Outbreaks and Pandemics: 
New Roles for Triage Call Centers

By David A Thompson, M.D., 
with Sue Altman and Barton D Schmitt, M.D.

October/November 2006

"My daughter is away at college and just phoned to tell me that her roommate was diagnosed with mumps today.  What should she do?  What symptoms should she be watching for?  How can I tell if she was adequately vaccinated?"

"One of our employees just returned from a business trip in the Far East, and he called in sick because of cold symptoms.  I'm in HR.  Should we be concerned about ‘avian flu' when he comes back to work?  Are my other employees at risk?"

Questions regarding respiratory viruses like mumps and avian flu have recently been popping up at medical call centers across the country.  Mumps is a significant clinical topic this year.  Although it is generally not a serious disease, there was a real outbreak centering on college students in Iowa.  Call centers that serve student health contracts or are convenient to college campuses need to have the facts ready and available to answer incoming questions. 

Early this year, Drs. Barton Schmitt and David Thompson wrote a Mumps Exposure guideline.  It was released to call centers that use their clinical content in July, 2006.  The guideline provides background information on mumps, potential complications, the MMR vaccination, and Centers for Disease Control and Prevention (CDC) recommendations for outbreak control.  In addition, the care advice section includes facts on contagiousness, symptom recognition, prevention, and isolation - responses to the common questions call center nurses would anticipate receiving.

Avian influenza is another significant clinical topic because of concerns about the possibility of a pandemic.  In May of this year, the White House published a National Strategy for Pandemic Influenza: Implementation Plan.  This document stated, "A system of effective home-based care would decrease the burden on health care providers and hospitals and lessen exposure of uninfected persons to persons with influenza.  Telephone call centers should be established or augmented within affected communities to provide advice on whether to stay home or to seek care."  Medical call centers can have an important role in local disaster preparedness.  One area of need in particular is having a plan in place for an influenza pandemic.  The Avian Flu Exposure guideline, written by Drs. David Thompson and Barton Schmitt, includes the latest public health recommendations for providing meaningful triage and advice. 

Les Mortensen, president of LVM Systems, served on an advisory panel for the Agency for Healthcare Research and Quality (AHRQ), which investigated the role of community call centers in supporting outpatient healthcare and monitoring in major healthcare crises.  Call centers could be instrumental in providing:

• Triage surge capacity (extreme volumes of calls from ill, injured, and worried well)

• Communication hubs to healthcare providers.

• Communications to and management of those quarantined.

• Information hotlines.

Remote workforce initiatives will be a key factor in disaster preparedness and shelter in place scenarios.  In this way, all employees can work via remote connections and a core group of IT staff will shelter at the headquarters to maintain servers, phone lines and connectivity.

Mumps:  In December 2005, an outbreak of mumps began in Iowa, and as of May 2006, involved at least ten additional states.  The 18-24 year old age group was most likely to be effected, with many mumps cases occurring on college campuses. 

What are the symptoms of mumps?  The majority of people who get mumps have general viral symptoms, such as fever, headache, muscle aches, and decreased appetite.  Approximately 30-40% of people develop a swollen tender parotid gland, called parotiditis.  The parotid gland is located at the angle of the jaw (in front of the ear).  Generally, the symptoms of mumps last 7-10 days.  

Mumps is caused by a respiratory virus.  Close contact with someone with mumps is needed before a person is at risk of getting mumps.  Certainly being a roommate qualifies as close contact.  A more detailed description of significant exposure to mumps would include the following activities: kissing or embracing, sharing eating or drinking utensils, close conversation, and performing a physical examination (relevant to health care providers).

There is no specific anti-viral treatment for mumps.  Instead, the most important part of prevention is assuring that one's mumps vaccination is up to date.  The CDC has recommended:

• Isolation of anyone with proven mumps for 9 days after symptom onset.

• Protection of persons at risk by being sure they receive a second MMR (if they have received only one).  One MMR is 80% protective and 2 are 90% protective. 

 Avian Influenza: Avian influenza is an infection caused by avian (bird) influenza (flu) virus.  It is also sometimes called avian flu or bird flu.  This influenza virus occurs commonly in wild birds which carry it in their intestines, but usually do not get sick.  There is a strain of influenza referred to as H5N1 that is easily spread to domestic birds such as chickens, ducks, and geese.  In domestic birds, this strain of influenza is deadly; up to 90% of infected fowl can die.

Usually, avian influenza does not infect humans.  However, since 1997, there have been about 200 cases of humans that have been infected with the H5N1 strain of influenza.  The World Health Organization maintains a current list of avian influenza outbreaks worldwide.  There have been no cases of human avian influenza in the United States.  Some international experts worry that there is the chance that a worldwide outbreak of avian flu could occur.  Such a worldwide outbreak would be termed a pandemic.

What are the symptoms?  Early symptoms of avian influenza are similar to regular human influenza.  Symptoms include fever, cough, sore throat, and muscle aches.  However, unlike normal yearly human influenza, most people infected with avian flu have a more severe illness.  Pneumonia is common. 

Who is at risk of getting avian flu?  Most cases of avian influenza infection have resulted from direct contact with infected poultry or contaminated surfaces with feces or body fluids from infected poultry.  Avian flu in humans typically develops within 5-10 days of exposure (possibly up to 14 days). 

Is there a treatment for Avian Flu?  There are two anti-viral medications that are possibly helpful in treating this infection: oseltamivir (brand name Tamiflu) and zanamivir (brand name Relenza). 

Whether it is a mumps outbreak or an avian flu pandemic, nurse triage call centers will play a critical role in responding to and with it.  Now is the time to make sure your call center and staff are ready.

The article was collaboration by David A Thompson, M.D., FACEP with Sue Altman.  Dr. Thompson is the author of the Adult Telephone Triage Protocols used internationally in medical call centers and physician practices.  He is Board Certified in both Internal Medicine and Emergency Medicine.  Sue Altman is the President of Call Center Consulting Network.  The article references clinical protocols recently developed through the partnership of Dr. Thompson and Barton D Schmitt, M.D., FAAP, author of the Pediatric Telephone Triage Protocols.

[Photos from the CDC's Public Health Image Library (http://phil.cdc.gov), ID#1861 and 8036, respectively, in the public domain.]