# I. Introduction

Public Health for many years has been thought of primarily as a safety
net for the poor. Yet its true role embraces the whole population and
shapes everyone's lives. It has and must played a significant, and in
some cases a singular, role in the nation's preparedness to prevent the
effects of terrorism, through its core functions of assessment,
assurance and policy development.

Public Health at the governmental and community level strives to assure
that ten public health essential services[^1] are being met for the
population it serves through cooperation with private and public
entities. These are:

1.  Monitor Health Status to identify community health problems.

2.  Diagnose and identify health problems and health hazards in the
    community.

3.  Inform, educate and empower people about health issues.

4.  Mobilize community partnerships to identify and solve problems.

5.  Develop policies and plans that support individual and community
    health efforts.

6.  Enforce laws and regulations that protect health and ensure safety.

7.  Link people to needed personal health services and assure the
    provision of health care when otherwise not available.

8.  Assure a competent public health and personal health care workforce.

9.  Evaluate effectiveness, accessibility and quality of personal and
    population based services.

10. Research for new insights and innovative solutions to health
    problems.[^2]

Public Health has not received due credit for its singular importance to
the nation's health. In fact, the great majority of the increase in the
average life span in the U.S. was due to public health efforts. The
success of the early public health system to incorporate biomedical
advances (e.g., vaccinations and antibiotics) and develop interventions
such as health education programs resulted in decreases in the impact of
infectious diseases. However, as the incidence of these diseases
decreased, chronic diseases (e.g., cardiovascular disease and cancer)
increased. In the last half of the century, public health identified the
risk factors for many chronic diseases and intervened to reduce
mortality. Public health efforts also significantly reduced deaths
attributed to a new technology, the motor vehicle. These successes
demonstrate the value of community action to address public health
issues and have fostered public support for the growth of institutions
that are components of the public health infrastructure.[^3] [^4]

Today however, public health faces many challenges, including inadequate
infrastructure, training of professionals, and especially funding.
Recently, the Institute of Medicine released a final draft version of
its revised *Future of the Public\'s Health in the 21st Century*[^5]*.*
This long-awaited document is a call for action for improvements in our
nation's public health system.

The committee authors state that the entities and systems that protect
and promote the public's health, which is already challenged by threats
such as obesity, the environmental toxins, and a large uninsured
population, are now facing enormous challenges such as anti-microbial
resistance and terrorism. The committee also embraced Healthiest People
2010, as a call for healthy people in healthy communities. [^6] [^7]

Unfortunately, the consensus among many public health providers[^8] is
that while there has been a considerable effort to improve both
terrorism preparedness and general public health preparedness, many
critical systems, especially at the local levels, are not yet prepared.
This feeling is particularly acute when the discussion turns to
preparedness for children.

It is important to note that neither this IOM Report or *Healthiest
People 2010* has any references to children and their inherent
vulnerability to the effects of terrorism, despite widespread
recognition by public health providers that children are a special
population.

Children have singularly unique biological features that make them more
susceptible to both chemical and biological threats. As a population
they are especially at risk for the psychological effects of terrorism.
As such, public health must play a lead role in fulfilling its core
function of assessing the threats to children on both an individual and
population level. Public health and its partners must also lead efforts
to assure full emergency access and care with appropriate treatments;
and shape the policies that will ensure that children are protected to
the greatest extent possible from the effects of terrorism.

Public Health assumed a lead role after September 11, and during the
anthrax scare and the ongoing smallpox vaccination campaign. However, in
looking back it appears that children's needs were not a high priority
in early planning efforts. Furthermore, neither HRSA nor the CDC
specifically required children's issues to be addressed in their
original large RFP's in response to the events of September 11^th^.
[(]{.underline}However, this has dramatically changed in the 2003 RFP to
States and Territories from both agencies.)

Two large CDC surveys directed at state and local health departments, an
ASTHO survey and a Department of Justice Survey, contained
[no]{.underline} specific questions on children's terrorism preparedness
([cite these surveys]{.mark}).

This consistent lack of mention of children's unique needs is
interesting in the light that there are relatively large federal, state
and in many cases local health agencies that have programs specifically
directed at children. However, these programs do not tend to function
holistically, improving children's health from a population perspective;
they are often client-centered or concentrate on a small segment of all
children. Most state and local health departments have not yet
concentrated significant efforts on the effects of terrorism, with some
notable exceptions.

During the anthrax investigations, the Public Health Practice Office and
the EpiX Alert System at the CDC disseminated a number of important
messages regarding drug dosages for prevention of anthrax in potentially
exposed cases. Information on governmental policies regarding the
non-provision of smallpox vaccine to children in the first stage and the
effects of terrorism on children was disseminated by SAMSHA, CDC, HRSA
and FEMA to state public health providers who passed on the information
to local health departments and clinicians. However, clinicians and
public health officials complained of feeling over-whelmed and confused,
as there were often conflicting messages regarding dosages,
interventions and other risk communication efforts from various federal,
state and local agencies, especially when children were mentioned.

The following will highlight some past and ongoing efforts:

**The Agency for Substance Abuse and Toxic Disease Registries** (ASTDR)
staff have considerable hands-on experience in the integrated response
to chemical emergencies such as spills, explosions, and other
uncontrolled releases. ATSDR maintains a 24-hour hotline and emergency
response team that is fully integrated with the CDC Emergency Operations
Center and has worked closely with the EPA, FEMA, FBI, Coast Guard, and
other response agencies at the federal, state, and local level.

ATSDR also supports and maintains a national network of pediatric
specialty clinics that provide expert consultation, training, and public
education on chemical exposures in infants and children. Co-funded by
the EPA as well as by local grants, these Pediatric Environmental Health
Specialty Units **(**PEHSUs) proved instrumental after the terrorist
attacks in 2001. They are training primary healthcare providers to
recognize chemical "toxidromes" and triage and treat chemical exposures.
They also provide community-based education and information on long-term
health issues of concern.

**The Substance Abuse and Mental Health Service Administration
(SAMHSA)** is currently funding the National Child Traumatic Stress
Network. This program has three components: 1) National Center for Child
Traumatic Stress; 2) Intervention Development and Evaluation Centers;
and 3) Community Treatment and Service Centers.

**The Agency of Health Care Research and Quality (AHRQ)** provided the
American Academy of Pediatrics with one year of funding for the
development of a new Pediatric Terrorism Preparedness Resource.
Currently in conceptual form, this Resource would include information
such as equipment lists, medication dosages, protocols and training
packages that could improve the ability of all health care professionals
to undertake pediatric preparation and planning activities for
hospitals, schools, EMS and their communities. The Resource also would
include educational and training material that could be used by
pediatricians and others health care professionals to guide government
agencies, schools, EMS and other disaster preparedness efforts
nationwide. The Pediatric Terrorism Preparedness Resource would take two
years to complete and distribute. It is modeled after the successful
TRIPP: Teaching Resource for Instructors in Pre-hospital Pediatrics
program.

# The Federal Drug Administration's (FDA) main public health mandate regarding counter-terrorism is facilitating the availability of safe and effective drugs, vaccines, and medical devices for individuals exposed to a biological, chemical, radiological or nuclear agent. The agency is working to get medical countermeasures off investigative and developmental status and approved with appropriate use information, including special populations such as children. There are several centers involved in this effort: Center for Drug Evaluation and Research (CDER) -- drugs; Center for Biologic Evaluation and Research (CBER) - vaccines, blood products and other biologics; Center for Devices and Radiological Health (CDRH) -- medical devices, diagnostics; and Center for Food Safety and Nutrition -- foods. In addition, to working with other federal agencies such as NIH, CDC, DOD and DOE to get the necessary studies conducted so that medical countermeasures can be approved/licensed, the agency is funding some of these studies through inter-agency agreements and contracts. The agency is also working to obtain data on the use of some medical countermeasures in pregnant and lactating women and in the elderly.

In CDER, there is an entire office devoted to Counter-Terrorism and
Pediatric Drug Development. Countermeasure activities for children
include: approval of a 65 mg tablet of potassium iodide and home
preparation instructions; the dosing of amoxacillin in adults and
children for post-exposure inhalational anthrax; and doxycycline
stability /palatability for home preparation. To ensure the ethical
conduct of research done in children, the FDA incorporated Subpart D of
the HHS regulations into the FDA regulations (Additional Safeguards for
Children in Clinical Investigations) and worked on the International
Conference on Harmonization document E11 -- Clinical Investigation of
Medicinal Products in the Pediatric Population.

**The National Institutes of Health has many key roles in children's
preparedness, under the auspices of the National Institute for Child
Health and Development. (NICHD):** In July of 2002, the NICHD hosted a
research agenda-building workshop on Children Exposed to Violence,
including domestic violence, community violence, and war/terrorism, in
collaboration with nine other federal agencies. These included the
National Institute of Mental Health (NIMH), the National Institute on
Drug Abuse (NIDA), the Office of Behavioral and Social Sciences Research
(OBSSR), and the Fogarty International Center (FIC) of the National
Institutes of Health, the Centers for Disease Control (CDC), the
Substance Abuse and Mental Health Services Administration (SAMHSA), the
Office of Special Education Programs of the Department of Education, the
Office of the Assistant Secretary for Planning and Evaluation (ASPE),
and the National Institute of Justice (NIJ) in the Department of
Justice. Based on recommendations from this workshop, the NICHD will be
issuing a Program Announcement with a special "set-aside" on this topic
in 2003. The Program Announcement will encourage research on the
epidemiology of children exposed to violence, measurement and
definitional issues, consequences and mediators of violence exposure,
and services and interventions for children and families. The Program
Announcement will be in effect for three years, with approximately \$3
million in set-aside per year to fund 8-9 new projects.

**The National Institute for Mental Health (NIMH)** supports a number of
national health and mental health surveys that will provide a snapshot
of mental health in the U.S. before and after the 9/11 terrorist acts.
These will include information about associations between exposure to
the attacks and levels of overall distress and function, mental disorder
onset or recurrence, medication use, substance use, and need for and use
of mental health services. Results of these benchmark surveys will aid
in developing future studies that explore the causes and treatment of
stress-related mental disorders. In addition, researchers will be able
to test hypotheses generated from case-control studies within these
larger, representative samples.

Promoting research is a public health essential service. NIMH is
currently funding significant research that includes a special focus on
childhood trauma.

**The Health Resources and Services Administration** (HRSA) is managing
five programs, which are focused on bio-terrorism and other public
health emergencies:

The ***Bioterrorism Hospital Preparedness Program*** will improve the
capacity of the nation's hospitals and emergency departments to respond
to biological terrorist attacks and large-scale epidemics. It will also
promote state and regional planning among local hospitals, EMS systems,
community health centers, poison control centers, and other health care
facilities to improve their readiness to work together to combat
terrorist attacks. In FY 2002, \$125 million was awarded for hospital
preparedness to 56 States/territories and 3 municipalities in two
phases:

-   *Phase One* supported the State Health Departments to initiate a
    planning process to conduct a needs assessment and to develop a plan
    of action to respond to a bio-terrorist incidents. States and
    territories were asked to involve appropriate entities such as state
    hospital associations, individual hospitals, emergency medical
    systems, health centers and poison control centers.

-   *Phase Two* funds were awarded for implementation of approved plans
    submitted by States/territories/municipalities to upgrade the
    ability of health care entities to respond to biological events,
    develop a multi-tiered system in which local health care entities
    are prepared to triage, stabilize and refer multiple casualties of a
    terrorist event to identified centers of excellence, or develop
    multi-state or regional consortia to pool limited resources to
    accomplish these goals.

In FY 2003, funding is currently proposed at a level of \$518 million.
HRSA will broaden the FY 2002 efforts by supporting the implementation
of the approved State-based Hospital Preparedness plans for
bio-terrorism to strengthen and upgrade the capacity of hospitals,
outpatient facilities, emergency medical services systems and poison
control centers to care for victims of bio-terrorism suffering from
infectious disease epidemics.

During FY 2003, there will be increased emphasis on building and
improving hospital infrastructure. One objective is to ensure adequate
hospital laboratory capacity throughout the U.S. to diagnose and report
on potential biological and chemical agents that might be used by
terrorists. A second objective is to help hospitals improve their
capabilities to control infection while treating individuals who have or
are at risk for a communicable disease. A third objective is to assist
hospitals with the purchase of personal protective equipment,
decontamination facilities and other equipment for decontamination of
biological and chemical agents.

***HRSA Bioterrorism Health Professional Schools Curriculum Development
and Training*:** The FY 2003 and FY 2004 budget includes a request for
\$60 million for the development of the Bioterrorism Educational
Incentives for Curriculum Development and Training Program. The goal of
this program is the development of a healthcare workforce possessing the
knowledge, skills and abilities to: (1) recognize indications of a
terrorist event in their patients; (2) treat their patients in a safe
and appropriate manner; and to (3) rapidly and effectively alert the
public health system of such an event at the community, state and
national level.

The program will focus on two particular areas: (1) the delivery of
continuing education to health professionals already in practice; and
(2) providing incentives for curricular reform in health professions
schools and training. It will be designed to develop an
interdisciplinary workforce of healthcare personnel to prepare for and
respond to a bio-terrorist attack, as well as to address the crucial
need for integration of healthcare professionals into the public health
network.

***HRSA Emergency Medical Services for Children (EMSC):*** This program
supports the bioterrorism effort because it makes specific contributions
to address the needs of the target population. The EMSC program,
proposed at a level of \$18.94 million in FY 2004, will be able to
assist states to improve emergency care for children, as well as
enabling them to continue to promote regionalized care and make systems
improvements to ensure that all components of an effective EMSC system
are in place. Systems improvement grants to States will be maintained, a
maintenance level of evaluation and data improvement will be funded, and
continued development of an evidence-based research network will be
supported. Each year over 31 million children and adolescents are seen
in emergency departments. Fewer than half of all hospitals (46%) with
emergency departments have the necessary equipment to stabilize ill and
injured children. This will help assure that the broader emergency
preparedness program accommodates the special needs of children.

***HRSA Poison Control Centers (PCC):*** The Poison Control Centers
(PCC) are proposed for a funding level of \$21.2 million in FY 2004 .
They are an integral and vital part of the health system and part of the
continuum of necessary emergency services that should be available to
all Americans, particularly in light of the new bioterrorism threats.
Funding will present an opportunity to broaden the mission of the PCC to
serve as a source of public information for chemical and biological
events. HRSA will work with CDC to maintain a national toll free number
for poison control services.

***Trauma/Emergency Medical Services Program:*** This program managed a
National Assessment of Needs in State Trauma Systems in 2001-2002. The
assessment identified the following five priorities that must be in
place for state trauma system development to be able to effectively
plan, communicate, and implement future statewide trauma system
initiatives: (1) state assessment; (2) lead agency; (3) State level
manager; (4) statewide stakeholder group; and (5) state plan for trauma
care delivery. It is proposed that these activities be funded from the
Maternal and Child Health Block grant in future years.

**The Centers for Disease Control (CDC)** has responded to public health
emergencies for decades, and had been preparing for bio-terrorism since
1998. Current or future efforts include:

-   CDC guidelines to the states will include specific recommendations
    for children.

-   The CDC and the U.S. Department of Education are collaborating to
    help schools prepare for possible terrorism by providing state and
    local education, health, emergency management, law enforcement and
    homeland security agencies with updated information on biological,
    chemical, and radiological threats; answering questions about school
    preparedness and response; and describing roles of partnering
    agencies in the case of a terrorist threat.

-   Information and fact sheets on children and terrorism are being made
    available on a CDC web site.

-   The National Center for Injury Prevention and Control (NCIPC) is
    developing guidelines for rapid assessment of injuries and mental
    health, for children and adults, in the immediate aftermath of
    large-scale disasters and emergencies.

-   The CDC gave technical assistance to a survey commissioned and
    sponsored by the New York City Board of Education that assessed the
    mental health effects of the September 11 attacks on over 8,000
    school children in New York City public schools.

The 2002-2003 CDC Preparedness Grant was a large step in getting states
prepared for bio-terrorism events. Through the states, the CDC last year
disseminated approximately \$918,000,000 to improve national, state and
local health preparedness. It divided efforts into six focus areas,
which did not specifically address children. It is believed that the
next grant cycle will require an emphasis in each of the following areas
regarding preventing or ameliorating the effects of terrorism on
children:

1.  **Emergency Preparedness:** State and local health departments will
    need to actively ensure careful planning for prevention of
    anti-biological and vaccines, treatment protocols, coordination
    between emergency response and public health and many other
    functions.

> **Recommendation:** It is incumbent on the Secretary of HHS to ensure
> that each Emergency Preparedness Focus Area addresses the needs of
> children, including vaccines, emergency transport, biologicals,
> chemical protection and appropriate mass causality response.

2.  **Surveillance:** Children's hospitals and child health providers
    must be included in both active and passive surveillance systems
    being developed at the state and local level. Increased stress must
    be placed on out-patient and syndromic surveillance methods that may
    detect community and specific patient threats early. Providers and
    public health providers need to interact frequently on common
    disease threats to make sure they have the ability to communicate
    and interact during a terrorist situation.

> Recommendation: Surveillance and assessment is essential to detect
> disease threats and children's conditions must be monitored by both
> active and passive systems. Pediatricians and pediatric hospitals must
> be trained to report suspected cases of biological or chemical events
> to local health departments and/or law enforcement officials.

3.  **Laboratory:** Laboratories are becoming better prepared to detect
    biological and chemical threats but it is unclear whether or not
    this is being stressed at children's hospitals.

> **Recommendations:** Laboratories at children's hospitals should have
> referral mechanisms to laboratories capable of detecting highly
> dangerous biological and chemical threats.

4.  **Chemical:** Not currently funded in most states.

> **Recommendation:** We recommend that this should be funded and
> include funding for pre-measured antidotes for children, laboratory
> capacity, protective devices and training.

5.  **Health Alert Network (HAN): Recommendation:** We recommend that
    the HAN be linked in all states to HHS web sites on the children and
    terrorism and the Academy of Pediatrics. We also recommend that the
    information on the special needs of children in regards to
    anti-terrorism prevention be widely linked to portals to hospitals,
    local health, laboratories, and professional associations.

6.  **Risk Communication: Recommendation**: We recommend that targeted
    resources be used to educate the public and providers on the special
    needs or children regarding terrorism preparedness.

7.  **Education and Training**: Along with specific drug, equipment and
    hospital preparedness, this may be the current weakest link in
    preparedness for childhood terrorism on a widespread scale; despite
    current efforts, many providers would have no idea what to do with
    children in a terrorism scenario.

> Recommendation: Local and state health workers, EMS personnel,
> laboratorians, hospital workers, providers, and community partners
> must get needed training on the special needs of children regarding
> preventing, treating, and ameliorating the physical and mental effects
> of terrorism. The CDC should mandate that all counties have trained
> personnel who can deal with terrorism preparedness for children at the
> provider and public health level. Tabletop and other exercises,
> courses and other methods of instruction should be used and repeated
> to sustain these competencies. The use of the HAN needs to become
> widespread by all those working to combat the effects of terrorism on
> children.

8.  **Hospitals:** It is assumed that HRSA will continue to play the
    lead role here, working with the CDC, state and local public health
    and other partners. It is encouraging that funding for HRSA grants
    to state and hospitals has increased substantially. The CDC had
    considered the following draft language in its upcoming RFP to state
    health officials. However, it did not make the final RFP:

\"Children: Emergency preparedness plans should pay special attention to
the unique needs of children. Because of a host of special anatomical,
physiological and psychological considerations, young children are more
susceptible to the untoward consequences of disasters and acts of
terrorism.

> *Planning should consider, but not be limited to, special treatment
> areas for mass pediatric casualties in hospitals, triage areas and
> health centers; development of pediatric response protocols paying
> special attention to appropriate medications and dosages; appropriate
> decontamination units that reduce the possibility of heat loss and
> shock while permitting young children to be held by caretakers;
> pediatric-specific training and drill procedures; and, provision of
> psychological support to children and families, including methods to
> ensure reunification of children with family members as needed.
> Furthermore plans should ensure inclusion of pediatric expertise in
> the development of overall disaster plans.*

Many of the above tasks cannot be done by local or even state health
departments in isolation. Rather they must work actively with community
partners, hospitals, and key agencies such as the Red Cross to ensure
that the guidelines of the RFP will be met."

:

Some states produced web sites during the last year specifically to
address children's terrorism needs from a public health perspective. For
example, Maryland at the height of the anthrax scare set up a toll-free
Youth Crisis hotline and links to other sites at
<http://www.dhmh.state.md.us/html/terrorism.htm>.

Local health departments also placed information on the web; one fine
example is the San Francisco Health Department, which shares how both
adults and children are affected by terrorism at
<http://www.dph.sf.ca.us/CopeTerror/CopeTerrorGenl.htm>.

We are pleased with these efforts, but they do not currently go far
enough from a public health perspective. We are hopeful that the future
federal grants to states have stronger language about community needs,
which will bring sustained emphasis to this area and include an
enforcement mechanism.

## Disaster Planning for Children by Public Health

# A. Mitigation

It is impossible to prepare children fully for the effects of terrorism
from both a physical and emotional perspective. In the substantial
ongoing literature regarding children and the effect of terrorism or
crisis, one of the most interesting topics is resiliency, the idea that
some children and communities seem better prepared to handle stressful
events. There is a large body of literature suggesting that individuals,
families, and even communities can prepare children for stressful events
by ongoing awareness and preventive practices. Kiser, Ostoja and Pruitt
emphasize building family awareness of resiliency factors to help
overcome disasters or other stressful events. Severe unexpected
stressors that place significant strain on family functioning include
serious illness, death, violence, and both natural and man-made
disasters. However, families and children that have learned to handle
expected stresses usually deal better with these situations.[^9]

B. Preparedness:

Before commenting on the potential effects of the CDC and HRSA grants,
which could go a long way towards local and state health preparedness to
ameliorate the effects of terrorism, it is helpful to review an
abbreviated testimony of Joseph L. Wright, MD, MPH, FAAP before the
Senate Committee on Health, Education, Labor, and Pensions' Subcommittee
on Children and Families on 11/02/01

Pediatricians are fond of saying \"children are not little adults.\" But
what precisely does this mean in relation to biological or chemical
attack? Since children are smaller than adults, it is obvious that they
may get sicker from the same amount of a harmful substance. The unique
anatomic, physiologic and developmental characteristics of children
place them at disproportionate risk from biologic and chemical agents in
a number of specific ways.

First, children are particularly vulnerable to aerosolized biological or
chemical agents because they breathe more times per minute than adults,
meaning they would get relatively larger doses of the substance in the
same period of time. Because some such agents, (e.g., chlorine and
sarin) are heavier than air, they accumulate close to the ground, closer
to the breathing zone of children.

Second, children are more vulnerable to agents that act on or through
the skin because their skin is thinner and they have a larger
surface-to-mass ratio than do adults. In other words, children have
relatively more skin surface in relation to their total body mass.

Third, children are more vulnerable to the effects of agents that
produce vomiting or diarrhea, because they have less fluid reserve than
adults, increasing the risk of rapid dehydration. Also, children have
smaller circulating blood volumes than adults, so without rapid
intervention, relatively small amounts of blood loss from physical
trauma can quickly tip the physiologic scale from reversible shock to
profound, irreversible shock and death.

Fourth, children have significant developmental vulnerabilities not
shared by adults. Infants, toddlers, and young children do not have the
motor skills to escape from the site of a chemical, biological, or other
terrorist incident. Even if they are able to walk, they do not have the
cognitive ability to figure out how to flee from danger or to follow
directions from others.

Like adults, all children are also at risk of psychological injury, such
as posttraumatic stress disorder, from experiencing or living under the
threat of biologic-chemical terrorism. In a mass casualty incident,
children may witness injuries and deaths, possibly of their parents,
which would produce both short- and long-term psychological trauma
(\"psychiatric casualties\"). Unlike adults, however, children and
adolescents may not have the cognitive or maturational capacity to fully
comprehend what has happened. While parents would be psychologically
devastated at the loss of a child, children who lose parents also lose
emotional and financial support. If orphaned, a child would have to be
placed in another home or institutional setting and suffer the trauma of
dislocation, as well as parental loss and adjustment to new caretakers.

Finally, children are highly influenced by the emotional state of their
caretakers. When the parents or other caretakers of a child are
psychologically harmed by the events around them, it is likely to affect
the psychological well-being of the child.

Once a child is critically ill or injured, his or her body will respond
differently than that of an adult in a similar medical crisis. A
child\'s condition can go from stable to life-threatening quite rapidly,
since they have less blood and fluid reserves, are more sensitive to
changes in body temperature, and have faster metabolisms. Therefore,
pediatric treatment needs are special in a number of ways.

Unfortunately, even the most well-meaning planners are sometimes
unprepared to meet pediatric needs. For example, after the terrorist
attack on September 11, two Federal Disaster Medical Assistance Teams
were dispatched from Washington to assist in New York. Appropriately,
these teams included pediatric health experts. But, when these experts
examined their equipment kits, they did not find all the supplies they
would need to treat children. Fortunately, federal officials, in
cooperation with the private sector, were able to get two pediatric
emergency medical kits to Washington in time for the teams to take them
to New York. These \"Broselow-Luten\" kits contain various sizes of
medical equipment and pre-measured pediatric doses of medications, keyed
by color to the size of the child as indicated on a special color-coded
measuring tape.

In addition to special medical needs, children and/or their families
will also have particular, psychosocial, logistical, and social services
needs that may arise in a disaster situation. Some of these needs, gaps
in meeting them, and recommendations for addressing the shortcomings,
are discussed below.

**Medications, Antidotes and Vaccines.** Children need different dosages
of medicine than adults, simply because they are smaller. In addition,
drugs and biologicals may have effects on developing children that are
not a concern for adults. For example, they can discolor a child\'s
developing teeth, or cause growth retardation.

**Equipment and Supplies.** Obviously, children need different sized
equipment than adults. Their veins are smaller, so small needles and
tubing are needed. Smaller masks are needed to administer oxygen, and so
on. At present, many ambulances and emergency departments do not have
child-sized equipment and supplies, such as oxygen masks, IV-tubes, and
neck braces. In fact, fewer than half of hospitals with emergency
departments have the necessary equipment for stabilization of ill and
injured children and few states require that advanced life-support
ambulances, whose personnel can start IVs, administer medications, and
insert airway tubes, carry all equipment needed to stabilize a child.

**Health Care Personnel.** Health care workers taking care of children
must be able to recognize the signs and symptoms that may indicate a
life-threatening situation and intervene rapidly. This requires special
training and, ideally, experience. Most emergency medical personnel,
both in the field and in non-pediatric hospitals, treat relatively few
children, which means that many of those who would respond to a
terrorist attack or other disaster do not have well-honed skills in
dealing with children.

Even pediatric health care experts are unfamiliar with the signs and
symptoms of unusual biological, chemical or nuclear agents. For example,
most pediatricians in this country have never seen a case of anthrax or
smallpox. In addition, pediatricians, family physicians, and other
health care providers must be encouraged to consider unusual causes of
otherwise common symptoms (e.g., flu-like symptoms being caused by
anthrax instead of the flu). They must be trained to recognize and treat
the effects of the agents that might be unleashed by terrorists and to
report suspicious cases to public health authorities. Methods for
rapidly disseminating accurate information to health care personnel will
be essential should a release of such substances occur.

Finally, health care workers who have treated children in a critical
incident often suffer extraordinary stress, so the workers themselves
may need special debriefing and psychological counseling.

**Treatment Facilities and Transport.** After a terrorist attack or
other disaster, many children may need a high level of pediatric medical
or surgical care. When there are many casualties, it will be important
to ensure that resources are used in the most efficient manner possible,
matching the patient\'s medical need with the capacity of the facilities
available.

In 1993 the Institute of Medicine issued a report on emergency medical
services for children, which recommended that local and regional systems
be developed to identify hospitals that can provide advanced pediatric
care and to ensure that ill or injured children are transported or
transferred to a facility that provides the level of care needed.

Currently only 40% of hospitals with emergency departments have formal
agreements to transfer children to a hospital with more advanced
services, and few states have guidelines to identify hospitals with
special resources for children, such as a trauma center or pediatric
intensive care unit. Pediatric transport equipment and personnel may
also be needed to accompany children in transit. In a large-scale
terrorist attack, it is also likely that alternative health care sites
(e.g., physicians\' offices, community health centers, schools, and
arenas), will need to be used to provide medical care, since hospitals
themselves may be damaged, inaccessible, or unable to handle the number
of people who need treatment. Therefore, it is important to ensure that
these facilities have first-aid equipment and supplies appropriate for
treating children.

**Mental Health.** As discussed above, children may suffer from
posttraumatic stress disorder and other consequences of a terrorist
attack, including those related to distressed caretakers. Many children
will need mental health services. Yet, there is already a shortage of
pediatric mental health professionals, and even children who are insured
often do not have sufficient coverage for mental health services. In
addition, it is important that information be disseminated about the
various ways that post-traumatic stress disorder and other mental health
problems may be manifested in children and adolescents.

**Health Supervision in a Medical Home.** Primary care providers,
including pediatricians, may be the first line of defense in a
bioterrorism or chemical attack because they can play a critical role in
identifying sentinel cases of illness. In addition, they can quell the
fears of the \"worried well,\" recognize and respond to the psychosocial
consequences of a terrorist incident or threat, and counsel families
regarding preparation for and response to possible terrorist attacks or
other disasters. Preparing for emergencies is particularly important for
children with special health care needs who are on medications or
dependent on medical technology.

Yet many children do not have adequate access to a primary care
provider, or \"medical home\" that provides continuous, comprehensive,
and coordinated preventive care and medical treatment. As a result, many
families delay or forego care for their children. It is easy to imagine
a delay in detecting an anthrax or salmonella release, for example, if
the first few cases are among children whose families hesitate to seek
medical care for financial reasons. Delays in detection can affect the
health of the public at large. In addition, children who are uninsured
or underinsured may strain the limited resources of emergency
departments and public clinics with concerns about possible exposure to
biological or chemical agents. They may not have access to physical
rehabilitation and mental health services needed after terrorist
incident. Also, when uninsured children are admitted to the hospital for
expensive critical care, local taxpayers will bear the costs.

Thus, one of the ways in which this nation can prepare for and respond
to a terrorist attack is make sure that every child has a \"medical
home\" to provide preventive care, detect possible signs of an attack,
provide necessary treatment, prescribe medications (e.g., prophylactic
antibiotics for anthrax), and recognize mental health problems that may
result from a terrorist attack or threat.

In addition, children need insurance coverage for the cost of health
supervision, vaccinations, medications, and treatment, including mental
health care. The official AAP position on this can be found at
[www.aap.org/advocacy/releases/medicalhome.htm](http://www.aap.org/advicacy/releases/medicalhome.htm).[^10]

**Out-of-Home Care and Activities.** Most children spend much of their
day in school, child care, after-school care facilities, and/or
participating in athletic programs or other activities away from home.
Public Health and Emergency Medicine should work together to assure that
these settings are prepared to evacuate children (including those who
are too young to walk and/or follow directions), take them to a safe
place, notify parents, reunite children with their families, care for or
arrange care for children whose parents are incapacitated or cannot
reach them, and render first-aid.

The CDC, due to funding limitations, has not been able to increase the
number of state school health programs through federal programs, and it
is believed that this agency should be given the resources to ensure
that each state has a program, and that key staff are trained in
bio-terrorism preparedness.

In addition, parents and those acting *in loco parentis* should make
arrangements for authorization of medical treatment when parents cannot
be reached, and share information about special health care needs,
medications, or medication allergies. In addition, facilities where
children congregate should always be vigilant about sanitation
practices, so that biological contaminants are not spread among the
children, bearing in mind that a biological attack may not be detectable
until symptoms are expressed. Such facilities should also require or
encourage children to be vaccinated against biological agents, if and
when such vaccinations become available.

**Social Services.** Unlike adults, children need someone to take care
of them. If their parents or guardians are killed or incapacitated in a
terrorist attack or disaster, arrangements must be made for their care
on a temporary or permanent basis. The Academy of Pediatrics recommends
that federal, state, and local health agencies continue to develop
coordinated plans for meeting the consequences of a chemical-biological
event. These plans should include specific protocols for management of
pediatric casualties, and should include pediatricians in planning at
every organizational level (e.g., the Departments of Defense and
Justice, Federal Emergency Management Agency, and state/local emergency
medical services).

Pediatric health care facilities (e.g., children\'s hospitals, pediatric
emergency departments, and pediatricians\' offices) should also be
included in all aspects of preparation since they are likely to become
primary sites for managing child casualties. Financial support should be
given to create specialized areas such as isolation zones and
decontamination rooms.

Planning should also involve local health departments and poison control
centers. Poison control centers should be used as resources and central
clearinghouses for toxicological information to be given to the public
and health care personnel. Information including antidotes and
decontamination strategies may be rapidly distributed by poison centers
to hospitals, police, and the public.\
\
Government agencies should work to ensure that adequate supplies of
antibiotics, antidotes, and vaccines are available to children, that
they are safe and efficacious, and that pediatric doses are established.
Resource allocation plans should ensure that these agents are readily
available to pediatric health care sites.

[It is not necessary for government to \"reinvent the wheel\" in order
to prepare thoroughly for terrorist attacks or other disasters. There
are many programs at the federal, state and local levels that have
already been working on preparedness issues, or could make valuable
contributions to this effort, particularly if their funding is
enhanced]{.underline}.

**The current CDC Preparedness Grant**: Through the states, the CDC last
year disseminated almost a billion dollars to improve preparedness in
the six content areas noted above. The CDC should mandate that all
counties have trained personnel who can deal with childhood terrorism
preparedness at the provider and public health level. Tabletop and other
exercises, courses and other methods or instruction should be used and
repeated to sustain these competencies. As was noted above, the use of
the HAN needs to become widespread to all affected "players" who are
working to combat the effects of terrorism on children.

**Hospitals:** HRSA will play the lead role here, working with state and
local public health and other partners. It is encouraging that funding
for HRSA grants to state and hospitals has increased substantially.

Public health must assure that hospitals are prepared to deal with
children in a surge or emergency situation with appropriate equipment,
biologicals, and transport to triage facilities. Providers must be aware
and recognize biological or chemical agents in children and be prepared
to treat them in a calm and reassuring manner, keeping the families in
the loop.

Public health must also ensure that hospital and other services are
provided to temporary or permanent orphans from the terrorism event and
that there is adequate access for all children for needed emergency and
follow-up services, including mental health.

C.  **Response**

The CDC at [www.bt.cdc.gov](http://www.bt.cdc.gov/) informs the general
public about the primary role of local public health departments and/or
law enforcement as the primary contacts for concerns about chemical or
biological attacks. Therefore, it is incumbent that the emergency
preparedness efforts detailed above be robust, comprehensive and
sufficiently funded to ensure that local health departments are prepared
for this role throughout the US. Enhanced preparedness for the
population at large, with specific planning for children will help
prevent and/or ameliorate the effects of terrorist acts.

As has been shown in the case of the anthrax cases and the smallpox
vaccine distribution, local health departments rely on state health
departments and the CDC for accurate information to deal with specific
threats. The CDC has developed "Interim Recommended Notification
Procedures for Local and State Public Health Department Leaders in the
Event of a Bio-terrorist Incident," which would also be applicable for
chemical/environmental at
[www.bt.cdc.gov/EmContact/Protocols.asp](http://www.bt.cdc.gov/EmContact/Protocols.asp).

**Response General Recommendations:**

It is crucially important to train health care workers, hospitals, and
local health departments beforehand in their reporting responsibilities.
Just as crucial is for local and state public health leaders to continue
to become fully integrated into city, county and state emergency
preparedness plans through table top and other simulated exercises.

Pre-planning must ensure that all U.S. children have access to hospitals
prepared to deal with the biological or chemical effects of terrorism
with medications and the proper equipment to handle children's unique
physiological needs, as well as the emotional after effects.

It will also be important to contact specific pediatric experts in the
case of a terrorist attack on a large group of children, which means
maintaining up-to-date rosters and relationships with pediatric
organizations, pediatric mental health experts and pediatric specialty
hospitals.

Finally, federal agencies need to establish a single web site where
specific children's information in a threat event can be linked with
others sites such as that of the OEP or the CDC.

**D. Recovery:**

Public health will have to help in the healing phase of any terrorist
event that involves children. It is hoped that preexisting relationships
with community partners like the Red Cross, the American Academy of
Pediatrics local chapters, health care providers, and other governmental
agencies will help in the healing of children at both the individual and
population level. Substantial resources from federal, state and local
funds may be needed to help communities and children heal.

Magne Raundalen and Atle Dyregrov from the Center for Crisis Psychology,
Bergen, Norway have detailed how children recover emotionally from
terrorism and how to help them on a website.[^11] There are many
potential models and studies in this area and further research should be
encouraged.

As was pointed out earlier, it is crucial for public health to assure
mechanisms to get primary care experts (in this case, pediatricians and
family practitioners) to work with children and their families. Many
researchers, including the Harvard Program in Refugee Trauma (HPRT),
have found that the primary health care systems and providers are at the
center of recovery and healing for a general population that has been
victimized by mass violence and terrorism.

The Harvard Program states that Primary Care Providers (PCPs) are an
essential part of the indigenous healing system of the local population.
They can "ask the question" about the patient's traumatic life
experiences, such as those resulting from terrorism, without opening up
"Pandora's box." Through implementation of simple concrete steps, they
can support the healing process of human suffering caused by terrorism
and inoculate their patients against the potential psychological and
physical distress caused by possible future terrorist attacks. The HPRT
gives information on its efforts at
<http://www.hprt-cambridge.org/Layer3.asp?page_id=41>

Local and state public health workers need to be trained on how to
advise parents to talk with children. Coordination with the local
American Academy of Pediatrics Chapter and other public health providers
is an excellent place to start in this regard.

Continued health care access for all exposed children at risk of and
after a terrorist attack is also essential to ensure that adequate
preventive and ameliorative measures are taken. This should include more
provisions for expanded social and psychological care than currently
allowed by most insurance programs.

[^1]: 1 Turnock BJ, Public Health -- What it is and How it Works, Aspen,
    2001.

[^2]: Ibid.

[^3]: Epidemiology Program Office, Achievements in Public Health,
    1900-1999; Changes in the Public Health System. *MMWR*, December 24,
    1999.(48(50):1141-47, CDC, DHHS..**8**

[^4]: Baker EL Jr, Koplan JP, Strengthening the nation\'s public health
    infrastructure: historic challenge, unprecedented opportunity,
    [Health Aff (Millwood). 2002
    Nov-Dec;21(6):15-27](../../../../../../../../entrez/query.fcgi%3Fcmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12442836)

[^5]: Institute of Medicine, The Future of Public Health in the 21^st^
    Century (Unedited final proof), used by permission. 2003

[^6]: U.S. Department of Health and Human Services. *Healthy People
    2010*. 2nd ed. With Understanding and Improving Health and
    Objectives for Improving Health. 2 vols. Washington, DC: U.S.
    Government Printing Office, November 2000.

[^7]: U.S. Department of Health and Human Services. Healthy People in
    Healthy Communities, Washington, DC: U.S. Government Printing
    Office, January 2003.Healthy People in Healthy Communities.

[^8]: Local Health and state health directors have provided testimonies
    and or given feedback federal officials or to their professional
    associations including NACCHO, ASTHO, AMA, APHA and CSTE. A number
    of local and state health officials have testified to the U.S.
    Congress on preparedness since September 11, 2001 -- source CSTE,
    Atlanta, GA. (No record was found of specific testimony by a local
    or state health leader to Congress on children's needs).

[^9]: Kiser LJ, Ostoja E, Pruitt DB, Dealing with stress and trauma in
    families, Child Adolesc Psychiatr Clin N Am 1998 Jan;7(1):87-103

[^10]: Several members of the committee praised the State of New York
    and New York City for working with HHS to get Medicaid coverage for
    many children and families affected by 9/11. Such efforts should be
    commended and may be a short-term alternative, but do not replace
    the need for a permanent medical home for children.

[^11]: [http://www.icisf.org/articles/Acrobat%20Documents/TerrorismIncident/Dyregrov_terrorism.html](http://www.icisf.org/articles/Acrobat Documents/TerrorismIncident/Dyregrov_terrorism.html).