. 

As a volunteer, you will receive calls on May 2nd and 3rd from the IR system during the following call periods: 

9:00am – 11:00am and 2:00pm – 4:00pm. The IR will make two attempts per calling period to contact you. In 

the event that you miss the two IR call attempts, our system will flag you as non-compliant. 

When you receive the call, please answer the phone as you normally would. Your voice signals the IR to begin 

its message. Please follow the prompts based on your assigned scenario. By volunteering, you are assisting 

us in gathering a baseline capability assessment of the IR. Please do not try to “trick” the IR. After completing 

each quarantine call from the IR, please fill out the call log below. At the end of the exercise, please complete 

the attached survey regarding your experience with the IR. Thank you for your assistance in testing this system. 

Volunteer Name: ___________________________________________________ 

Volunteer Phone Number: ____________________________________________ 

May 2nd, 9:00am – 11:00pm Call Period

1. What time did the IR contact you? ____:____ AM PM 

2. Did you answer your phone on the first or second call attempt of the IR? 

Please circle: 1st 2nd Unknown 

3. Based on your assigned scenario, what was your response to the IR? Please circle the letter of the correct 

response: 

a. High temperature, spoke to COHELP 

b. Normal temperature, no assistance needed 

c. Normal temperature, needed assistance with food, finances, or medication 

d. Not able to take temperature, spoke to COHELP 
214

May 2nd, 2:00pm – 4:00pm Call Period

1. What time did the IR contact you? ____:____ AM PM 

2. Did you answer your phone on the first or second call attempt of the IR? 

Please circle: 1st 2nd Unknown 

3. Based on your assigned scenario, what was your response to the IR? 

Please circle the letter of the correct response: 

a. High temperature, spoke to COHELP 

b. Normal temperature, no assistance needed 

c. Normal temperature, needed assistance with food, finances, or medication 

d. Not able to take temperature, spoke to COHELP 

May 3rd, 9:00am – 11:00pm Call Period

1. What time did the IR contact you? ____:____ AM PM 

2. Did you answer your phone on the first or second call attempt of the IR? 

Please circle: 1st 2nd Unknown 

3. Based on your assigned scenario, what was your response to the IR? 

Please circle the letter of the correct response: 

a. High temperature, spoke to COHELP 

b. Normal temperature, no assistance needed 

c. Normal temperature, needed assistance with food, finances, or medication 

d. Not able to take temperature, spoke to COHELP 

May 3rd, 2:00pm – 4:00pm Call Period

1. What time did the IR contact you? ____:____ AM PM 

2. Did you answer your phone on the first or second call attempt of the IR? 

Please circle: 1st 2nd Unknown 

3. Based on your assigned scenario, what was your response to the IR? Please circle the letter of the correct 

response: 

a. High temperature, spoke to COHELP 

b. Normal temperature, no assistance needed 

c. Normal temperature, needed assistance with food, finances, or medication 

d. Not able to take temperature, spoke to COHELP 
215

Dear Quarantine Exercise Volunteer: 

Please answer the following questions regarding your experience receiving calls from the IR during the 

Quarantine/Isolation Monitoring Exercise. 

Questionnaire responses will use a scale of 1 to 5: 

1 = Strongly Disagree 

2 = Disagree 

3 = Undecided

4 = Agree 

5 = Strongly Agree

Please tell us how much you agree or disagree with the following statements: 

1. The directions given by the IR were easy to follow. 1 2 3 4 5 

2. The recorded voice on the IR message was easy to understand. 1 2 3 4 5 

3. The recorded voice on the IR went at a proper speed. 1 2 3 4 5 

4. The recorded voice on the IR was at a proper volume. 1 2 3 4 5 

5. I am satisfied with my experience using the IR. 1 2 3 4 5 

6. My opinion of the IR was positive during the exercise. 1 2 3 4 5 

7. During actual public health quarantine, I would trust receiving 

health department supportive contact via an automated system 

like the IR. 

1 2 3 4 5 

8. Based on my experience with the IR, I would prefer to receive 

health department contact from an automated system vs. 

speaking to a live person. 

1 2 3 4 5 

Comments (Please use the back of this sheet for additional room if necessary) 

 

 

Thank you again for your assistance in evaluating this communication tool. Your support will allow us to assist 

its public health partners in the event of community quarantine and provide important information to a large 

portion of the region’s population in a public health emergency. 

If you have questions about this tool or the testing process, please contact <Insert Test Coordinator Name> at 

the <Insert Their Agency Name>: <Insert Their Phone#> or <Insert Their Email Address> 
216
217

Appendix 4-C. DI Evaluation Form 

North Central Region Exercise 

Drug Identification Line Instructions 

In addition to the quarantine calls you will be receiving over the next 2 days, the Interactive Response (IR) 

system has other possible uses in a public health emergency. As a volunteer, we request your assistance in 

testing one of these additional capabilities. 

You have been requested to test the Drug Identification (DI) Line. In the event of a biologically based public 

health emergency, it may be necessary to distribute antibiotics to the entire Denver Metro region within 48 to 72 

hours. Not all Point of Dispensing (POD) locations will be dispensing drugs that have the same appearance. It 

is also possible for an individual to forget which pills they received or become confused which pills are theirs. 

An automated inbound call system allows a caller to access this information using pill imprints, color, shape and 

size. 

Using the automated system, please identify the pill pictured below by following the instructions and prompts 

provided by the IR. Please fill out the evaluation after you complete the call. Thank you for your assistance in 

testing this communication tool. 

Volunteer Name: ___________________________ 

1. Please call XXX-XXX-XXXX. 

2. Using the photo above, follow the prompts to identify this pill. 

3. Based on the information provided by the IR, what is this pill? 

 

Please fill out the evaluation questions on the second page, and thank you for your assistance in testing the 

Drug Identification Line. 
218

Dear Quarantine Exercise Volunteer: 

Please answer the following questions regarding your experience using the Drug Identification Line. 

Questionnaire responses will use a scale of 1 to 5: 

1 = Strongly Disagree 

2 = Disagree 

3 = Undecided

4 = Agree 

5 = Strongly Agree

Please tell us how much you agree or disagree with the following statements: 

1. The directions given by the IR were easy to follow 1 2 3 4 5 

2. The voice on the IR message was easy to understand 1 2 3 4 5 

3. The recorded voice on the IR went at a proper speed 1 2 3 4 5 

4. The recorded voice on the IR was at a proper volume 1 2 3 4 5 

5. I trust that the automated system correctly identified my pill 1 2 3 4 5 

6. I am satisfied with my experience using the IR 1 2 3 4 5 

7. If a public health emergency actually occurred and I needed 

antibiotics, I would trust receiving health department information via 

an automated system like the IR 

1 2 3 4 5 

8. Based on my experience with the IR, I would prefer to receive 

information from an automated system vs speaking to a live person. 

1 2 3 4 5 

Comments (Please use the back of this sheet for additional room if necessary) 

 

Thank you again for your assistance in evaluating this communication tool. Your assistance will allow us to 

provide important information to a large portion of the region’s population in a public health emergency. We 

believe these tools have the greatest potential to reduce patient surge demands on the traditional health care 

delivery system facilities and allow public health agencies to focus on epidemiology and control measures. 

If you have questions about this tool or the testing process, please contact <Insert Test Coordinator Name> at 

the <Insert tHeir Agency Name>: <Insert Their Phone#> or <Insert Their Email Address> 
219

Appendix 4-D. POD Evaluation Form 

North Central Region Exercise 

POD Information Line Test Instructions 

In addition to the quarantine calls you will be receiving over the next 2 days, the Interactive Response (IR) 

system has other possible uses in a public health emergency. As a volunteer, we request your assistance in 

testing one of these additional capabilities. 

You have been requested to test the Point of Dispensing (POD) Information Line. In the event of a biologically 

based public health emergency, it may be necessary to distribute antibiotics to the entire Denver Metro region 

within 48 to 72 hours. This POD Information Line will assist callers in finding the closest POD location based on 

the entered zip code and county. Please follow the instructions below and fill out the evaluation after you 

complete the call. Thank you for your assistance in testing this communication tool. 

Volunteer Name: 

1. Please call XXX-XXX-XXXX 

2. Please follow the prompts, using the phone keypad to enter the zip code recorded on your volunteer 

registration form. 

3. Please provide this entered zip code: 

4. Please provide your county of residence: 

5. Continue to follow the prompts to receive the location of your county’s POD. 

6. Which POD location did the IR message indicate for your county? 

____________________________________________________________

___________________________________________________________ 

Please fill out the evaluation questions on the second page, and thank you for your assistance in testing the 

POD Information Line. 
220

Dear Quarantine Exercise Volunteer: 

Please answer the following questions regarding your experience using the POD Information Line. 

Questionnaire responses will use a scale of 1 to 5: 

1 = Strongly Disagree 

2 = Disagree 

3 = Undecided

4 = Agree 

5 = Strongly Agree

Please tell us how much you agree or disagree with the following statements: 

1. The directions given by the IR were easy to follow 1 2 3 4 5 

2. The voice on the IR message was easy to understand 1 2 3 4 5 

3. The recorded voice on the IR went at a proper speed 1 2 3 4 5 

4. The recorded voice on the IR was at a proper volume 1 2 3 4 5 

5. The POD information I received from the IR was accurate based on 

my county of residence 

1 2 3 4 5 

6. I am satisfied with my experience using the IR 1 2 3 4 5 

7. If I were actually needing antibiotics, I would trust receiving health 

department information via an automated system like the IR 

1 2 3 4 5 

8. Based on my experience with the IR, I would prefer to receive 

information from an automated system vs speaking to a live person. 

1 2 3 4 5 

Comments (Please use the back of this sheet for additional room if necessary) 

Thank you again for your assistance in evaluating this communication tool. Your assistance will allow us to 

provide important information to a large portion of the region’s population in a public health emergency. We 

believe these tools have the greatest potential to reduce patient surge demands on the traditional health care 

delivery system facilities and allow public health agencies to focus on epidemiology and control measures. 

If you have questions about this tool or the testing process, please contact <Insert Test Coordinator Name> at 

the <Insert Their Agency Name>: <Insert Their Phone#> or <Insert Their Email Address> 
221

Appendix 4-E. FAQ Library Evaluation Form 

North Central Region Exercise 

FAQ Library LineTest Instructions 

In addition to the quarantine calls you will be receiving over the next 2 days, the Interactive Response (IR) 

system has other possible uses in a public health emergency. As a volunteer, we request your assistance in 

testing one of these additional capabilities. 

You have been requested to test the Frequently Asked Question (FAQ) Library Line. For commonly asked 

questions specific to a public health emergency, an automated inbound call system was developed for callers to 

access recorded messages directly. The information is approved by the CDPHE, and therefore will maintain 

standardization with information being broadcast through other venues. This tool was originally developed and 

tested during Colorado’s West Nile Virus outbreaks in 2003 and 2004 but can be supplemented with information 

about many other events. 

Please follow the instructions below and fill out the evaluation after you complete the call. Thank you for your 

assistance in testing this communication tool. 

Volunteer Name: 

1. Please call (XXX)-XXX-XXXX 

2. Using the prompts, please find an answer to the following question: 

What is the incubation period for West Nile Virus in humans? 

3. Based on the information provided by the IR, please record the answer to the provided question: 

 

Please fill out the evaluation questions on the second page, and thank you for your assistance in testing the 

Frequently Asked Question (FAQ) Library Line. 
222

Dear Quarantine Exercise Volunteer: 

Please answer the following questions regarding your experience using the FAQ Library Line. 

Questionnaire responses will use a scale of 1 to 5: 

1 = Strongly Disagree 

2 = Disagree 

3 = Undecided

4 = Agree 

5 = Strongly Agree

Please tell us how much you agree or disagree with the following statements:

1. The directions given by the IR were easy to follow 1 2 3 4 5 

2. The voice on the IR message was easy to understand 1 2 3 4 5 

3. The recorded voice on the IR went at a proper speed 1 2 3 4 5 

4. The recorded voice on the IR was at a proper volume 1 2 3 4 5 

5. I was able to easily navigate through the options to find the 

information I needed. 

1 2 3 4 5 

6. I am satisfied with my experience using the IR 1 2 3 4 5 

7. In an actual public health emergency, I would trust receiving health 

department information via an automated system like the IR 

1 2 3 4 5 

8. Based on my experience with the IR, I would prefer to receive 

information from an automated system vs speaking to a live person. 

1 2 3 4 5 

Comments (Please use the back of this sheet for additional room if necessary) 

 

 ____________________________________________________________ 

 

Thank you again for your assistance in evaluating this communication tool. Your assistance will allow us to 

provide important information to a large portion of the region’s population in a public health emergency. We 

believe these tools have the greatest potential to reduce patient surge demands on the traditional health care 

delivery system facilities and allow public health agencies to focus on epidemiology and control measures. 

If you have questions about this tool or the testing process, please contact <Insert Test Coordinator Name> at 

the <Insert Their Agency Name>: <Insert Their Phone#> or <Insert Their Email Address>.