The current guidelines and procedures for EMS workers in Saudi Arabia do not adequately address risks of infectious diseases. Some EMS workers have contracted MERS since 2012. This research intends to investigate if infections in responders result from inadequate policy/guidelines or personal failings. The researcher will use observation of EMS workers over 3 months to assess behaviors relating to infectious disease patients. The results aim to provide guidance to EMS agencies in Saudi Arabia for pandemic influenza plans and protocols.

1. EMS responders to pandemic influenza
EMS responders to pandemic influenza (Red Crescent) in Saudi
Arabia
Emergency service providers and agencies alike participate in
life-saving activities every day. Workers in these agencies
provide assistance in daily emergency situations, transporting

2. and treating patients in various situations. Their input in the
medical process is incontrovertible as they ensure the welfare of
the patient.
The healthcare sector is exposed to varying infections despite
the availability of multiple disinfection procedures.
Contamination remains a significant issue to the EMS
responders as ambulances become a constant source of various
pathogenic bacteria as a result of transporting patients from
emergency scenes to the medical facilities. The transportation
procedure creates a situation where the paramedics as well as
the patient are exposed to the pathogens, a majority of which
may be infectious (Reed, et al., 1993). Although there are
various safeguards and disposable equipment which reduce the
risk to the medical staff, the transportation process remains
susceptible to contamination from blood and infectious
substance. The result of these infections on the EMS in Saudi
Arabia specifically is significant, as estimated 35 to 45 medical
providers have been infected .
The ambulance service managed by the Red Crescent is the
source of focus for this project for its lack of policy and
guidelines on the pre-hospital process. Precautions such as
disinfection and sterilization can often not be accompanied by
corresponding infection control procedures. Currently in the
Kingdom, there are over 5, 000 EMS staff using approximately
1,400 ambulances, and they are all at risk (Reed, et al., 1993).
To ensure effective control of possible infections, a
significantly holistic approach is required; one which is
evidence-based and also cost-effective. Comment by Microsoft
Office User: Look at the year of this reference – is it the same
in 2018 as it was in 1993 – I think not
Problem Statement
Inadequate policies and interventions or personal failures of the
emergency medical services team are a facilitator for infections
among the healthcare workers. Comment by Steve Parrillo: How
do you plan to apply this to disasters and MCIs? Comment by

3. Microsoft Office User: expand
Description of the Problem
The requirement for disaster medicine is more crucial than ever
before with diseases such as MERS affecting areas deemed
disaster-prone. Medical workers and emergency service
providers at large require the evidence as a stepping stone to
new decisions and measures involving medical care for health
workers. EMS in Saudi Arabia has faced its fair share of
challenges, with a number of its employees contracting the
deadly virus MERS. EMS plans to use this information in
creating effective influenza plans which will enhance its
existing operational protocols. Comment by Microsoft
Office User: ref and supporting details? Comment by Steve
Parrillo: Reference? Comment by Microsoft Office User: Who is
doing this? EMS means who -?
In particular, influenza plans will require thorough assessment
carried out, which will benefit all parties involved. According
to Costa et al. (2015), interventions should be prioritized before
travel to ensure that volunteers and medical professionals going
on a mission abroad are adequately considered in regards to
their health. The assessment will use observation as the tool.
Information will be derived by working with the EMS
employees and observing them to assess their response to the
issues of workplace infections. The study will get permission
from the Red Crescent to speak to its employees on how the gap
can be bridged. The study once carried out will be useful to
both the authority and the employees. The employees will have
proper medical care, while the authority will benefit from the
job security provided by the employees. The organizational
structures will also support the humanitarian aspect while
securing the fair decisions in the daily operations of the
workers. Comment by Microsoft Office User: This paragraph is
confusing – are you only looking at flu? Comment by Microsoft
Office User: Flow is off – what assessment? Of flu plans? I
think you mean your project but this paragraph needs to be re-

4. worked. Did you submit for IRB?? Comment by Microsoft
Office User: REMEMBER – this is not a proposal or future
tense – it is real time the assessment uses, information is
derived etc. Comment by Steve Parrillo: Make sure you
include comment about approval from IRB to do this.
Comment by Steve Parrillo: I believe you already did this,
correct?
Literature Review
The importance of adequate policy guidelines in preventing
infection of healthcare workers is inarguable, with benefits such
as better individual health. Costa et al. (2015) focused on
reviewing existing information on the delivering interventions
before the workers were deployed to their missions. They aimed
to understand the benefits of the intervention. Majority of the
identified results contended that workplace health is crucial to
the success of the lifesaving efforts of the employees. Just as in
the case of the EMS from Red Crescent, the policies did not
place emphasis on the workplace assessments. The study
discovered that the workers were exposed to high-risk
infections which included TB, influenza, HIV, and other
hazardous infections (Costa, et al. 2015). These infections
depended on the region, but the results are a clear indication
that the pre-mission assessment policy should be mandatory.
The importance of having a clear policy by authorities is clear
in this study. Comment by Steve Parrillo: ??
Effective policy is significant in identifying and managing the
risk posed by these diseases to the workers. For any health
care worker, especially those in humanitarian crises, blood-
borne pathogens may be transmitted through exposure to the
infected patients. It could either be percutaneous or mucosal,
with the risk of exposure ranging between 0.3% to 30 % in
cases where the worker is exposed to HIV and HBV
respectively. According to Beltrami, Williams, Shapiro, and
Chamberland (2010), only a sustained obligation to the health
care workers will provide the prerequisite protection they

5. require. Due to the risky aspect of their occupations, the threat
of exposure is ever present (Beltrami et al., 2010). The authors
call for adherence to disease control regulations on dealing with
the threats of infectious diseases by providing vaccines,
creating exposure control plans, and ensuring frequent training
of their employees. Hence, the need arises to ensure continuous
improvement of definitions of exposure, the effectiveness of the
preventive procedures, as well as sustained commitment to the
overall health of medical workers.
Recent rises in the number of infectious diseases in
humanitarian crises led to an unwillingness by workers to take
part in risky missions Gee, S., & Skovdal, M. (2017). One of
the hazardous infections which have caused the apathy among
emergency services workers is MERS. The infectious disease
has broken in some of the areas which already face limited
healthcare infrastructure. In their study, Haggman, Kenkre, and
Wallace (2016) focus on reviewing the impact of Ebola in
regards to the overall willingness of healthcare workers to move
to areas such as Liberia and Sierra Leone which are some of the
most affected such diseases. Comment by Steve Parrillo:
Word choice. Comment by Steve Parrillo: What were the
results?
Figures in recent studies show that in 2015, only two cases of
Ebola were reported, but in the following 1 ½ years, more than
11,000 people died, including 400 medical workers. Their study
also focused on Red Cross and Red Crescent employees and
their issues with deployment to such regions (Haggman et al.,
2016). The workers raised concerns about their overall welfare
in such countries, while also highlighting the apprehensions
cited by their close relatives. A major aspect underlining the
issues they raised was the lack of adequate operating procedures
to guarantee their quality of life. There was also no guarantee of
their safety. This study highlights the changes posed by
infectious diseases and why it is critical for service providers to
enhance the health conditions of their workers. In addition to
health, safety was also highlighted as a precondition for

6. ensuring the occupational health of the professionals in these
situations (Haggman et al., 2016). Hence, the need arose to
create policies which will guarantee the two aspects highlighted
by the healthcare workers.
Various methods of managing infectious diseases by the health
workers have been discussed. (Koenig, 2014) stresses various
approaches to be utilized by EMS to limit their exposure. A
critical policy proposed is the identity, isolate, and inform
policy. The emergency services workers already have training
on the signs of an infectious disease, which should be applied in
this instance. They should then isolate the risk, which will
reduce their exposure and others to the deadly infections. The
last step involves using the protocol in place to provide the
information to fellow workers and relevant authorities (Koenig,
2014a). Due to the direct threat posed by the infections, the
author provides these screening methods to service providers to
protect themselves, while also protecting the patients. The
methods applied in this study stress the fact workers should also
take the initiative to protect themselves (Koenig, 2014b). Due to
the bureaucratic nature of this step, the EMS should ensure they
put the details in their policies to ensure notifications of
infectious diseases are dealt with before they affect the first
responders.
The articles by various authors have raised the same concerns
― the risks posed by infectious diseases to the humanitarian
workers. The consensus is that EMS should do more to protect
the workers from infection, by the implementation of various
policy decisions. Despite the dangers posed by these diseases,
the responsibility still lies with the Red Crescent and its
workers. Hence, disaster disease management should include
protecting the employees to ensure a better quality of life and
overall satisfaction.
Description of the Project Comment by Microsoft Office

7. User: Methods section is where I am focusing this week –
Please build out a specific methds section that describes the
process for doing the project. This includes details on how you
created the observation tool and validated it – IRB etc.
The project will lay its foundation on the question of whether
authorities, specifically, the EMS, play a part in the workers
contracting infectious diseases. Red Crescent’s guidelines and
procedures will be assessed to note the specific impact they
have on addressing risks faced by their employees. The research
will be carried out in 2018 between January and May. The
participants of the study will include employees of The EMS,
Saudi Arabia. The authority is an emergency services provider
whose employees are exposed to infectious diseases during
treatment and transport of victims. The employees in the study
will include field officers as well as office workers of various
ranks. The assumption is that they are all exposed to infectious
diseases or have been in contact with a fellow employee who
was infected. Diversity in the respondents will be a
consideration, to ensure different views on each observation
made.
The study devised the observation technique as an effective tool
in gathering information. This technique will be useful in
measuring the impacts of risky exposure to a worker’s general
demeanor. The study will minimize the impact of interference,
since the workers may provide information which is incorrect,
by changing their behavior. Saudi Arabia is home to victims of
various infectious diseases such as MERS. Consequently, these
victims may expose other people to these infections. The
reaction during transport and treatment of patients deemed risky
will be crucial when collecting the data. Although the
respondents will be informed of the study, during the data
collection, there will be no interference on the worker’s
assignments through questioning or coercion. The Red Crescent
will also need to provide permission to gather the data.
Information on the respondents will not be shared with any
other party, as names will be used.

8. The data collected will be collated in regards to various types of
behaviors observed. The patterns will be identified in
comparison to treatment of normal patients. Risk related
behavior such as withdrawal from patients or willingness to
treat patients is one of the expected behaviors. Behavior that
does not align with the transport and treatment of infectious
patients will be disregarded. The data will be processed,
classified, and tabulated, reducing it in terms of specificity. A
graphical analysis will be included to help me understand the
observation data collected. The new information will then be
shared with the relevant parties, including the Red Crescent.
The data collected from this study is susceptible to various
challenges, including workers who do not show their behavior
publicly. In addition, the idea of being watched may force the
respondents to change their behavior, as such leading to false
data being collected. Despite the challenges, the study will
provide an opportunity for the EMS authority and the medical
field at large to learn important lessons. Lessons will be on how
to improve the quality of care of workers as well as any policies
which require improvement in the treatment process.
Conclusion
It is the responsibility of Red Crescent to realize the danger
posed by exposure to infectious diseases. Despite their
contribution to society, the medical and trauma workers also
require consummate medical health. This proposal provides a
guideline for collecting data which will be used to prove the
impact of infectious diseases on their willingness to treat

9. patients. authorities such as Red crescent will, consequently,
use this information to enhance their policies which will then
enhance the quality of life and work for healthcare workers.
Observation:
The current guideline and procedures for EMS (Red crescent)
workers in Saudi Arabian do not adequately address potential
risk associated with treating patients who suffer from infection
disease. Since 2012, a few EMS workers have contracted to
MERS. This research intends to investigate whether infection in

10. responders is a result from Inadequate policy and guidelines or
EMS personal failing to follow the guideline. The results are
intended to provide guidance to EMS agencies in Saudi Arabia
in their pandemic influenza plans and operational protocols. The
audience for this subject is EMS agencies (Red Crescent).
Use observation Technique as tool. And use randomly time
assignments to reach most of the EMS workers.
Red Crescent (EMS)
Hail City, Saudi Arabia
EMS station 1 (36 paramedics)
EMS station 2 (24 paramedics)
EMS station 3 (24 paramedics)
A
3 days on + 3 days off
EMS station 1
EMS station 2
EMS station 3
8:00 - 20:00
4 paramedics
2 paramedics
2 paramedics
20:00 - 8:00
2 paramedics
2 paramedics
2 paramedics

11. B
3 days on + 3 days off
EMS station 1
EMS station 2
EMS station 3
8:00 - 20:00
4 paramedics
2 paramedics
2 paramedics
20:00 - 8:00
2 paramedics
2 paramedics
2 paramedics
(EMS) providers play an important role in the prevention and
control of infections. EMS providers are at the front line of
medical care and have a high risk of exposure to patients with
known or unknown infectious diseases.
Concentration on seven key strategies as infection control
measures in the EMS:
· Use of personal protective equipment, e.g. gowns, gloves,

12. eye, face and respiratory protection
· Hand hygiene
· Environmental cleaning and disinfection
· Source control measures aimed at containing the patient’s
secretions
· Limiting contact with patients
· Ambulance cleaning and disinfection.
· Knowledge of EMS workers about infection prevention and
control standards
Comment by Steve Parrillo: Did you create these tables?
If not, cite your source.
References
Bekefi, T., Epstein M. J., & Yuthas, K. (2008). Managing
opportunities and risks. Ottawa: The Society of Management
Accountants of Canada.
Beltrami, E. M., Williams, I. T., Shapiro, C. N., &
Chamberland, M. E. (2000). Risk and management of blood-
borne infections in health care workers. Clinical Microbiology

13. Reviews,13(3), 385-407. doi:10.1128/cmr.13.3.385-407.2000
Costa, M., Oberholzer-Riss, M., Hatz, C., Steffen, R., Puhan,
M., & Schlagenhauf, P. (2015). Pre-travel health advice
guidelines for humanitarian workers: A systematic review.
Travel Medicine and Infectious Disease,13(6), 449-465.
doi:10.1016/j.tmaid.2015.11.006
Gushulak, B. D. (2017, May 31). Humanitarian aid workers.
Retrieved from
https://wwwnc.cdc.gov/travel/yellowbook/2018/advising-
travelers-with-specific-needs/humanitarian-aid-workers
Haggman, H., Kenkre, J., & Wallace, C. (2016). Occupational
health for humanitarian aid workers in an Ebola outbreak.
Journal of Research in Nursing,21(1), 22-36.
doi:10.1177/1744987116630578
Koenig, K. L. (2014a). Identify, isolate, inform: A 3-pronged
approach to management of public health emergencies. Disaster
Medicine and Public Health Preparedness,9(1), 86-87.
doi:10.1017/dmp.2014.125
Koenig, K. L. (2014b). Ebola triage screening and public health:
The new “Vital Sign Zero”. Disaster Medicine and Public
Health Preparedness,9(1), 57-58. doi:10.1017/dmp.2014.120
Reed, E., .daya, M. R., Jui, J., Grellman, K., Gerber, L., &
Loveless, M. O. (1993). Occupational infectious disease
exposures in EMS personnel. The Journal of Emergency
Medicine,11(1), 9-16. doi:10.1016/0736-4679(93)90003-p
Gee, S., & Skovdal, M. (2017). The role of risk perception in
willingness to respond to the 2014–2016 West African Ebola
outbreak: a qualitative study of international health care
workers. Global Health Research and Policy, 2, 21.
http://doi.org/10.1186/s41256-017-0042-y