**National Advisory Committee on Children and Terrorism**

**Department of Health and Human Services**

**Centers for Disease Control and Prevention**

**April 30, 2003**

**Emory Conference Center -- The Abbott-Turner Center**

**Atlanta, Georgia**

Dr. Angela Diaz, Committee Chair, called the meeting to order at 8:05
am.

# Committee Members present 

Dr. Angela Diaz, Committee Chair, Director, Mount Sinai Adolescent
Health Center, Mount Sinai Medical Center

Joseph Henderson, Executive Secretary

Mr. Kevin Dinnin, President and Chief Executive Officer, Baptist Child
and Family Services, San Antonio, Texas

# Ms. Brenda Greene, Director, School Health Programs, National Schools Boards Association

Dr. Alexander Kelter, Chief, Epidemiology and Prevention for Injury
Control Branch, California Department of Health Services

Dr. Bobbie Maniece-Harrison, Adjunct Associate Professor, Department of
Health Studies, New York University

Dr. Angela Mickalide, Program Director, National SAFE KIDS Campaign

Dr. Richard Mollica, Director and Associate Professor of Psychiatry,
Harvard Program in Refugee Trauma, Massachusetts General Hospital

Mr. Richard Ricciardi, Chief, Primary Care Nursing, Department of
Ambulatory Care Center, Fort Meade, Maryland

Dr. Peter Rumm, Chief Medical Officer, Division of Public Health,
Wisconsin Department of Health and Family Services

Dr. Jean Wright, Executive Director, Backus Children's Hospital

Dr. Steven Marans was not present.

**Federal Advisors present**

Dr. Robert Amler, ATSDR

Dr. Joanne Cono, CDC

Dr. Loyd Kolbe, CDC

Dr. Larry Pickering, CDC

Ms. Cyndi Shaffer, CDC

Dr. Wanda Jones, DHHS

Dr. Woodie Kessel, DHHS

Ms. Liza Veto, U.S. Department of Education

Dr. Rosemary Roberts, FDA

Mr. Rick Smith, HRSA

Dr. Margaret Feerick, NIH

Dr. Farris Tuma, NIH

# Consultants present

Dr. Claude Chemtob, Mount Sinai School of Medicine

Dr. Louis Cooper, American Association of Pediatrics

Dr. Peter Holbrook, Children's National Medical Center

Dr. David Markenson, Mailman School of Public Health, Columbia
University

Dr. Betty Pfefferbaum, University of Oklahoma Health Sciences Center

**Committee Staff**

Victor Balaban

Amy Loy

# Others

Jeni Schmitt, American Institutes for Research

Heidi Taylor, American Red Cross

Beth Blair

Lisa Barrios

Sonya Hubel.....

Don Dornberg

Paul Simac

Angela Fuzah (contractor)

Dr. Diaz reminded everyone that the next meeting will be May 21^st^ in
Washington, DC, and that the final report is due on June 6.

The minutes had been sent to all committee members, but not everyone had
received or reviewed them. Therefore it was decided to delay approval of
the minutes until everyone could review them.

The agenda for this meeting included presentations of all the committee
members, with discussion of particular issues and specific
recommendations for the Secretary. Presentations covered the following
areas: Schools; Risk Communication and Public Education; Primary Care
Pediatricians, Office-based Practice and Urgent Care Centers; Community
Involvement; Training; Mental Health Response Phase; Mental Health
Recovery and Mitigation Phase; Public Health Departments, Government
Agencies/Government Role; Surveillance and Assessment Mechanisms; and
Pre-Hospital and Critical Care and Hospital Preparedness. The goal was
to reach consensus on ten to twenty recommendations. The report
submitted to the Secretary will be a short document, with clear
recommendations and actions. There will also be a larger document with
all the details and rationales supporting the recommendations. This
larger document will be part of the public record, together with the
short document.

Dr. Diaz asked whether there was any new business and there was none.

Before the individual committee member presentations, there were two
other presentations.

# Overview of Strategic National Stockpile Program

# Dr. Nicki Pesik, The Strategic National Stockpile Program, Centers for Disease Control and Prevention

# 

The mission of the Strategic National Stockpile is to delivery medical
materiel to the site of a national emergency. The program components
include logistics, operations (planning, coordination and security),
science (medical, clinical and pharmaceutical oversight of formularies),
program preparedness (state planning for receipt, delivery and
distribution), knowledge management, and program integration.

Emergency response has three components:

-   Provide rapid delivery of a broad spectrum of support for an
    ill-defined threat in the early hours of an event, including the
    12-hour Push Package.

-   Provide large shipments of specific materiel when a threat is known.

-   Provide technical assistance to receive and distribute Program
    materiel during an event.

The 12-hour Push Packages are scattered through out the United States.
Each is identical and contains a broad range of materiel, including
bandages, IV supplies, burn treatment, antidotes, antibiotics, and much
more. They are guaranteed to arrive within 12 hours of request, by air
or by land. For specific items, the CDC maintains a Vendor Managed
Inventory (VMI), which sits in manufacturers' warehouses even though
owned by the NPS (National Pharmaceutical Stockpile Program).
Manufacturers rotate inventory constantly so that there is also fresh
product on the shelves. There are also repositories of vaccines
throughout the U.S. The Veterans Administration Acquisition Center
partners with the CDC for rapid purchase of items, such as respiratory
masks, at the lowest possible prices.

Rapid deployment is possible because the material is pre-packed and
configured in color-coded transport-ready containers, which are stored
in secure facilities near major transportation hubs. They are delivered
by world-class transporters, such as UPS and FedEx.

The formulary has evolved over the years in response to new treatments
and threats. Based on recommendations from experts regarding Category A
threat agents, it contains treatment for smallpox, anthrax, botulism,
viral hermorrhagic fevers, plague and tularemia, as well as chemical
nerve agents. It also contains medical supplies and equipment and
vaccines. Each Push Package can provide 34,400 children under the age of
five with post-exposure prophylaxis, 4000 5-day doses of ciprofloxacin
suspension, 4000 7-day doses of doxycycline syrup, and 25,400 10-day
doses of chewable amoxicillin tablets. It also has equipment in
pediatric sizes, such as ventilators, emergency airway equipment, IV
equipment and supplies, antibiotic formulations, and medication delivery
systems.

General Recommendations

The SNS committee met on April 29^th^ and came up with 18
recommendations for the Advisory Committee on Children and Terrorism.
Those can be summarized as follows:

-   The Committee recommends that a regular review process by subject
    matter experts of the SNS program be established to ensure continued
    and enhanced pediatric capability and capacity.

-   The Committee recommends that a formal process be established to
    determine prioritization of recommended formulary additions and
    modifications to maintain and enhance pediatric capability and
    capacity.

The Committee recommends:

-   That the SNS program increase the public visibility of the pediatric
    capabilities of the program.

-   Evaluating purchasing mechanisms for pediatric-specific equipment

-   That state and local communities evaluate their pediatric equipment
    and medical inventories and capacities to treat pediatric patients
    and coordinate this assessment with neighboring states

-   That state and local communities review the distribution plans for
    pediatric-specific equipment

-   That state and local communities \[allocate\] time and staff for
    distribution and administration of pediatric resources

-   That a working group be created to develop a list of emergency use
    INDs needed for treatment of the pediatric population for events
    involving biological, chemical or radiological agents.

-   That a working group be created to review pediatric treatment
    protocols for events involving biological, chemical or radiological
    agents. The primary goal is achievement of a national standard for
    treatment protocols.

-   That specific data for the pediatric population be obtained through
    future research on the impact of disasters on the pediatric
    population and more specific population demographics of communities
    (currently 2000 U.S. census data is used)

-   An annual review of the SNS formulary content for pediatric
    capability by subject matter experts

-   That tetanus toxoid for emergency use is included in the strategic
    planning of the NPS.

Formulary Specific Recommendations

The Committee recommends:

-   That the SNS program use 9 years of age as the cutoff age for
    determining the requirements for antibiotic suspensions. The
    committee favors antibiotic suspension formulations over chewable
    tablets.

-   That the 12-hour Push Package be designed to have pediatric-specific
    containers, to assist in distribution

-   Review of Epogen for treatment of anemia secondary to trauma to
    reduce the need for blood transfusions.

-   Inclusion of cytokines for treatment of radiation-induced
    neutropenia

-   That sufficient qualtities of thiosulfate for the treatment of 1000
    pediatric patients be added to the formulary

-   That emergency-use IND be developed for Mark 1 Jr Kits

-   That future SNS formulary additions include assets to treat
    burn/blast and radiation injuries. At a minimum these additions
    should be sufficient to treat 2500 pediatric patients.

The Committee strongly supports the addition of the following
pharmaceuticals and medical supplies as identified by SNS pediatric gap
analysis, and SNS burn/blast and radiation review:

-   Additional airway management equipment

-   Medication Delivery Systems such as spacers and masks

-   Additional ancillary supplies for IM administration of medications

-   Alternative sedatives and analgesics

-   Additional IV antibiotics

-   Alternative concentrations of intravenous antibiotic solutions.

Questions and comments:

Dr. Diaz noted that these recommendations would need to be prioritized,
depending on the specific threat/response.

Dr. Pickering asked whether these products were all in storage and Dr.
Pesik explained that some were for emergency use only, while others are
used constantly and can be rotated out by vendors, sold, and replaced
with fresh stock. The NPS Program participates in the FDA shelflife
extension program. Some drugs are stable past manufacturer expiration
dates, so the military developed ways to test drugs for continuing
potency. If they meet standards, the expiration is date extended.

Dr. Pickering asked whether this program was just for civilians, or
included the military. Dr. Pesik explained that the DOD has its own
stockpile, but there is a great deal of coordination.

# Emergency Medical Service Systems and Protocols

# Dr. David Markenson, Director, The Program for Pediatric Preparedness, Mailman School of Public Health, Columbia University

EMS training occurs at the following levels:

-   Certified first responders get CPR training only, with limited
    concentration on how to treat children

-   EMT Basic is a 110-hour training program, with six hours of
    pediatrics.

-   EMT Intermediate includes limited pediatric training, which may
    include airway levels and intravenous access. Some medications are
    also discussed.

-   EMT Paramedic training has one whole module devoted to pediatrics,
    but the time spent on this module is variable. Most states use
    existing coursework and add pediatric component/topics.

The first priority is to make sure there are resources for general care
of children, then focus on terrorism-specific care.

The EMSC program was created in 1984. Its mission is "to reduce child
and youth mortality and morbidity sustained due to severe illness or
trauma. It aims to ensure state-of-the-art emergency medical care for
the ill or injured child and adolescent; to ensure that pediatric
service is well integrated into an emergency medical services system
backed by optimal resources; and to ensure that the entire spectrum of
emergency services, including primary prevention of illness and injury,
acute care, and rehabilitation, is provided to children and adolescents
as well as adults."

The ultimate goal of EMSC is to save the lives of children and
adolescents. Several secondary goals relate specifically to disaster and
terrorism preparedness for children:

-   Goal F: Ensure that integration of health services meets children's
    needs.

-   Goal H: Include pediatric protocols in medical direction for all EMS
    agencies

-   Goal K: Improve pediatric emergency medical services through public
    education

EMSC has been developing model pediatric protocols. A review of the
literature on pediatric EMS found that existing protocols were extremely
limited, mostly epidemiological and with no outcome data. There was some
data on cardiac arrest and recent data on fibrillation in children. The
National Consensus Conference of Stakeholders included professional
medical organizations, firefighters and EMT organizations, national
registries, and other national programs. General issues addressed
included medical control, regional variation and BLS vs. ALS. Model
protocols developed will now be reviewed and distributed. Revision will
be ongoing, based on new technologies and literature, and new protocols
will be developed around new topics.

Recommendations:

1.  The Secretary should support and enhance the existing HHS programs
    which assure that the needs of children and met in the EMS system
    through:

    -   Increased funding to the EMSC Program to allow for enhanced
        activities related to Emergency and Terrorism Preparedness via:

        -   Creation and distribution of educational program and
            resources for EMS providers related to pediatric emergency
            and terrorism preparedness

        -   Revision of the Model Pediatric Protocols to include
            protocols for Emergency and Terrorism Response based on the
            National Consensus Conference

        -   Targeted issues grants focused on emergency and terrorism
            preparedness

        -   Development of mental health resources for EMS providers
            including triage tools and information regarding the
            importance of mental health in emergency and terrorism
            preparedness and response

        -   Increased program staff to provide support and consultation
            to state, territorial and tribal EMS offices, professional
            organizations and EMS providers

-   Integration of the EMSC program in all HHS emergency and terrorism
    preparedness cctivities

-   Assurance that all HHS emergency and terrorism preparedness
    activities that involve EMS require that pediatric considerations be
    included in these efforts.

2.  The Secretary should increase funding for research on EMS pediatric
    emergency and terrorism preparedness and response via:

-   Establishing as an MCHB research priority EMS pediatric emergency
    and terrorism preparedness and response

-   Establishing, in the form of RFP and RFA from NIH and its
    institutes, research funding for studies related to EMS and
    pediatric emergency and terrorism preparedness including triage,
    assessment, and treatment, including mental health

-   Creating mechanisms for pediatric emergency and terrorism
    preparedness research gaps identified by the EMSC program to be
    funded.

# Discussion

Dr. Rumm commented that it is hard to get money from state legislatures
for EMS. An important question involves the legal authority of
non-physicians to give medications, which is often a county decision.

Dr. Markenson said that PALS was originally designed as a
hospital-specific intervention, and it was modified for the EMS
community. The PALS program has now been supplanted by other programs.
More federal direction would be useful, but still maintain state
physician-licensing. He would prefer that the emphasis be on pediatric
capability first, with EMS capability second.

Dr. Mollica noted out that many people see EMS workers as invaders
coming into complex communities with complex social norms. He asked
whether EMS workers should try to be mini-pychiatrists, especially when
responding to situations where families are in acute distress. Dr.
Markenson replied that studies show pediatric emergencies exceed adults
emergencies in stress levels, however EMS providers' first priority is
to stabilize the situation, assess, treat and transport the patient.

Dr. Mollica asked whether EMS workers ever do any follow up. Dr.
Markenson replied that in cases where child abuse is suspected, EMS
workers should at least have the ability to assess risk levels so that
appropriate information is transmitted to ER staff. Mr. Ricciardi added
that EMS personnel are trained to ensure safety (including their own)
rather than sorting out mental health issues.

# Schools

# Brenda Greene, Director, School Health Programs, National Schools Boards Association

# Overarching recommendation

It is incumbent on the U.S. Secretary of HHS to ensure that each major
content area in DHHS-funded terrorism initiatives, and in federal
initiatives in which DHHS in a partner, addressed the role of schools.
These programs should require through regulatory and fiscal oversight
that states and local health departments, and other agencies involved in
this work, truly build partnerships with state and local education
agencies and schools in order to meet standards.

# Supporting Recommendations 

-   Revise the **Federal Response Plan**, indicating the need for
    schools to be an integral part of preparedness, response, recovery,
    and mitigation efforts.

-   Site visits by CDC to states to provide technical assistance in
    implementing Cooperative Agreement Awards for **Public Health
    Preparedness and Response for Bioterrorism**, specifically to review
    efforts to include educational agencies in the planning process and
    to meet the needs of schools. Funding should also be provided to
    bring educational agencies into the planning process.

-   As the *Model Public Health Act* is currently being revised, add
    language indicating the need for schools to be an integral part of
    bioterrorism planning.

-   Recommend to states and territories funded through the HRSA
    Bioterrorism Hospital Preparedness Program that state and local
    education agencies be invited to participate in Terrorism
    Preparedness Planning Committees.

-   Assure that all funding for disaster mental health services allow
    for funding of school mental health and counseling.

-   Ensure that HHS research agencies conduct and support new research
    on post-disaster children's mental health that study the
    effectiveness of school-based interventions.

-   Integrate schools with public health surveillance programs that
    allow for trends in increased disease incidence and early detection
    of possible chemical, biological, or radiological terrorism.

-   [Revise state & local Plans to include [surveillance]{.underline}
    methods for schools, day care facilities and other venues for child
    care.]{.mark}

-   All DHHS agencies which develop materials on the handling,
    identification, response, and decontamination for acts of chemical,
    biological, and radiological terrorism must include consideration
    for children in schools and, when appropriate, provide any
    educational materials in a format directed toward schools.

-   Develop school-specific information related to preparedness for
    biological, chemical, radiological, and mass trauma terrorist
    events, place this information on the CDC bioterrorism and mass
    trauma websites, and make it available to schools using their
    preferred delivery methods.

-   [Assure that school-based [mental health]{.underline} services are
    part of a network that provides not only outreach but also triage
    and referral to those with specialized training and expertise who
    can offer more comprehensive and intensive treatment. These linkages
    can and should be established pre event.]{.mark}

[]{.mark}

Discussion

Dr. Rumm endorsed the idea of linking schools with public health, but
cautioned that without funding there can be no coordination. Ms. Greene
agreed that there is never sufficient funding, but that this is a
significant recommendation and there are models in other states. Dr.
Kolbe informed the group that DASH has been trying to build the capacity
of state health and education agencies to work on health problems
together. They have funded 20 states over the years and are working to
get funding in 2004 budget. Dr. Rumm recommending encouraging the DHHS
to support a position in each state to work with the Department of
Public Instruction.

Dr. Modzeleski noted that the recommendations should be written in
plainer English, with more specificity and fewer vague terms and
platitudes. The recommendations should be presented in terms of actions.
He also suggested making sure schools are specifically linked into the
recommendations. In other words, they need to be involved in developing
training modules. Finally, he pointed out that there is a role for
students in terrorism, and a role for parents in health and
bioterrorism. This should be clearly articulated.

Dr. Rumm wondered whether there were legal issues around quarantining a
pediatric population. Dr. Mollica noted other issues related to the
post-terrorist period, e.g., assistance for families damaged by
terrorism, disruption of schools, and children infected by disease who
would need home care and education. Dr. Modzeleski pointed out that
there is never enough money in education budgets for major catastrophes,
including alternate sites for education or home education. Ms. Greene
commented that although one can never anticipate the details, planning
and relationships can be set up in advance.

Dr. Mollica brought up the issue of resiliency and that keeping children
in school is therapeutic. He also underscored the role of parents and
children as ombudsmen and the importance of asking children about their
feelings and needs.

Dr. Modzeleski felt that there was nothing wrong with recommending that
the Secretary of HHS work with the Secretary for Education. All federal
agencies have a responsibility to expand their roles around children in
recovery, preparation, mitigation issues.

Dr. Kessel commented that since history classes teach about world
conflict, preparedness could be incorporated into the education domain,
in terms of understanding violence and conflict in the world. Long-term
preparedness and prevention is about education.

Dr. Holbrook was concerned there were too many micro recommendations. A
recommendation that one of best things for the mental health of children
is to get them back in school as quickly as possible seems to be a macro
recommendation and a principle around which state and local communities
could frame their actions. Dr. Kolbe thought this was an excellent idea,
but it was not a recommendation that could be acted on by the Secretary
of HHS. Dr. Modzeleski stated that the issue was how to get children
back into a routine. Schools may not be able to open, but that's where
faith-based communities, youth services can play a role. Ms. Greene
asked the group to think about having an overarching vision for the
Committee's work, which might include getting children back into
routine.

Dr. Chemtob pointed out that in a disaster teachers often become
non-traditional first responders and then have to come back to work,
even though their own families are often affected. Teachers need
instruction in emergency management. There needs to be a more rapid
funding mechanism to support recovery, and a mechanism to support
schools in how to deal with mental health issues.

Dr. Malkenson noted that the Office of Emergency Management never
considers schools as an integral part of the emergency planning process.
School issues around transportation and sheltering considerations all
require integration with other emergency planning and management.

# Risk Communication

# Angela Mickalide, PhD, Program Director, National SAFE KIDS Campaign

# Remarks

There are many consistent themes in materials on risk communication to
parents, including: maintain the daily routine, avoid exposure to the
media, and anticipate children's questions. But other content varies,
such as how much information to give children and how that relates to
age level and maturity. None of the materials seem to be
research/evidence based, and there is no guidance on how to disseminate
information to parents or which messages have most relevance and
clarity.

# Recommendations

-   Encourage federal agencies and national organizations to develop
    clear, concise and consistent and situation-specific guidance for
    parents concerning helping children to cope with terrorism

-   Encourage all stakeholders to disseminate the same information to
    parents via websites, print materials, public service announcements
    and other communication channels.

Discussion:

[Mr]{.mark}. Henderson noted that there are 31 centers of public health
preparedness funded by CDC at universities, and that it would be
important to assure that those institutions are deriving communication
messages.

Dr. Tuma pointed out the importance of concrete, scenario-specific
messages and guidance. The risks are different for every event and
messages about self-care are different from those about information
shared with children. NIMH and SAMSA are looking at different scenarios
and developing messages based on what is known about decision-making
behavior. He recommended building in additional detail that is situation
specific.

Dr. Kolbe said that communication should allay parents' concerns
regarding systems being put into place. Parents need to know what will
happen at schools in the event of an emergency, whether children be
locked in or sent home, cell phones may not work, etc.

Dr. Kessell noted that in addition to message and content, it is
important to determine who is best positioned to deliver and reinforce
messages. Individuals like the late Fred Rogers are can be very
important. There are multiple issues about style, sensitivity, and
credibility of communicators. When television is interrupted with
breaking news, who is the voice?

Ms. Schmitt gave some information about a course that has been developed
by the American Institutes for Research on writing and communicating
messages. It addresses the issue of the best voice to communicate public
health messages during a crisis.

Dr. Kelter stressed that messages need to be prepared in advance because
emergency response is always local.

Dr. Modzeleski felt that the conflict between closing schools or using
them as shelters was a primary issue to be addressed. What is the
message to the schools? How will parents react to keeping children in
schools? Messages from public health, law enforcement and schools have
to be consistent.

Primary Care Pediatricians, Office-Based Practice and Urgent Care
Centers

Dr Angela Diaz, Director, Mount Sinai Adolescent Health Center, Mount
Sinai Medical Center

Remarks

Many providers take care of children, and all have to be involved in
preparedness. Children have different needs\--developmental,
psychological, emotional and social. Adolescents have very different
needs from smaller children in reacting to trauma, but teenagers are
often left out of discussions about pediatric needs. The special needs
of children have not been addressed in preparedness in the past.
Children have fears and parents have fears for their children. The
commitment to children's safety is universal. Finally, it is important
to remember that first responders have children and emotions too.

Recommendations:

-   Ensure that there is universal insurance coverage for all children
    and that every child has a medical home with a primary care
    pediatric provider who provides services in a bio/psycho/social
    manner to assess the needs of children and ensures that all these
    needs are addressed in a holistic manner, with an emphasis on
    primary prevention.

-   Ensure and make provisions for the primary care pediatric provider
    to be involved in all stages: planning and preparation; first
    response to identify, triage, and treat the special needs of
    children in the acute phase; providing ongoing care in a holistic
    manner; and participating in the healing process of the community
    after the event, capitalizing on the strengths and resiliency of all
    those involved.

Discussion

Dr. Rumm noted that the AMA's call for universal medical access relates
to this recommendation. He suggested there could be a mandate that in an
emergency situation, all children/families are covered by some kind of
funding.

Dr. Diaz elaborated on the recommendations, saying that when a child has
a medical home, it is an easy place to go with questions. Emergency
rooms are overwhelmed in a crisis and have to provide medical, social
and psychological services. Pediatric providers have to be able to
assess all needs and provide holistic care. Providers should be involved
in all phases, from planning to first response to ongoing services to
helping community health, taking into account resiliency of community.

Mr. Ricciardi worried that spending so much time on disaster
preparedness without universal health care coverage seemed to be a
disconnect.

Dr. Jones noted that a major focus of this administration is expanding
community health centers and wondered whether they were captured in this
recommendation or somewhere else. Dr. Diaz replied that the
recommendation is to link all providers and centers because the
pre--event status of the child determines his or her outcome after the
event.

Dr. Mollica wondered how the first recommendation would deal with the
fact that many adolescents don't see pediatricians. Dr. Diaz replied
that the wording needs to be "children and adolescents" and this must be
consistent. Mr. Ricciardi added that it would be even more accurate to
say "children, adolescents and young adults."

Dr. Diaz pointed out that adolescent health care goes up to age 21, but
there are legal differences between those under age 18 and those over
18. Dr. Cooper added that there were other statutes to consider as well,
such as Medicaid.

Dr. Amler told the group about a network of specialists (general
pediatricians, toxicologists, environmental health and medicine) formed
at ATSDR to discuss clinical problems of children living around waste
sites. After 9/11, they fielded phone calls regarding exposures around
the WTC, such as asbestos. It would be useful to have such units placed
around the country.

Dr. Kessel noted that when children that are healthy, fully immunized,
and screened, they are more resilient and able to deal with threats.
Prevention is the best means of preparedness.

Dr. Roberts pointed out that one goal is to have approved products in a
stockpile for children, but the issue of getting permission from parents
has to be considered. Dr.

Cono added that this is a problem whenever children are separated from
their parents, so part of preparation is amassing information to
facilitate contact with parents. This includes first responders during
disaster events. Standards and procedures must be in place for their own
families so they can pay attention to their activities. Dr. Diaz
suggested expanding the recommendations to include all providers of
services for children.

Community Involvement

Kevin Dinnin, President and Chief Executive Officer, Baptist Child and
Family Services, San Antonio, Texas

Remarks

There should be a national spokesperson to reassure families the way the
First Lady did after 9/11. She encouraged families not to let children
watch all the media coverage. The majority of families have little
understanding of the difference between real vs. perceived threats.

Even with separation of church and state, faith-based organizations want
and expect to be involved, and are often first responders themselves,
but coordination can be a challenge. The majority of clergy not prepared
to respond. However they can offer mental health advice, and have as
much information in this area as EMTs.

Volunteer organizations need to be inventoried regarding their
capacities and resources.

Government social service agencies have legal responsibility for
children, in such areas as emergency shelter and guardianship issues.
Childcare facilities not equipped to shelter and place children;
childcare workers will want to go home to their own families, but they
often have inadequate contact information about alternate guardians if
parents are unable to pick their children up.

# 

# Recommendations

-   Develop support and training for pastoral and volunteer counseling

-   Provide small grants to facilitate meetings among faith-based and
    volunteer organizations and other community agencies.

Discussion

Dr. Makilide said that training protocols for faith-based organizations
should be developed first, and that they should be ecumenical in nature.

Dr. Rumm pointed out that there is never enough funding at the state
level when children and ethnic issues are involved. It would be better
to have small grants to bring organizations together at the local level.

Dr. Feerick outlined some training issues, such as mental health,
trauma, response to disaster, and coping activities, such as vigils.
Churches play a huge role in public information/communications. People
go to church even when they can't afford doctors.

Dr. Cooper noted that the CATCH program gives small grants to
pediatricians and communities to do outreach. They have been successful
in mobilizing beyond the pediatric community, including the faith-based
community. The emphasis should be on local organizations, ministers and
interdenominational organizations, together with hospitals.

Mr. Henderson commented that community preparedness is about bringing
people to the table and deciding who has the responsibility and
authority to fill in gaps in the plan. The Secretary could help to
enable those linkages at community level as related to special needs for
children.

Dr. Amler emphasized that people want to know who to call in a disaster.
That contact is different in every community, and depends on the
scenario. However there are always commonalities and table-top exercises
are useful to determine some of the responses needed in any scenario.

Dr. Mollica referred to the refugee community, which has been
traumatized and does not always see health as a social good. It can be
difficult to link primary care providers with refugee communities.
Health promotion is a community responsibility, but it would help to
fund the refugee communities themselves to promote health. Those people
with less access to mental health care are more apt to use the clergy,
however, the clergy often have no financial support or training. They
are often pushed aside by professional mental health people, even though
over 90 percent of the population turns to the clergy during a crisis.

Dr. Kessel reflected that in times of crisis communities summon strength
and eliminate barriers and wondered how those strengths could be
fostered prior to a crisis. In CT and NC, small seed grants enable
communities to come together to think about prevention. This leverages
and links talent, expertise and resources, adding to community
resilience and support before rather than after a crisis.

Dr. Harrison suggested looking at community health centers, which are
already forming response teams trained by experts, and training
community people in how to respond to emergencies. A pediatric component
could be added.

Dr. Malkenson pointed out that the real first responders are people in
the community. If given the tools, funding and resources to respond,
they can take care of themselves, their relatives, neighbors and
friends.

Dr. Chemtab informed the group that FEMA has established 10
demonstration projects for disaster assistance. He proposed similar
demonstration projects for building psycho-social and terrorism
preparedness in communities.

Dr. Kolbe wondered to what degree communities' formal government
structures and the current preparedness infrastructure could be
involved. It would be useful to develop templates for bringing the
public sector response together with the private sector, volunteers, and
faith-based organizations.

Dr. Cooper said that the best way to prepare for terrorism was to build
on fundamental health infrastructure. The process may be more important
than the structures themselves. CATCH showed how to empower AAP
physicians to go out and talk to the community.

Mr. Henderson reminded the group that 120 cities in the U.S. received
Metropolitan Medical Reponse funds, which is now part of Homeland
Security. He suggested that MMRS funding contracts could include
empowering local communities to respond to the special needs of
children.

Dr. Roberts asked whether the committee was addressing children in
juvenile detention system. Dr. Diaz responded that there was a session
on children with special needs, but Dr. Chemtab explained that this was
about special-needs children in schools.

Training

Dr. Bobbie Maniece-Harrison, Adjunct Associate Professor, Department of
Health Studies, New York University

Remarks:

Training must be addressed at every level of bioterrorism planning.
Content has to be specific for different professionals. Training should
include: protection of oneself, protection of the hospital environment,
resources (equipment and human), and when to request defense medical
assistance teams and national strategic stockpiles. Content should be
organized so there is coordination among entities responding to a
bioterrorist attack (who is in charge, channels of communication, roles
and responsibilities, training for first responders\--school personnel
or parents and people in the community).

Training should be consistent, up to date, and organized so it can be
accessed from a number of sources and on trainees' own time.

Recommendations:

-   Incorporate training into all disaster planning, at different levels
    of providers and responders, with accurate, appropriate, up-to-date
    information.

-   Review training already going on and add or enhance the pediatric
    component in existing training programs.

Discussion:

Ms. Schmitt informed the group that American Institutes for Research and
CDC have developed training curricula on communications, which is
offered free to state and local health departments, and other
organizations. AIR can go out and conduct training. They have added a
scenario where children are quarantined, with information on how to
communicate that to children and parents.

Dr. Amler suggested that training is much more effective when
accompanied by drills. There is no way to write down what everyone has
to do in a complicated scenario. Drills gives people confidence. Second,
he noted that there are vehicles already in place to reach certain
groups, such as the American Academy of Pediatrics. Third, specialty
units have trained pediatricians in environmental topics such as lead
poisoning, pesticides, etc.

Dr. Maniece-Harrison commented that didactic and simulated drills are
needed, in the medical community as well as in communities and schools.
Some schools are already doing evacuation drills with children. A
long-term goal is to incorporate bioterrorism training related to
children into the medical school curriculum. Dr. Amler added there is
already an effort to get terrorism training into medical schools, so we
just need to ensure that pediatrics is included.

Dr. Rumm pointed out that no one has assessed pediatric preparedness.
The first step is assessment of communities, local health, and states to
see what people are not being trained in. Ms. Shaffer added that
training must be offered to everyone involved in pediatric response,
emphasizing how they are an integrated team.

Mr. Ricciardi noted that training has to include academics as well as
those with on-the-ground experience. The military has extensive training
courses in disaster preparedness, including field exercises. The
American Academy of Pediatrics has a humanitarian assistance course,
which could be modified. Vanderbilt University has an international
nursing coalition for disaster preparedness, with a set of core
competencies.

Dr. Kessell emphasized that special needs of pregnant and post partum
women must be included.

Ms. Taylor informed the group about some Red Cross resources that are
specific to schools. The Facing Fear curriculum specifically deals with
terrorism. Information could be folded into existing CPR and First Aid
Training. The Red Cross can provide training programs and help develop
materials. Dr. Maniece-Harrison added that the Red Cross has people
trained to educate communities about disaster preparedness.

Mr. Henderson asked whether training was a separate issue or part of all
components. He cautioned the committee to be clear about who needs to be
trained and what competencies are required. Some people in the community
have received no training in terrorism response, such as community
health centers, which makes assessment very important.

Dr. Maniece-Harrison wondered how much training children should receive
as victims.

Mr. Smith explained that HRSA's training priorities include education
and preparedness training for adult and pediatric hospitals, out-patient
clinics, and pre-hospital health care professionals responding to
terrorist events. Pediatric needs are included throughout. Part of the
task is needs assessment, and part is estimating numbers of pediatric
patients to prepare for. These training needs can be met through
partnerships.

Mr. Riaccardi commented that children and adolescents can be first
responders among themselves too. How can we train adolescents in schools
to care for their peers and teachers?

Dr. Reissman commented that children might go to primary care providers
with increased symptoms and risk behaviors, but the office might not
know what the stimulus was. Clinicians need a set of questions to ask.
Dr. Diaz added that having a psycho/social history is key.

Dr Kolbe said that pre-service training was another issue, as applied to
each profession. It is difficult to fit disaster preparedness into
pre-service training because of competing curricula, but it should
become imbedded in nurses or physicians or teacher education and be
viewed as an integral part of their profession, rather than an add-on.
Dr. Malkerson responded that one of his recommendations was to make
disaster response a priority and a core competency in pediatric
training.

Dr. Amler noted that training is fundamentally very empowering for
adolescents, like CPR training or boy scouts. Let them become part of
the solution, not just victims. Also, sometimes the best training is
that which piggybacks on existing knowledge.

Dr. Chemtob tried to summarize the discussion, saying that parents,
providers, first responders, and non-traditional first responders all
have general everyday roles, so we're talking about expanding their
roles focused on specific emergency response in disasters. One way to do
this is through existing organizations and core competencies. A second
focus should be on collaborative skills, working with people brought
together into *ad hoc* teams by necessity. The third task is
dissemination, using existing groups. However he cautioned that research
shows training has little effect, so a recommendation is to do research
to evaluate training effectiveness. The role of HHS is to provide
infrastructure to develop, disseminate and evaluate these role
extensions. We are talking about training system enhancement to support
existing structures.

Dr. Kolbe asked what the likelihood of pre-service training would be if
the likelihood of terrorism was small. Training should perhaps be for
emergency preparedness, not just terrorism. Dr. Chemtob added that most
people in the civilian sector don't want to think of themselves as
needing competencies in terrorism.

Mental Health Response Phase

Dr. Steven Marans, Harris Associate Professor of Child Psychoanalysis,
Yale University School of Medicine, presented by Victor Balaban.

Remarks

Mental health must be represented in pre-event planning and preparation.
Interagency agreements should be formalized as part of the planning
process. A primary aim of instituting new partnerships is to determine
in advance, capacities and deficits of each provider/responder group
prior to the advent of critical, potentially traumatic events.

Training in mental health disaster management and treatment is needed by
many professionals in many disciplines who will respond to children post
event. These include emergency management first responders, primary care
mental health, schools, clergy, and the media. In order to maximize
their acute response effectiveness, acute response providers will need
cross-training and familiarization with principles of child, family and
community responses to trauma. The best response to trauma is a local
response and cross disciplinary. Disaster mental health should be
incorporated into clinical training of all mental health disciplines.

Training content should include disaster mental health organization,
management and coordination; response issues and considerations (safety
and security, meeting basic needs, obtaining disaster assistance,
evacuation, reuniting families, quarantine, and public education);
physical reactions and safety, distinguishing symptoms from a biological
or chemical agent from those associated with mental conditions; the
range of acute trauma reactions; ability of parents and other adults to
assess response of children; mental health interventions; and others.

A mechanism for establishing credentialing should be built into the
recruitment and training of mental health first responders and
implemented well before any critical event. National qualifying
standards would be useful in identifying and registering mental health
professionals who have had significant experience and training in
responding acutely to events involving violence, terror, disaster and
mass casualties.

School-based interventions must not supplant efforts to identify, refer
and treat children in need of more traditional and intensive treatment.
School-based services should be part of a network that provides not only
outreach, but also triage and referral to those with specialized
training and expertise who can offer more comprehensive and intensive
treatment. These linkages can and should be established pre event.

Federal guidelines and regulations regarding use of funding should be
examined and modified to increase flexibility with respect to services.
A longer period of service with specialized treatment services may be
needed to address terrorist victims.

Existing programs potentially provide a needed source of clinicians to
assist in the planning process pre event, in disaster mental health
training, and in service delivery and supervision post event.

Recommendations

-   Determine the role of mental health providers in the immediate
    aftermath of disasters

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-   There is a tremendous need for basic knowledge about appropriate
    treatments and interventions that support resilience. Mental health
    outreach and triage should be connected to surveillance, so
    information can be translated into program development.

A third commendation is using a standard of passive parental consent in
the limited circumstance of federal or state disaster to facilitate
screening and identification of children in need, however the committee
recommends retaining the requirement for active consent prior to
referral for actual service provision.

Discussion

Dr. Chemtob provided information about a recent study of downtown middle
school children in downtown NYC (Ground Zero area). Researchers had to
use active consent with incentives just get parents to return forms.
Still they were able to screen only 10% of children and of those, 20%
met the criteria for post traumatic stress. Of those, only one in three
received any services. So of 9000 children who were never screened, a
minimum of 10% needed but never received services. Schools are afraid of
being sued, but they are freer to do screening than mental health
providers.

Dr. Rumm turned the discussion to trying to pull out action steps. He
liked the idea of registries and credentialing. This is related to
response, it is dramatic, on site, and gets teams on the ground.

Dr. Reissman cautioned that when talking about outreach, triage and
referral, there should be a connection with surveillance. When there is
a disconnect between screening and surveillance, it's hard to transfer
information to drive program development.

Dr. Tuma noted that even if all the human and material resources are in
place, there still may be questions about effectiveness. More needs to
be known about how to promote resilience and what treatment and services
to being to bear and when, in order to prevent severe psychological
reactions. He recommended trying to close the knowledge gap by
identifying what resilience is and how it can be bolstered at different
levels, and also to close the gaps between primary, secondary and other
interventions.

Dr. Jones felt there was a need to include developmental aspects in the
recommendations.

Dr. Mollica pointed out that mental health always seems to support other
responders, as opposed to interventions that will help prevent post
traumatic stress down the road. He wondered about the role of formal
psychiatric providers' assistance at the moment of a disaster. Theirs is
mostly a support and training role; they don't rush in and provide
assistance.

Dr. Tuma wanted to include recommendations about the right time to get
out of the way and when to have screening processes in place.

Dr. Pfefferbaum pointed out that different people play different roles
at different times and there needs to be acknowledgment of special
expertise.

Ms. Greene brought the discussion back to the issue of needs
assessments, to determine what problems children have and what issues
they present. What does mental wellness in children mean? Let needs
assessments drive the funding and prioritization.

Dr. Dinnen felt that the discussion was too focused on the locale of the
event, whereas it might be important to equip local communities in how
to communicate better. He also wondered if the committee should be
looking at global action as well as local.

Dr. Chemtab noted there had been no discussion of the role of the media,
which is a major instrument of psychological recovery. Dr. Pfefferbaum
acknowledged that the media can be used for the benefit of public as
well as its detriment. Many opportunists appear on the scene of a
disaster, which creates the need for credentialing and weeding out those
who could be detrimental.

Dr. Kolbe offered some YRBS data about whether kids feel safe at school;
before Columbine 4% felt unsafe, after Columbine the percentage rose to
10%. He thought there should be a recommendation for surveillance
systems for mental health of children, primarily for pathologies such as
post traumatic stress disorder, anxiety, and depression, but also how
kids feel generally about living in this society.

Dr. Reissmen added that surveillance and communication should be
connected, in order to understand people's beliefs going into the
response. Any surveillance of developing symptoms has to be connected
back to resilience and mental health. Mental health is hard for people
to get their hands around, but there are concrete things that can be
done around mental health and keeping children well.

Dr. Kessell suggested that the Department of HHS have a working group on
mental health issues. This area needs very careful language specificity
re mental health, behavior, care, and how do to intervene on the
continuum of mental health. It can be complicated talking to children
because we don't know enough about normal behavior. They might only need
a hug when we are concerned with post-traumatic stress and illness.
Children's responses may be appropriate for their age.

Dr. Holbrook asked whether there were enough providers to provide the
care we decide children need. Dr. Tuma replied that there was currently
an IOM study asking these questions about capacity and the work force.

Mental Health Recovery and Mitigation

Dr. Richard Mollica, Director and Associate Professor of Psychiatry,
Harvard Program in Refugee Trauma, Massachusetts General Hospital

Remarks:

The Surgeon General is asking whether the mental health system is weak
for children and adolescents. In many communities children don't have
access to mental health services and many children don't have health
insurance.

There is an important distinction between mental health in the seriously
mental ill population and mental health in general public. These are two
different policy discussions.

The indigenous healing system includes primary health care, clergy,
schools and local volunteer agencies and families. Many of these don't
always realize their importance as healers.

An enormous number of children have already experienced violence in
their communities---which is much more serious and real than the threat
of terrorism.

Mexican children think about violence in different way than Chinese---so
we need to recognize cultural diversity and context.

Primary care physicians are stressed out, afraid of anthrax and SARS,
and flooded with people drinking and smoking more, having unsafe sex.
Their issues are much more complex than 9/11 and terrorism.

Studies should focus on symptoms, behavior personality, school
performance, and resilience. We can't go to policy makers and say 80%
children have PTSD, we have to talk about numbers of children flunking
out of school.

Children look different in the psychiatrist's office than they do at
school. We need spiritual and psychological ethnographies on children,
their physical, spiritual, and psychological symptoms, behaviors, and
attitudes.

Even before doing evidence-based research, we have to determine best
practices and deliver action plans to different groups, including
teachers, school counselors and nurses, primary care physician and
pediatricians, families, and clergy.

Training doesn't necessarily lead to improved health care and
performance. Primary health care providers need on-site supervision.
Training is an on-going process. How would we train parents; do they
need hot-lines, ongoing support?

Do we have culturally valid and reliable screening instruments for
identification of problems by teachers, clergy, etc. Many people don't
like screening for mental health. If the best instruments don't fit the
culture, they won't work.

Are there simple basic things kids need to know to protect themselves in
extreme situations?

The issue of needs assessments keeps coming up. However, just polling
teachers, clergy, pediatricians and asking them what they need to deal
with terrorism is too negative. Also, you need data to get money for
interventions.

There are no national guidelines for use of [psychotrophic
drugs]{.underline} for children in emergency situations. Are there any
national studies on antidepressents for kids? Perhaps we should look at
fear and anxiety instead of depression

Pediatricians know practically nothing about
ethno-psycho-pharmacology---i.e., practices in African-American,
Cambodian populations. Most psychotrophic drugs are given to children by
pediatricians.

What about the media's role in giving prevention messages to children
(Sesame Street)?

[S]{.underline}omeone should pay for children's health care in an
emergency even if they have no insurance coverage.

**Recommendations:**

-   There is a need for a financial mechanism to provide post-disaster
    mental health care to all children, regardless of insurance coverage
    or presence of pre-existing conditions.

-   Surveillance of the range of post-disaster mental health outcomes
    must be developed.

Discussion

Dr. Roberts informed the group that the FDA is studying several
antidepressants for children ages 7-17. Prozac is the only one proven
efficacious, for conditions like obsessive-compulsive disorder, but
other studies are underway for other mental health conditions.

Dr. Kessell commented that Hollywood scriptwriters and other media have
indicated they would welcome exchange and dialogue about getting
prevention and other public health messages across, but they are not
sure what boundaries are. There is a precedent for the Secretary to meet
directly with the news media, but no one is sure how to do that.

Mr. Dinnin asked if there was any merit to having a national mental
health communications system. This would be proactive, not just a
website and there would be someone with real knowledge and expertise,
similar to Homeland Security, not just talking heads.

Dr. Rumm recommended finding ways to make studies easier. There will be
other events in the future and we need the power to do these studies.
Mr. Henderson said his experience was that mental health issues are the
first on the table and the first off. There need to be very clear and
specific recommendations around mental health. This can't just be
academic exercise. It would include special needs of children with
pre-existing mental health problems, during the event and post event, as
well as resiliency.

Mr. Henderson recommended combining the two mental health sections into
one, especially because of the need to streamline the recommendations.
Dr. Mollica added that the issue was priority setting. How do we boil
all these recommendations down and prioritize them?

Dr. Rumm commented that it was hard to access all the studies that have
been done and recommended a clearinghouse of federal information and
published studies. There is a committed workforce of psychologists,
social workers, and others who will do the work anyway and we need to
partner with and support them.

Dr. Jones asked whether there was enough data from Oklahoma City and New
York City to understand what the gaps in immediate and longer-term
response were there. Grief counseling is not the same as mental health
counseling. What can we learn from the past? Dr. Pfeffermaum replied
that there was plenty of research that identified the gaps and Dr.
Reissman added that an IOM report on the consequences of terrorism was
coming out soon.

Dr. Chemtob said he felt that the infrastructure was missing to address
and act on these questions. He would recommend to the Secretary that a
network of regional terrorism and disaster-related centers be
established (similar to those established by the American Public Health
Association). Together the two networks could provide research, training
and action foresight.

Dr. Wright pointed out that there were no children at the meeting today,
and recommended going to focus groups with kids, or getting data from
Columbine. Children are often able to recognize symptoms and indicators
in their friends and classmates. Also how can we use children to
mitigate during the response, and as a screening tool? Dr. Kessel noted
that the Sesame Workshop interviewed children before and after 9/11.
This methodology is not as scientific as we are used to---they used open
questionnaires, drawings, etc. But it is very interesting information
and they would welcome collaboration.

Public Health Departments, Government Agencies/Government Role

Dr. Peter Rumm, Chief Medical Officer, Division of Public Health,
Wisconsin Department of Health and Family Services

Remarks:

Public health has three core functions: assessment, assurance, and
policy development.

Recommendations

HHS as the leading health agency should work with other federal agencies
to assure that preparedness at state and local levels, particularly in
the upcoming HRSA and CDC grants and funding, assures action on the
following items:

1.  Comprehensive assessment: Work with ASTA and NAACHO to help state
    and local health departments assess preparedness and at least have
    state results

2.  Commit to schools of public health to focus on physical and mental
    health preparedness for terrorism.

3.  Work with DHS to dramatically increase the number of pediatric DMAT
    teams.

4.  Work on CDC's website to set up separate page on pediatric
    preparedness linked to all other federal and other sites, with a
    24/7 operator available.

5.  Fund in all states a school health officer, who would work with the
    State Department of Education on terrorism preparedness initiatives.
    Part of the funding would support a course on bioterrorism
    preparedness and risk communication.

6.  Develop a web-based network linking all hospitals and laboratories
    so that real time information can be disseminated in an emergency.

7.  HRSA should assess their funding to hospitals in states, regarding
    children's equipment and special needs.

8.  Set up Emergency Medicaid, special needs, quarantine issues.

9.  Strive to find a medical home for all children, possibly using the
    NYC model in the aftermath of 9/11.

10. Reconvene an annual meeting of this Committee for up to three years,
    to follow up on recommendations.

Discussion

Dr. Holbrook commented that one reason DMAT teams haven't taken off is
that people can't see how they are in their best interests. As hospitals
begin thinking more about evaluation and other issues, the teams will
become more central to their thinking. He recommended emphasizing the
creation of pediatric DMAT teams, rather than giving specific numbers.

Mr. Henderson noted that in order to have this Committee reconvene
regularly, it would have to be engrained in an existing institution at
HHS or attached to an official body looking at emergency pediatric
preparedness. There should also be changes in charter, so that children
and bioterrorism is always discussed in the context of other emergency
PH issues.

Surveillance and Assessment Mechanisms

Dr. Alexander Kelter, Chief, Epidemiology and Prevention for Injury
Control Branch, California Department of Health Services

Remarks:

This whole subject should be called health intelligence, based on CDC's
old Epidemic Intelligence Service. In the 1950s CDC stationed
epidemiologists all over the country to detect diseases in case Russians
put E-coli or some other infectious agent into the water system. We have
been assuming the capacity to monitor conditions and diseases that might
be associated with terrorism still exists, but it does not.

The Secretary should commit resources to establish and sustain PH
infrastructure for surveillance, which includes all public and private
health institutions that serve the mental and physical health needs of
the population, including emergency and pre-hospital care, trauma
systems and children's hospitals, and venues where substantial numbers
of people might shelter during an event (schools, nursing homes, major
employers, etc.). The system should be capable of real-time reporting to
state centralized surveillance systems for policy development and
decision making.

Another recommendation is related to research to understand whether the
interventions effective, and what needs to be done to prepare
communities for future events. The recommendation is to embed
epidemiological capacity into all surveillance and response systems, to
document the response and create the scientific basis for conducting
outcome studies

We assume the need for surveillance speaks for itself. We know how to
count cases of E-coli, anthrax or smallpox, but our ability to do
surveillance for mental health outcomes is not well developed. States do
not know how to report on mental health symptoms and conditions, so we
need to recommend to the Secretary that definitions for mental health
conditions and disorders be created.

# Recommendations

-   Commit resources to the establishment of a public health
    intelligence infrastructure specifically to support health needs of
    children, with data made available to policy and decision makers.

-   Emergency planning and response must include the epidemiological and
    analytical capacity necessary to establish the scientific basis for
    outcome studies, direct researchers so hospitals are not
    overwhelmed, document surveillance methods, and recommend mitigation
    methods.

Discussion

Dr. Jones shared her experience in determining the set of common
definitions recently released around domestic violence and categories of
sexual assault. It was very difficult to get all communities to agree.

Dr. Mollica wondered if it would be possible to work backwards, from
surveillance to defining mental health phenomena\--see what the children
are presenting with in the ER and then work backwards. Dr. Kelter
thought this was research rather than surveillance. It would have to be
planned in advance, so a sufficient number of people with research
capacity would be deployed.

Dr. Rumm pointed out that children are more likely to show up at the ER
with diarrhea or vomiting. Having robust surveillance for typical
childhood diseases still is important to keep in mind. Dr. Kelter added
that it was important to have this surveillance as a day-to-day system.
It doesn't work in an emergency if not used, sustained and improved on a
day-to-day basis.

Dr. Kessel was concerned about how to present these recommendations.
There is plenty of data and no information. It is better to start with
applications and what the information will enable us to do, as opposed
to just constantly recommending more surveillance and research. What are
the product, the benefit, the consequence and the outcome? He was
concerned that people at the community level don't know enough about the
conditions, needs and vulnerabilities of children in their own
communities. Public health tends not to know where schools are, schools
don't know where the fire departments are, and we have never integrated
information on resources, assets and vulnerabilities. He cautioned
against using the words "surveillance and assessment" without knowing
how they will make people at the state and community level more
knowledgeable and able to respond. Dr. Rumm responded that they don't
have that kind of data at the local level, which is why assessments are
needed.

Dr. Kelter pointed out that in 1997 people had to be evacuated in
northern California during floods. There was no inventory of where
people with special needs (such as dialysis patients who are cared for
at home) were and what their needs were. Dr. Kessel suggested looking at
other data and information systems and integrating them. Even police
reports can be useful. All data is local and has to be collected at that
level.

Ms Cono mentioned a set of tools called MAPP that has been pilot tested
in several communities. There are instruments for mapping community
assets, survey forms for assessing health status and outcome. These
could be shared and modified.

Another person suggested that a recommendation might be to assure that
children's hospitals and health care centers are incorporated into the
surveillance system. It's also important to know the baseline for cases
being seen. A year ago, when there were rash outbreaks among children,
pediatricians, dermatologists and schools nurses contacted state health
departments, who in turn contacted CDC's bioterrorism unit. This
demonstrates local concern and interest at the local level.

Dr. Markenson commented that part of the recommendation is to support
existing surveillance systems and noting unusual clusters of symptoms,
illness and behaviors. Funding existing public health surveillance
systems would help improve terrorism capability. We might not need new
systems if we can replicate federal level systems at the state and local
level.

Mr. Henderson agreed that it would be a good idea to collect information
to support actions. In disease surveillance, what are we doing
specifically for children? Where and how do we recognize when children
are symptomatic or victims of terrorism in schools? Schools have to
recognize symptoms and know whom to call first. What is unique with
children?

Dr. Reissman extended her congratulations to the committee on even
considering trying to get definitions of mental health proxies. CDC has
been trying to tap into systems and come up with answers to questions
communities might ask. But there are still no proxies for problems that
are not purely organic in nature. We know many physical symptoms that
are reactions to trauma at home; children react by letting their
existing diseases go rampant. This is one way to get a handle on mental
health issues. In adults, chest pains and gastric distress are all
symptoms of stress.

Pre-Hospital, Critical Care, and Hospital Preparedness

Dr. Jean Wright, Executive Director, Backus Children's Hospital and
Richard Ricciardi, Chief, Primary Care Nursing, Department of Ambulatory
Care center, Fort Meade, Maryland

Remarks

Our task is more than just adding children to current preparedness
plans. The recommendations relate to three phases: preparation, response
and mitigation. The focus is on preparedness and communication.

Preparedness for children involves proper nourishment, vaccinations, and
environments where children are cared for well. Preparedness for
hospitals means being well staffed, with adequate resources, but
hospital facilities across the nation not operating at the same level.
Therefore money for disaster preparedness has to come from the outside.

All hospitals should have some degree of preparation, even if the care
of children is not part of their mission. Best practices for hospitals
include inclusion, decontamination and training. The second part of
training is sustaining it over the long term. How often to train? What
happens to day-to-day operations during training? Who pays for it? What
do you do with real patients during training? It is complicated,
difficult and expensive.

A second major recommendation has to do with communication, command and
control. What's happening with children out in primary care, faith-based
areas, emergency medical systems, other hospitals---how does everyone
communicate with each other to facilitate response to a disaster and
recovery? How does information get from rural area to hospitals?

A third are would be medical and pharmaceutical supplies. We looked at
the NPS list, and found nothing on pain and sedation medications for
children.

There is a need to support health care workers in the hospitals.
Hospital personnel are thinking of their own children during a disaster.
This may be 5 days or even several weeks of activity. Hospitals are
primary people, so how do we keep staffing up during a long siege. We
haven't had a test of surge capacity. Patients may be there for weeks or
months, or we may be even moving staff from one state to another.

A fifth recommendation has to do with decontamination and quarantine.
SARS is showing our lack of preparation. We do a poor job with universal
precautions.

Sixth, civilian hospitals not well equipped to do triage. Usually they
deal with one patient and one outcome. Triage is a military mindset. All
hospitals use standardized protocols. How do hospitals manage surge
issues, not just when patients peak, but when their care could be
handled closer to home (expatriation of patients)? We need exceptions to
rules during emergency.

Another question is how do we hold hospitals accountable?

What about special needs kids? Can we use MAPP tools to determine where
special needs kids are, who may be mainstreamed in schools and not at
home.

Recommendations

-   All hospital institutions should have some degree of preparation
    even if the care of children is not the majority of their daily
    mission, since they may find themselves providing disaster
    management and bioterrorism care for children should they be the
    closest provider or if other institutions are overwhelmed.

-   There should be communication systems available for in-hospital
    communication, bioterrorism surveillance/detection and notification,
    amateur radios in the event of telephone failure, communications
    systems between hospitals and local officials, and communication
    between the hospital and children's specialty centers and other
    child care facilities.

-   There should be an ample supply of medical and pharmaceutical
    supplies at the hospital and arrangements made with suppliers and
    government through the National Pharmaceutical Stockpile, of age and
    size-appropriate supplies, medications and equipment, including
    ventilators.

-   Support for health care workers in hospital

-   There should be biohazardous decontamination and protection
    equipment appropriate for caring for children in quarantine.

-   Hospitals should develop and utilize pediatric triage systems that
    incorporate physiological and logistical differences unique to
    children, so they can be appropriately triaged according to their
    needs and available resources.

Discussion

Mr. Smith said that the new HRSA guidance was going out the day after
this meeting, with a specific section on children and families.

Mr. Henderson noted that the child escort issue was missing, especially
when the system is jammed. Information on child wellness is also
missing.

Dr. Wright explained that communication should come first, such as how
to communicate with other hospitals that have more beds. Another point
was that if a large number of children become ill, each one needs an
adult escort until appropriate guardian arrives.

Ms. Greene asked how telemedicine would fit in. It would be one way to
meet the challenge of getting children to primary care providers, and
could also help with assessment and triage. Mr. Ricciardi responded that
his experience with telemedicine has been very frustrating, especially
during a disaster. He felt it would be better to see schools as primary
providers. Ms. Cono explained how the CDC set up telemedicine links to
the University Utah during the last Olympics. They found digital cameras
invaluable in diagnosing and treating. Re stockpile issues, a working
group met yesterday and identified deficits.

\*\*\*\*\*\*\*\*\*

Next Steps

Dr. Diaz asked committee members to think about the recommendations and
feedback from today's meeting and respond by May 7^th^. Victor Balaban
and the committee staff will turn these recommendations into a seamless
report. The assignment is two recommendations per person plus action
steps and supporting recommendations. Binders will have all the
supporting documentation. The Secretary will get a 15-page summary, with
supporting materials binder. The next meeting may 21^st^ in DC. There
will probably be a conference call before that meeting.

Dr. Diaz asked if there was any public comment and there was none.

Approval of minutes: Ms. Greene pointed out two corrections. The first
had to do with the spelling of her name. The second was that "childcare
should be moved to the community focus area."

There was a motion to approve the minutes. This motion was seconded,
there was a vote and the minutes were unanimously approved.

A final announcement was that a new website specific to this committee's
work is now up. The public can send comments to the committee through
this website. The address is <http://www.bt.cdc.gov/children/index.asp>.

The meeting adjourned at 4.50 pm.