1. Pandemic Preparedness -Risk assessment and infection control in health care settings-
This lecture is developed under the Fulbright Grant for development of US-Macedonian Collaboration in Higher Education in the field of Global Public Health Security. The title of Fulbright Project is ”New educational Pathway for Global Public health Security” (
Elisaveta Stikova, Ronald LaPorte, Faina Linkov, Margaret Potter, David Piposzar, Sam Stebbins

2. Learning objectives
To introduce student with five components of pandemic preparedness and response and whole society approach
To enlighten the differences between WHO’s 2005 and 2008 pandemic phases
To add more information about risk assessment, use of risk assessment matrix and risk classification of the
workers
To bring forward to the development of the one peak-week scenarios for needs assessment
To set up hierarchy of control measures for workers’ protection during the pandemic

3. SEE Public Health Preparedness Supercourse Network
Elisaveta Stikova
Present position
1991-Present, Professor, University “Ss. Cyril and Methodius”, Medical faculty, Skopje, Macedonia (courses taught: Occupational Health, Public Health, Medical Ecology, Hygiene
1994 – Present, Director and Advisor, National Public Health Institute, Skopje, Macedonia
2009 – Fulbright Visiting Scholar, Pittsburg University, Graduate School of Public Health – New Educational Pathway for Global Public Heath Security
Previous experience:
Director, National Public Health Institute (Republic Institute for Health Protection),
– Industrial physician, Chief of the Department for planning and organization, Institute for Occupational Health
Other present relevant position:
Present, UNDP National expert for chemicals and health
2008 – Present, Member of Editorial Board of EuroSurveillance
Visiting Professor, Erasmus Mundus-Europubhealth Master Studies, University of Sheffield, Sheffield, UK and Krakow, Poland. Courses taught: Disaster Management and International Health (Environmental disasters).
2006 – NATO Partner Country Co-director, Advanced Study Institute, Science for Peace and Security Program, Project title: Strengthening Public Health Preparedness for Chemical, Biological and Radiological Agents Threats.

4. SEE Public Health Preparedness Supercourse Network
Co-Authors and collaborators:
Ronald E. LaPorte, PhD, UPGSPH, Director, Disease Monitoring and Telecommunication, WHO Collaborating Center
Faina Linkov, PhD, Assistant Professor, Cancer Institute
Margaret Potter, JD, MS, Associate Dean and Director, UPGSPH, Center for Public Health Practice
David Piposzar, MPH, UPGSPH, PPLI Co-director
Sam Stebbins, MD, MPH, UPCPHP Principal Investigator/Director, Center for Public Health Preparedness

5. What is pandemic ?
Public health emergency that rapidly takes on significant political, social an economic dimension
Influenza Pandemic would be:
extended event
multiple waves (2-3)
each waves will last
6-8 weeks

6. Five components of pandemic preparedness and response
Planning and coordination
Communication
Situation monitoring and risk assessment (likelihood and severity)
Reducing the spread – infection control
Striving to ensure continuity of health care provision and businesses

7. A whole of society approach to pandemic preparedness and response
INDIVIDUALS FAMILIES AND COMMUNITIES
HEALTH SECTOR
NON HEALTH SECTOR
Provide leadership and guidance
Take actions to reduce health consequences
Raise awareness about risk and potential consequences.
Develop guidance and implement actions needed to minimize the effects of a pandemic on non health sectors.
Take actions needed to minimize the effects of a pandemic on families and individuals
PLANNING AND COORDINATION
COMMUNICATION

8. WHO Guidance, core documents
Supporting Technical Documents
Disease
Control
Measures
For
Pandemic
Influenza
Outbreak
Communicat
ions
Global
Pandemic
Influenza
Surveillance
Laboratory
Preparedness
For
Pandemic
Influenza
Surge
Capacity in
Health
Care
Facilities
Non-
Health
Sector
Preparedness
Tools
Self-
Assessment
Checklist for
Preparedness
Planning and
Executing a
Preparedness
Exercise
Training
CD-ROMs
For Trainers
Rapid
Containment
Training
Package
Handbook
For the
Public
Sample
Preparedness
Plans

10. Comparison of the 2005 and 2008 WHO pandemic phases
Structure & Pandemic Disease “Risk”
Structure & Pandemic Disease “Risk”
Geographic
Pandemic
spread
Predominantly animal
Pandemic
Phase 6
Infections;
5 - 6
Post
Alert
Limited
Peak
transmissibility
Inter pandemic
Post
among people
Sustained
Post
Phases 3-5 4
Pandem
Pandemic
Period
H-2-H
transmission
Phases 1-2
1 - 3
Time
Time

11. Risk assessment The risk assessment analyzes:
Threat (probability of occurrence)
Consequences of the occurrence
Vulnerability

12. Risk analysis circles RISK RISK ASSESSMENT MANAGEMENT Dose assessment
Decision control a z k i s r
Hazard i e R t c
identification a
Acceptable risk r a h
level definition
Exposure c
assessment
Mitigation
measures
Feedback
RISK
COMMUNICATION

13. Risk assessment The risk assessment process involves the
following tasks:
❍ Preparing the risk assessment matrices
❍ Determining the risk ratings
❍ Prioritizing observations

14. Likelihood and severity of damage, 3x3 matrix
S e v e r t y
Likelihoodd
Low
Moderate
High
Very Unlikelihood
Low Risk (1)
Moderate Risk (2)
Likely
High Risk (3)
Very Likely
Likelihood

15. Classifying workers exposure to pandemic influenza at work
Occupational Risk Pyramid

16. Critical infrastructure and key resources workers

17. First line responders Health care workers with direct patient contacts
Workers engaged in health care supporting services
Public health emergency respond workers
Public safety workers (police, firefighters, dispatchers…)
Utility service workers
Transportation workers
Mortuary services’ workers

18. Very high exposure risk occupations
Healthcare workers performing aerosol-generating procedures on known or suspected pandemic patients
Healthcare or laboratory personnel collecting or handling specimens from known or suspected pandemic patients

19. High exposure risk
Health care delivery and support staff exposed to known or suspected pandemic patients
Medical transport of known or suspected pandemic patients in enclosed vehicles
Performing autopsies on known or suspected pandemic patients

20. Medium exposure risk
Workers with high-frequency contact with the general population

21. Lower exposure risk (caution)
Workers who have minimal occupational contacts with general public and other co-workers

22. What an influenza pandemic might look like

23. One waves – peak week scenario severity and extend
25% Attack rate
35% Attack rate
50% Attack rate
Per
Total
MKD
Affected –symptomatic patients
25000
35 000
50 000
Out patient contacts (22%)
5500
7700
11 000
Complication (25% of symptomatic)
1370
27 500
1 700
34 000
2 400
48 500
Hospitalization
(rate 4%)
200
4000
310
6500
440
8800
Critical care (25% of hospitalization) 50
1000 80
1550
110
2200
Deaths (rate 2,5%)
140
2800
280
5600

24. How pandemic influenza could affect our business?
Absenteeism
Change in patterns of commerce
Interruption of supply/delivery

25. Key responsibilities of every organization
Estimate the level of staff absence
Estimate potential impact on its own activities
Estimate potential impact of its resources to the community

26. Impact on the workforce
Up to 50% of the workforce may require time off at some stage over the entire period of the pandemic
15% and 20% of staff may be absent during the peak lasting
Up to 30–35% absenteeism for small organisations/units/teams (5 to 15 staff)
5–6% of staff could be absent as a result of school closures or other restriction

27. Protection in an occupational setting employers duty:
Provide safe place of work
Require to maintain safe working systems
Implement protective measures based on local risk assessments
Implement appropriate infection control measures
Provide physical barriers o stop transmission
Working procedure adjust to needed social distances
Enhance cleaning regime
Provide appropriate PPE

28. Business continuity plan-BCP
Plan for the impact of a pandemic on business
Plan for the impact of a pandemic on employees and customers
Establishment of appropriate working policies during a pandemic
Allocation of resources to protect employees and customers during a pandemic
Communication to and educate employees
Coordination with external organizations

29. How to reduce the risk of workplace exposure during pandemic influenza
“Hierarchy of controls” – workplace risk assessment matrix
Work Practice and Engineering Control
Administrative Controls
Personal Protective Equipment (PPE)
Vaccination

30. Infection control precautions - Key points
Standard infection control
Hand hygiene among staff and patients
Droplet precautions
Respiratory hygiene - managing coughing and sneezing
Use of PPE proportionately to the risk
Placement of patients within the facility
Single room
“Cochorted” patients (epidemiological and clinical data)
Duration of isolation precautions
Vaccination

31. Infection control - Supplementary guidance
Primary health care clinics
General practice premises
Primary care teams making home visits
Allied health professionals (AHP)
Transfer and transport of patients
Centres for mental health
Elderly people care
Dental practices

32. Infection control - Supplementary guidance
Guidance for non-healthcare settings and personnel, including:
Prisons
Fire and rescue service
Police service
Universities and schools
Funeral workers

33. General practices – Infection control
Key points
non-essential clinics should be cancelled
staff should be allocated to either influenza or non-influenza patients
a separate waiting area should be set aside for influenza patients
hand hygiene facilities and paper tissues should be made available
the environment should be cleaned frequently with neutral detergent
Organisation of work flow and appointments
Telephone triage
Segregation

34. Checklist for pandemic infection control in GP practices(1)
Layout and configuration of the practice
separate waiting areas for influenza and non-influenza patients.
designate particular clinical rooms or doctors’ offices for * influenza patients
* non-influenza patients
remove extraneous items (toys, soft furnishings, magazines) from waiting areas.
mortuary issues
Organisation of work flow and appointments
telephone triage
entry points procedure

35. Checklist for pandemic infection control in GP practices(2)
Staffing
assign GPs for influenza or non-influenza patients
Infection control
Availability of hand hygiene facilities for staff and patients
(sinks, soap, alcohol hand rub, paper towels)
Personal protective equipment
supplies of PPE appropriate for needs
perform risk assessment for aerosol-generating procedure

36. Checklist for pandemic infection control in GP practices(3)
Education and training
Provide training in pandemic influenza infection control procedures
Tested FFP3 and training for proper use
Record keeping
Track and document staff sickness and absence
Track and document staff assignments
Patient information
Display posters
provide information sheets, pamphlets…

37. Personal protective equipment
ENTRY TO CONORTED AREA BUT NO CONTACT WITH PATIENTS
CLOSE PATIENT CONTACT (WITHIN ONE METRE)
Hand hygiene 
Gloves xb c
Plastic apron
Gown x
xd,e
Surgical mask
FFP3 respirator
Eye protection
Risk assesment

38. Vaccine Priority Group Recommendation
HCW with direct patient contact and PHW and vaccinators B
Persons > 65 years with 1 or more IHRC (Influenca high-risk conditions)
Persons 6 months to 64 years with 2 or more IHRC C
Pregnant women
Household contacts
Immunocompromised patients
Children < 6 D
Public health emergency response workers
2. A
Healthy 65+
6 months to 64 years with 1 IHRC
Other public health emergency responders workers
Public health safety workers (police, fire, dispatchers…)
Utility workers
Critical infrastructure 3.
Healthy persons 2 – 64 years

39. Checklist for pandemic infection control in GP practices
Environmental infection control:
Clinical and non-clinical waste
Linen and laundry
Staff uniforms
Environmental cleaning and disinfection
Patient care equipment
Furnishings

40. Pandemic Business Continuity of Operations Planning BCOP-Essential
Preparedness 2. Response Recovery
BCOP-E
Planning
Pandemic Business Continuity of Operations Planning BCOP-Essential

41. Business continuity plan-BCP

42. KEY ACTIVITIES
PLANNING
TRAINING AND EDUCATION