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

1. Biological Attack—Aerosol Anthrax^1-3

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.
  • Vomiting.
  • Dyspnea.
  • Chest pain.
  • Sore throat.
  • Fever.
  • Headache.
  • Nausea.
  • Sweats.
  • Cough.
• 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.

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 Centers for Disease Control and Prevention (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 Food and Drug Administration (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 Influenza^3-10

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.
• 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.
  • Rigors.
  • Conjunctivitis.
  • Myalgia.
  • Chills.
  • 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).
• 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:
  • Amantadine.
  • Rimantadine.
  • Oseltamivir.
  • 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:
  • Central Nervous System (CNS): nervousness, anxiety, insomnia, difficulty concentrating, lightheadedness and potentially delirium, hallucinations, agitation, and seizures in severe instances.
  • Gastrointestinal (GI) System: nausea and anorexia.
• Both oseltamivir and zanamivir are more effective and lack antiviral resistance, as well as have fewer side effects:
  • Oseltamivir can have GI side effects.
  • 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.

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—Plague^11,12

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:
  • Household members of infected individuals.
  • Health care and laboratory workers.
  • First responders.
  • Patient transporters.
  • Coworkers.
  • 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.
• 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 Contamination ¹³

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.

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.

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/treatment/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 2000 283(17):2281-90.

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/food/illness.htm Accessed February 5, 2007.

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