crisis preparadness planning for the health system in the republic of

Transcription

Ministry of Health
of the Republic of Macedonia
CRISIS PREPARADNESS PLANNING
FOR THE HEALTH SYSTEM
IN THE REPUBLIC OF MACEDONIA
ISBN 978-608-4531-05-0
The printing and development of this document is supported by World Health Organization, Country Office, Skopje
CRISIS PREPARADNESS PLANNING
FOR THE HEALTH SYSTEM
IN THE REPUBLIC OF MACEDONIA
JUNE 2009
Authors and contributors:
The working group within the Intersectoral Commission for disaster preparedness and response,
Ministry of Health
Editors and authors:
Assoc. Prof. Mihail Kochubovski MD PhD
Prim. Zarko Sutinovski MD
M-r Margarita Spasenovska
Co - authors:
Prof. Spase Jovkovski MD PhD
Prof. Zvonko Milenkovic MD PhD
Prof. Fimka Tozija MD PhD
Prim. Kiro Salvani MD
Prim. Bozin Petrevski MD
Vera Menkovska MD
Prim. Zarko Karadzovski MD
Vesna Nedelkovska MD
Ms Maja Timovska
Ms Tatijana Olumceva
Colonel Andrea Naumovski MD
Bogdan Karovski MD
Vladimir Nikolovski MD
Translation: Magdalena Simionska
Print: Media Konekt
CIP - Katalogizacija vo publikacija
Nacionalna i univerzitetska biblioteka “Sv. Kliment Ohridski“, Skopje
614.2-022.326.5(497.7) (083.9)
CRISIS preparadness for the health system in the Republic of Macedonia : (authors and contributors Mihail Kochubovski ... (i dr.); translation Magdalena Simionska). - Skopje : Svetska zdravstvena organizacija,
2009. - 73 str. ; ilustr. ; 23 cm
Prevod na deloto: Plan za podgotovka i odgovor na zdravstveniot sistem pri vonredni/krizni
sostojbi vo Republika Makedonija. - Sodr`i i : Appendix I-III
ISBN 978-608-4531-05-0
1. Kochubovski, Mihail (avtor) (urednik)
a) Zdravstven sistem - Krizni sostojbi - Makedonija - Programi
COBISS.MK-ID 80462858
C O N T E N T S:
I.
INTRODUCTION........................................................................................................................................... 5
II. HAZARD ASSESSMENT AND HEALTH SYSTEM RESPONSE DURING CRISIS IN
THE REPUBLIC OF MACEDONIA............................................................................................................... 6
III. PLAN STRUCTURE.................................................................................................................................... 10
IV. LEADERSHIP AND GOVERNANCE.......................................................................................................... 11
IV.1. Policy and legislation........................................................................................................................... 11
IV.1.1. National crisis preparedness policy of concern to the health sector........................................ 11
Activation plan during crisis of a public-health concern...................................................................... 13
Notification structure in the MoH according to hierarchyin case of crisis........................................... 14
IV.1.2. MoH Crisis preparedness policy.............................................................................................. 16
IV.1.3. Compliance with international policy, legislation and agreements........................................... 18
IV.1.3.1. The International Health Regulations (IHR).............................................................. 18
IV.2. Institutional framework......................................................................................................................... 20
IV.2.1. Health Crisis Management Unit (HCMU), donations and strategic planning........................... 21
IV.2.2. Multi-disciplinary CPP committee............................................................................................ 21
IV.2.3. Bureau for Drugs..................................................................................................................... 22
IV.2.4. State sanitary and health inspectorate.................................................................................... 22
IV.2.5. Food Directorate...................................................................................................................... 24
IV.2.6. Crisis preparedness planning for health systems.................................................................... 25
IV.2.7. Public communication and education in crisis......................................................................... 26
IV.2.8. Monitoring and evaluation....................................................................................................... 27
IV.3. Partnership and coordination............................................................................................................... 28
IV.3.1. Partnerships and union building.............................................................................................. 28
IV.3.2. Multisectoral coordination........................................................................................................ 28
IV.3.3. International technical cooperation and mutual aid agreements............................................. 29
V. RESOURCES GENERATION..................................................................................................................... 29
V.1. Human resources................................................................................................................................. 30
V.1.1. Development of Human Resources Strategy for crisis across the health system.................... 30
V.1.2. Capacity building in disaster management............................................................................... 32
V.2. Medical supplies and pharmaceuticals (critical supplies and equipment management)..................... 32
V.3. Data collection, analysis and reporting process.................................................................................. 33
V.3.1. Early warning systems.............................................................................................................. 34
V.3.2. Health crisis assessment.......................................................................................................... 39
V.3.3. Laboratory testing..................................................................................................................... 41
VI. HEALTH FINANCING................................................................................................................................... 42
VI.1. Preparedness financing..................................................................................................................... 42
VI.1.1. CPP budget............................................................................................................................. 42
VI.1.2. Budget for vulnerability analysis and risk reduction of the critical health facilities.................. 42
VI.2. Contingency funding.......................................................................................................................... 42
VI.2.1. Contingency fund exists.......................................................................................................... 42
VI.2.2. International contingency funds.............................................................................................. 42
VII. SERVICE DELIVERY............................................................................................................................ 43
VII.1. Procedures, guidelines and protocols for critical services during crisis............................................. 43
VII.1.1. Rapid need assessment......................................................................................................... 43
VII.1.2. Emergency surveillance, procedures and control of communicable diseases . .................... 43
VII.1.3. Ability to respond to a radiation crisis..................................................................................... 44
The Activation Plan of the Head Office for Radiation Security in case of a radiation
crisis of public-health importance ...................................................................................................................... 48
VII.1.4. Ability to respond to chemical incidents during crisis............................................................. 48
VII.1.5. Ability to respond to the specific health consequences of the crisis....................................... 49
VII.2. Mass casualty management.............................................................................................................. 49
VII.3. Risk management of health facilities.................................................................................................. 53
VII.4. Life lines, logistics, telecommunication and security in a crisis.......................................................... 52
VII.4.1. Lifelines.................................................................................................................................. 52
VII.4.2. Logistics................................................................................................................................. 52
VII.4.3. Emergency telecommunication.............................................................................................. 52
VII.4.4. Security system...................................................................................................................... 52
APPENDICES.................................................................................................................................................... 54
APPENDIX I - WHO – Emergency reference values......................................................................................... 56
APPENDIX II - Strategy for water-supply and sanitation
in the former Yugoslav Republic of Macedonia during crisis (catastrophes)...................................................... 58
Ten hygiene rules during crisis........................................................................................................................... 67
Manuel for the Aquatabs® for water disinfection during crisis............................................................................ 67
APPENDIX III - Triage protocols for the injured (scoring-systems).................................................................... 68
I. INTRODUCTION
According to the Crisis Management Law (“Government Gazette of MKD num.29/05”) the
crisis is a state caused by risks and hazards that can threaten the supplies, health and
lives of people and animals and the security of the Republic, for whose prevention and/or
management a greater use of a bigger volume of resources is needed.
The catastrophes are actually a change in the living conditions followed by a change in
the normal way of life and are expressed with a higher exposure of the affected population
to the nature’s risk elements. The World Health Organization (WHO) defines these states
as: “creating a catastrophic situation in which the every day life style is suddenly
stopped, and the people are exposed to helplessness and suffering that result in a
need for food, clothes, shelters, medical care and other needs of life, as well as
protection from the unpleasant factors and conditions of the environment”.
The risk represents a phenomenon which has the potential to disturb or harm a human
being or the environment. The extreme events are either natural or human made (ex.
landslides, floods, coastal storms, grasshopper invasions or rats are natural, but extreme
events whose volume and probability for occurring can be estimated). Many of these
events, like for example strong floods, were monitored and noticed during many years and
knowledge has been gained for their probable occurrence. Man-made risks exist, like for
ex.: the flow out of chemically dangerous substances or radiation, but there is also the
occurrence of the so called natural hazards that were instigated as a result of human
activities. The floods in Bangladesh in 1990 worsened because a lot of plastic bags
blocked the drainage systems.
The extreme events cause a stress in the human system and structure because they are
much greater forces than those that the body possesses and which are normally
overcome. For ex.: all houses can withstand some type of wind, but they will all fall under
a higher wind speed. A lot of the agricultural communities can cope with a mild drought,
but they will all be “squashed” by a fierce and repetitive drought. The extreme events
often occur in complex “cascades”.
Crisis concept in the health system:

Crisis states occur when:
 The local systems from which the people depend on are overloaded.
 The systems can not meet the needs.
 The people can not fulfill the basic needs.
Reasons for crisis:
 Unexpected, catastrophic events (chemical incidents, mass poisoning,
release of biological materials, earthquakes, accidents…).
 Prolonged social violations (violence, fights and depopulation).
 Catastrophes with a slow flow (reducing of the woods and widening of the
deserts, global warming, high HIV prevalence).
The preparation process scope is to emphasize the importance and the positive aspects
of the adequate health system crisis preparedness planning of a bigger scale, which
disrupt the organizing and the flow of the work in terms of the health system as a whole.
The plan is prepared according to the guidelines given in the Practical tool and checklist
by the World Health Organization (WHO, 2008). A review of the WHO program for crisis
states and the preparedness activities, a response and recovering/softening of the
consequences that are focused on the health system, as well as guidelines for the basic
5
elements during the health system crisis preparedness planning on a national level are
presented in the practical tool.
A preparation of a technically appropriate and operative plan for an adequate response for
the health system during crisis can minimize the morbidity and mortality caused by a
specific crisis, including also the consequences from the climate changes, as well as
pandemic influenza.
II. HAZARD ASSESSMENT AND HEALTH SYSTEM RESPONSE DURING CRISIS IN
THE REPUBLIC OF MACEDONIA
А. Main hazard
1. Heat waves (forest fires)
a. Global climate changes
b. Geographical position
c. Regional climate conditions
2. Pandemic influenza
a. Global public-health threat
3. Floods
a. Shallow riverbeds
b. Downpours (insufficient erosion protection zones)
c. Inappropriate maintenance of the riverbeds/canals
Picture 1. Critical flood regions in the Republic of Macedonia
Data source (Hydro meteorological Office)
In picture 1 the most common critical regions in the Republic of Macedonia are shown
during conditions of fast snow melting with intensive rainfalls. From the above shown it
can be ascertained that there is a potential threat of flooding the heath facilities and a
possible obstruction of the regular work of the same in the Skopje region (where there are
Clinics, Institutes, Special Hospitals, General Hospitals, Public Health Centers – PHI and
PHC-Skopje, Health House and etc.), the Gevgelija region (where there is a General
Hospital and a Special Hospital), the Strumica region (where there is a General Hospital,
a Health House, an Institute for Health Care and etc.), as well as Makedonski Brod where
6
there is a Health House. Due to the potential threat, in the future planning of building new
public heath facilities, it is necessary to take into consideration the assessment of the
flood vulnerability, as well as to plan a procedure for reducing the damages of the already
build capacities.
In case of a flood in the Skopje region, upon the request of the Ministry of Health, through
the Center for crisis management and with the permission on behalf of the Ministry of
Defense, an additional number of hospital beds (40) can be activated in the infirmary in
the Ilinden Barracks which is on a higher elevation and is protected from a possible flood
wave.
4. Earthquake
a. Seismic suitable region
b. Historical evidence (Skopje, 1963 with 1070 dead)
Due to the regional geological and tectonic characteristics, Macedonia is located in a very
active seismic region, liable to strong earthquakes. The main earthquake zones are down
the river Struma on the border between Bulgaria and the Republic of Macedonia, the
Vardar zone in central MKD, including Skopje and the Drim zone to the West, along the
border with Albania. In the Republic of Macedonia, from 1900 there have been 14 strong
earthquakes with a magnitude from 6 to 7, 8 according to the Richter scale, out of which
the strongest was in Skopje in 1963 (1070 dead, 77% of the building severely damaged),
and the last was in Bitola in 1994, with a material loss estimated to around 3, 5% from the
MKD gross social product for that year.
The regional infrastructural systems (roads, railways, transmission lines, water-supplies
etc.) are sensitive to earthquakes because they are located along the lines with a frequent
seismic activity. Even if the earthquake causes a small immediate damage, there is
danger of long-term economic damages as well as damages to the living environment.
Except the parts of Skopje, the spacious infrastructure and the homes in the other cities
have not been designed to withstand a medium to strong earthquake. The basic law by
which the building is being regulated is the Law for Building Investment Objects. On the
grounds of this law, there have been made numerous regulations that determine the
technical standards and operations for building of seismic regions. The contemporary
world scientific achievements in seismology have been incorporated, and the standards
are strictly obeyed during the designing of the new builds. The seismological occurrences
are being monitored by the Seismological Observatory at the Faculty of Natural Sciences
and Mathematics in Skopje, according to the Law for Participation of the State in the
Financing of Seismic and (seismic and engineering activity) Engineering Activities. There
are seismic stations in Skopje, Valandovo, Ohrid, Bitola, Kriva Palanka and the village
Vranovci. The Institute for Earthquake Engineering and Engineering Seismology, at the
University “Ss. Cyril and Methodius” – Skopje, is working with the research aspects of
seismology.
5. Chemical incidents
a. Industrial
b. Transport
6. Land-slides – sliding of the land
a. Deforestation (insufficient erosion protective zones)
7. War state – (civil war and/or wars)
a. Politically unstable region
7
B. Risks
1. Heat waves (forest fires)
Mb (h), Mt (l)
(h = high risk, l = low risk)
a. Economic losses
(reduction of the forest
infrastructure, of goods)
2. Pandemic influenza
a. Mb (vh), Mt (vh)
fund,
damaging
of
(vh = very high risk)
3. Floods
a. Mb (l), Mt (vl) (l = low risk, vh = very high risk)
b. Economic losses
(agriculture, damaging of infrastructure, of goods)
4. Earthquake
a. Mb (h), Mt (h)
b. Economic losses
c. Displacement
(h = high risk, h = high risk)
(damaging of infrastructure, of goods)
(homeless people and etc.)
5. Chemical incidents
a. Industrial
 Mb (h), Mt (l)(h = high risk, l = low risk)
b. Transport
 Mb (l), Mt (l) (h = low risk, l = low risk)
6. Land-slides – sliding of the soil
a. Mb (l), Mt (l)
(l = low risk, l = low risk)
b. Economic losses
7. War state – (civil war and/or wars)
a. Mb (vh), Mt (h)
(vh = very high risk, h = high risk)
b. Economic losses
c. Displacement
(homeless people and etc.)
The potential of the natural hazards in the Republic of Macedonia is shown on Map num.1
8
9
III. PLAN STRUCTURE
The four core functions that make up the health systems framework are:
leadership and governance, resource generation, health financing and health
services (Figure 1).
Figure 1. HEALTH
SYSTEMS FRAMEWORK
FUNCTIONS OF HEALTH
SYSTEM
GOALS / OUTCOMES OF
THE HEALTH SYSTEM
Better health
(level and equity)
Leadership and governance
(stewardship)
Resource generation
Responsiveness
(to population’s
expectations)
Health financing
Financial fairness
(equity of financial
contribution with
protection against
financial risk)
Service delivery
The key components of the four functions relative to the CPP process may be
shown as follows (Figure 2):
Figure 2. Key Components by Function
Leadership &
Governance
Resource
Generation
Policy & Legislation
Human Resources
Institutional
Framework
Medical Supplies &
Pharmaceuticals
Partnerships &
Coordination
Data Collection,
Analysis &
Reporting
Health Financing
Service
Delivery
Preparedness
Financing
Procedures,
Guidelines and
Protocols
Contingency
Funding
Mass casualty
management
Risk Management of
health facilities
Lifelines, logistics,
telecommunication
and security
10
Health system performance is measured not just on how well each function in the
framework is performing but how well each is inter-relating with the others.
Interaction between functions is critical to attaining better health outcomes.
IV. LEADERSHIP AND GOVERNANCE
Leadership and governance is the careful and responsible management of the health
system by influencing policies and actions in all the sectors affecting population health. In
preparedness planning, this means ensuring that national policy incorporating health
system crises preparedness exists. It also involves effective coordination structures,
partnerships, advocacy, risk assessment, information management, and, monitoring and
evaluation.
IV.1. Policy and legislation
The Ministry of Health of the Republic of Macedonia is conducting a preparation of the
health system for functioning and responding not only in peacetime conditions, but also
during crisis.
IV.1.1. National crisis preparedness policy of concern to the health sector
In case of a crisis, the Crisis Management Center calls for an urgent meeting of the
Assessment Group (from CMC) in order to draw conclusions for taking necessary
measures and activities of the subjects in authority.
The assessment group considers all the findings, information and reports for the specific
state.
On the basis of the stated assessments to the Management committee (Government body
for coordinating and managing the crisis management system which is consisted of the
ministers of internal affairs, of health, of transport and communication, of defense, of
external affairs and the Manager of the assessment group, the Manager of CMC D-r
Pande Lazarevski; when necessary other functionaries may get involved, a representative
from the Parliament of MKD and from the Cabinet of the President of MKD also
participate) it is recommended to take the necessary measures and activities on behalf of
the subjects in authority that are in the crisis management system, and according to the
Law for Crisis Management (“Government Gazette of MKD num. 29/2005”).
The management committee taking into consideration all the findings for the existent
state in the Republic of Macedonia and the proposal of the Assessment group, notifies the
Government for the specific state, or proposes to the Government of the Republic of
Macedonia to declare a crisis state.
On the basis of the conclusions of the Management Committee, the Government of the
Republic of Macedonia, on an urgent meeting, makes a Resolution for declaring a
crisis state for the threatened region and engaging all the available human and
material resources for eliminating the consequences from the same.
After the decision making, the Main Headquarters from the Crisis Management Center is
activated, which has to be in constant session.
11
The Government of the Republic of Macedonia on the basis of the need shown, can
suggest to the President of the Republic of Macedonia to use the Army, for managing the
crisis.
The President of the Republic of Macedonia permits the engaging of the Army.
According to the Crisis Management Law (“Government Gazette of MKD num.29/2005”) a
cancellation of the crisis state is made by the Government of the Republic of Macedonia.
On Chart 3 the Activation Plan in case of a crisis of a public-health concern is shown.
In the plan for activating the institution in authority as well as the manner of their
notification is given, and also calling for help from the international organizations. The role
of the factors in the crisis response system is given in more detail in the following
chapters.
12
13
NOTIFICATION STRUCTURE IN THE MINISTRY OF HEALTH ACCORDING TO
HIERARCHY IN CASE OF CRISIS:
Responsible person for coordination and a health system response during crisis in the
Ministry of Health as well as for cooperation with the World Health Organization is:
1. D-r Bujar Osmani, Minister of Health
Tel: +389 2 3126-206, Fax: +389 2 3113-014
Mob:
Е- mail:
2. Prof. D-r Vladimir Popovski, Vice Minister of Health
Tel: +389 2 3126-206, Fax: +389 2 3113-014
Mob:
Е- mail:
3. D-r Zoran Stojanovski, State Secretary, Ministry of Health
Tel: +389 2 3123-009
Fax: +389 2 3113-014
Е-mail:
Responsible for coordination with the World Health Organization and for a health care
response during crisis is:
Sector for organizing and functioning of the health system in crisis, crisis
management, donations and strategic planning
Manager, Prim. D-r Zarko Shutinovski
National associate collaborator with WHO for a response during crisis
Tel: +389 2 3112-500 loc.115, Fax: +389 2 3113-014
Mob:
Е-mail:
Sector Assistant Manager
D-r Silvana Delevska
Tel: +389 2 3112-500 loc.232
Mob:
Е-mail:
Doc. D-r Mihail Kocubovski
National associate collaborator with WHO for a response during crisis
Tel: +389 2 3125-044 loc.214, Fax: +389 2 3223-354
Mob:
Е-mail:
14
For the need of managing the consequences from Pandemic influenza according to the
Pandemic Influenza Plan, the coordination is done through the President of the
Pandemic Influenza Committee:
Prim. D-r Jovanka Kostovska
Tel: +389 2 3112-500
Mob:
E-mail:
In the Health Care Law (Government Gazette of the Republic of Macedonia num.
38/91, 73/72,…), with all the supplements, in article 170 it has been put in order – during
the planning and the conducting of the activities in crisis, the Ministry of Health and the
health organizations cooperate with the Head Office for Protection and Rescue, the Red
Cross organizations and the other social organizations and associations, the working
people and the citizens.
The coordination with the Crisis Management Center is carried out through:
1. Dushko Petrovski, Manager of the Sector for Operation and Coordination
Tel: +389 2 3249-210, Fax: 3136-226
Mob:
Е-mail:
2. Zoran Blazevski, Manager of the Department for Emergency States
Tel: +389 2 3249211, 3249212 (working hours: 24 hours)
Mob:
Е-mail:
Emergency calls: 195
The coordination with the Head Office for Protection and Rescue is carried out through:
1.Maja Timovska, member of the Multisectoral Committee for preparation of the health
system for a response and functioning in crisis
Tel: +389 2 3247-216; Fax: 3247-225
Mob:
E-mail:
Other contacts from the Head Office for Protection and Rescue:
Shaban Saliu, Manager of the Head Office for Protection and Rescue
Tel: +389 2 3247-201, Fax: +389 2 3247-225
Mob:
Ljupce Petroski, Responsible person for coordinating the quick intervention teams
Tel: +389 2 3247-215, Fax: +389 2 3247-225
Mob:
E-mail:
Responsible person for coordinating the quick intervention team in case of RCB
(radiological-chemical-biological) contamination:
15
Blaga Cvetkovska, Head Office for Protection and Rescue
Tel: +389 2 3247-275, Fax: +389 2 3247-225
Mob:
E-mail:
Ilija Gorgievski, Head Office for Protection and Rescue
Tel: +389 2 3247-275, Fax: 3247-225
Mob:
The institutions listed below are informed in order to make an assessment of the current
endangerment from a possible contamination:
Rumen Stamenov, Manager of the Head Office for Radiation Security
Tel: +389 2 3099-031, Fax: +389 2 3099-032
Mob:
E-mail:
Faculty of Chemistry (at the Faculty of Natural Sciences and MathematicsSkopje)
Contact: Prof. D-r Valentin Mircevski
Tel: +389 2 3249-913
Mob:
E-mail:
The coordination with the Red Cross of the Republic of Macedonia is carried out
through:
Secretary Sait Saiti
Tel: +389 2 3114-355, Fax: +389 2 3230-549
Mob:
Е-mail:
The activities of the Red Cross are conducted through several commissions, depending
on the type and character of the natural disaster and for the reduction and the elimination
of the consequences there is a unit formed for rapid interventions which is consisted of 6
teams and which is equipped with all the necessary material and technical means as well
as equipment.
IV.1.2. MoH Crisis preparedness policy
The Ministry of Health policy delineates the structure for decision making, coordination
and resource allocation to prepare for and respond to a health crisis.


16
In the systematization of the Ministry of Health, the role and responsibility of the
Coordinator for a health system crisis response has been assigned, i.e. to the
Sector for organizing and functioning of the health system during crisis, donations
and strategic planning.
A Multisectoral Commission has been formed for health preparedness response
during crisis.



It has been assigned that the risk estimation and the reducing of the risk should be
a part of the health system crisis preparedness process (including the safety of the
heath facilities).
From the national health budget for the process of crisis preparedness planning in
the Program for Preventive Health Care for 2009 for the Estimation of the crisis
preparedness planning there are 3.000.000 denars provided. The estimation will
be performed through an evaluation of the managing, the state and the
preparedness of the health sector for a correct and timely response during crisis.
A training of the manager staff involved in the domain of managing and decision
making for the crisis preparedness planning and response of the health system
has been planned, as well as for the people in authority and the professionals
assigned for different phases of the crisis preparedness planning on the level of
heath facilities.
Role of the Sector for Organizing and Functioning of the health system during
crisis, donations and strategic planning
•
•
•
•
Preparing an Action Plan for crisis preparedness and strengthening the health
systems and services in case of a crisis;
investing in means of reducing risk in order to minimize the morbidity and mortality
during crisis;
insuring an multi-sector coordination with the key ministries in order to optimize the
resources and effects from the health crisis response;
cooperation with international factors, the civil society and the private sector in
order to establish a joint operative regional platform for a timely mobilization of
expertise and resources during crisis.
The health system’s role for a response during crisis





The health system response to specific and sudden crisis as well as the
effectiveness and capacity in terms of supplying adequate health services and
medical help to the affected population depend on the level of hospital
preparedness and the other heath facilities.
It is expected that they continue to function during crisis, but experience has
shown that they tend to be very fragile during crisis (for example during natural
disasters and especially earthquakes) from the point of view of infrastructure, and
consequently unable to satisfy the pressing needs.
The hospitals must be designed so that they satisfy the security standards
and the standards in terms of effect, which will provide security for the patients
and the medical staff in the hospital during crisis.
The emergency department and hospitals need to have the necessary capacity
and infrastructure to respond to the urgent medical needs of the population and to
the prompt changes that occur in every crisis.
It is necessary to maintain a high level of preparedness with all the
emergency units in the country, especially with those located in the hospitals,
and in case of a crisis “the hospital plan for crisis preparedness” needs to be
activated. In the Republic of Macedonia there are Plans for a crisis response with
a special accent on pandemic influenza on the level of PHI General HospitalStrumica, Shtip, Veles, Kocani, Prilep, Kavadarci, Gevgelija, Ohrid, Debar,
Gostivar, Tetovo and Kumanovo, as well as from the PHI Clinical Hospital-Bitola
and PHI University Clinic for Surgical Diseases “Ss. Naum Ohridski”-Skopje and
PHI Clinic for Infective Diseases and Febrile States-Skopje. The resources and the
staff are included in both the plans for the PHI Health Houses and the PHI Centers
for Public Health on the level of individual regions, as well as all the relevant
factors.
17

The access to and the providing of urgent medical help during crisis is one of
the most important strategies for reducing the morbidity and mortality during any
critical event.
IV.1.3. Compliance with international policy, legislation and agreements
IV.1.3.1. The International Health Regulations (IHR)
WHO member states:
 Negotiated, agreed and approved the IHR in 2005.
 Now, according to the Constitution of WHO, the IHR (2005) are obligated by law
for every member state of WHO in the whole world (with the exception of 3
countries).
 The deadline for going into force is prolonged only for certain obligations
that are to do with surveillance, response and the place of entry in the
countries.
The use of the International Health Regulations (into force from 15.06.2007) in the
Republic of Macedonia is carried out through an assessment of the current state in order
to bring into accord with the IHR.
By going into force of the International Health Regulations from 15 June 2007, the Institute
of Public Health of the Republic of Macedonia (former REPUBLIC INSTITUTE FOR
HEALTH PROTECTION) is a contact institution in charge of announcing public health
crisis events that are of international significance (i.e. there is a possibility of spreading in
the neighboring countries and wider) and is in constant communication with WHO on one
side, and with the PHI Public Health Center (former Centers for Public Health) on the
other side in MKD (10 regional in Skopje, Kumanovo, Shtip, Kocani, Veles, Strumica,
Prilep, Bitola, Ohrid and Tetovo).
The harmonization of the national legislative with the International Health Regulations,
also in the context of approximation of our legislation with the EU legislative, is in
progress.
The further continuation of the process of strengthening the capacities of the public-health
sector for a timely and coordinated response and functioning of the health system during
crisis is of great necessity, and for the same there is professional help provided on behalf
of WHO.
In case of a public health event crisis that is of international significance with a possibility
of spreading also in the Republic of Macedonia, the National Contact Institution is the
Institute of Public Health in the Republic of Macedonia represented by acting Director Ass
D-r Shaban Memeti:
Shaban Memeti, Director, Institute of Public Health of MKD
Tel: +389 2 3125-044, Fax: +389 2 3223-354
Mob:
Е-mail: [email protected]
This institution will be available for communication at all times with the WHO contact about
the IHR, and to:
 Deliver and receive urgent communications.
18
 Disseminate information on a national level (political and professionaltechnical level), to consolidate the answer of the relevant sectors of the
state administration including the responsibility for:
 Surveillance and registering,
 Places of entry,
 Public-health services, and
 Clinics and hospitals and other government departments.
The points of entry into the country have been identified (border crossings and airports in
Skopje and Ohrid), that may undergo corrections in the near future depending on the
demands and the actual state (Picture 2).
Picture 2. Map of the Republic of Macedonia with border crossings for
entry into the country
Border crossings where the SSHI during crisis are activated: Airport Alexander the GreatSkopje, Deve Bair-Kriva Palanka and as a transit in cooperation with MI-Tabanovce,
Bogorodica-Gevgelija, Kafasan-Struga and Blace-Skopje.
19
IV.2. Institutional framework
The organ-chart of the Ministry of Health is shown on Chart 4.
Chart 4. The organ-chart of the Ministry of Health
Minister of Health
Bujar Osmani MD
State Secretary
Zoran Stojanovski
MD
Deputy Minister
Prof. Vladimir
Popovski MD PhD
Organs belonging to
the Ministry of
Health
*
Sector for secondary
and tertiary health
care
Sector for primary
health care
Bureau for Drugs
Sector for preventive
health care
Sector for health
insurance and
monitoring of Health
Insurance Fund
State Sanitary and
Health Inspectorate
Sector for
modernization, health
management and IT
Sector for EU
integration
Sector for general,
legal and executive
affairs and
coordination and
technical assistance
Sector for
development,
investment and
international technical
cooperation
Dentistry Sector
Sector for common
affairs
Sector for disaster
preparedness and
response
20
Food Directorate
State Counselor for Preventive
Health Care
Prim. Kiro Salvani MD
State Counselor for Primary
Health Care
State Counselor for Secondary
and Tertiary Health Care
State Counselor for general
and legal affairs and human
resources
State Counselor for Preventive
Health Insurance and
monitoring of work of the
Health Insurance Fund
IV.2.1. Health Crisis Management Unit (HCUM), donations and strategic planning
The HCUM, donations and strategic planning is responsible for managing all the crisis
(natural, technological, social) including outbreaks, bioterrorism or conflicts.
The HCUM, donations and strategic planning is to do with work connected to managing
and participating in the organizing and functioning as well as health system management
during crisis, and it:











organizes the tasks connected with health system preparedness for working in
crisis and in war conditions;
conducts the work that is to do with forming and organizing of territorial
(temporary) heath facilities;
forms and controls the State medicine stocks, the medical equipment and
sanitary material, it monitors and organizes the supplying of the same in crisis
or war;
cooperates with the Public Health Center of the Republic of Macedonia and the
Crisis Management Center, the Head office for Protection, as well as with the
other relevant government and non-governmental organizations; the Red
Cross, WHO and the local self-government. It cooperates with the NATO units;
manages the organizing and functioning of the helicopter service for
emergency and rescue;
prepares studies for practise activities and participates in practise activities in
and out of the country;
manages crisis including epidemic communicable diseases; keeps record of
the medical equipment and determines priorities in supplying the same;
is in charge of the preparation of opinions for sub-specializations, their
schedule and priority in accordance with the specific available medical
equipment; and the developing plans of the region;
is in charge of receiving donations and humanitarian help in medical equipment
and medicines, it organizes and manages such donations and help; it issues
grants and other documents for exemption from duty and other expenses;
organizes the process of confirming the strategic priorities of the Ministry and
monitors their realization through determined priorities in the programs
according to the Budget of the Republic of Macedonia;
participates in passing laws and sub-legal acts from this domain; cooperates
with the customs units, civil associations and etc. The sector is organized in
the following departments:
IV.2.2. Multi-disciplinary CPP committee
The multi-disciplinary CPP committee is a key mechanism that oversees and guides the
CPP process.





Terms of reference that clearly delineates roles, responsibilities and authorities.
Regularly scheduled meetings are maintained for developing and updating
preparedness plans.
Members of this committee are senior managers of departments in the Ministry of
Health and technical experts with knowledge of specific types of crisis.
It also includes representatives from partners (public and private health entities,
WHO, national and international organizations) selected for their capacity to
contribute (technically and operationally) to the CPP process.
The committee members should have the authority in their organizations and
departments to commit to decisions made by the committee.
21


It is responsible for developing evidence-based crisis policies.
The CPP committee is duplicated on a sub-national level.
On 20.07.2007 on behalf of the Minister of Health, a Resolution num. 14-11018/1 has
been signed to form a Multisectoral Commission for crisis preparedness planning and
functioning of the health system.
IV.2.3. The Bureau for Drugs at the Ministry of Health monitors the supplying with
medicine, auxiliary medicinal means, medicinal aids, intoxicating drugs and poisons as
well as the production and the turnover with poisons and intoxicating drugs. It is the
Board’s responsibility to monitor the medicine’s putting into circulation, the auxiliary
medicinal means, the medicinal aids, the intoxicating drugs and poisons and carrying out
the registration procedure.
Bureau for Drugs, at the Ministry of Health
Prim.Ph M-r Ilcho Zahariev, Manager
St.50 Divizija num.6
1000 Skopje
Tel: +389 2 3298-435 Fax: +389 2 3112-500
Mob:
Е-mail:
IV.2.4. State sanitary and health inspectorate
State sanitary and health inspectorate
Manager, D-r Shemsi Musa
1000 Skopje
Tel: +389 2 3122-355 Fax: +389 2 2722-560
Mob:
Е-mail:
Table 1: Communication scheme of the employees at the SSHI
Manager
Sector for inspection
surveillance – 18 depart.
D-r Vera Menkovska
0
Sector for professional advisory
matters – 5 depart.
The information will be spread vertically, from the manager to the directors of the
sectors, and from them to the directors of the departments in the Sector for inspection
surveillance as field operatives. The departments include the municipalities and populated
places according to the latest territorial division (Table 2a).
22
Table 2а: Communication scheme of the employees at the SSHI
Departments
Inspection Surveillance Department in
the epidemiological field
Inspection Surveillance Department in
the field of radiation protection, nonionizing radiation, dangerous
substances (poisons and intoxicating
drugs)
Inspection
Border
Surveillance
Department
Regional Department-Skopje
Regional Department Karposh-Skopje;
Responsible person
D-r Vesna Nikolovska
Dimitrovksa
Contact phone
D-r Olivera Stojkovska
D-r Ljubica Giaco
D-r Liljana Koceva
D-r Liljana Ristevska
Despotovska
Regional Department Kisela Voda- D-r Roza Maleska
Skopje
Regional Department - Chair-Skopje
D-r Suzana Manevska
Regional Department – Gazi Baba- D-r Marija Milanova
Skopje
Regional Department Kumanovo
D-r Lence Maksimovska
Regional Department Veles
D-r Vesna Vishinova
Regional Department Shtip
D-r Branko Mancevski
Regional Department Strumica
D-r Ljubica Dimitrova
Regional Department Prilep
D-r Trajko Stojanovski
Regional Department Bitola
D-r Dushanka Bosilkova
Regional Department Gevgelija
D-r Mile Toshev
Regional Department Ohrid
Regional Department Gostivar
Regional Department Tetovo
D-r Naser Rakipi
D-r Amet Ljushi
If the crisis is on the whole of the territory of the country, the working groups through
which the preparations, the conducting, the communication and the coordination will be
done, will be with the involvement of the managers of the regional departments as
responsible people.
If it is a matter of a crisis in a separate region, a special crisis group is formed depending
on the danger and a responsible person is assigned to the group, the inspectors of the
crisis region will also be involved and they will be in contact with the responsible people
from SSHI and the Manager.
SSHI is involved in the operational plan for monitoring the pandemic influenza, made by
the Ministry of Health, with precisely assigned responsibilities to the people appointed for
specific activities.
On Graph 4, the manner of coordinating the SSHI, MoH, the Communicable Diseases
Commission, PHI and PHC (10 regional) during crisis is shown, as well as with the MIASector for border crossings.
23
Graph 4. Coordinating the work between SSHI, MoH, the Communicable Diseases
Commission, PHC and MIA
MINISTRY OF HEALTH
Communicable Diseases
Commission
Sector for Primary and Sector for Preventive
Health Care
State Sanitary and Health
Inspectorate
Institute of Public Health of MKD
MIA – Sector for border
crossings
10 Public Health Centers
IV.2.4. Food Directorate
Food Directorate
Manager, D-r Marina Popovska-Domazetova
1000 Skopje
Tel: +389 2 3296 430; Fax: +389 2 3296 823;
Mob:
Е-mail:
Food emergency warning system
The food and store food emergency warning system is a system that is operated by the
Ministry of Health - FD in order to exchange information for identified threats connected
with food.
The announcements are categorized as warnings in cases when there is an identified
direct or indirect human health risk (alert), or as informative announcements that are to do
with information about consumables for people, and which have a smaller probability of
being a health risk. These announcements may be of use for the food control organs in
authority (blocked packages at the border inspection points and terminals) because of an
inconsistency of the products or because of the development of specific conditions that
influence the food safety.
Announcement due to food warning (alert)
The food warning means that the announcement from FD followed through from the
Sector for Inspection Surveillance to the food operators is to do with the identified
danger. The food warning may be received through EU RASFF (DG Sanco), a problem
identified from FD during food testing or during researches.
24
Hazard characterization (high, medium and low)
High – is considered the one where the negative influence on the health is usually
strong and fast (for ex.: E. coli 0157, Cl. Botulinum acute toxic and caustic
chemicals, presence of allergens).
Medium – is considered the one where the influence on the health is usually serious
but is connected with a longer exposure or consumption to big quantities of
food (for ex. chemical contaminants).
Low - is considered the one where the health effects are minimal or are not evident (for
ex. the level of chemical residue that is above maximum allowed
concentrations, or foreign bodies, but which do not represent a health risk.
The food distribution may be classified as limited and/or spread.
Limited distribution – is when the food is distributed in a specific limited space (for
example a kitchen that prepares food for a children’s collective-kindergarten).
Spread distribution - is when the food is distributed in a wide territory, including the
export out of the country. In the following table you can see the managing of the incidents
according to the distribution and characterization of the hazards in terms of FD:
When food incidents occur, the FD forms a tight cooperation with PHI, PHC,
other scientific institutions and laboratories, regardless of the level of danger
and distribution. When food incidents occur, and when there is export of the
given food into the EU member states, it is necessary to promptly inform the EC
(through the EC Office in MKD) through the RASFF system.
IV.2.5. Health crisis preparedness planning
There have been activities and measures conducted for producing and updating effective
Crisis Preparedness Planning for Health Systems. The Ministry of Health has access to all
the data necessary for the preparation of a complete plan, in which there are:








Maps (the health map and the map of MKD)
Data from other sources (specialized agencies)
The CPP for Health Systems covers all the hazards on a national level.
The National Plan and the Hospital Plans are prepared through a process of
participation and consultations, and are regularly updated.
The plans are distributed to the relevant health staff and are shared with the other
partners.
The CPP for Health Systems is designed to be compatible with the National Plan
for Protection and Rescue from Natural Disasters and Other Accidents (when it will
be passed).
There have been mechanisms defined with which the obstacles for access of the
vulnerable groups to services have been discarded (including financing).
Profiles on national health risks have been created.
25

Certain public and private heath facilities have been marked from the point of view
of vulnerability, that have to ensure continuous work, especially the critical heath
facilities, if a crisis should occur.
IV.2.6. Public communication and education in crisis
There is a deliberate and planned process of building and maintaining a trust between the
Ministry of Health and the community before and during a crisis by strengthening
mechanisms for effectively communicating and disseminating risk information to all the
sectors of the population.
In the Ministry of Health there is a clearly defined system for communication in which the
information come directly from the Minister, after which the Department for Public
Relations prepares a written information for the media with concise health-educational
messages for prevention and reducing the risk.
The information is delivered to the Minister, and after his approval, the people
responsible for public relations send the information electronically to the
Macedonian Information Agency (MIA),
to the agencies: MAKFAX and
NETPRESS, as well as to all the press and electronic media in Macedonian and
Albanian language:
1. Daniela Aleksoska
Tel: +389 2 3112-500, lok.113, Fax: +389 2 3113-014
Mob:
Е-mail:
2. Lirim Isahi
Tel: +389 2 3096-522, lok.113, Fax: +389 2 3113-014
Mob:
Е-mail:
Communication during crisis on a health level
In many countries where the population is with an increased knowledge, the
communication during crisis is very important. The effective communication about the
risks has become a key responsibility of the public health professionals, with several
goals, in accordance with the status of the crisis: to inform, to convince and to motivate.
The crisis communication must take into consideration the different legitimate factors such
as the health journalists and the health executives, which have different work tasks.
It is necessary that the health professional:

26
are more active and start the communication with the public as early as possible at
the beginning of the crisis, because the information has a calming effect, even if it
is to do with health risks;















are available for the journalists and communicate regularly during crisis, but they
have to avoid excessive communication (generally, daily press conferences are
necessary only in the peaks of the crisis);
make no compromise in providing a competent communication with the journalistsregardless whether that person is a spokesperson, a person responsible for crisis
management or his/her subordinate;
combine the information about the health risks with an advice for the public to
respond to the risks by itself;
communicate in a simple manner, precisely, transparently, without patronizing and
timely before actions have been taken;
are honest and also avoid keeping the health information as a secret, but also to
allow gaining the trust back from the public;
are precise about what they know and what they don’t know (yet);
are not inferior in front of the journalists when they admit that there is lack of
evidence;
provide consistency in the messages addressed to the journalists on behalf of the
health organs in authority (aiming towards the effect of one-voice);
have all the correct numbers for a precise presentation and specific action;
show respect for and compassion with the public and communicate in accordance
with that;
try to understand the public interest and what the public media ask for, and to
strengthen the synergy in accordance with that;
organize structured contacts with the journalists;
look at the possibility of mutual press-conferences with other relevant public and
private authorities;
decide about the design and structure of the teams for communication during crisis
and to pay attention to the capacity of the team during crisis, including tiredness
and exhaustion;
maintain close contacts between the crisis management teams and the
communication teams.
Between crisis, it is important that the health professionals:








ensure that the communication does not stop, because it may be useful to
introduce the public with the concept of health threats in general, and not only as
a health crisis component;
seriously consider the communication as a relevant part of the health response to
crisis and as a part of CPP;
develop an infrastructure for communication (press materials and plans) and well
trained public-health professionals;
include the communication in all the public-health programs, particularly during
the preparation of the health threat responses;
ensure that the training is an integral part of the communication in any publichealth training;
prepare strategic plans for communication with a distinction between different
scenarios for alert, alarm, crisis and catastrophes;
talk regularly with the journalists in order to accustom them to communicate with
individual health executives, not only when there is a crisis;
be prepared for the worst - to maintain regular public-health communication.
IV.2.7. Monitoring and evaluation
There are systems already maintained for monitoring and evaluation for all the Health
Crisis Preparedness Planning aspects, whose goal is to learn from the experiences and to
27
provide evidence that will assist in the future planning, programming and policy
development.



Regular health crisis simulation exercises for various scenarios are held (outlined
in the risk assessment), with a build-in methodology for utilizing lessons learned.
Every 2 years, the MoH as a part of the Government, participates in practice
activities with simulated crisis with a participation of the largest part of the NATO
member states and the Partnership for Peace. At least once a year there is a
participation, in practice activities, of the Ministry of Internal Affairs, the Ministry of
External Affairs, the Ministry of Living Environment and Spacious Planning, the
Ministry of Finance, the Army of MKD, the Head Office for Protection and Rescue
organized by the Crisis Management Center, on previously defined crisis
scenarios. Participation in international practice activities with defined scenarios
“SEESIM”.
The reports from the monitoring are prepared, analyzed and it is acted according
to the recommendations given in them. After every exercise an evaluation is done
and the reports are elaborated and delivered to the Crisis Management Center.
An internal and external evaluation of the effectiveness of the Crisis Preparedness
Planning. A team of inspectors from CMC will monitor the Crisis Preparedness
Planning when they will be passed. The Head Office for Protection and Rescue
controls them in terms of interoperability after they are approved by the MoH.
IV.3. Partnership and coordination
For an appropriate response and functioning during crisis, the Ministry of Health has made
a series of preparations for changes in the systematization and has appointed a
Multisectoral Committee with representatives from different ministries, public health
institutions and other institutions. In the period between 2007 until the present moment,
there have been several workshops held for training responsible people from PHI for the
preparation of hospital plans (which is presented in the other chapter), as well as the
National Plan.
IV.3.1. Partnerships and alliance building
The process of identifying the partners that will interact in the CPP process. The MoH in
the crisis preparedness planning has a close cooperation with the Ministry of Defense,
MIA, CMC, HOPR, CC, the local self-government and the urban communities. There is no
specific agreement signed for cooperation and the same arises from the Crisis
Management Law, the Protection Law and the lawful Regulations (given in the legislation
chapter)
 Stakeholder analysis undertaken (such are other government players, the private
sectors, non-governmental organizations and international organizations).
 An inventory of the key capacities and resources of the main partners.
 Building alliances and utilizing the opportunities for cooperation.
IV.3.2. Multisectoral coordination
There is a formal mechanism to coordinate all of the national Multisectoral preparedness
and response activities.
 The Ministry of Health is responsible for all the matters concerning the protection
of the population’s health.
 The Health Crisis Coordinator of the Sector in authority for the functioning of the
health system during crisis is a member of the National Multisectoral Committee
(in forming) and is also a member of the Main Headquarters. The Minister of
Health is a member of the Managing Committee, and the Vice Manager of the
Sector is a member of the Operational Headquarters of HOPR.
28


Regular scheduled meetings are held.
Regular conducting of Multisectoral training and simulation exercises upon the
Government Resolution of MKD is conducted with the participation of people from
the MoH in multinational practice activities - GMX, SESIM and etc.
IV.3.3. International technical cooperation and mutual aid agreements
The agreements with the other countries strengthen the ties among nations and improve
the capacity of each to respond to crisis.
 Mutual Assistance Agreements have been made with the neighboring countries (to
help in crisis and to exchange information and share expertise, as well as help in
sanitary materials and medicines). The Ministry of Health of MKD has signed
mutual-agreements for cooperation with:













Mutual Agreement between the Ministry of Health of the
Macedonia and the Ministry of Health of the Republic of Albania.
Macedonia and the Ministry of Health of the Republic of Bulgaria.
Macedonia and the Ministry of Health of Russia.
Macedonia and the Ministry of Health of China.
Macedonia and the Ministry of Health of the Republic of Croatia.
Macedonia and the Ministry of Health of Ukraine.
Macedonia and the Ministry of Health of Montenegro.
Macedonia and UMNIK Kosovo.
Macedonia and Slovenia.
Macedonia and Turkey.
Macedonia and Stuttgart.
Republic of
Republic of
Republic of
Republic of
Republic of
Republic of
Republic of
Republic of
Republic of
Republic of
Republic of
The coordination for CPP with other countries is always done through a Resolution
of the Government of MKD with the help of CMC.
Identifying resources that may assist other countries. There are agreements for
help and cooperation with the neighboring countries through the NATO
mechanisms (as a candidate country) where we have also entered the agenda for
mutual help with all the member states, as well as mutual cooperation with KFOR.
The International Health Regulations in act 57 stance 1 has stipulated the relation with
other international agreements. In stance 2 it is defined that the usage of this Book of
Rules does not prevent the parties that have some mutual interest due to health,
geographical, social or economic conditions, to make individual (special) agreements or
contracts in order to ease the usage of this Book of Rules.
V. RESOURCES GENERATION
The creating of resources defines all the health workers who participate in actions
whose primary goal is to protect and better the health of the population of the Republic of
29
Macedonia. CPP ensures that, taking into consideration the available resources and
circumstances, there will be a sufficient staff number that will respond to a given crisis.
This function also includes: education and training; collecting and analyzing data and
reporting; stock and equipment management needed as reserves in case of crisis.
In the Republic of Macedonia the protection of the population’s health is conducted on
three levels: primary, secondary and third level. In the year 2006, it was conducted in the
following state heath facilities, public sector: 5 health stations, 34 health houses and 11
off-hospital infirmaries on a primary level, 16 general hospitals, 7 specialized hospitals, 7
centers for treatment and rehabilitation and spas, 10 Public Health Centers on a
secondary level, and the University Clinical Center with clinics and institutes, Transfusion
State Institute, 1 Dental Clinical Center, Clinic for Maxilo-Facial Surgery and a Health
Care Institute on a third level. The private sector is comprised of 3 hospitals: General
Hospital-Remedika, Specialized Hospital for Gynecology and Obstetrics-Mala BogorodicaSistina and the Hospital for Cardiac Surgery-Filip II, as well as private doctors’ offices,
pharmacies and laboratories.
On chart 12, in addition, the schematic view is given of the primary, secondary and third
level of hospital health care in the Republic of Macedonia (data source ”Health Map of the
Republic of Macedonia for 2006”).
The net of heath facilities in the Republic of Macedonia (data source ”Health Map of the
Republic of Macedonia for 2006”) is given in addition.
V.1. Human resources
V.1.1. Development of Human Resources Strategy for crisis across the health
system
On the Army level of the Republic of Macedonia, i.e. the Ministry of Defense in the Military
Hospital, according to the internal plans, has the following available:




two surgical teams (one ready for surgery in an hour);
two internist teams (one ready for surgery in an hour);
one team for preventive-medical care;
one team for general medical help.
Organizational placement of the Emergency Units in the Republic of Macedonia
In MKD there are 18 organized services for providing off-hospital emergency help in the
sense of selected working units with an individual personnel, rooms and vehicles.
In the other smaller towns like: Sveti Nikole, Resen, there is a telephone number 194 and
a sanitary vehicle (in Resen there are even more), but there is no personnel and the
employees on shift are used.
The telephone number for the whole of the country is 194.
From two years ago, when dialing 194 the nearest emergency services respond. The call
is free from all the fixed and mobile networks. The services have no possibility of direct
communication among each other nor with the police, or the fire department, nor with the
other services, head offices, as is the Head Office for Protection and Rescue, besides
through the fixed network with three digit i.e. six digit numbers.
Organized emergency services are:
 Skopje 40 (doctor, nurse and driver) operational teams on field and 10 (doctor,
nurse) in a dispatcher center plus 5 chiefs of shift placed in five groups.
30
















Bitola 18 teams placed in four groups (two on field, one in the emergency clinic,
one on the phone).
Prilep 15 teams on field and a clinic (there is no strict division during the shift) plus
4nurses on the phone.
Kavadarci 6 teams on field.
Shtip 4 dispatcher nurses and 6teams on field.
Struga 4 teams on field and a clinic, and 3 nurses on the phone.
Kicevo 8 teams on field and a clinic (there is no strict division), two teams per
shift.
Strumica 12 teams on field and a clinic and 4 dispatcher nurses, three teams per
shift and 1 dispatcher.
Tetovo 2 teams per shift with a dispatcher, altogether 8 teams and four
dispatchers.
Gostivar 8 teams, 2 per shift.
Kocani 8 teams on field and a clinic, and 4 dispatchers (2 per shift).
Kumanovo 8 teams (2 per shift) and 4 dispatchers.
Veles 12 teams plus 4 dispatchers.
Ohrid 8 teams and 4 dispatchers.
Gevgelija 4 teams.
Negotino 4 teams.
Debar in formation.
Organizational Plan for the PHI Emergency Center-Skopje during crisis
Activation plan:
 Immediately after the received information, the person informed, informs the
manager of the emergency center.
D-r Redzep Seljmani
Manager, Emergency Center, Skopje
Tel: +389 2 3147-238
Mob: + 381 71 387-180









The manager, until he/she comes to work, informs the closest co-workers and
immediately initializes an urgent meeting with the managers of all the surgery
branches, laboratories, X-ray institute, the Health Care Institute -Skopje, the
clinical security, the clinics’ fire department units, the funeral services and the
technical services.
Constant communication and cooperation with the emergency services.
For the welfare and economic usage of time, the other health staff from the
emergency center is organized by the main nurse.
Depending on the size of the natural disasters, there is a selection of the
admittance of patients from other pathologies, and when necessary even a stop of
admittance and a transfer to other heath facilities.
All medical apparatus and aids, dispensable medical material and medicine are
available.
Numerous people as well as employees are not allowed due to unnecessary
crowd and disorder.
Forming a sufficient number of medical teams for admittance and triage in the
emergency center.
Forming teams for the surgery rooms with vital indication.
Forming teams for transport of patients for diagnostics and transferring them to
appropriate clinics.
31






Maximum engagement of all the employees and cooperation with all the
employees at the surgery clinics.
24 hours information service.
Precise and professional record of all the admitted patients.
Increased security at the clinics’ entrances.
Good cooperation with the holding company for funeral services.
Good cooperation with the Ministry of Health and the Ministry of Internal Affairs.
At the moment, the surgical emergency center has 57 employees: 8 doctors, 1
psychologist, 1 pharmacist, 2 nurses with university degree, 17 nurses, 12 orderlies, 13
people in the administration and the technical personnel, ALL ARE MOBILIZED
ACCORDING TO DEMAND. THEY ARE AVAILABLE 24 HOURS.
The initializing of meetings and a good cooperation with the other clinics on the basis of
an agreement may bring good results as up till now.
The employees from the emergency center perform the admittance and the triage
together with the surgeons and the anesthesiologists. In the surgery department, the
surgeons, anesthesiologists, personnel in charge of instruments and etc., are in charge.
V.1.2. Capacity building in disaster management
The national programs for health staff education and training, created and adapted to the
local context, and are an integral part of the CPP process.
V.2. Medical supplies and pharmaceuticals (critical supplies and equipment
management)
During crisis, there is an urgent need of medical materials and equipment. It is essential to
have a previously determined system for rapid supplying and delivering of these articles in
order to have an effective response to the crisis.

Logistic software to manage the movement of the medical supplies (for ex. SUMA
for the medicines from the positive list). The Bureau for Drugs during crisis, when
the demand for medicines and medical aids are urgently necessary in an
increased quantity, can answer immediately with all its capacities, and that is:
-
-
-
32
Import of medicines according to the Medicine and Medical Aids Law
(“Government Gazette of MKD” num. 106/07). The Bureau for Drugs is
responsible for the import of raw material for the production of medicines, the
import of ready factory-made medicines, medicines from foreign companies,
and it is responsible for the medicine wholesale turnover and medicine smallsale turnover. The software solutions for both the medicine registry and for the
import of medicines allow for the procedures to be completed for a relatively
short time, i.e. for one day.
Import of medical aids in accordance with the Medicine and Medical Aids Law
(“Government Gazette of MKD” num.106/07), if they are notified in the
notification body of the European Union, it is automatically done and they are
not registered in the Republic of Macedonia. The import permit is issued in
one day.
The same procedures are conducted in the field of intoxicating drugs,
psychotropic substances and poisons.
-


The quality control of all the imported medicines and medical aids can be
performed in a very short time by the authorized laboratories in the Public
Health Institute-Skopje and the Faculty of Pharmacy-Skopje.
Unexpected (intervene) import in accordance with the Medicine Law.
The crisis management sector establishes procedures for coordinating the external
resources (coordination, request, receiving, storing of medicines, registry,
dispersal, control and warehouse security. Additionally, experts are engaged that
will work with the donated sanitary materials or a contract is made with a specific
Mega-Pharmacy).
The materials and the equipment for pandemic influenza (antivirus preparations,
protection equipment, vaccines, laboratory diagnostic equipment and etc.) are to
be kept in a secure, but easy to access location. In the state, the whole quantity of
56.000 doses of Tamiflu-Oseltamivir are stored at the PHI University Clinic for
Communicable Diseases and Febrile States -Skopje, that is to say under
conditions prescribed from the manufacturer (at 40С) and if a need should occur in
a short period of time (2-3 hours) it is easy to distribute to any health institution
where it is necessary to be applied.
V.3. Data collection, analysis and reporting process
The heath facilities in the Republic of Macedonia are classified in 3 (three) basic
categories:



Hospitals, Clinics and Institutes;
Health Houses and Institutes and Public Health Centers;
Clinics.
The total number of beds in hospitals, clinics and rehabilitation centers is 9.569 with a
total usable area of 453.636 м2 (state in 2005). Some of the objects - 16,6% are build
before 1960, 23,4% in the period between 1961-1970, and about 60% of the objects are
build in the period between 1971-2005. On Table 3 the number of hospital beds, the
realized hospital days, the average duration of the treatment and the usage rate of
hospital capacities is shown.
Table 3. Basic markers for the development of hospital duty in the
Republic of Macedonia
Year
Hospital beds
Number For 1000
people
Realized
hospital
days
The
average
duration
of the
treatment
in days
11,4
11,3
11,1
10,5
Capacity usage
rate in %
2003
9743
4,8
2.193.229
61,7
2004
9699
4,8
2.259.512
63,8
2005
9569
4,7
2.220.083
63,6
2006
9440
4.6
2.215.235
64,3
Source: Public Health Center-Skopje
A report of the Service for hospital-infirmary treatment, 2007.
Number
of treated
ill people
on 1 bed
a year
19,7
20,7
21
22,4
According to the WHO criteria, 4, 6 beds/1.000 population in 2006 is a medium supply of
the population with beds.
33
The objects of the heath facilities are less vulnerable during crisis than the school objects,
but with an unacceptable risk level for objects of that importance, that may result in a
function loss of 10-67% of the health objects that will be damaged or collapsed.
In terms of the integral health care, the health sector of the Republic of Macedonia,
provides a continuous health care for the population, and it should be especially
intensified in times of natural disasters and other accidents.
The existing net of health activity in the Republic is comprised of 144 heath facilities, with
about 1063 medical units from the primary and 439 from the secondary health care, which
with their organizational structure, the spatial conditions, health workers and material
possibilities, represent a solid base for an organized and effective passage of work in
severe conditions in times of natural disasters. In such conditions, if needed mobile
medical units can be formed in the near vicinity or at the location of the disaster.
This kind of rapid intervention is enabled by the structure and number of the health net
staff whose number is 5.946 health workers with high professional preparedness, out of
which doctor-specialists 3.025, doctors non-specialists 1.465, dentists 1.134, pharmacists
322 and associate collaborators 447. The number of health workers is 22.877 out of which
75,83% work at providing immediate health care (fragment of the Resolution for Hazard
Assessment from Natural Disasters, Epidemic Outbreaks, epizootic and Other Accidents
on the Territory of the Republic (“Government Gazette of MKD” num.117/07).
Because of the need of supplying the necessities for the functioning of the health system
during natural disasters, there has been set a fund of state medicine reserves and other
sanitary materials, with a selection and quantity that improve continually.
V.3.1. Early warning system
There is a surveillance and response system which has been designed to detect the
health threats outlined in the risk assessment, as soon as possible.
 Early warning system on behalf of the hospitals/clinics and institutions on a
national and local level, with a special accent on:
Epidemic outbreaks
 At the moment of the conducted examination (in regular working hours
or when working on call), when the doctor- communicable diseases
specialist will determine a communicable disease, or in certain cases
(in accordance with regulations from the Communicable Diseases Law)
a suspicion of a communicable disease, he/she fills a registry form
which is delivered to the Public Health Center-Skopje. The procedure is
conducted continually, during 24 hours, 7 days a week. The delivery of
the registry forms is done during 24 hours via the person in charge
(medical technician or an epidemiologist) from the PHC-Skopje that
collects the filled and registered (outlines in the Communicable
Diseases Book of Evidence) forms every day (except on Sundays, but
in cases of epidemic outbreaks, even on Sundays) in the period
between 08-12 am – with a deposited signature that he has collected a
stated number of forms. Each of the registry forms is previously
registered in the Communicable Diseases Book of Evidence, in which
the following data are listed: ordinal number, diagnose, how the disease
proved-clinically or via laboratory, name and surname of the diseased
person, year of birth, profession, place of work/study/kindergarten,
address, if the disease is subject to compulsory immunization, if the
person has been immunized, date of illness, source of the disease,
date of examination/admittance, which doctor registered the person,
bacillus carrier (yes-no), death registry (when was the person admitted
and date of death).
34

In case when the doctor in charge confirms an unusual increase (or
occurrence) in the number of the patients from a specific illness that are
connected with the place of occurrence or are subject to a same
source, he/she also informs the following via phone:
1. Manager of the PHI University Clinic for Communicable Diseases and Febrile
States-Skopje
Prof. D-r Zvonko Milenkovik, Tel: +389 2 3228-224
Е-mail:
2. The Epidemiologist in charge of the PHC-Skopje
D-r Lile Lazarevska, Tel: +389 2 3298-788
Е-mail:
The announcement continues to:
3. State Sanitary and Health Inspectorate (SSHI) and PHI-Skopje
(MSc D-r Gordana Kuzmanovska, Tel: +389 2 3147-055 or +389 2 3125-044
Mob:
Е-mail:
o
Pandemic influenza
 In case of an occurrence of a patient that fits the definitions (clinical and
epidemiological definitions) for bird ‘flu/avian influenza/А Х1/N1, the
Manager of the PHI University Clinic for Communicable Diseases and
Febrile States - Skopje (PHI UCIDFS-Skopje) is informed immediately
and the mechanisms for the notification procedures and manner of
acting for that kind of activities that are a part of a wider elaboration of
the Crisis/Bird ‘Flu/Pandemic Influenza Preparedness Planning at the
PHI UCIDFS -Skopje. In the beginning and the developed phases of
pandemic influenza there are regular notifications to the responsible
services (PHC-Skopje, SSHI, PHI-Skopje, MoH).

o
The second notification system – ALERT, is consisted of notifications to
an authorized electronic-computer connection of the PHI UCIDFSSkopje for a syndrome (according to strictly defined criteria-upper
respiratory track infections, lower respiratory track infections, rasheswithout chicken pox, meningoencephalitis, watery diarrhea, hepatitis,
hemorrhagic fever) register of patients according to age (0-6 years, 719 years, 20-59 years, above 60 years) every week (from Monday to
Wednesday) for the previous week (from Monday at 00.01 till Sunday at
24.00), for which the Clinic receives a return information about the
epidemiological state in the country. In agreement with the responsible
epidemiologist at the PHI-Skopje (Prim. D-r Zarko Karadzovski, Tel:
3125-044 ) the access to the system in an early phase
of pandemic influenza will be maintained at every 24 hours (from 08 till
09 for the previous 24 hours), and in the developed pandemic phase –
at every 12 hours (from 08 till 09 and from 20 till 21 for the past 12
hours).
For handling the consequences from extreme weather conditions in 2007,
there was a Commission formed for monitoring the effects on the people’s
health from the high/low temperatures on behalf of the MoH, with a
35
participation of all the relevant factors, with a mandate to suggest
professional prevention measures on the basis of received data from the
Hydro Meteorological Department-Skopje. There is a guide translated into
Macedonian – “Health Action Plans for Heat Waves” (WHO, 2008) and the
same has been distributed to all the relevant factors.
o
The consequences from lack of food are planned to be handled in the
second Action Plan for Food and Nutrition in MKD, which should be made
in 2009 according to Government program, in the chapter for unsafe food.
On Chart 5 the flow of transfer of information is shown when a public-health threat of
international significance occurs.
On Chart 6 the manner of event detection is shown that may cause epidemic outbreaks
and may present a public-health threat of international significance.
36
Chart 5. Flow of transfer of information
Information from a net member
state
European Commission
Assessment
News
Alert
Information
Elaboration of
the notification
Notification
transfer of third
affected
countries
Net transfer
Return
information from
the member
t t
Reports
Statistics
Member states
Border places
for inspection
Return
information
from EFSA
European Food
Safety
Authority
37
Chart 6. Events detected by the national surveillance system
Cases of the following
diseases:
 Smallpox - Variola
 Poly-myelitis from a
wild type of a polyvirus
 Human influenza
caused by a new
subtype
 SARS – severe
acute respiratory
syndrome
Any event from a
potential
international
public-health
threat, including
those from
unknown causes
or sources
Cases of the following
diseases:
 Cholera
 Pulmonary form of
plague
 Yellow fever
 Virus hemorrhagic fever
(Ebola, Lassa, Marburg)
 West Nile fever
 Other diseases from a
significant national or
regional threat, ex.
Dengue fever, Rift
Valley fever,
meningococcal
diseases
Application of criteria in the decisive algorithm:
 Is the influence of the event serious for the public
health?
 Is the event unusual or unexpected?
 Is there a significant risk of international spread?
 Is there a significant risk for international traveling
or restrictions in trading?
Yes, to any 2 of the above stated criteria
WHO should be informed for the event through monitoring the procedures
from the International Health Regulations from 2005
(IHR – International Health Regulations)
Source: Emerg infect Dis ® 2006 Centers for Disease Control and
Prevention (CDC)
38
The National Contact Institute - Public Health Institute of the Republic of
Macedonia informs WHO, which is represented by Vice Manager Ass. D-r
Shaban Memeti, through informing the Ministry of Health in cooperation
with the National Associate Collaborator for Communicable Diseases with
WHO Prim. D-r Zarko Karadzovski and Prof. D-r Zvonko
Milenkovik
in the capacity as President of the
Communicable Diseases Commission.
Maintaining a surveillance disease system
During crisis, the routine disease registering system is either insufficient, or damaged as a
direct consequence of the disaster, or can not promptly supply the necessary data for
making of timely solutions. It is recommended to prepare a surveillance system for
disease occurrence on a national level, temporarily established immediately after
the catastrophe. The disease registering system should be more flexible and prompt
than in normal conditions. The routine surveillance system has to be maintained again, as
soon as possible.
V.3.3. Health crisis assessment
An immediate on-site investigation following an alert of an unusual event reported by the
early warning system.
 QUICK RESPONSE TEAMS FROM THE HOPR
In actions that demand quick intervention, the Head Office for Protection and
Rescue has formed teams for quick intervention from different areas of specialties.
The manner of engaging the teams is organized with a Government Regulation.
The engaging of the teams with a full staff and material-technical preparedness is
done in cases when a quick intervention is needed, in cases when:
 there is a real danger of an occurrence of natural disasters and
other accidents;
 there is need of a quick and professional engaging due to reducing
of consequences and;
 there is a need of increasing the readiness of the state forces for
protection and rescue.
The teams are engaged for performing of complicated tasks and activities primarily
in the area where they are formed, and if necessary on the whole of the territory of
the Republic of Macedonia. The teams have up to three hours to prepare in any
kind of weather conditions, time of the year or of the day. During the preparations,
the teams provide full operative readiness and preparedness for an effective
response to the arisen natural disasters and other types of accidents. In cases
when the teams are not able to respond to the arisen situation, additional forces
for protection and rescue are engaged.
 FORCES FOR PROTECTION AND RESCUE
The type, size and organizing of the forces for protection and rescue is organized
with a Government Regulation. For protection and rescue of the population and
the material goods from natural disasters, there are specialized and universal units
for protection and rescue formed at the Head Office for Protection and Rescue.
Specialized units in state and spatial forces for protection and rescue.
Depending on the hazards that may occur during the technological process, the
trade associations, the public enterprises, institutions and services have
specialized units in the spatial forces.
39







Among the other specialties there also exist specialized units for first aid, for
evacuation and providing for the injured and endangered population, for field
improvement (as of health conditions), for rescuing from the ruins and many more.
There is a Resolution for forming the forces for protection and rescue that are
formed on behalf of the Republic.
 There are 35 first aid units out of which: 8 platoons in the regional
organizational units in Tetovo, Ohrid, Bitola, Veles, Strumica, Shtip,
Kumanovo and Skopje, and 27 departments.
 There are 35 units for field improvement (as of health conditions)
out of which: 8 platoons in the regional organizational units in
Tetovo, Ohrid, Bitola, Veles, Strumica, Shtip, Kumanovo and
Skopje, and 27 departments.
 8 units for providing for the injured and endangered population.
 and many more.
Standard operational assessment steps. The Scoring – systems present
vulnerability scales. They basically wage the vulnerability numerically, in order to
predict the possibility of survival, i.e. the invalidity of the injured. Their usage is
recommended for massive accidents, with a large number of injured, where heavy
injuries have occurred, i.e. when there is a bigger number of multi or poly
traumatized patients. The manner of children triage is also shown (given in
Supplement 7).
There have been defined Guidelines for Detection, Confirmation and Registering
of unusual events, and the investigation is done by the MIA.
There was a training conducted by NATO for the representatives of the Ministry of
Health, the Ministry of Internal Affairs, the Ministry of External Affairs, the Ministry
of Agriculture, Forestry and Water-Supply, the Ministry of Living Environment and
Spacious Planning, the Ministry of Defense, Customs Department, the Public
Health Institute of MKD and other factors for a quick assessment of the risk of
contamination with radiological-chemical-biological agents during terrorist
incidents.
3 professional people from the Public Health Institute of MKD nominated on behalf
of the Ministry of Health, together with 21 representatives from the Ministry of
Internal Affairs and the Customs Department, were in a training for people from the
technical/emergency services that provide responses to incidents that include
chemically dangerous substances, in June 2007 in West Virginia, USA organized
by the Program for Export Control and Border Safety with the USA Embassy.
There is a Republic Multi-sectoral Commission for damage assessment that
occurred during crisis.
There has been developed ability for preparing periodical reports for the state,
event reports and reports after the occurrence of a specific disaster by the PHI and
the Sectors from the MoH.
 There have been given procedures and forms for warning during
epidemic outbreaks in the National operational Plan for Pandemic
Influenza Surveillance with a special review on bird ‘flu, approved
by the Government on the 61st meeting in October 2005, updated
in August 2007, September 2008, as well as in April 2009. For
dangerous materials and other threats there still have not been
prepared standard operational procedures.
Guidelines for investigation and registering of unusual events are used by CMC.
Time is also an important factor and very often the number of injured, i.e. dead depends
on the promptness of the measures taken.
40
In cases when there is a bigger number of injured and dead people, the
standard triage categorization according to the level and type of the injuries is
conducted (given in Supplement 2).
V.3.3. Laboratory testing
There are procedures for diagnosing samples, which are regularly tested, in order to
establish quickly and accurately their nature for highly infectious materials.
 At the PHI they work according to the WHO Protocols for seasonal ‘flu diagnostic.
The Virus Department Chief D-r Golubinka Boshevska performs inoculation of
embryo eggs, reaction to hem-agglutination and reaction to inhibition of hemagglutination with a kit from the WHO reference laboratory at CDC Atlanta. With a
conventional RT-PCR a detection of the matrix gene of the influenza-A is
performed. There is also a detection of H5, H9 и N1 with a conventional RT-PCR
(suspicious case in 2006, confirmed as negative by the WHO ‘Flu Reference
Laboratory Mill Hill, London). From the serological analyses, RVK detection
reaction for influenza A and B antibodies is done. There was a diagnostics
performed with RT-PCR on samples suspicious for SARS (2005). With the
pronouncing of a world pandemic outbreak of А (H1N1) and a pandemic phase 6
(2009), the Republic of Macedonia actively got involved in the diagnostic of the
new factor, with the supplying of a new machine PCR RT, appropriate tests and
standard working methodology according to the WHO Guidelines.
 For an increased number of influenza isolates, as well as in the case of a possible
bird ‘flu/pandemic influenza/ A (H1N1), the epidemiological service at the PHI is
informed, as well as the Sector for Preventive Health Care at the Ministry of Health
and the Manager of the PHI (as a contact institution for the IHR).
 The Virus Department, as the single laboratory for ‘flu diagnostics, is recognized
by WHO. Since the beginning of 2008 there is communication, in the sense of
sending information for the isolates to FluNet (WHO net). There is also
communication with the WHO ‘Flu Reference Laboratory Mill Hill, London where in
2008 samples were sent from the Virus Department for confirmation. There is an
educated person (D-r Golubinka Boshevska ) from WHO for transport
of infectious materials.
VI. HEALTH FINANCING
A good health financing system provides adequate quantities of means for the health
system as well as financial protection in case of a crisis. It also enables access to the
necessary services of the victims of crisis and also allows the heath facilities and the
equipment to be appropriately secured from damage or loss.
The Republic of Macedonia has maintained a system of health care based on health
insurance where the Government and the Ministry of Health provide a law frame and
political leadership for this activity. The Health Insurance Fund is responsible for collecting
and managing of the funds, and the health care institutions for the services.
Obligatory health insurance (Health Insurance Law “Government Gazette of MKD
num.25/00, 34/00, 96/00, 50/01, 11/02 и 31/03) is the main system’s financing source and
together with the use payment makes 95% of the income in health care. The Fund covers
the employees in the public as well as in the private sector, the pensioners, the students
and the people with disabilities, as well as the minors. The Health Care Fund provides
financial support for the emergency services for the insured (even when the health
41
insurance contribution is not paid). The expenses for certain citizens that are not a part of
the health insurance are covered by the national budget.
VI.1. Preparedness financing
VI.1.1. CPP budget
The employees and the structures at the MoH that work on crisis management do not
have a special budget for this activity. The necessary funds for functioning, education,
training and etc. are covered from the regular budget incomes of the MoH. It is also
possible to use specific funds from CMC, WHO and USAID.
For working in times of war, there is a yearly war budget of the MoH prepared according
to the Defense Law and the same is approved by the Ministry of Finance. The total budget
from the ministries, as well as from the MoH is approved by the Government of MKD.
PHI incorporate their activities in the existing monthly budget financed by the Health
Insurance Fund. The public health institutions through their managing teams conduct
property insurance and people insurance in specific Insurance Companies.
VI.1.2. Budget for vulnerability analysis and risk reduction of the critical health
facilities
There isn’t a specifically intended yearly budget for reducing the construction and nonconstruction vulnerability of the key heath facilities (hospitals, laboratories, blood banks,
warehouses, etc.) and their improvement according to the plan based on risk assessment
and the critical importance of the institution. For its needs, MoH additionally asks for funds
from the Budget, by a Government Resolution in order to provide a quick and adequate
response to crisis without having a negative effect on the normal budget expenditures.
VI.2. Contingency funding
VI.2.1. Contingency fund exists
At the MoH there isn’t a Contingency Fund from where all the unplanned increases in
health expenditures will be covered. For its needs, the MoH additionally asks for funds
from the Budget by a Government Resolution in order to provide a quick and adequate
response to crisis without having a negative effect on the normal budget expenditures.
There isn’t a Reserve Contingency Fund in the Health Insurance Fund, especially for
epidemic outbreaks, and that is why we suggest that to provide funds for this purpose with
a direct budget rate from the Budget of MKD which should be managed by the Ministry of
Health.
VI.2.2. International contingency funds
In certain cases, when pronouncing a crisis, the coordinating body at the Crisis
Management Center sends a support request to the United Nations representative in
order to receive help.
In case where help is needed by the World Health Organization-Skopje Office, an official
letter is needed or contact has to be maintained with the World Health OrganizationSkopje Office representative, D-r Marija Kishman, Head of Office or the responsible WHO
crisis person M-r Margarita Spasenovska. WHO contact, Skopje Office St. Mirka Ginova
17, 1000 Skopje. Republic of Macedonia, Tel: 02/3064-299, Fax:02/3063- 710, Е-mail:
[email protected]
42
VII. SERVICE DELIVERY
Providing services represents a combination of contributions in the process of service
production as a result of which effective, safe and quality health interventions are
performed for individuals or communities that have the need for them, in a righteous way,
when there is a need, with a minimum usage of resources. The crisis preparedness
planning process gives the opportunity to reexamine the way the services are organized
and managed in order to provide accessibility, quality, safety and continuity of the health
care for different health conditions and heath facilities during crisis.
VII.1. Procedures, guidelines and protocols for critical services during crisis
VII.1.1. Rapid needs assessment
The providing of rapid assessment of response needed immediately after the determined
crisis is elaborated more into detail in chapter IV.3.2.
Previously formed teams that become available in a very short period of time and that
gather information needed for determining the size of the resources for an effective
response (in IV.3.2.).
VII.1.2. Emergency surveillance, procedures and control of communicable diseases
Pre-established systems and activities to detect, identify and contain an outbreak of
communicable disease within a community/institution/region during a given time period.
 An active and pre-established epidemiological surveillance system during crisis
has to be activated. According to the positive legislative regulation, i.e. the Law for
Protection of Population from Communicable Diseases (“Government Gazette of
MKD num.66/04”), in MKD, 48 entities are registered (communicable diseases).
The family doctors from the primary, secondary and third level health care are
obliged, in 24 hours, to register a suspicion or disease, in an appropriate form
intended for that use and to deliver the same to the local/regional level of PHI
Centers for Public Health that record, process and evaluate in an appropriate
manner. They also send a copy of the admission card to the Public Health Institute
of MKD. PHI is obliged to collect, process, evaluate and prepare a seven day, a
monthly and yearly report for the movement of the communicable diseases in the
country. If there is an increased number of diseased people or epidemiological
spread of the disease, the same is registered in an appropriate form (epidemic
outbreak register) and after finishing, the same is signed out in an appropriate form
(epidemic outbreak sign out). If there is registered an increased number of
diseases from seasonal influenza, the same are registered, besides on an
individual form, also on a so called collective form for ‘flu movement which is
delivered once a week, and which contains 4 age groups as well as the
municipality that is registering. The registering of suspicious cases of pandemic
influenza is explained in the National Operational Plan for Pandemic Influenza and
the Guidelines, in addition.
 The contact person for epidemiological surveillance that directly reports to the
Health Crisis Coordinator is M-r D-r Gordana Kuzmanovska 3125-044 loc.104 and
3147-055,
 The laboratories are equipped with staff, but there is a lack of equipment and
reagents (the request has been prepared, but has to be followed through to MoH),
and the same are prepared for the health consequences caused by biological
incidents.
 During a radiological incident the Department for Radioecology and Radiation
Dosimetry from the PHI-Skopje is involved in cooperation with the Head Office for
Radiation Security (a more detailed explanation follows).
43
VII.1.3. Ability to respond to a radiation crisis
Public Health Institute of MKD
Radioecology Department
Chief
Dusho Nedelkovski, Engine. Techno.
The department has been accredited, with a certificate num.LT-005 from 25.12.2006, to
the Institute for Accreditation of MKD, for testing water samples and nutritious products.
There is an ongoing procedure for an accreditation for air samples, atmospheric
sediments, soils, building materials and livestock food...
1. Equipment
 On-line gamma detector stations (12) for measuring the outside intensity of
the gamma radiation, with a wireless transfer of data to a server, Berthold
received as a donation from IAEA after the project МАК 7002
 Gamma spectrometers with detectors from HPGe, software Genie 2000
Canberra-Packard with all the necessary calibration sources from different
geometries
 low phonatory alpha/beta counters with 4 gas geyser detectors, geometry 2π
 and necessary calibration sources on Ni-disc
 alpha spectrometer, detector PIPS, software Genie 2000, CanberraPackard with a necessary calibration source from U-238
 transmittable dosimeter Berhold, type LB 133-1, energetic region of 30 keV
till 1,3 MeV and a measurable region of 0,03 μSv-3m Sv/h
 air samplers in Skopje and Gevgelija
 collectors for atmosphere sediments, with a collective surface of 1м² in
Skopje, Gevgelija and Ohrid
 rotary-vapor BUCHI, capacity 10l./hour
 radiochemical laboratory, equipped with digesters, a furnace for burning,
laboratory drier and all other necessities.
2. Professional staff
 Spec. of Sanitary Chemistry
 MSc Med. of Nuc. Phys
 Qual. Phys
 Qual. Eng. Tech
 Chem. Tech
 Med. Labor
1
1
1
1
2
1
3. Monitoring
 Monitoring the speed of external gamma radiation dose in 12 locations in the
Republic of Macedonia (Skopje, Veles, Negotino, Gevgelija, Strumica, Berovo,
Kriva Palanka, Debar, Kicevo, Ohrid, Bitola and Krushevo). The measuring is
on-line.
 Monitoring the radioactive contamination of the air in Skopje and Gevgelija.
The following parameters are examined: total alpha activity, total beta activity,
gamma spectrometer analyses, determining the contents of Sr-90 and the
contents of natural uranium.
 Monitoring the radioactive contamination of the atmospheric sediments, in
Skopje, Gevgelija and Ohrid. The following parameters are examined: total
alpha activity, total beta activity, gamma spectrometer analyses, determining
the contents of Sr-90 and the contents of natural uranium.
 Monitoring the radioactive contamination of the soils in Skopje and Shtip. The
following parameters are examined: gamma spectrometer analyses,
determining the contents of Sr-90 and the contents of natural uranium.
44









Monitoring the radioactive contamination of the geographical waters (the Ohrid
lake, Vardar, Lepenec).
Monitoring the radioactive contamination of the drinking waters (the Skopje and
Ohrid water-supply in monthly samples, and the other water-supplies once a
year). Also, once a year all the natural mineral waters are analyzed.
In the geographical waters and the drinking waters, the following parameters
are being tested: total alpha activity, total beta activity, gamma spectrometer
analyses, determining the contents of Sr-90 and the contents of natural uranium.
Monitoring the radioactive contamination of human and livestock food.
The total agricultural production and readymade products are under control.
Also the natural grass from the locations: Skopje, Mavrovo, Ohrid, Prilep and
Gevgelija, as well as the corn and different concentrates are under control.
Building materials, cement, tiles, ashes from the thermal power station are tested for
the contents of the natural radioactive elements: К-40, Ra-226 and Th-232.
Upon the request of the inspection organs, the food import is controlled, as well
as the natural mineral waters, the building materials, the objects of general use
and the waste metals.
In terms of the MAK 7002 Projects “Environmental Radioactivity Monitoring”
the equipment for testing Radon/Toron in the living and the working
environment has been delivered (in May 208).
On Picture 4 the map of radioactivity control points in the Republic of Macedonia is
shown.
Picture 4. Map of radioactivity control points
in the Republic of Macedonia
Infrastructure for radiation protection in MKD
Authorizations:
PHI is an authorized operative service for radiation protection with the Law for Protection
from Ionic Radiation and Radiation Security (“Gov. Gazette of MKD” num.48/02, act 6)
and the law for changing and amending the Law for Protection from Ionic Radiation and
Radiation Security (“Gov. Gazette of MKD” num.135/07”, act 7). The authorization refers
45
to monitoring the outside gamma radiation, monitoring the level of radioactive
contamination of: the air, the atmosphere sediments, the soil, the drinking waters and the
geographical waters, the human and the livestock food, making of monthly and yearly
reports about the states and their delivering to the Head Office for Radiation Security.
responsible monitoring person is: the Chief of the Department for Radioecology. The
responsible person maintains contacts with the Manager of the Head Office for Radiation
Security.
Contact phones: +389 2 3147067, +389 2 3125044/120,
Fax: 02 3223 354
Executive organ for risk management from the field of radiation security is the Head Office
for Radiation Security (Chart 7).
Graph 7. The organ-chart of the Head Office for Radiation Security
Manager
Human Resources
Department
General and Legal
Sector
Department for law
management and
international cooperation
Department for MaterialFinance Working and
Informational Systems
Contact:
www.drs.gov.mk
[email protected]
Tel: +389 2 3099-030
Fax: +389 2 3099-032
Manager:
Rumen Stamenov
Tel: +389 2 3099-031
Mob:
[email protected]
[email protected]
46
Internal Revision
Department
Sector for Licenses,
Monitoring, Crisis and
Inspection Surveillance
Department for Licenses,
Monitoring and Crisis
Inspection Surveillance
Department
Department for Licenses, Monitoring and Crisis:
Svetlana Nestoroska, junior associate for monitoring and crisis
Mob: +389 71 231 334
[email protected]
The Activation Plan in case of a radiation crisis is shown on Chart 8.
Chart 8. The Activation Plan of the Head Office for Radiation Security in case of a
radiation crisis of public-health importance
Juridical person/other
activates
notifies
HORS
Notifies IAEA (IEC, ITDB)
Seeks help IAEA (ENAC)
CMC
activates
Crisis Plan
Plan for Population protection in case
of a Radiation Crisis in the former
Yugoslav Republic of Macedonia
MIA-Police, inspector
Fire Brigade
Medical help (it may be a team**)
IAEA, IcSRS
Advice and support from the incident
commander on the place of the event
Radiation Security Commission
(Head Office Advisory Body)
Radiation assessment team:
1. HORS – Radiation Security Inspector
2. PHI – Dep. for radiation dosimetry
and radioecology
3. HOPR – Quick response team during
a radiation accident and decontamination
4. Other professional institutions
Ministry of Health** (Food
Directorate)
Maintains a unique population
warning system; informing the
population and the media
MLESP
MAFWS (Veterinary Institute)
through
MoH**
Local
hospitals
through
MLESP
1. Old waste
metal dealers
2. Industries
where the old
metal is
processed
3. Wastes
MoD
Technical service
Other...
47
** It is necessary that the Ministry of Health fully recognizes its capacities for injury
recognition of people which are a result of ionic radiation exposure, as well as for treating
these patients or the patients that come to the hospital from the lace of radiation crisis.
The total capacities do not only represent the spatial and technical treatment conditions,
but also well trained personnel. The possessing of such personnel enables forming teams
of doctors of medicine (a list of their contact details) that on the place of the event will
have an advisory role in the emergency team about managing the situation that has
occurred, but also to the local hospitals, i.e. local doctors of medicine. Also in this way,
with the help of this team, and in cooperation with the Head Office, the Ministry of Health
may conduct an introduction and training of the local doctors of medicine in the
recognition and treating of this group of patients, and also their introduction with the
responsibility, that if they notice such injuries, to inform the Head Office without delay.
Dosimetry and radiation security assessment is done by the Department of Ionic
Radiation Dosimetry at the Public Health Institute of MKD, Chief MSc Zdenka
Stojanovska, Spec. for Medical Nuclear Physics, Tel: 3125-044 Loc.202, Mob:
.
а) Monitoring the level of exposure to ionic radiation with professionally exposed people
through:
- personal monthly dosimetric monitoring of the whole body for all the people
professionally exposed to ionic radiation, with the use of TL – dosimeters,
- activity identification and selection of people with the biggest exposure of the extremities
and their involvement in a monthly/three month personal dosimetric monitoring of the
extremities with professionally exposed people to ionic radiation,
- radiation monitoring on the place, in controlled working zones of ionic radiation and a
report of the measured doses, estimated doses and the level of working exposure.
Department for Occupational Medicine at the PHI performs medical surveillance of
exposed workers, Chief Prim. D-r Angelina Kuka, Tel: 3147-069,
The health condition of the people professionally exposed to ionic radiation is monitored
through medical examinations at least one a year with taking any necessary measures for
health protection of those people.
VII.1.4. Ability to respond to chemical incidents during crisis
During a chemical incident, the laboratory capacities at the PHI are activated (through
the MoH), MIA, the Institute of Chemistry at the Faculty of Natural Sciences and
Mathematics-Skopje – contact person Prof. Valentin Mirchevski 3249-913 (through
MLESP) and the Faculty of Pharmacy-Skopje (through the MoH). CMC has signed a
Cooperation Agreement with PHI for Forming a National Net of Laboratories that are of
significance to the crisis management system (num.03-556 from 06.02.2009).
Even though there is a new equipment (GC-MS, HPLC, IR Spectrometer, ICP-AES)
given to the Faculty of Natural Sciences-Skopje on behalf of the Customs of MKD,
the same has still not been fully put into functioning because there is lack of staff
training.
There is also a problem with the present laboratory of MLESP where there is also a
new laboratory equipment, but still no diagnostic procedures are conducted for the
organic polluters in different mediums of the living environment (oils, aliphatic and
aromatic hydrocarbons, polycyclic aromatic hydrocarbons or benzene, toluene and
xylen as the most common polluters, solvents-chlorinated and non-chlorinated,
polychlorinated biphenyls-РСВ etc.). At the laboratory of MLESP there isn’t enough
staff and the same has not been trained enough to perform the necessary, above
stated laboratory analyses in regular circumstances, and especially during crisis.
48
At the PHI there is lack of contemporary equipment and consequently staff training
for the diagnostics of the above stated polluters in the drinking water and food.
VII.1.5. Ability to respond to the specific health consequences of the crisis
 The standards for supplying safe drinking water and sanitation are given in the
Strategy for Water-Supply and Sanitation in the Republic of Macedonia during
crisis (catastrophes) in supplement num.6.
 patients suffering from extreme heat, cold etc. The First Report of MKD towards
the Framework Convention for Climate Changes of UN has been prepared. The
Second Report of MKD towards the Framework Convention for Climate Changes
of UN is approved by the Government of MKD in 2008. Here the measures and
activities of MKD in relation to the adaptation, vulnerability and mitigation, for all
the sectors and especially for the health sector have been processed. At the
moment, there is a preparation of the Action Plan for Heat Wave Response and a
Strategy for Climate Changes and Health of the MoH in cooperation with WHO.
 The health consequences from other hazards according to the local risk
assessment (for ex. earthquakes, floods etc.) are given in Assessment for
Endangerment of the Republic of Macedonia from Natural Disasters and other
accidents in accordance with the Resolution for Endangerment Assessment from
Natural Disasters, Epidemic outbreaks, epizootic and other accidents on the
territory of the Republic, Government Gazette of MKD num.117/07.
 The providing of adequate and safe services of blood transfusion is done through
the Red Cross of the Republic of Macedonia which is a partner of the Ministry
of Health during the conducting of the program for Organizing and Advancement of
Blood Giving in MKD (“Government Gazette of MKD num.146/07”). the criteria for
supplying secure and safe blood in MKD is 3% or 58.356 units of blood (450 ml)
on a yearly level. The Red Cross cooperates with the State Institute for Blood
Transfusion-Skopje (Manager D-r Risto Dukovski) and the
other blood transfusion services in MKD (21), as well as with the department for
blood transfusion medicine at the Military Hospital-Skopje..
VII.2. Mass casualty management
Systems for mass casualty management are in place with the necessary human
resources, tools and procedures for efficient implementation at the national and local
level.
 The national and local plans for mass casualty management. There are regional
departments for protection and rescue that are developing a plan for protection
and rescue on a local level, and in that plan the measure for field improvement (as
of health conditions), first aid as well as other measures are prepared. Besides the
local plan, the Head Office for Protection and Rescue has a national plan for
protection and rescue, and those topics are processed here (at the moment the
plan is in procedure of being passed by the Government).
 The roles and responsibilities of all the responders are clearly delineated in terms
of coordination authority and management of resource. The Head Office for
Protection and Rescue forms teams for a quick response from different fields of
specialties. The type, the number, the personnel and material content of the teams
has been defined with a Government Resolution. The arrangement of the teams in
the regional organizational units is determined by the Head Office Manager. The
teams represent a basis of the national forces for protection and rescue. They are
filled up with employees in the Head Office and professional people from the state
administration organs, the public enterprises, institutions and services, as well as
with civil associations and expert citizens with which participation agreements
have been signed.
 There are search and rescue services and the same are well developed (including
international agreements, SOP and guidelines) as a part of HOPR.
49


-
o
o
o
50
The emergency services for crisis victims. There are state forces for protection and
rescue for first aid in 35 departments for protection and rescue (84%) and eight
teams are formed for a quick first aid response, which cooperate with CC.
There are procedures for treating dead bodies. According to Act 16 from the
Regulation for conducting field improvement (as of health conditions) in the
planning and field improvement (as of health conditions) incorporate:
o In 35 Departments for protection and rescue there are state forces for
protection and rescue for field improvement (as of health conditions) (84%
are filled) by the Head Office for Protection and Rescue.
o Health sector;
organizing and preparing sanitary-hygienic measures during collecting, transport
and burials of the dead;
confirming the reasons for death;
identification of the dead;
organizing of sanitary-hygienic measures during collecting and destroying of the
waste materials and other dangerous materials that are life threatening to the
people;
disinfection, extermination of insects and rat-catching on fields and in the objects
and
improvement (as of health conditions) of the water-supply objects
o SSHI;
o Central laboratory for forensics and crime-technique at MIA;
o Reference laboratories at the Ministry of Health and at the research centers
and specific institutions and enterprises;
o Institute of Occupational Medicine;
o Public utility enterprises;
o Authorized people for death confirmation;
o Court organs;
o Professional commissions;
o Police Academy.
Even at the region of the catastrophe, the general characteristics of the corpse
need to be described (sex, race, age, body length, outer signs). A photographic
documenting is done, as well as dactyloscopy, laboratory analyses of cloths and
objects is done, as well as the recognition by the relatives and close friends. The
collecting of dead bodies and parts of the dead bodies is done for identification
and field improvement (as of health conditions) – in the morgue, the chapel,
crematorium; in objects on the field (coolers); in vehicle coolers.
A team for expert evidence and identification is consisted of:
 spec. of forensic medicine;
 spec. of pathology;
 spec. of toxicology;
 biologist;
 dentist;
 radiologist;
 assistants and administrators;
 center for informing and expedition;
 police inspectors and crime-technicians;
 the victims’ relatives can also be consulted.
MI’s tasks in the part of prevention, early warning and preliminary response during
crisis are:
 localizing and helping during accidents of local character by saving lives
and property;
 prohibitions, redirecting and maintaining a movement regime on local roads
and motorways;
 evacuation, rescue and increased security in objects of vital importance to
the state;







o
transport and security during epidemic outbreaks of quarantine and
other diseases of people and animals;
search and raid on field;
securing the state border;
maintaining the public law and order in the crisis regions, maintaining
patrols and control points;
searching the field and helping all the victims;
taking in teams and helping by following through to the crisis regions;
helicopter surveillance and transport of seriously injured, coordinating the
work with the other organizations involved in providing help;
coordinating the activities with CMC, the Army of MKD, MoH, CC and
others. Government and non-government organizations.
VII.3. Risk management of health facilities
The structural and non-structural risk assessment for the heath facilities in order to ensure
that they are capable of withstanding any threats outlined in the risk assessment.
 The new heath facilities are built in the manner that will secure their continuous
working during crisis, especially from the aspect of possible damages during
earthquakes. An obligatory statistics assessment is performed (in relation to
protection from seismic influences) in the building projects of new heath facilities,
according to the positive law regulation for building skyscraper constructions. This
is done according to the Law for Building (“Government Gazette of MKD”
num.51/05 and 82/08) and the Law for Building Products (“Government Gazette of
MKD” num.51/05 and 82/08).
 The existing heath facilities are assessed from the point of vulnerability by the civil
engineers, i.e. statics. The architects design the functionality of the object. The
existing objects of the heath facilities are build according to the then existing Book
of Technical Regulations for Building Objects in the Skyscraper Construction in
Seismic Regions and the Book of Rules for Concrete and Ferroconcrete.
 Possibility assessment for continuous work for the key heath facilities and
programs in case of structural and non-structural damages. Such plans have been
developed by the IEEES:
In 1995 on the part of IEEES (Institute for Earthquake Engineering and Engineering
Seismology), and upon the request of the Ministry of Health there has been conducted a
Study for Preparation Planning for Catastrophes for Small and Big Hospitals, for
Assessment of the Structural, Non-structural and Functional Vulnerability.
In 1998 on the part of IEEES, and upon the request of the Ministry of Health there has
been conducted a Study for the Capabilities of the Big Hospitals in the Republic of
Macedonia to Respond to Crisis Caused by Earthquakes.
With the assistance of WHO on the part of IEEES, and upon the request of the Ministry of
Health, there has been conducted an assessment of seismic vulnerability of the Clinic for
Children’s Diseases-Skopje in May 2006.
With the assistance of WHO on the part of IEEES, and upon the request of the Ministry of
Health there has been prepared a Guideline for Assessment of Seismic Vulnerability of
the Heath facilities in the Republic of Macedonia, July 2006.
An assessment of seismic vulnerability for all the existing heath facilities is done
by the IEEES is needed.
VII.4. Lifelines, logistics, telecommunication and security in a crisis
VII.4.1. Lifelines
The lifelines are consisted of the essential infrastructure systems that carry water,
sanitation, energy, telecommunication and transport.
51

Water, sewage and electricity are supplied during crisis. The road access is in
jurisdiction of MIA.
 MoH is negotiating to provide, from the USA, 9 drinking water purifying stations,
the same will be divided in the 9 Regional CMC Centers which will be activated
according to the size of the crisis, and upon the previous decision of CMC and the
Government of MKD.
 There are standby generators available as well as fuel for provision of electricity.
Every hospital has a generator available in order for the surgery rooms to function,
but not the X-ray department.
It is necessary that alternative springs of drinking water are provided (as in the
General Hospital in Kumanovo and Prilep) and all the heath facilities to be provided
with generators that will meet the urgent needs during crisis.
VII.4.2. Logistics
Logistical support is critical to ensure the transportation of the essential health staff, goods
and services continues during crisis.
 During crisis the transport and delivery of fuel is provided in cooperation with the
MIA.
 Essential stores of non-medical supplies like for example fuel, food etc. needs to
be supplied for a specific period of work. The Ministry of Defense as a part of its
activities, in accordance with the Defense Law is preparing a Plan for Fuel Needs
and Other Kinds of Energy on the Republic level for the needs of the Government
organs and the public heath facilities of special interest.
 There are available medical materials such as medicines, medical equipment and
reserve parts. The Agency for Stock reserves manages them, whereas the Plan
for the Needs of Medicine is prepared by the Board of Medicines, and for the used
medical material, the Sector for Crisis Management at the MoH.
 The waste disposal and laundry services should capable of continuing the work
even during crisis.
VII.4.3. Emergency telecommunication
The satellite telephones, radios and mobile phone systems which can be used for
communication during a crisis.
 There should be a secure and effective telecommunications between all the
responders in case the normal infrastructure overloads or fails. For that purpose
there should be a possibility of using at least two communicational systems.
 The responders have to be trained to use the emergency telecommunication
equipment.
 The public broadcasting system should be able to function during crisis.
 CMC has maintained a net of radio connections with radio users that cover the
whole of the Republic and other users from the whole territory of MKD can join the
same, in order to notify and transfer information for events and situations that may
cause a crisis.
 From 2010 the system with a unique calling number 112 is expected to start
functioning, which will provide a complete coverage of the mobile and fixed
telecommunication connection on all possible radio waves.
VII.4.4. Security system
The civil unrest may lead to attacks on hospitals and the heath facilities.
 A security plan to protect the critical heath facilities together with the local police
authorities (including simulation tests) has not been developed yet, but there is
cooperation and upon a request physical security from MIA is possible.
 Security procedures established with the partners.
 According to the Hospital Crisis Preparedness Planning the marking has been
defined:
52
the doctors wear identity cards with red color;
the nurses and the other middle personnel wear identity cards with blue
color;
o the administrative personnel has identity cards with grey color;
o the hygienists wear identity cards with yellow color.
The Head Office for Protection and Rescue has identity cards for the rescuers. One
measure covers marking (marking out, designating, ranking) of the personnel according to
the mandate in the system and the measures for protection and rescue. There is also
planned a securing of the Protocol of Procedures and Consultations among the
participants in the protection and rescue (including the health service). The crisis
management is established, i.e. the line of management and command, and the locating
of the rescue structures in a specific case is stated precisely (danger zone, restriction
zone).
o
o
53
APPENDICES
Appendix 1 - WHO – Emergency reference values
Appendix 2 – Strategy for water-supply and sanitation in the Republic of Macedonia
during crisis (catastrophes)
Appendix 3 – Triage protocols of injured (scoring-systems)
54
APPENDIX I
WHO – Emergency reference values
Emergency indicators
Average values for emergency warning:
Health status
Rough daily mortality rate
Daily mortality rate with children under 5 years
Nutritious status
Acute malnutrition (W/H or MUAC) children under
5 years
Incorrect rate of growth with children under 5
years
Low body weight during birth (< than 2,5 kg)
7% from the live born
Standard population structure
Adult group
0 – 4 years
5 – 9 years
10 – 14 years
15 – 19 years
20 – 59 years
Pregnant women
Population average (%)
12.4
11.7
10.5
9.5
48.6
2.4
More than:
1/10,000 population
2/10,000 children under 5 years
10% from the children under 5 years
30% from the observed children
Life needs (needs during crisis)
Drinking water
Amount
Quality
(1 m3 = 1 ton = 1.000 liters)
Food
Indicator
Average need
liters/person/ day
users/ place for
water distribution
20 liters /person/day
200 people/place for water
distribution
(not further than 100 m from the
home)
Portion, kg/person/month
Kcal content
Cereals
350/100g
13.5
Legumes
335/100g
1.5
Oil (vegetable)
885/100g
0.8
Sugar
400/100g
0.6
Kcal value of a recommended portion,
2,116 Kcal
person/day:
Total kg./person/month for nutrition
16.4 kg
Micro-nutrients (ex: iodine, Vitamin A) are important. Consulting local nutrition guidelines.
Sanitation
Latrines
Soap
Waste disposition
Fuel for domestic furnaces
Fire wood (kg)
ideal for 1 family;
minimum 1 space for 20 people
(maximum 50m, minimum 6m from
the home)
250 g/per person/month
1 pit for communal waste (2m x 5m
x 2m) for 500 people
Average needs
15 kg/home/day
55
Notice: with 1 economical furnace for
the family, the needs can be reduced:
5 kg/furnace/day
Average needs
Accommodation place
4 m2/person
30 m2/person
Individual need (only shelters)
Collective needs, including shelters,
sanitation, services, community
activities, warehouse and access
Health protection needs
Main health hazards
Acute respiratory infections with children
under than 5 years
Diarrhea diseases with children under 5
years (other than dysentery and cholera)
Malaria, with the total non-immunized
population
Rash fevers
Cholera
Expected rate during crisis
10%/per month during cold weather
50%/month
50%/month
5-30% in an acute phase (during the first days)
Essential activities for public health protection
Target groups
Children under 5 years, clinical
all children between 0-59
and growth monitoring
months
Pre-natal clinically
all pregnancies
Tetanus toxoid
Assisted birth
1.5 for pregnancy
all pregnancies
BCG
all new born
DTP1-TT1
0-1 year
DTP2-TT2
0-1 year
Rash fevers
9-12 months
STD/HIV prevention (with
condoms)
Consultation with infirmarypolyclinic duty (IPD)
Treatment & monitoring sessions
all sexually active men
Optimal goal coverage
100% of children under 5
years per month
50% from the pregnancies/
month
30% per month
1/12 from the total group per
month
month
month
month
month
12 condoms/man per month
1.5 per person/year
0.13 per person/ month
Health workers’ needs
Activity
Vaccination
Children under 5 years clinically and growth monitoring
Pre-natal clinically
Assisted birth
Consultation in infirmary-polyclinic duty
IPD treatment (clothing, and etc.)
Notice: 1 person/day = 7 hours filed work
Health workers’ needs during crisis (ex: refugee camps) for
vaccination, growth monitoring, prenatal clinically, assisted birth,
56
4 for consultation in the
infirmary-polyclinic duty
Outcome from 1
person/working hour
30 vaccinations
10 children
6 women
1 births
6 consultations
6 treatments
60 employees for 10,000
population
IPD consultations and treatments, registration and clerical
duties.
Health material needs
Needed
Essential medicines and
medical equipment
WHO Basic crisis packet
1 packet for 10,000
population/3 months
1 packet for 10,000
population/3 months
need/patient under 5
years/day
90 g/day
120 g/day
70 g/day
Amount
WHO Additional crisis packet
Nutrition rehabilitation
Oil
Milk
Sugar
Safe drinking water
a) preparation of 1 l of solution for a
reserve 1%
Or
Or
Or
b) using a solution from a reserve
Calcium Hypo-chloride 70%
15 g/l water
Lime powder 30%
33 g/l water
Sodium Hypo-chloride 5%
250 ml/l water
Sodium Hypo-chloride 10% 110 ml/l water
for 1 liter of water
0.6 ml, or 3 drops
for 100 liters of water
60 ml
(Notice: make sure that the chlorinated water is left al least 30 minutes before use)
Epidemiological response
Dysentery
Highest expected event rate
25% cases that need IV
100% cases that need antibacterial
medicine:
Choice in accordance with the anti-microbe registry form
If it is not available, aim for the most risk-exposed population
100% cases that need ORS
Meningococcal meningitis
Highest expected event rate before
vaccination
100% cases treated with Tifomycine amp
Children
Adults
100% population to be vaccinated
Rash fevers
Highest expected event rate with the nonimmunized under 12 years
100% non-immunized under 12 years to be
vaccinated
100% under12 years to be given Vitamin А
Children under 1 year
Children 1 years of age
and more
Typhus
100% population to be cleared from lice
Soap the clothes and dip it into a solution of 1 dose of 400 mg
for ex. Permethrin 1% doxycycline
Important: for safe vaccination, selfdestructive syringes and alcohol cottonbuds are needed
25% for 3 months
3 l/patient
6,5 packets/ patient
0.1-1%
100 mg/kg
3 g single dose
1 dose/person
10%
1 dose/child
100,000 IU/ child
200,000 IU/ child
57
Logistics
Weight and volumes
Food
Medicine and means:
Vaccines:
Food for therapeutic nutrition:
Family tents:
Blankets:
Warehouse needs
Average capacity of a truck
Capacity of a small aero
plane
Unit
Standards
Standard individual
portion
16.4 kg/month
41 tons/10,000 people/week
(1 ton of food, whole-wheat grains/beans
in standards 50 kg bags takes up 2 м3)
45 kg/0.2 м3
1 WHO Basic crisis
packet
1 WHO Additional crisis
410 kg/2 м3
packet
1.000 doses for rash
3 liters
fevers
1,000 doses for DTР
2.5 liters
1,000 doses for BCG
1 liters
1,000 doses for Polio
1.5 liters
1,000 doses for Tetanus
2.5 liters
Standard portion for
2 kg/week
children under 5 years
35-60 kg unit
1 metric ton is 4.5 м3
Compressed
1 metric ton is 4.5 м3
Non-compressed
1 metric ton is 9 м3
2
About 25 m for 1,000
population
30 metric tons (between 2 and 50 metric tons)
3 metric tons
Source: SPHERE
Appendix II – Strategy for water-supply and sanitation in the Republic of Macedonia
during crisis (catastrophes)
During crisis, the inadequate water-supply of the population, as well as the sanitation may
be the reason for serious health impairs, and even death to some individuals, and even
more for an impaired standard and comfort of living.
1.1 Hygiene and epidemiological water significance during crisis
The human can not survive without water for more than 3-5 fays, whereas without food 23 weeks. If there is not enough water, then physical activity should be avoided, as well as
food rich with proteins. Every movement and/or work should be brought to a bare
minimum, and especially in a high temperature living regime.
The World Health Organization criteria for hygienic water-supply are:
 proper healthy drinking water (Safety);
 well-stocked with sufficient amount of healthy water (Adequacy);
 usage comfort (Convenience);
 water-supply continuation (Continuity).
In Table num. 1 the recommended values and standards according to the World Health
Organization are shown, as well as accepted standards during crisis.
58
Table num.1 Minimal daily quantities of drinking water during crisis
Type of crisis
During evacuation:
-in cold and moderate climates
-in hot climates
Field hospitals and first aid stations
Centers for temporary
accommodation
Temporary shelters and camps
Bathing installations
Animal fund needs*:
-big livestock
-small livestock
Necessary amount of
water in liters/man
(animal)*/day1
Necessary
amount of water
in liters/man /day2
3
7
40-60
20-30
5-9
60
30
15-20
35
30
-
30 (cows)
15 (goats and small
livestock)
-
source: 1WHO. Water in emergency situations.1998
2
Здравствена заштита у општонародној одбрани;1977 - (eng. Health Protection in the
National Defense; 1977)
1.2. Possibilities for crisis occurrences (catastrophes) in the water-supply and
sanitation of the population of the Republic of Macedonia
Potential reasons for an occurrence of a crisis in the Republic of Macedonia are the
following:
1. Earthquakes
2. Floods
3. Land sliding
4. Droughts
5. Big fires
6. Wars
7. Different and larger industrial, diversionary, traffic or other incidents
8. Lack of energy of the systems that work on electrical or other type of energy
In the newer history of the territory of the Republic of Macedonia all these reasons, with
the exception of big fires, have caused crisis (catastrophes) in the water-supply system
and the sanitation of the population.
The conditions for a reoccurrence of the incidents or catastrophes are high, and even
present.
1.3. Which parts from the water-supply system, the sewerage and the disposition of
the hard waste are especially vulnerable
During crisis (catastrophes), the most risk exposed parts of the water-supply are the
sources of water-supply, the intake and their objects, the reservoirs, the filters and the
water-system. These objects and installations are described in accordance with their
importance and the rate of risk occurrence. With the take away of the waste water, the
parts most exposed to risk are the sewerage objects, the purifying stations and all the
canal manholes, than the main collectors and the remaining installations.
In case when the water-supply and the sewerage systems use also propulsion energy, the
pump stations for re-pumping and drawing water are severely exposed to risk.
With the disposition of solid waste materials during crisis, the most exposed to risk are:
the unsecured and inappropriate dumping grounds (sliding, explosions, fire, inconsistency
in work and etc.), the mechanization and the transport and waste collecting containers,
59
the insufficient number of engaged personnel, the big lack of discipline and the bad
working organization.
In Table 2 the most common possible effects during some specific occurrences of the
health ecology in the Republic of Macedonia are described.
Floods
1
1
1
1
1
Main intakes damaged
1
2
2
1
1
Damaging of the water sources
1
2
2
1
1
Lack of energy
1
1
2
1
1
Pollution (biological or chemical)
2
1
1
1
1
Transport damages
1
1
1
1
1
Lack of personnel
1
2
2
1
1
3
1
1
1
1
1
1
1
1
1
System overload
(due to people displacement)
Lack of equipment, spare parts and supply
1
2
3
Wars
Storms
Damaging of building constructions
Most common effects
Volcanic
eruptions
Earthquake
Table 2. The most common effects during specific occurrences of the health
ecology for the water-supply and the disposition of waste water
serious possible effects
less serious possible effects
the least or no possible effects
The basic tasks of the health care during crisis will be:
1.
2.
Preventive-medical care (hygiene-prophylactic measures, anti-epidemic measures,
sanitary surveillance, measures for medical radiological, biological and chemical
protection) of the entire population.
Treating the injured and diseased through providing medical help, acceptance and
evacuation, hospital treating, mental and somatic rehabilitation.
The managing during crisis can be divided into three time phases:
 Phase 1, before a catastrophe of natural or human origin. It represents a sum of
measures and activities for preventing or reducing the influence, through personnel
training and developing, testing and modernizing of an action plan and its activation in
Phase 2. The duration of Phase 1 will depend on the occurrence of the following crisis,
which can not be precisely determined.
 Phase 2, urgent response. Begins with the influence, including the possible warning
period. During this period, the preparedness is checked and increased. In Phase 2urgent response, the actions that are taken must be intended for the priority areas.
Usually the measures taken for health ecology control from this phase, last 7 days,
and with the warning period in the first 3 days represent the most critical time of action.
From a sanitary and hygiene aspect, the accommodation conditions, the food and
water-supply, the disposition of solid and liquid waste will be evaluated with defining of
the sanitary and hygiene state:
60
 accommodation hygiene and sanitation;
 supplying the people with a sufficient amount of proper hygienic drinking water
and water for personal hygiene; proper and healthy food; regular conducting of
measures for personal hygiene and providing appropriate clothes and shoes;
 providing a sufficient number of hygienic sanitary knots, with a special attention
to the final disposition of the liquid waste;
 providing a sufficient number of containers for solid waste and their daily
discharge by an authorized public communal company. In cases when there is
no possibility of conducting hygienic collection and final disposition on a settled
dumping ground, its local discharge has to be done, if possible with a
controlled pour out;
 conducting prophylaxis measures in order to keep the psychophysical shape
as well as injury and non-communicable diseases prevention;
 regular disinfection, extermination of insects and rat-catching from an
authorized health organization (Public Health Centers) or educated people that
are a part of civil protection;
 conducting of specific prophylaxis measures: vaccination.
Table num.3 Number of personnel from the filed of health ecology needed during
crisis
Encompassed population
(number of people)
Less than 1.000
1.000-10.000
10.000-50.000
50.000-100.000
For every additional 100.000
Number of the personnel
Technicians
Sanitary
D-r
engineers Specialist of
Hygiene
1
1-2
1
1
1
2
2-3
2
1-2
2-5
5-10
10-15
10
source : WHO, Guide to sanitation in natural disasters.1971
In Table num.3 the number of needed personnel from the filed of health ecology during
crisis is shown, according to WHO.
 Phase 3, rehabilitation. It represents involving of the services connected to the
protection of the human environment and the health in levels of activities and
equipment from before the beginning of the crisis, and the reconstruction measures
will impose as a long-term solution.

1.5. Activating the Crisis Preparedness Planning
The Crisis Preparedness Planning is activated by a Resolution of the Minister of Health,
after a Government Decision, and it has to:
 Identify all possible available organizations of human resources and to appoint
members in its collective, including voluntary and help personnel.
 To maintain and keep coordinative and communicational connections with relevant
public agencies responsible for the warning measures, and to enact action consents
during crisis.
61
 To maintain and keep contacts with private agencies and companies that can help in
the urgent actions during crisis about the water-pipes, chemicals and disinfection
agents, as well as equipment and professional help.
 To record the equipment and the needs, as well as their stocks in several places and
safe locations.
 To define the responsibilities in the context of strategy and the role of the references
on all levels: from the highest resolution making body to the people who do field work.
 Helps with the sensitivity of the analyses received from and for the field.
 Forms priority areas in accordance with the local needs that are in a crisis state, as
are: health care need, tents, promptness of filling up the accommodation capacities
with their accommodation density in the context of supplying sufficient amount of
healthy drinking water and etc.
 To coordinate the communication and make connections with specific centers for civil
protection from the affected area in order to identify the crisis caused damage on the
health service as well as its complete re-operating.
 To coordinate the communication with relevant international organizations: WHO,
UNICEF, UNHCR and others, as well as to accept help from government and nongovernment international organizations and its distribution.
 To prepare the action plan during crisis with measures and activities of all the
organizations and subjects, in all the phases of action.
For an efficient use of the necessary resources, a quick response on the affected terrain is
necessary, in order to urgently identify the needs and the level of the following reparation.
1.6. Preparations, that have to be done in order to respond to the catastrophe
in order to prevent these consequences, the Crisis Preparedness Planning of the Health
Systems is activated. one of its most important tasks is also water-supply to the
population and sanitation.
After the catastrophe, an appropriate response has to be prepared immediately,
rehabilitation teams have to be prepared and a reconstruction of the situation as well, the
state’s improvement has to be worked on and it is necessary to show complete
preparedness in solving the problems that occurred with water-supply and sanitation of
the population in the crisis areas and regions where the catastrophe occurred.
The preparations, that have to be done are various and they depend on the type of the
catastrophe and what has to be put into function, or in its primary state.
That is why various operation plans have to be prepared with a description of the actions
that are going to be taken, as well as a list of all the organizations and people that have to
participate in the eliminating of the consequences and defects.
There are difficulties in securing the wider protection zone (restriction zone or the second
sanitary-protection zone), around the springs Vrutok, vicinity of Gostivar, the springs
Rashce 1 and Rashce 2, as well as around the raw water, i.e. the accumulations Glaznja
and Lipkovo in Kumanovo.
From a hydro meteorological aspect in the Republic of Macedonia there have already
occurred crisis with the water-supply in the following cities: Tetovo, Kumanovo, Kriva
Palanka, Sveti Nikole, Probishtip, Shtip, Radovish, Strumica, Veles, Negotino, Kavadarci,
Resen, Prilep, Krushevo, Makedonski Brod and Demir Hisar.
The reason for this crisis is the lack of water because of the existing drought. Besides
that, with the water-supply systems that use surface water from the accumulations, during
the working of the filters an enormous amount of aluminum sulphate is used and reserves
are necessary for a minimum of 6 months.
The same goes for the means of disinfection of the drinking water. In order to supply the
necessary amounts of disinfected drinking water in the crisis areas, PHI-Skopje has
62
supplied a contingent of 2 million tablets for disinfecting the drinking water for the first
hours.
It is a task of the Health Crisis Headquarters to coordinate between the water-supply and
the main water-supply companies in order to urgently provide the necessary
mechanization, if possible the professional personnel and the remaining workers and
spare parts for the installations.
In cases of bigger disasters of the drainage systems, it is necessary to provide an
appropriate re-pumping of the waste water, the necessary installations and the
disinfecting of the waste water and the recipients-in case they are not used for fishing.
The treatment of the solid waste and the dry toilets is very important during sudden longterm gatherings and residing of the population in temporary homes, camps and etc. In
such a case, an appropriate mechanization is necessary, as well as dry toilets in monoblocks, disinfection of the same and the latrines and good, regular and continuous
organization.
3.
Maintaining a diseases surveillance system
During crisis, the routine system for disease registry is either insufficient, or damaged as a
direct consequence of the catastrophe, or can not quickly supply the necessary data for
making timely solutions. It is recommended that a diseases surveillance system on a
national level is prepared, temporarily established immediately after the catastrophe
occurs. The system for disease registry has to be more flexible and faster than in usual
conditions. The routine surveillance system has to be re-established as soon as possible.
For a regular collection of the health data it is necessary to engage an epidemiological
specialist, who together with the hygiene specialist will engage in collecting of health and
ecology indicators from the Public Health Institute; they will manage the system for regular
control of the acute diseases and the changes in the regular water-supply, nutrition,
disposition of solid and liquid waste materials.
The data have to be collected according to the geographically affected region, the main
disease risk and the main health and ecology indicators relevant in the prevention of
diseases, dehydration and malnutrition. Such data will be monitored through receiving
reports from the daily registry for monitoring of epidemiological and sanitary-hygiene
states on the filed of the affected region which will be done by the regional Public Health
Centers and their regional hygiene and epidemiological services.
The daily registry for monitoring the epidemiological and sanitary-hygiene state of a
specific location and a specific period of time is given as a quick and efficient registry
system with health and ecological indicators, with a gradation of the state as unchanged,
worsened or improved (Table 5). In that way the Crisis Headquarters could efficiently and
quickly intervene in the prevention and alleviating the situation.
63
Table 5. Daily evidence for monitoring the epidemiological and sanitaryhygienic state
at ________________ for day ________ 20___ year
Hours
8 o’clock
Health indicators
Acute food poisoning
Infectious diarrhea
Acute respiratory communicable
diseases
Equipped with tetalpan/ tetabulin
Proper healthy drinking water from the
city water-supply
Proper healthy drinking water from
objects for production of consumables
(milk, bread)
Hygienic disposition of liquid waste
substances
Hygienic disposition of solid communal
waste
Proper healthy basic groups of
consumables (bread, milk)
Legend:
U = unchanged state
W = worsened state
I = improved state
64
11
o’clo
ck
2 pm
5 pm
4.
A practical guide for managing the sanitary and hygiene state of the watersupply and the disposition of liquid waste water
 protection of the water springs:
 Protection of the water springs from human and animal access and making sure
that the water is pumped out into the reservoir for further distribution.
 Appropriate disposition of animal excretions safe distance from the water spring.
 In case of a river, bathing, washing or cattle breeding is not allowed downriver
from the place where water is taken out.
 In case of a well with a manual pump, proper drainage of the spilled water away
from the well is necessary.
 Rationalizing of the water-supply if there is danger of the well to dry out.
 Water assessment whether it is safe for drinking:
 Absence of pathogen microorganisms.
 Absence of chemical pollution from toxic substances.
 Residual chlorine from 0.5-1.0 mg/l at the final point of the water-supply system, or
a noticeable smell of chlorine in the water.
 Water tests that have to be done with mobile devices:
 routine рН testing,
 muddiness,
 residual chlorine,
 testing of thermo-tolerant bacteria (incubation at 440С) can be conducted when:
 chlorination of the water has not been done,
 residual chlorine has not been found in the water,
 new springs have been selected,
 there is a possible pollution of the spring,
 corrective action can be conducted, as well as routine testing.
 Providing disinfection of the water with chlorination.
 The waste water from the washing and any flow out has to be drained into a river or
stream downriver from the place where water is taken out or from the settlement. If
there is no river, a pit for drainage has to be dug out with an oil-catcher. It is necessary
for eliminating of fats and oil otherwise the pores of the soil will block.
 Avoiding water restrictions and providing enough pressure in the water-supply net for
preventing secondary drinking water pollution.
 Mobile equipment for water purification and disinfection can be very useful. That
equipment is very expensive, takes up a lot of valuable space, demands a presence of
an experienced operator.
 The public communal companies need to have available necessary equipment, spare
parts and chemicals necessary for regular and exceptional cases for a continuous
maintenance of the water-supply with health drinking water.
65
TEN HYGIENE RULES DURING CRISIS
1. WASH YOUR HANDS BEFORE EATING!
2. EAT YOUR FOOD IMMEDIATELY! DO NOT KEEP OPEN TINS-THEY MAY BE
DAMAGING TO YOUR HEALTH!
3. FRESH FRUIT AND VEGETABLES HAVE TO BE WASHED WELL BEFORE
EATING!
4. USE VERIFIED WATER THAT IS SAFE AND APPROVED BY THE PUBLIC
HEALTH CENTER!
5. USE PERSONAL CUTLERY AND WASH THE SAME BEFORE AND AFTER
EVERY MEAL!
6. FOR PERSONAL HYGIENE USE ONLY YOUR PERSONAL SET (RAZORS,
TOWELS, BRUSHES, COMBS...)!
7. THROW THE WASTE IN THE CONTAINERS, BINS, OR OTHER APPOINTED
VESSELS AND PLACES! THE SAME ARE CARRIED OUT, WHILE THE
GARBAGE NEXT TO YOUR DWELLING PLACE REMAINS YOURS!
8. THE SANITARY KNOTS ARE MUTUAL, AND AFTER USE LEAVE THEM IN
THE CONDITION AS YOU WOULD WANT TO FIND THEM THE NEXT TIME!
9. WASH YOUR HANDS AFTER EVERY TIME YOU USE THE TOILET!
10. IMMEDIATELY CALL THE DOCTOR WHEN YOU HAVE STOMACH CRAMPS,
THE RUNS OR OTHER HEALTH PROBLEMS!
66
MANUEL FOR THE AQUATABS® TABLETS FOR WATER DISINFECTION DURING
CRISIS
Clear water
1 disinfection tablet in 5 liters of water (during high risk)
1 disinfection tablet in 10 liters of water (during low risk – water consumed from a
known spring, as is the home water-supply)
The tablet(s) are previously dissolved in water and in that form are put in the
reservoir or the volume of the water for which the disinfection is intended and are
left there for 30 minutes, during which the active chlorine performs the disinfection.
The manufacturer guaranties for this type of conducted process of hyper
chlorination of an amount of 4 mg/liter chlorine (during disinfection of 5 liters of
water), or 2 mg/liter chlorine (during disinfection of 10 liters of water).
1 tablet contains 33 mg Sodium Dichloroisocyanurate (20 mg chlorine).
If the water that is supposed to be disinfected is muddy, it has to be previously
filtered through a clean cloth/gauze.
Sodium Dichloroisocyanurate is approved by USEPA for routine treatment of drinking
water and meets the European standards for drinking water (EN12931:2000) and the
WHO/FAO specifications for drinking water.
AQUATABS® tablets provide up till 6 log reduction of the number of bacteria and 4
log reducing of the number of viruses in 30 minutes, and 3 log reduction of the cysts
(Giardia lamblia) after 4 hours, when used in clear water.
Warning:
The tablets must not be swallowed!
Keep the tablets out of reach of children!
Manufacturer: Medentech Ltd., Wexford, Ireland
Tel: +353 53 60040
Fax: +353 53 41271
www.medentech.com
E-mail: [email protected]
67
APPENDIX III
Triage protocols for the injured (scoring-systems)
The scoring – systems represent injury levels of value. They, basically, are numerical
values of injuries, in order to foresee the possibility of surviving i.e. the invalidity of the
injured. Their application is recommended during massive accidents, with a large number
of injured, that have severe injuries, i.e. when there is a big number of multi or poly
traumatized patients.
This predicting possibility of the scoring – systems has significance in all the phases of the
treatment of injured:
 pre-clinical;
 clinical;
 rehabilitation phase.
How do these systems function?
 In order to predict the outcome with the injured patients, it is necessary to
determine:
o the seriousness of the individual injuries;
o the sum of the injuries on different parts of the body.
 to predict
o the evolution of the lesions;
o the reaction of the body in whole to the injuries that occurred.
Additional factors from which the prediction depends on – important factors that influence
the outcome – surviving and invalidity, are:
o age of the injured;
o previous diseases;
o pre-clinical treatment;
o complications during the treatment.
Characteristics of the effective grading levels:
o quick, early and objective assessment of the level of injuries;
o prompt triage of patients;
o quality control of the initial therapy received;
o appropriate transport of the injured;
o transferring of relevant information to the next stage of care providing for
the received therapeutic measures.
Types of scoring-systems:
o anatomical;
o physiological;
o combined;
o biochemical.
Anatomic levels of grading
 AIS – Abbreviated Injury Scale
o previously defined anatomical regions;
o the grading of the injuries is: 0-6 (minor injury, medium to serious, serious,
serious to life threatening, critical, fatal);
o there are many revisions to the original AIS-scale;
o AIS-90 represents a catalogue with 2000 diagnoses and symptoms.
 ISS – Injury Severity Score
o represents a sum of the squares of the highest AIS-values with poly
traumatized patients
o ISS = AIS12 + AIS22 + AIS32
o connecting the results represents a difficulty, especially when there are
serious injuries in several organs that are localized in one region;
o the assessment of the cranio-cerebral injury is inappropriate;
o there is no assessment of the physiological parameters.
68
Physiological grading levels
 GCS-Glasgow Coma Scale
o is applied in the assessment of the cranio-cerebral injuries;
o it is often a part of another, i.e. combined grading level;
o it is simple because only three elements from the neurological status of the
patient are estimated;
o has a large forecast value;
o the patients with GCS: 7 are in a comatose state, but above 50% with a
sum 8 are also in a coma.
o is not appropriate for assessment of children’s injuries;
o it is difficult to assess the scale elements with patients that are already
intubated;
o the assessment is not certain with patients that are under the influence of
alcohol or sedatives;
o the peri-ocular swellings disable the assessment of the possibility of
opening the eyes;
o the duration of the coma needs to be at least 6 hours.
 Trauma Score (TS)
o the original scale (1981) was used for triage on the place where the injury
happened while providing first aid;
o the following are assessed: state of consciousness, the respiratory function
and the capillary filling;
o insufficient assessment of the neurological status with the poly traumatized;
o subjectiveness in the assessment of the capillary filling.
 Revised Trauma Score (RTS)
RTS = GCS + P + RF
(P=systolic blood pressure
RF=respiratory frequency)
o it is applied in all phases of the treatment, but before all it is significant in
the prompt triage and transport to the next phase of the treatment;
o there are five levels (0-4), gained on the basis of the assessment elements:
GCS: 13-15 P: > 89 mmHg
RF:10-29 / 4
3
0
0
0
Combined grading levels
 PTS-Polytraumaschussel
o the original system was anatomical (1985);
o the revised (1994) is combined and functional, including the anatomical
elements, the physiological reaction of the body and the biochemical
values (oxygenation and base deficit) and the patient’s age;
o it is a drawback because it can be used before all in the hospital phase.
 TRISS - scale
o represents a combination of RTS (Revised Trauma Score) and ISS (Injury
Severity Score), and the age is an additional element;
o the big prognostic accuracy represents an advantage - 97%.
Biochemical scales of value
o they are the last included as scales of value;
o represent a defining of the substances that are released from the damaged
tissues with poly traumatized patients;
o have significance mainly in the intensive care departments
69
Integrated management for children’s diseases assessment
Triage and management during crisis
Triage and sign assessment during
crisis (including danger signs and
assessment of the priority states
yes
no
Assessment of the main symptoms
Assessment of malnutrition and
anemia
Nutrition and immunization
assessment
no
Assessment of the other problems
yes
yes
Assessment of the emergency state
and managing.
Categories after triage:
- urgent cases = immediate treatment
- priority cases = prompt attention
- waiting line or not urgent cases =
goes back to the waiting line
Diarrhea and dehydration
Coughing or difficulties during
breathing
Fever
Malnutrition
Paleness/Anemia
Newly born and small child
HIV/AIDS
Injuries
Burns
Poisoning
Who should perform the triage?
The whole doctor’s personnel involved in the care of sick children should be prepared to
conduct a quick assessment for identification of the small number of children which are
seriously ill and which need urgent treatment.
How to perform the triage?
The steps RBCD:
respiratory track;
breathing;
circulation/coma/convulsions;
dehydration.
Triage of cranio-celebral injuries (CCI) - GCS (Glasgow Coma Scale):
3-8
coma (heavy)
=
neurosurgery institution
9-12
moderate CCI
=
trauma center
13-15 mild CCI
=
closest, surgical center
Source: WHO. Manual for the health care of children in humanitarian emergencies. Geneva;
2008: 3-14.
70
Summery of the case integrated management process (CIMP)
The core of the strategy for integrated management of the assessment of children’s
diseases is a case integrated management of the most common problems during
children’s age. the case integrated management is based on case detection using
simple clinical signs and empirical treatment. To use clinical signs and laboratory tests
as little as possible.
For all the sick children brought to a health institution
Make an ASSESSMENT of the child: What age is the child? Check the general signs1. Ask for
the main symptoms2. Check every child for malnutrition, anemia and immunization status and
for HIV infection in general HIV epidemiological stations.
CLASSIFY the child’s diseases: Use a triage system to classify the main symptoms of the child
and its nutrition, anemia or nutrition status
IF URGENT REPORT
IDENTIFY URGENT PRE-REFERRAL
TREATMENT (S)
TREAT THE CHILD: Give urgent prereferral treatment(s)
REPORT ON THE CHILD 1: In urgent
cases, there may not be a possibility
for reporting; the cases have to be
treated in the institution according to
protocols.
IF NOT URGENT REPORT
IDENTIFY A TREATMENT
TREAT THE CHILD: Give oral
medicine in the health institution
and/or advise the child’s caretaker.
Perform immunization.
ADVISE THE MOTHER: Assess the
child’s nutrition, including breast
feeding and solve the nutrition
problems.
MONITORING the health care: Monitor the care when the child goes back to the health
institution and if necessary, make an assessment of the child again to check for new problems.
1
General hazard signs include convulsions, inability for drinking or breast feeding, vomiting
everything or lethargy, or unconscious state.
2
Main symptoms are diarrhea, coughing or breathing difficulties, fever, malnutrition, anemia,
and/or problems for whose assessment protocols should exist.
Source: WHO. Manual for the health care of children in humanitarian emergencies. Geneva;
2008: 3-14.
71
Chart 12. Schematic view of the primary, secondary and third level
hospital health care
TERTIARY HEALTH CARE
Clinics and
Institutes
2033 beds
(21.5%)
Clinic for
Surgical
Diseases
St.Naum
Ohridski
171 beds
(1.8%)
Institute for
Medical
Rehabilitation
215 beds
(2.3%)
Specialized
Hospitals
818 beds
(8.7%)
Clinic for
Maxillofacial
surgery
43 beds
(0.5%)
Total: 3280 beds (34.7%)
SECONDARY HEALTH CARE
General
Hospitals
4055 beds
(43%)
Specialized
Hospitals
1391 beds
(14.7%)
Total: 6048 beds (64.1%)
PRIMARY HEALTH CARE
Out-patient stationers
Total: 112 beds (1.2%)
TOTAL BEDS IN 2006: 9440
72
Rehabilitation
Centers
+ Spas
602 beds
(5.4%)
73

crisis preparadness planning for the health system in the republic of

Transcription

Similar documents

Ministry of Sound and its worldwide evolution to the present

MINISTRY INISTRY MENTORS®

Banana Republic

Client Information Form - Tax Administration Jamaica

to Veiw Javier Buelna Vision Statement and Bio

Student Leadership Application

Layout 15 - Goforth Media

May 4, 2014 - Alfred Street Baptist Church

KnoWhat2Do brings in Results!