Pandemics break out due to transference of infection between individuals, involving uncontrolled mass exposure and global transmission. Attempts to increase public health protection create a surge in the consumption of medical services.^{Reference Colizza, Barrat and Barthelemy1,Reference Einav, Hick and Hanfling2} At the most critical level, this includes the need for more intensive care unit beds and ventilators. Demands from staff and material resources increase and coordination is required among many health agencies.^{Reference Einav, Hick and Hanfling2} Pandemics also drive a heavy consumption of medical resources, including those of emergency medical services (EMS).^{Reference Chow-In Ko3}

The process of infection on a global scale follows a timeline that calls for varying degrees of alertness and preparedness as the disease spreads. The World Health Organization (WHO) identifies 6 stages of pandemic preparedness and response. After community-level outbreaks have been verified (WHO, stage 4), medical professionals must attempt rapid containment, manage multiple resources, and continue updating the public.⁴ The Centers for Disease Control and Prevention (CDC) identifies 7 domains of action in the response of medical services to pandemic risks. In the pre-outbreak stage, the first domain is Surveillance, Epidemiology, and Laboratory Activities.⁵ A 2012 study called for increasing the role of EMS in pandemics and particularly in ongoing disease surveillance and mitigation strategies.^{Reference Oliver, Poplin and Kahn6} Besides being responsible for the traditional role of stabilizing and treating patients in emergent prehospital situations and transporting them to definitive care, EMS can provide the first layer of rapid recognition and response before the implementation of pandemic protocols. During pandemics, the role of EMS in managing risk is a front-line position.^{Reference Bielajs, Burkle, Archer and Smith7}

EMS organizations are not only active during an infectious outbreak, but also in the pre-exposure period when the global pandemic is spreading but has not yet been identified in that specific region. However, a study from the United States claims that most EMS agencies are fundamentally unprepared for a pandemic event.^{Reference Maguire, Dean and Bissell8}

Border management plays a debated role in early containment efforts. According to the CDC Pandemic Influenza Plan, the goal is to detect those suspected of infection at the border so that they can be placed in isolation or prevented from entering the country and spreading the disease.⁵ The WHO 2015 guidance on pandemics suggests considering entry screening in countries not yet affected.⁹

Based on previous pandemics, Israel’s Ministry of Health (MOH) chose to assemble a full preparedness plan, so that in 2009 when H1N1 broke out globally, the country was well prepared with protocols for hospitals, community health care, and prehospital services.^{Reference Shemer and Israeli10} Magen David Adom (MDA), Israel’s national emergency prehospital medical organization, is accustomed to operating in a continuous state of flexibility due to its experience in mixed civilian/military scenarios based on many years of operating in a heavily conflicted region.^{Reference Jaffe, Strugo and Wacht11}

As the national EMS organization, MDA must balance the increased needs created by a pandemic risk with the ongoing national EMS needs. When dealing with large-scale events such as a mass casualty incident or pandemic, MDA designates resources based on projection rather than on immediate need, thereby increasing the preparedness factor.^{Reference Einav, Feigenberg and Weissman12} Preparedness for pandemics must begin in the pre-exposure stage so that containment can be at the highest possible level and personal protective equipment can be worn by EMS in anticipation of the earliest detection.

MDA responds to thousands of calls daily (via the designated medical emergency number 1-0-1) through 8 regional dispatch centers staffed solely by paramedics and emergency medical technicians (EMTs). In both standard and large-scale events, MDA operates as the primary source of triage, dispatch, treatment, and transport. MDA operates a sophisticated technological command and control platform that allows rapid intake, telephone guidance, auditing, archiving, automatic ambulance dispatch, and automatic mobilization of volunteer first responders using a designated smartphone application. The application allows access to pre-uploaded medical information, transmitting Global Positioning System coordinates, and video calling. The technology enables rapid live updates and consultations about cases with medical specialists both internal and external to MDA. Databases are available to the relevant governmental agencies.

RESULTS

The total number of protected “suspected COVID-19” transports during the 32 days was 121 (median of 4 per day; range 1–12). Of these, 44 (median of 2 per day; range 1–7; 36.3%) were referred by medical sources, and 77 were identified as “suspected COVID-19” by dispatchers (median of 2 per day; range 1–8; 63.7%) (Figure 1).

FIGURE 1 COVID-19 Pre-Exposure Activities of Magen David Adom (From January 21, 2020, Until February 22, 2020).

The MDA report on the pre-exposure actions at Ben-Gurion International Airport included data from January 31, 2020, until March 1, 2020, several days past the official pre-exposure date. During those dates, 156 people accessed the checkpoint (median of 4 per day; range 0–23) and were categorized into 4 groups: 87 travelers were sent to home-quarantine; 12 received protective transport to the hospital; 18 were refused entry; and 39 required no further action (Figure 2).

FIGURE 2 Border Control Actions of Magen David Adom During the Pre-Exposure Period.