Influenza viruses have plagued the globe for centuries. However, a pandemic only occurs when a novel strain of the virus emerges, leaving the human population vulnerable and without immunity. The pandemic threat we are currently facing is a new influenza strain, Influenza A (H5N1). Presently, human-to-human transmission has been limited, but once a pandemic begins, it cannot be easily controlled. The potential impacts of an influenza pandemic can be severe both globally and locally in terms of lives lost, community suffering, and economic and social systems disruption. Historically, the 20^th century has seen three pandemics of influenza:

1918 influenza pandemic resulted in ~675,000 US deaths and up to 50 million deaths worldwide.

1957 influenza pandemic resulted in at least 70,000 US deaths and 1-2 million deaths worldwide.

1968 influenza pandemic resulted in about 34,000 US deaths and 700,000 deaths worldwide.

Assumed impacts of a modern pandemic influenza include:

• Rapid worldwide spread: It is expected that the virus will affect all populations globally. Some countries and localities may be able to inhibit transmission by implementing community mitigation measures.
• Healthcare systems overload: The majority of the population will have little or no immunity to a pandemic influenza virus. Infection and illness rates will be high and a substantial percent of the population will require health care where staff, facilities, equipment and supplies, and hospital beds may be inadequate to deal with this population.
• Medical supplies may be inadequate: Vaccines and antivirals, as well as other medical supplies will be in high demand which may result in mass shortages. Shortages may result in prioritizing populations for care.
• Economic and social disruption: A high rate of worker absenteeism will be likely due to infection, caring for sick family members, and fear of exposure. Travel bans, school closures, and cancellation of mass gatherings will also have an impact.

It is unlikely that a well-matched pandemic strain vaccine will be available during the first six to nine months for mass distribution in the event of pandemic influenza. In addition, it is unknown if the currently available antiviral medications will be effective against a novel pandemic virus. Arizona recognizes that Emergency Medical Services (EMS) will likely be overwhelmed during an influenza pandemic and has developed a Statewide EMS Pandemic Influenza Plan (SEPIP) to address the associated EMS demands. The goal of this plan is to provide a framework for Arizona’s Statewide EMS system to optimize the delivery of emergency care and 9-1-1 services and to ensure that the role of EMS is defined in preparing for, mitigating, and responding to a pandemic influenza. The operational processes identified in this plan ensure that EMS providers and Public Safety Answering Points (PSAP) will:

• Have access to up-to-the-minute information about the nature, scope and potential of the incident.
• Understand the regulatory requirements/relaxations for each provider type under specific pandemic scenarios.
• Comprehend the additional scope of practice, treatment modalities, transport modalities, and medical direction strategies associated with mass-care situations.
• Clearly understand their role within the broader public health and health care systems.

The National Strategy for Pandemic Influenza: Implementation Plan addresses the importance of pre-hospital EMS during a pandemic scenario:

Pre-hospital EMS transportation capability will play a critical role in responding to requests for assistance, providing treatment, and in triaging patients. 9-1-1 call centers/public safety answering points (PSAPs) will experience a significant surge in calls and will determine how and when EMS units are dispatched. Coordination and communication among public health, PSAPs, EMS, and hospital officials will be necessary to ensure optimal patient care as hospital bed availability and pre-hospital resources are strained. Planners should consider modifying PSAP call-taker and dispatch protocols and developing pandemic-specific pre-hospital triage and treatment protocols. A robust Statewide or regional system for monitoring PSAP medical calls, EMS responses and transports, and hospital bed availability will be critical for tracking and responding to a pandemic.

1.1  Activation of the Plan     

When to activate the PSAP Plan will depend on the coordinated efforts between the State, County, and local EMS partners and will include several factors affecting the community. Specifically, if there is a declared state of emergency by the Governor, the State Emergency Operations Center (SEOC) will be activated and therefore be the trigger to activate this plan.

Public Safety Answering Points (PSAPs) are an integral component to Arizona’s State EMS Pre-Hospital Plan (SEPIP) and will play a key role in the event of a pandemic event when resources are most constrained. It is critical that PSAPs have up-to-date information on triage, treatment, and transport options specific to the event. Also, keeping PSAPs healthy prior to, during, and following a pandemic influenza will ensure the stability of the 9-1-1 infrastructure.

2.1  Guiding Principles for Public Safety Answering Points

The role of PSAPs, in conjunction with other communication platforms, will serve as the conduit of information for a number of constituencies during a pandemic event, including:

A statewide PSAP Working Group has been established and is comprised of representatives from BEMSTS, and local PSAPs, dispatch, and emergency services agencies from throughout the state. Participation from these PSAP stakeholders was solicited for their assistance and involvement in statewide planning for pandemic influenza. Pandemic influenza planning and preparedness activities have been reviewed by this working group and their feedback has been implemented into this document.

Pandemic influenza planning is also accomplished at the local level. This requires that local county health and emergency management departments routinely involve their jurisdiction’s city and county law enforcement, fire department, hospitals, and EMS agencies in routine exercises and responses to real events and planning groups. For example, in Maricopa County, the Maricopa Association of Governments (MAG) maintains the MAG PSAP Managers Group. This committee consists of PSAP Managers from the MAG member agencies and oversees the technical needs and provides overall coordination of the Maricopa County 9-1-1 system. Other regional forums for communicating relevant information regarding pandemic planning efforts include:

• Maricopa County Department of Public Health and Community Partners - Pandemic Influence Advisory Committee
• Maricopa County Hospital Disaster Preparedness Committee
• Arizona Emergency Medical System (AEMS) Regional Councils
• Arizona Association of Public Safety Communications Officials/National Emergency Numbers Association (APCO/NENA)

The statewide mechanism for communicating pandemic influenza updates specifically to each individual PSAP statewide will be made directly from the BEMSTS Bureau Chief or his/her designee at the ADHS Health Emergency Operations Center (HEOC) to each County Emergency Management Department and Tribal Health Directors through the pathway illustrated below (see Figure 1). Pre-established email list serves maintained by ADHS are available for each county and tribe. The directory for each individual Arizona PSAP is located in Appendix 7.

Figure 1: ADHS Communications Pathway to PSAPs

3.0  Training and Education for Call-Takers and Other PSAP Personnel

All Arizona fire emergency dispatchers are trained and able to determine without delay the location, nature, and source of the emergency. Phoenix, Mesa, Tucson, and Rural Metro fire emergency dispatchers are also Emergency Medical Dispatch (EMD) certified. The fire emergency dispatcher initiates the dispatch process and, if applicable, will provide self-help for the caller while fire department resources are en-route. However, dispatcher training for scenarios occurring during a pandemic influenza event will be developed and facilitated by ADHS. ADHS will notify County Emergency Management Departments and Tribal Health Directors through the pre-established email list serves to announce pre-event and event training and education/drills for PSAPs.

3.1  Just-in-Time Training

Prior to a pandemic event, PSAPs and 9-1-1 stakeholders will be involved in pandemic readiness exercises as they are developed and introduced to the community. As an example, just-in-time training and education for call-takers is developed and administered by the Phoenix Fire Department’s Medical Director who establishes and maintains emergency medical dispatch (EMD) guidance. These just-in-time training materials will be updated to reflect the most up-to-date information and then modified for statewide use.

Several platforms will be utilized to provide just-in-time training for PSAPs as the most recent information regarding the pandemic and the emerging viral strain becomes available. Just-in-time trainings will be modeled after the CDC EMS and Non-Emergent (Medical) Transport Organizations Pandemic Influenza Planning Checklist located in Appendix 6 and will be available through the following communication outlets:

1. EMSystem will be broadcast to affected EMS resources. Several local EMS, fire department, and law enforcement agencies have access to and regularly utilize the EMSystem capabilities. Arizona hospitals and emergency departments also have access to and utilize the EMSystem.
2. AZ 2-1-1: The State of Arizona developed Arizona 2-1-1 (http://www.az211.gov) to serve as a central portal to provide up-to-the-minute information to the general public, and all other agencies not linked to EMSystem, in the event of an emergency.
3. Arizona Association of Public Safety Communications Officials/National Emergency Numbers Association (APCO/NENA) in-house quarterly training session for PSAPs.

3.2  Exercises and Drills

BEMSTS will seek assistance from the Bureau of Public Health Emergency Preparedness’ Exercise Coordination Team to ensure that PSAP exercises and drills are coordinated in an objective fashion that is consistent with the exercise activities of the broader Arizona Pandemic Influenza Operational Plan. Upon completion of an exercise and after action reports, the PSAP Plan will be revised to reflect lessons learned, completed corrective actions, and best practices.

The following should be addressed in exercises and drills to ensure that EMS agencies and PSAPs understand their roles in responding to an influenza pandemic:

• Drills should be coordinated with local public health and emergency management agencies.
• Pre-pandemic exercises should be able to test just-in-time training.
• Exercises should incorporate National Incident Management System (NIMS) principles to ensure that all participants are comfortable with the system and language.
• Integrate best practices or lessons learned during previous pandemic wave.
• Issue after action reports.

3.3  After Action Reports

Arizona has implemented a policy of following the Homeland Security Exercise and Evaluation Program (HSEEP) guidelines with regard to after action reports. Strict guidelines are in place for the finalization of after action reports (60 days), improvement plans and corrective actions. Corrective actions are always assigned to a specific section, organization, or role within the public health/healthcare system with a definitive date for the implementation of a specific corrective action.

After action reports will be completed by the responding agency to ensure the integration of best practices or lessons learned during the previous pandemic wave. The HSEEP model provides a standardized methodology (templates) for after action report development and improvement planning. The templates are used for all emergency preparedness and response exercises and responses to real events at local, regional, and state levels. Additionally, all emergency response partners are strongly encouraged to utilize compliant templates and improvement planning techniques. The State continues to foster a supportive relationship with the preparedness community, aiding in the development of compliant documentation which helps to ensure consistent planning, execution, and improvement planning for all emergency response-related events and exercises in the state. The ADHS Bureau of Public Health Emergency Preparedness exercise team is on hand to assist all agencies with after action reports.

3.4  Continuing Education

Continuing education for PSAPs and call takers will be facilitated at the Arizona Association of Public Safety Communications Officials/National Emergency Numbers Association (APCO/NENA) in-house quarterly training sessions for PSAPs.

4.0  Standardized 9-1-1 Protocols

Arizona is working towards developing standardized 9-1-1 guidelines for pandemic influenza that will be triggered by a Governor’s declaration of emergency. These guidance documents include call flow charts to be used during a pandemic influenza, EMS dispatch instructions, EMS operating guidance, and EMS post-dispatch/pre-arrival guidance. All written guidance, including a 9-1-1 call flow chart, is located in Appendix 4. This guidance also directs PSAP triage and patient classification during a pandemic event and the paperwork generated can easily be shared with state and county health officials, hospitals, and laboratories.

PSAPs and 9-1-1 call centers will be notified (as described above) as updates to the pandemic event occur (such as the symptom set for caller screening for data collection/analysis, pandemic severity, phases, and intervals used to determine community mitigation strategies, use of altered standards of care and dispatch guidance, etc.). Notifications will generated by ADHS BMETS and forwarded to the County Emergency Management Departments/Tribal Health Directors to be rapidly disseminated to PSAPs as the information becomes available.

4.1  PSAP Triage and Patient Classification

PSAPs will triage and classify patients depending on the guidance detailed in Appendix 4. This guidance was developed with the assistance of the State PSAP Working Group and is dependent on the nature of the dispatch priority level of the call in conjunction with the pandemic severity/category. The guidance was developed by the state to distribute to PSAPs for local use.

4.2  Assistance with Priority Dispatch of Limited EMS

There are currently mechanisms in place to transfer callers to alternate call centers from 9-1-1 centers or to a secondary triage specialist/alternate call center. Most PSAPs utilize these rollover numbers when the call load becomes overcapacity. Each call center has the capability to install a push button transfer or dial out system. An additional call transfer button or dial out line can easily be installed by the local telecommunications service provider for non-emergency calls related to pandemic influenza to be directed to either the county public health hotline, 2-1-1, or the bi-lingual, 24/7 menu-driven public health information hotline coordinated, scripted and activated by ADHS. This hotline can be accessed throughout Arizona [Metropolitan Phoenix (602) 364-4500 and statewide (800) 314-9243].

In addition, the Arizona Department of Health Services has the capabilities in-place to activate a public health emergency information call center (Metropolitan Phoenix (602) 364-0244 and statewide (866) 894-1594). This center would be activated and utilized to serve as the State’s official “hotline” for Arizona citizen to call with question about pandemic influenza and to screen ill persons and their need to seek medical attention. Staff operating the call center will be trained by the Arizona Department of Health Services’ Bureau of Public Health Emergency Preparedness exercise and training personnel.

However, Arizona fully anticipates disseminating information to the public regarding alternate call centers to reduce the surge from the 9-1-1 system. For example, the Arizona Division of Emergency Management (ADEM) will implement the 2-1-1 system during and following a pandemic influenza event. The public will be instructed to call 2-1-1 when needing information and/or are not experiencing an acute, emergency event. 9-1-1 call takers will direct the public to this website/phone number when deemed appropriate according to the dispatch protocol.

Arizona Department of Public Safety (AZDPS) is able to communicate messages to the majority of city and county law enforcement agencies within the state. The Arizona Law Enforcement Telecommunication System (ALETS) allows law enforcement agencies Statewide to communicate real-time information via teletype. These agencies must have access to the Arizona Criminal Justice Information System (ACJIS) in order to participate in ALETS. This includes agencies on a State wide level such as:

• Police & Sheriff departments
• Game and Fish
• AZDPS

Statewide legal authority and protocols to allow tiered response of different EMS units will to meet the needs of the community is addressed in the SEPIP under separate cover. The SEPIP also addresses the legal authority for alternate standards of care and triage, treatment and transport of patients in the pandemic event.

5.0  Role of 9-1-1 in Community Surveillance and Mitigation

A coordinated statewide messaging system intended to communicate updated public health information to PSAPs and the public will be available on AZ211.gov. In addition, public health messaging will be communicated through local and state emergency communications via the local and state emergency operations centers, in addition to the other statewide interoperable emergency communications systems such as EMSystem.

Many of the PSAPs in Arizona serve rural communities, and in the event of pandemic influenza, ADHS anticipates their actions will be mostly aimed at the dissemination of appropriate information and the coordination of health care resources. 9-1-1 dispatchers can only handle immediate emergencies. Therefore, the public will be either transferred to or instructed to call the state or county health department’s public health hotline, 2-1-1, or access the az211.gov website when appropriate, for community containment measures, including:

·        The status of the pandemic event

·        What mitigation measures are already in place

·        Isolation, treatment, and voluntary quarantine recommendations

·        Locations of Alternate Care Sites for self referral

·        Additional support

It is important to note that the realities of the demographic and geographic characteristics of Arizona may result in some variance from national guidelines. The 2008 ADHS Nonpharmaceutical Interventions Community Containment Plan for Pandemic Influenza outlines the methods of pandemic influenza transmission intervention, including: isolation & treatment, quarantine, child social distancing, and adult social distancing. Given that the characteristics of a pandemic influenza event will vary (severity, transmission, morbidity, mortality), how EMS personnel will assist in community mitigation strategies, such as targeted layer containment, will vary. How long the given interventions will remain in place will also depend on the declared severity of the event. The timing and duration of interventions are outlined in Appendix 2.

5.1  Sharing Pertinent Data

Legal protections for sharing pertinent data with state and local public health authorities are outlined in the Arizona Revised Statutes (ARS) §36-782 to 787. The ADHS Director has the authority to declare an enhanced surveillance advisory if the governor has reasonable cause to believe that an illness, health condition or clinical syndrome caused by bioterrorism, epidemic or pandemic disease or a highly fatal and highly infectious agent or biological toxin has or may occur or that there is a public event that could reasonably be the object of a bioterrorism event. The enhanced surveillance advisory shall include:

·        Those persons and entities require to report

·        The clinic syndromes, any illness or health condition that may be associated with bioterrorism or a specific illness or health condition to be reported

·        Patient tracking

·        Information sharing

·        Specimen testing coordination

Additionally, §36-785 addresses information sharing during an enhanced surveillance advisory and states, “During an enhanced surveillance advisory, when a public safety authority learns of a suspicious disease event, or it learns of a threatened bioterrorism act at any time, it shall immediately notify the department or the local health authority, and the agency that receives this information must immediately notify the other agency.”

When the local health authority identifies a reportable illness or health condition, unusual disease cluster or suspicious disease event that it reasonably believes may be caused by bioterrorism, the local health authority will immediately notify at any time the appropriate public safety authority and, if appropriate, tribal health authorities.

Sharing of information on reportable illnesses, health conditions, unusual disease clusters or suspicious disease events between public safety and local health authorities is limited to the information necessary to affect the enhanced surveillance advisory and does not include the release of medical records to public safety authorities. Information from which a person might be identified that is received by the department, local health authority or public safety authority in the course of an enhanced surveillance advisory is confidential and not available to the public.

When an outbreak is suspected, PSAP personnel are instructed to report to the 9-1-1 supervisor on duty. The 9-1-1 supervisor will then contact the relevant county health department to report the suspected influenza outbreak.

6.0  Continuity of Operations

The Arizona Department of Administration (ADOA) has established and has oversight of the rules governing the requirements for funding the PSAPs in Arizona. These rules are under Arizona Administrative Code (A.A.C.) R2-4-401 and stipulate that the 9-1-1 centers or PSAPs must establish operational procedures for the continuity of services for the expedient and appropriate processing of 9-1-1 calls in their area. Additionally, the service plans required by ADOA of all 9-1-1 centers addresses redundancy and business continuity issues. The following pandemic influenza provisions sections must be developed to supplement to the current continuity of operations plans for 9-1-1 centers.

Business continuity planning issues with PSAPs originate from the objective to ensure the health and stability of local PSAPs and the 9-1-1 infrastructure prior to, during, and following a pandemic influenza event. Some strategic direction to be considered by the PSAPs includes the following:

• Restrict access to the PSAP and PSAP personnel. Only essential personnel should be permitted access to the PSAP. Lock out of all non-essential personnel to the PSAP.
• Encourage PSAP personnel to limit contact with others outside of the PSAP (other than family).
• Institute the practice of wiping surfaces in the PSAP with each shift change using recommended disinfectants appropriate for flu viruses.
• Declare by county a proclamation that 9-1-1 employees are mission critical.
• Ensure that essential personnel agree to come to work, and limit vacation leave during a declared emergency.
• Allow and make available measures such as masks and gloves to call-takers and their families as appropriate.
• Allow each call-taker to have a personal keyboard and mouse to be kept in a wrapped and clean area when not in use.
• Start education of 9-1-1 employees regarding the value of the call-takers and dispatchers to the system, risks to the employee and their family, and best hygiene practices for PSAP at home.
• Ask all suppliers of services and materials to supply a copy of their plans for business continuity in a pandemic influenza situation.
• Request contact information in preparation for credentialing if necessary in late phases.
• Obtain protocols from state and local emergency management departments, ADHS, local health departments and others so that callers to 9-1-1 can be given accurate information for certain specific questions.
• Encourage all employees to have personal emergency plans and supplies.
• Establish working relationships with ADHS, the Arizona Department of Homeland Security, Arizona Division of Emergency Management and others for sharing data, procedures, and protocols.
• Plans for the use of mental health professionals to support PSAP personnel.
• Cross-train clerks and other non call-taker personnel to work as call-takers.

6.1  Freedom of Movement of PSAP Personnel

It is anticipated that there may be travel restrictions imposed as a result of a declared pandemic influenza emergency. If isolation and quarantine measures are in effect, travel to and from the workplace may be impacted. To ensure that PSAPs and resources are able to move freely to perform essential functions, advanced coordination is addressed in the 9-1-1 centers’ business continuity plans. PSAPs must be able to continue to operate regardless of the severity of the situation outside of the 9-1-1 center.

Each PSAP and dispatch center should develop a list of essential employees that must be present at the workplace during a declared state of emergency. This list can be shared with the SEOC. PSAPs may also consider issuing ID cards to essential personnel to present to law enforcement, if necessary, indicating that they are part of the 9-1-1 infrastructure and must return to work.

6.2  Maintaining Day-to-Day Response

Persons with medical conditions unrelated to influenza will continue to require emergency, acute, and chronic care. This includes EMS transportation, treatment, and triage. In order to continue to provide optimal care to the community at large, PSAPs should continue to use the established systems for their region. Procedures for the use of alternate methods, such as 2-1-1 or other call centers, has been established to reduce the demands on EMS and 9-1-1 resources.

6.3  Interoperability of EMS Communications

The Federal Communications Commission (FCC) has defined 9-1-1 lines as designated for emergency calls, such as reporting a crime in progress, reporting a fire, or requesting an ambulance. Using 9-1-1 for non-emergency calls may delay help for people caught in real emergencies.

Arizona has a strong regional EMS structure that has established relationship with the provider community of their region, enabling rapid and reliable communications and an understanding of the capabilities and needs of the region. Interoperable communications systems among EMS, 9-1-1, Emergency Management, Public Safety, Public Health and Health Care Agencies are effective and reliable. Currently, EMS agencies are served Statewide by a combination of 800 MHz, UHF and VHF frequencies. At present, no single radio platform is able to provide border-to-border coverage. Equipment and frequencies are detailed in the ADHS Pandemic Influenza Risk Communication Plan dated June 2008.

With EMS participation, considerable efforts are underway to establish a uniform radio communication plan for the Arizona. This is part of the system being developed by the Public Safety Communication Commission Statewide Land Mobile Radio Project. As part of the development of the SEPIP, BEMSTS has undertaken a statewide assessment of current needs.

Statewide communications to support common hospital diversion and bed capacity situational awareness is covered by EMResource, a multi-function web-based application accessible to each hospital, major 9-1-1 communication centers, ADHS and every county health department that details: Bed availability for every hospital; Ambulance load for each hospital; and, Urgent messaging capability which automatically triggers a message alert on each PC

Resources are currently in place and in use to achieve these components. EMResource combines active bed polling of all Arizona hospitals, emergency department diversion and ambulance load along with a mandatory-response messaging system in a web-based utility that is available in the major 9-1-1 communications systems, all hospitals, every county health department and each EMS region.

The EMSystem (hospital EMS diversion computer system) is used on a daily basis by hospitals and first responders to communicate capacity levels and help recognize when patient diversion is an optimal choice. ADHS is able to notify hospital EDs Statewide and local health departments of outbreak alerts and other messages. The system enables hospital facilities to update their available bed status and to also respond to other inquiries.

The 9-1-1 workforce will undoubtedly be at risk of exposures to pandemic influenza, just as the general population will be. To lessen the threat of PSAPs contracting and transmitting influenza to co-workers and their families, workforce protection is a planning priority. Several strategies to assist with the protection of the 9-1-1 workforce and their families include:

• Infection control/decontamination, personal hygiene, PPE, social distancing
• Vaccines and antivirals
• Isolation and quarantine & internal medical surveillance
• Labor representatives including mental health
• Support for families

7.1  Recommendations for Basic Infection Control & Decontamination Procedures

Infection control and decontamination measures are essential components to daily activities to reduce the transmission of infectious diseases and other pathogens. BEMSTS, through a variety of communications platforms, will ensure that the most up-to-date infection control procedures and supplies are made available to the PSAP provider community.

Specific infection control and decontamination procedures, such as hand washing, respiratory hygiene/cough etiquette, and personal protective equipment suggestions, are outlined in Appendix 5. Basic infection control procedures are also available in the Arizona Pandemic Influenza Response Plan dated June 2006. This plan has been shared with the healthcare and EMS community via a number of methods including participation in the 2006 Statewide Pandemic Influenza Tabletop Exercise.

Specific infection control procedures for PSAPs include the following:

1. Surface wipe-down: Viruses are known to survive on non-porous surfaces, such as steel and plastic, for up to 24 to 48 hours after inoculation and on cloth, paper, and tissues for up to eight to 12 hours. Viable virus can be transferred from non-porous surfaces to hands for 24 hours and from tissues to hands for 15 minutes.
   1. Surfaces to be disinfected should be cleaned with each shift change or at all staff changes for shared workstations. Janitorial visits should be at least every 24 hours.
   2. Listed surfaces should be cleaned with an EPA registered disinfectant by the person starting the shift. The person should wear gloves during cleaning procedures. When using chemical disinfectants, all manufacturers’ instructions should be followed.
   3. List of surfaces to disinfect: The following is only a suggestion of the items needing disinfection within a PSAP. Additional surfaces may be added to this list: doorknobs, telephone handsets, touch pads, keyboards, mice, control knobs, all work surfaces, chair arms, seats and adjustment handles, any object that’s touched or potentially coughed on in and around the PSAP. A personal keyboard and mouse may be stored in call taker’s/dispatcher’s private and clean space. An FDA-approved hand sanitizer should be made available at all workstations, in break rooms and in common areas.

2. Disinfectants: Clean and disinfect high-touch, non-porous surfaces using an EPA registered disinfectant labeled for activity against influenza viruses. Carefully follow all label directions and safety precautions, including mixing, use and contact time. If an EPA-registered disinfectant is not available, apply a diluted solution (1:100 volume/volume-600 parts per quart) to a cleaned surface, preferably with a cloth moistened with the bleach solution, and allow the surface to remain wet for five minutes.

3. Hand-washing technique: Proper hand washing is probably the single most effective barrier to infection. Hands must be thoroughly and properly washed at the beginning and end of each shift.

·        Remove all debris from hands and arms.

·        Rinse hands under cool running water and apply antimicrobial soap, lather well.

·        Wash hands and fingers for a minimum of 15 seconds.

·        Work soap around fingers and nails. Do not use a scrub brush, because it may cause abrasions.

·        Rinse thoroughly with cool running water. (Hot water opens pores and dilates capillaries.)

·        Dry hands with paper towels, and use the towel to turn off the faucet.

·        Cover cuts and abrasions with adhesive bandage or finger cot until fully healed.

·        If hands are not visibly soiled or sticky, they may be sanitized with an alcohol-based hand rub.

4. Masks: Make available and encourage 9-1-1 personnel to wear facemasks, which can help reduce the user's exposure to airborne viruses. N95 facemasks help stop droplets from being spread by the person wearing them and keep splashes or sprays from reaching the mouth and nose of the person wearing the facemask. Only purchase masks that are certified by NIOSH to provide adequate filtration without hampering the ability to breathe. Facemasks should be used once and then thrown away in the trash.

5. Restricted entry: To see that the PSAP remains as virus free as possible by limiting entrance to non-essential personnel will limit exposure to essential personnel within the PSAP. Prior to entry, the person seeking entrance should have their oral temperature taken. It must register 99º F or lower. (Oral electronic thermometers should be available for self-use outside the entry to the PSAP, with directions for decontamination between users. Employees will be trained on their use.) Persons seeking entrance must also answer the following questions with a negative:
   1. Have you had a fever since your last shift?
   2. Does anyone in your household have a fever?
   3. Do you now feel sick in any way?

If in doubt, personnel should be denied entrance. Those seeking entrance should be directed to a hand-washing station prior to being admitted. Questions and/or disputes regarding entry should be directed to the County Public Health Medical Doctor (MD) or their designee. (Note: In settings where county sheriff personnel and/or jail personnel share close quarters with PSAP operations, it may be necessary to move these non-PSAP employees, such as sheriff administrative staff, deputies and prisoners, to different quarters.)

7.2  Vaccines and Antiviral Medication for 9-1-1 Personnel

Vaccination is one of the most effective ways to minimize suffering and death from influenza. Research efforts have led to the development of a vaccine for one of the two strains of the H5N1 influenza virus in humans. In the event of a pandemic, however, it could take months to develop an effective vaccine.

EMS is a component of the Nation’s critical infrastructure. Without a healthy EMS workforce, emergency services and response will be crippled. During all phases of a pandemic, the US DHHS and US DHS have identified EMS personnel (including supporting personnel such as 9-1-1 personnel and family members) as part of the high priority group (Tier 1) for receiving the pandemic influenza vaccine once it becomes available. Arizona has adopted the Federal Guidance on Allocating and Targeting Pandemic Influenza Vaccine in order to establish priority groups for distributing antivirals and vaccines to the State’s population, putting EMS and 9-1-1 personnel as a high priority group. The State of Arizona has established a Vaccine and Antiviral Prioritization Policy Committee (VAPPC) that will have oversight of the effectiveness of the implemented distribution strategies. However, it will be local health departments that administer vaccines and antivirals as they become available, as outlined in the Arizona Mass Vaccination Plan Appendix of the 2008 Arizona State Emergency Operations Plan.

7.3  Isolation and Quarantine of 9-1-1 Personnel

Isolation and quarantine are effective mitigation strategies to prevent transmission of disease by separating ill and exposed individuals from those who have not yet been exposed. 9-1-1 call centers should plan for isolation and quarantine provisions for staff that have been exposed to pandemic influenza or have become ill.

It is recommended that medical surveillance of 9-1-1 personnel occur at each job site daily. Temperature readings and a brief diagnosis of potential symptoms should be undertaken by responders and support personnel at the beginning of each shift. If symptoms exhibit potential flu-like indications, the employee should return home or to alternate temporary living quarters.

Isolation is a standard public health practice applied to persons who have a communicable disease. Isolation of pandemic influenza patients may prevent transmission of the disease by separating ill persons from those who have not yet been exposed. Quarantine is a contact management strategy that separates individuals who have been exposed to infection but are not yet ill from others who have not been exposed to the transmissible infection; quarantine may be voluntary or mandatory. Persons who become ill may shed virus and can transmit infection for one-half to one day before the onset of illness. Viral shedding and the risk for transmission will be greatest during the first two days of illness. Isolation and quarantine policies and procedures are outlined in detail in the Community Containment Plan for Arizona.

PSAP employees who have been exposed to pandemic influenza or are suspected to be ill should not come into work when ill with a febrile respiratory illness. Attendance policies should be amended to support this expectation. Additionally, EMS and 9-1-1 agencies should collaborate with occupational health and public health officials to establish policies on when a previously ill person is no longer infectious and can return to work after illness.

Provisions for off-duty 9-1-1 personnel to have alternative housing arrangements during a pandemic should also be considered. Alternative housing arrangement may be used to protect the provider from infecting family members or vice versa.

Prior to implementing any standards or protocols, symptoms and complications of the Flu must be made clear to the public. Flu symptoms can be mild or severe. It is important to note that mild symptoms can become severe without much notice. Not all of the listed symptoms need to be experienced to have the flu. The common symptoms of the flu include:

Complications of the flu can include bacterial pneumonia, ear infections, sinus infections, dehydration, and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes.

During a pandemic, it is recommended that the non-acutely ill refrain from going to the hospital. Flu related symptoms requiring emergency care include trouble breathing, being confused or incoherent, or a seizure. Hospitals will be overwhelmed with patients during a pandemic and many sick people may have to be cared for at home or at a non-hospital location such as an Alternate Care Site. Ill individuals may have to rely on old fashioned remedies such as rest and re-hydration as antiviral drugs will be scarce. Consider the following:

• Stay home from work or school, and rest
• Drink plenty of non-caffeinated fluids
• Use acetaminophen or ibuprofen to help with fever and body aches
• Wash hands often to protect other people
• Avoid getting close to other people, especially when coughing or sneezing
• Cover mouth and nose when coughing or sneezing

This information will be widely distributed, in collaboration with Arizona acute care hospitals, to the public through print and electronic media. The process for making a presumptive/definitive diagnosis will be handled at the local level and will include:

• Case definition for presumptive/definitive diagnosis (fever of at least 101^o F along with either cough or sore throat)
• A plan to train local health department personnel on diagnosis in early and later stages of pandemic.
• Assured stock of test kits for rapid diagnosis.
• Developed agreements with laboratories for rapid diagnostic testing 24/7.
• Developed and planned distribution of educational materials for patients (fact sheets about pandemic influenza, including signs and symptoms, self care, and infection control).
• Plan for notifying businesses that ill persons should not go to work until no longer infectious.

A specific clinical case definition for pandemic influenza will be developed when more is known about the circulating pandemic flu virus (any unique symptoms or epidemiological links such as geographic or contact with chickens, etc.). In the meantime, the CDC clinical and epidemiological guidance factors regarding testing for suspect avian influenza will be taken into consideration (see http://www2a.cdc.gov/han/ArchiveSys/ViewMsgV.asp?AlertNum=00246).

A public health information line has been established and can be coordinated, scripted and activated by the Arizona Department of Health Services. The bi-lingual, 24/7 menu-driven information line can be accessed throughout Arizona [Metropolitan Phoenix (602) 364-4500 and statewide (800) 314-9243]. In addition, the Arizona Department of Health Services has the capabilities in-place to activate a public health emergency information call center (Metropolitan Phoenix (602) 364-0244 and statewide (866) 894-1594). This center would be activated and utilized to serve as the State’s official “hotline” for Arizona citizen to call with question about pandemic influenza and to screen ill persons and their need to seek medical attention. Staff operating the call center will be trained by the Arizona Department of Health Services’ Bureau of Public Health Emergency Preparedness exercise and training personnel.

The Arizona Department of Health Services (ADHS) also has a wide variety of public education materials that can be downloaded from http://www.azdhs.gov/flu/flu_toolkit.htm. The Flu Education Toolkit contains easily downloadable items in English and Spanish such as bookmarks, posters, information sheets and brochures for children, teachers, healthcare, hospitals, long-term care and assisted living agencies and the workplace.

“Just in case Arizona” is a statewide emergency preparedness campaign sponsored by the Arizona Department of Health Services. It simplifies the preparedness message by breaking all emergencies down into one of two types; those for which you need to be prepared to stay (or shelter in place), and those for which you need to be prepared to go (or evacuate). A wealth of information, including check lists and family plans, is also available through AZ 2-1-1 Online at www.az211.gov. AZ 2-1-1 Online helps Arizonans find information about local emergencies and health and human services and is the official sources of timely information during natural or man-made emergencies such as pandemic influenza, wildfires, floods, utility outages, and evacuations. The public wants to be prepared, and this campaign will help them get there and keep their families safe.

In a pandemic event, ADHS has the lead in public information functions. Since numerous other agencies will potentially work in support of the ADHS public information function, a Joint Information Center (JIC) may be established as required by the nature and scale of the event. The JIC will perform the following:

• Provide guidance and procedures for disseminating Emergency Public Information (EPI) in support of the State’s response and recovery to an emergency/disaster.
• Provide for the effective collection, monitoring, management and dissemination of accurate, useful and timely information to media outlets during emergencies/disasters.
• Disseminate emergency instructions and protective actions to the public.
• Maintain procedures to disseminate public information and instructions for obtaining disaster assistance.
• Provide procedures to develop and disseminate public information regarding governmental response and recovery operations.
• Coordinate EPI to avoid panic, fear and confusion resulting from rumors and hearsay.
• Provide long-term public education efforts related to hazard awareness, family protection planning and emergency self-help.

Arizona State, Counties and Tribes have developed their own distribution materials and have produced local messages for public broadcast. Examples of these messages and distribution materials can be provided upon request. Currently, some Arizona Counties have distributed pandemic influenza educational materials (brochures) to all households in their jurisdiction. Radio public service announcements have also been recorded and are ready for use. Subject matter includes snow days, hand washing, and cover-your-cough. Educational materials currently available to distribute include:

• Individual and Family – How to be Prepared for a Flu Pandemic Handbooks & Pocket Guides
• Individual and Family - Treating Seasonal or Pandemic Flu at Home Handbooks
• Healthcare Staff – Preparing for Pandemic Flu Handbooks
• Schools –Stop the Germs & Illness Handbooks
• Schools – Clean Hands are Healthy Handbooks
• Tip cards for first responders, clinics, home visitors and shelters regarding vulnerable populations
• Multiple brochures (in English and Spanish) for hand hygiene, avoiding the flu-6 things you can do, keeping clean at school, workplace preparation, what to do if you are sick, the difference between pandemic flu and seasonal flu, grief and recovering from loss
• Stickers for children reminding them to wash, cover cough, etc.
• Handbooks for communicating with patients during urgent care (English & Spanish)

Local public service announcements have been developed and recorded to promote the following information:

• Educate the public to recognize the signs and symptoms of the flu
• Encourage the public to voluntarily self-isolate or self-quarantine and for how long
• Notify businesses that ill individuals should not go to work
• Inform the public of hotline phone numbers and websites for pandemic influenza updates
• Inform the public of where to obtain educational materials
• Announce the cancellation of large public gatherings (concerts, sporting events, etc.)

Certain realities of the actual influenza strain, including severity, transmission, morbidity, mortality will impact the decision process of the Governor’s office and other state emergency response agencies. For that reason, the general regulatory requirements for the pandemic environment may become relaxed. During a Governor’s Declared State of Emergency, specific statutes and rules that will be temporarily waived or relaxed will be communicated to affected state agencies directly from the Governor’s Office.

Specifically, A.R.S. §26-314, Immunity of state, political subdivisions and officers, agents and emergency workers; limitation; rules, considers this “state and its departments, agencies, boards, commissions and all other political subdivisions are not liable for any claim based upon the exercise or performance, or the failure to exercise or perform, a discretionary function or duty by any emergency worker, excepting willful misconduct, gross negligence or bad faith of any such emergency worker, in engaging in emergency management activities or performing emergency functions pursuant to this chapter or title 36, chapter 6, article 9.

The immunities from liability, exemptions from laws, ordinances and rules, all pensions, relief, disability workers' compensation and other benefits that apply to the activity of officers, agents, employees or emergency workers of this state or of any political subdivision when performing their respective functions within this state or the territorial limits of their respective political subdivisions apply to them to the same degree and extent while engaged in the performance of any of their functions and duties extraterritorially under this chapter or title 36, chapter 6, article 9, excepting willful misconduct, gross negligence or bad faith.

Emergency workers engaging in emergency management activities or emergency functions under this chapter or title 36, chapter 6, article 9, in carrying out, complying with or attempting to comply with any order or rule issued under this chapter, title 36, chapter 6, article 9 or any local ordinance, or performing any of their authorized functions or duties or training for the performance of their authorized functions or duties, shall have the same degree of responsibility for their actions, and enjoy the same immunities and disability workers' compensation benefits as officers, agents and employees of the state and its political subdivisions performing similar work. This state and its departments, agencies, boards and commissions and all other political subdivisions that supervise or control emergency workers engaging in emergency management activities or emergency functions under this chapter or title 36, chapter 6, article 9 are responsible for providing for liability coverage, including legal defense, of an emergency worker if necessary. Coverage is provided if the emergency worker is acting within the course and scope of assigned duties and is engaged in an authorized activity, except for actions of willful misconduct, gross negligence or bad faith.

No other state or its officers, agents, emergency workers or employees rendering aid in this state pursuant to any interstate mutual aid arrangement, agreement or compact are liable on account of any act or omission in good faith on the part of such state or its officers, agents, emergency workers or employees while so engaged, or on account of the maintenance or use of any equipment or supplies in connection with an emergency.”

Lead Individuals for the State of Arizona:

This document was prepared by the Arizona State PSAP Working Group:

1. State of Arizona:

·        Alternate Care Site Plan for Pandemic Influenza

·        Arizona Administrative Code, Title 9, Chapter 25

·        Arizona Revised Statutes, Title 36, Chapter 21.1

·        Arizona State EMS Pre-Hospital Plan (SEPIP)

·        Community Containment Plan for Pandemic Influenza

·        Emergency Response Plan

·        Flu Vax Shortage Emergency Response Plan

·        Influenza Pandemic Response Plan

·        Mass Vaccination Clinic Plan

·        Pandemic Influenza Mass Fatality Plan

·        Pandemic Influenza Operational Plan

·        Pandemic Influenza Risk Communications Plan

2. US Department of Health & Human Services
   • Altered Standards of Care in Mass Casualty Events: Bioterrorism and Other Public Health Emergencies (Agency for Healthcare Research and Quality – AHRQ)
   • Guidance on Allocating and Targeting Pandemic Influenza Vaccine (Department of Homeland Security)
   • Pandemic Influenza Response Plan & Appendices

3. US Department of Transportation

·        EMS Pandemic Influenza Guidelines for Statewide Adoption

·        Preparing for Pandemic Influenza: Recommendations for Protocol Development for 9-1-1 Personnel and Public Safety Answering Points (PSAPs)