Applying the Prevention through Design (PtD) Framework to Develop a Decision-Matrix for Emerging/re-emerging Infectious Disease (EID) Preparedness in Maritime Ports

Background: Ports are critical gateways for the movement of people and goods and have a dual role in preventing the import and export of infectious diseases as mandated by the International Health Regulations (2005). Lessons from the COVID-19 pandemic underscored the need for actionable, rapid decision support in port operations. Objective: To develop a theoretical decision-making matrix for EIDs preparedness for Lembar Port, Lombok, Indonesia, adapting the National Institute for Occupational Safety and Health (NIOSH) Prevention through Design (PtD) framework. Methods: We adapted the PtD framework from general workplace safety to preparedness against infectious diseases in the port context. Two key epidemiological variables: basic reproduction number (RO) and case fatality rate (CFR), served as the basis for risk grading. We took four operational steps: (1) initiating early-phase risk reduction actions guided by transmission mode; (2) grading risk using two epidemiological drivers; (3) constructing a decision-making matrix aligning the hierarchy of controls (elimination, substitution, engineering, administrative, and PPE) to risk categories; and (4) engaging key stakeholders to assign shared responsibilities and validate feasibility. A stakeholder consultation was conducted in October 2024 involving the Harbormaster’s Office and Port Authority, the Health Quarantine Agency, the Fish/Animal/Plant Quarantine Agency, and port operators (PT Pelindo, PT ASDP). Results: A decision matrix was developed to guide port authorities on prohibiting, limiting, or modifying activities based on dynamic risk levels. We produced: (i) a set of early-phase risk-reduction actions mapped to six transmission modes (airborne, droplet, fecal-oral, water-borne, vector-borne, and zoonotic); (ii) a three-tier risk-grading instrument using RO and CFR with illustrative diseases; (iii) a decision‑making matrix translating risk categories to specific control measures and port activities (e.g., docking prohibition, passenger flow modification, isolation capacity, paperless processes); and (iv) a task‑sharing scheme across stakeholders. The approach emphasizes operational feasibility and rapid implementation Conclusion: A theoretical decision-making matrix provides a structured and actionable preparedness plan for EIDs in port settings. Conducting a simulation exercise with stakeholders is essential to test, refine, and validate the matrix.