# *Bioterrorism and Other Public Health Emergencies*

# 

# 

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# Pediatric Terrorism and Disaster Preparedness 

A Resource for Pediatricians

**Summary**

**Agency for Healthcare Research and Quality**

**Rockville, MD**

AHRQ Publication No. 06(07)-0056-1

September 2006

This document is in the public domain and may be used and reprinted
without permission except those copyrighted materials noted for which
further reproduction is prohibited without the specific permission of
copyright holders.

Suggested citation:

Pediatric Terrorism and Disaster Preparedness: A Resource for
Pediatricians. Summary. AHRQ Publication No. 06(07)-0056-1. Rockville,
MD: Agency for Healthcare Research and Quality. September 2006.

This summary presents highlights from a report that was prepared by the
American Academy of Pediatrics (AAP) for the Agency for Healthcare
Research and Quality. The American Academy of Pediatrics and AHRQ have
made a good faith effort to take all reasonable measures to ensure that
this product is accurate, up-to-date, and free of error in accord with
clinical standards accepted at the time of publication. Any practice
described in this product must be applied by health care practitioners
in accordance with professional judgment and standards of care in regard
to the unique circumstances that may apply in each situation they
encounter. The American Academy of Pediatrics and AHRQ are not
responsible for any adverse consequences arising from independent
application by individual professionals of the content of this product
to particular patient circumstances encountered in their practices.

The information and recommendations presented in this summary do not
necessarily represent the views of AHRQ. No statement in this report
should be construed as an official position of AHRQ or the U.S.
Department of Health and Human Services.

**Acknowledgment**

AHRQ gratefully acknowledges the work of Mary L. Grady in developing
this summary.

**Contents**

Introduction 1

Background 1

Children Are Not Small Adults 1

Systems Issues 2

Responding to a Disaster 2

Biological Terrorism 5

Chemical Terrorism 9

Radiological and Nuclear Terrorism 10

Blast Terrorism 15

Mental Health Issues 16

Integrating Terrorism and Disaster Preparedness Into Your Pediatric
Practice 21

Terrorism and Disaster Preparedness for Hospital-Based Pediatricians 24

Working with Government Agencies 26

Advocating for Children and Families in Preparedness Planning 27

Conclusion 28

Additional Resources 31

Number range CHAPTERNumber range CHAPTER

Number range CHAPTER**AHRQ's Bioterrorism Research Portfolio**

The Agency for Healthcare Research and Quality (AHRQ) is a component of
the U.S. Department of Health and Human Services. The Agency's mission
is to improve the quality, safety, efficiency, and effectiveness of
health care by:

-   Using evidence to improve health care.

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-   Improving health care outcomes through research.

-   Transforming research into practice.

    AHRQ\'s investment in bioterrorism research recognizes that
    community clinicians, hospitals, and health care systems have
    essential roles in the public health infrastructure. To inform and
    assist these groups in meeting the health care needs of the U.S.
    population in the face of bioterrorist threats, AHRQ-supported
    research focuses on the following:

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-   Emergency preparedness of hospitals and health care systems for
    bioterrorism and other rare public health events.

-   Technologies and methods to improve the linkages between the
    personal health care system, emergency response networks, and public
    health agencies.

-   Training and information needed to prepare community clinicians to
    recognize the manifestations of bioterrorist agents and manage
    patients appropriately.

Please visit the AHRQ Web site at
<http://www.ahrq.gov/browse/bioterbr.htm> to find out more about
AHRQ-supported research, tools, and activities related to bioterrorism
and public health preparedness.

**Introduction**

This summary presents highlights from a report prepared by the American
Academy of Pediatrics for the Agency for Healthcare Research and Quality
(AHRQ). The purpose of the report is to enhance the role and
capabilities of pediatricians in planning for and responding to natural
disasters and bioterrorist events. The goal is to ensure that the
special needs of children are considered and incorporated into local,
State, regional, and Federal disaster preparedness planning and
response. A list of resources is provided at the end of this summary to
help readers access additional information on each of the topics
discussed here.

### Background

A disaster is a calamitous event that affects a large population and
generally results in injury, death, and destruction of property. A
disaster can also be thought of as any occurrence that taxes or
overwhelms local response resources, including law enforcement,
transportation, shelters, and so on. Local resources can be overwhelmed
by natural disasters or other events that result in multiple casualties
such as earthquakes, fires, large motor vehicle crashes, and terrorist
incidents.

Disasters caused by terrorism or accidents (e.g., a multiple car crash
on an interstate highway) can occur without warning. In other types of
disasters, such as hurricanes, there usually is some time for warning
and preparation. Some disasters end quickly, while others can affect
large populations over an extended period of time (e.g., a humanitarian
disaster involving famine). Disasters can have physical, mental, and
emotional effects on a large number of people without regard to age or
other factors.

Terrorism is a reality in the United States, and bombs, germs, toxic
gases, and the forces of nature do not discriminate between children and
adults. Despite our best efforts to shelter and protect them, children
remain among the most vulnerable victims of terrorism and natural
disasters.

This resource is intended primarily to educate, inform, increase
awareness among, and assist pediatricians in recognizing and fulfilling
their important roles in disaster preparedness and response. Families
and communities turn to pediatricians for anticipatory guidance on all
issues involving children. In turn, pediatricians can help families plan
their response to disaster and, when disaster strikes, refer them to
available resources. Based on their traditional roles in prevention,
anticipatory guidance, and advocacy, pediatricians can make a difference
in ensuring comprehensive public health planning for disaster.

# 

# Children Are Not Small Adults

Many important differences distinguish children from adults and are the
origin of the oft-used truism "you can't treat children as small
adults." Some of these differences are:

-   Anatomic differences (e.g., size, more pliable skeleton).

-   Physiologic differences (e.g., age-related variations in vital
    signs, higher relative metabolism).

-   Immunologic differences (e.g., immature immunologic system, higher
    risk of infection).

-   Developmental differences (e.g., inability to vocalize symptoms or
    localize pain, dependence on others for necessities of life).

-   Psychological differences (e.g., age-related response to trauma,
    vulnerability to major psychiatric disorders such as depression).

These differences affect children's vulnerability to injury and response
in a disaster. Failure to account for these differences in triage,
diagnosis, and management of children is most often due to lack of
knowledge or experience or both. Unfortunately, grave errors can result,
increasing the child's risk of serious harm and even death.

# Systems Issues

The widespread injury and devastation associated with disasters can pose
difficult problems for health care providers, including triage of mass
casualties, disruption of the infrastructure (e.g., loss of power and
fresh water), and the need to deal with the mental anguish associated
with uncertainty and the loss of loved ones.

The degree of injury, death, and damage caused by disasters is
influenced by many factors, including population location and density,
timing of the event, and community preparedness (e.g., emergency
response infrastructure, local building codes, disaster planning, etc).
Similarly, recovery after a disaster is influenced by resources---for
example, insurance and relief aid---and by experience, access to
information, and preexisting environmental factors, such as season,
local infrastructure, and so on. In almost all cases, disasters are
associated with mental and physical stress (both during and after the
event) that can increase morbidity and mortality over and above that
caused directly by the event itself.

Usually, there are many deaths and widespread injury and destruction in
the aftermath of a disaster. For example:

-   The disruption caused by disasters can result in widespread disease
    from unhygienic conditions.

-   Fuel leaks, live wires, and other hazards can cause injury or start
    fires.

-   The physical and emotional stress associated with the event and
    cleanup can result in musculoskeletal injuries, mental illness, and
    other stress-related disorders.

-   Displaced wildlife can hamper relief efforts and endanger workers.

-   Injuries can also result from improper use of equipment involved in
    clean-up efforts.

Children are especially prone to injury or poisoning through exposure to
debris, chemicals, equipment, and other agents in the aftermath of a
disaster. Thus, management after a disaster is critically important to
minimize further injuries and destruction.

# Responding to a Disaster

There are four basic phases of response to a disaster. They are:

1.  Preparedness (including prevention and planning).

2.  Actual response to the event.

3.  Mitigation.

4.  Recovery (short- and long-term).

## Preparedness

Although we usually cannot predict disasters, we often can exert some
control over their impact through prevention and planning efforts.
Prevention through preparedness is probably the most important phase of
response in emergency management. During the preparedness phase,
governments, organizations, and individuals develop plans to save lives,
minimize disaster damage, and enhance disaster response. Such efforts
include preparedness and evacuation planning; emergency exercises and
training; warning systems; emergency communication systems; public
information and education; and development of resource inventories,
personnel contact lists, and mutual aid agreements.

Physicians participate in preparedness and prevention in many different
ways, including: immunization programs, dietary advice, health
education, and safety precautions and planning. As participants in an
emergency action plan, physicians need to help formulate ways of
preventing incidents from occurring or limiting the consequences from an
incident that has already occurred. Physicians need to know what will be
expected of them and their hospital in the case of a potential
infectious disease outbreak. They should also be prepared with the
knowledge and resources needed to help identify the etiology of a
problem and to provide timely treatment.

Pediatricians should be proactive in providing input regarding the
unique needs of children during disasters and ensure that children's
issues are included in all preparedness activities.

# Actual Response to an Event 

Response activities provide emergency assistance for casualties and
speed recovery. They include activating public warning systems,
notifying public authorities, mobilizing emergency personnel and
equipment, providing emergency medical assistance, manning emergency
operation centers, declaring disasters, evacuating the public,
mobilizing security forces, providing search and rescue operations, and
suspending some laws on an emergency basis.

# Mitigation

Mitigation includes actions taken to stop the incident from doing any
further damage and to stabilize the situation. Examples include putting
out a fire or plugging a leak in a hazardous material incident.
Mitigation also plays a role in preparedness through measures such as
building codes, tax incentives, zoning and land use management, safety
codes, and so on.

# Recovery

The objective is to return things to normal or near normal as quickly as
possible. Depending on the scope of the incident, the recovery period
can range from hours to years. Short- and long-term recovery measures
include returning vital life-support systems to minimum operating
standards; reconstruction; temporary housing; ongoing medical care; and
public information, health and safety education, and counseling.

# Regional Response to a Disaster

Although each area of the country differs somewhat in the way emergency
responses are handled, all agencies involved in emergency response use
some form of an incident management system. Almost all use the National
Incident Management System with unified command. Communication and
information sharing are key parts of successful incident
management---both before and during an actual event. Regional physicians
should review community emergency response plans, as well as the
collaborative efforts between responders and planners, to ensure that
they know what will be expected of them in the event of a disaster and
where they can turn for assistance. For example:

-   Emergency medical services (EMS) --- In recent years, the addition
    and expansion of initial and continuing education in prehospital
    pediatric trauma care, as well as the provision of expert pediatric
    medical direction, has greatly enhanced the capabilities of most
    regional EMS systems. In most regions, injured children can now
    receive emergency medical assistance comparable to that provided to
    injured adults.

-   Hospitals --- In mass casualty incidents, including those involving
    release of biological or chemical agents, both children and adults
    are likely to be significantly affected. Indeed, children are likely
    to be disproportionately affected by such an incident, so
    pediatricians should assist in planning coordinated responses for
    local hospitals that may have limited pediatric resources. Health
    care facilities could also be a primary or secondary target. At the
    very least, hospitals will be caring for large numbers of anxious
    and worried individuals, including children and parents. In
    addition, hospitals may be overwhelmed by numerous victims who
    appear at the facilities without benefit of EMS triage and
    transport.

-   Surge capacity --- Most of our medical systems are already operating
    at near capacity, so pre-event planning is essential to develop
    local capacity to expand health care resources. Surge capacity
    expressed in terms of beds is not specific enough. Specific
    pediatric surge capacity that is somewhat intervention-specific is
    preferable. For example, there may be 1,000 hospital beds available
    in a large community but only 10 pediatric intensive care unit beds.
    Regional response to a disaster may involve crossing State lines and
    tapping emergency services from many different jurisdictions. Thus,
    surge capacity needs to be considered from several perspectives,
    including local, State-wide, and regional facilities and services.

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-   High-acuity pediatric patients --- In large urban areas, there are
    likely to be multiple pediatric hospitals within a short distance of
    each other. However, many smaller communities have access to only
    one regional facility that is capable of handling high-acuity
    pediatric cases. This means that surge capacity for pediatric
    disaster victims may be critically limited. Transporting pediatric
    patients to facilities outside of the region may be required
    (particularly if a pediatric facility is damaged or incapacitated).
    Pediatricians should educate and advocate regarding this type of
    planning. This is similar to the situation for high-end pediatric
    cardiac surgery, organ transplantation, and burn unit care for which
    pediatricians already refer to resources outside their region.

-   Other facilities --- It may be necessary to use facilities other
    than hospitals to care for unaccompanied but medically stable
    children or for children with social but no serious physical issues.
    This will not occur unless pediatricians help the responsible
    agencies/facilities prepare in advance.

# Pediatricians as Planners

There are many ways that pediatricians can participate in regional
hospital and community planning to ensure optimum care for children in
the event of a disaster. Some examples include:

-   Meet with hospital planners to ensure children's needs can be met.

-   Help organize the response of community pediatricians to ensure
    appropriate distribution of pediatric expertise.

-   Participate in developing education and assistance packets for
    family preparedness.

-   Work with hospitals and schools to develop decision trees for the
    initial steps to be taken in decontamination, further triage,
    transport, and so on.

-   Help hospitals develop color-coded triage systems for patients who
    arrive without previous triage to ensure appropriate levels of care
    and that children are not separated from their caregivers in a
    chaotic situation.

-   Assist hospital disaster planning teams in developing a protocol for
    managing pediatric victims who have been separated from their
    primary caregivers during a disaster.

Triage to the appropriate facility can be critical for a child.
Pediatricians should work to ensure that a mass casualty plan is in
place that considers the unique needs of children, as well as the
importance of not overloading one local facility (whenever possible).
While there should be designated facilities for referral of critically
injured children, each facility should be able to care for and at least
initially stabilize both children and adults. Pediatric skills and
equipment should be maintained at all facilities.

Emergency departments and hospitals may be called upon to provide for
the both the physical and the medical needs of pediatric patients. They
may need to provide children, for the short-term at least, with shelter,
clothing, food, supervision, and entertainment, as well as protection
from the media in the critical period immediately after a disaster.
These nontraditional functions should be addressed during development of
disaster plans.

## Biological Terrorism

Biological terrorism is the deliberate use of any biological agent
against people, animals, or agriculture to cause disease, death,
destruction, or panic for political or social gains. A bioterrorist
agent may be a common organism, such as influenza or *Salmonella*, or a
more exotic organism such as Ebola virus or variola virus. The following
biological agents pose the greatest potential for use in a bioterrorist
attack and have been designated as Category A agents:

-   Variola major (smallpox).

-   *Bacillus anthracis* (anthrax).

-   *Yersinia pestis* (plague).

-   *Francisella tularensis* (tularemia).

-   Botulinum toxin (botulism)

-   Filoviruses and arena viruses (viral hemorrhagic fevers \[VHFI\]).

When there is no other explanation for an outbreak of illness, it may be
reasonable to investigate bioterrorism as a possible source. There are a
number of clues that should arouse suspicion of a bioterrorist event;
some examples include:

-   Disease caused by an uncommon organism (e.g., smallpox, anthrax, or
    VHF).

-   A disease identified in a geographic location where it is not
    usually found (e.g., anthrax in a non-rural area, or plague in the
    United States).

-   Antiquated, genetically engineered, or unusual strains of infectious
    agents.

-   An unexplained increase in incidence of an endemic disease that
    previously had a stable incidence rate.

-   A large number of people presenting with similar illnesses in
    noncontiguous regions (may be a sign that there have been
    simultaneous releases of an agent).

# Notification

Rapid reporting of a suspected bioterrorist event is essential, since
all public health and medical responses to bioterrorism begin at the
local level. Pediatricians are front-line health care providers in every
community and may become front-line responders in the event of a
bioterrorist attack. It is impossible to predict where a child or parent
may first seek care for an illness caused by a bioterrorist agent, so
primary care pediatricians, as well as those working at secondary and
tertiary care facilities, must be prepared to promptly diagnose and
isolate a patient who is contaminated or infected with a communicable
disease. If the illness is potentially related to bioterrorism, the
proper authorities must be notified promptly.

After the initial history and physical examination have been completed,
if the pediatrician suspects a disease related to bioterrorism, he or
she must notify the proper authorities, including the infection-control
practitioner (if one is available at the facility) and local public
health authorities. Each local public health system is organized
slightly differently, so pediatricians should know which local public
health agency to contact and have the correct phone number at hand.

# Laboratory Support

Collecting the appropriate clinical laboratory specimens when a
bioterrorism-related illness is suspected is critical for the medical
care of the patient, as well as for public health and legal
investigations. Specimen collection varies by the agent suspected and
should be done in consultation with public health authorities. Local and
State public health authorities can advise on specific specimen
collection and shipping in each case, and they can consult with the
Centers for Disease Control and Prevention (CDC) as needed.

# Limiting Spread

Rapid identification and isolation of patients with a communicable
illness related to bioterrorism are essential to prevent transmission in
health care settings. When such an illness is suspected, the patient
should be placed on contact precautions and airborne infection
isolation, in addition to standard precautions, until preliminary test
results are available and the transmissibility of the infection can be
reevaluated.

Agents of bioterrorism generally are not transmitted from person to
person. The release of an agent is most likely from a point source.
However, smallpox, VHFs, and pneumonic plague may be highly
transmissible from person to person via respiratory droplet and, in some
cases, by aerosol spread.

All patients in a health care facility and all patients suspected of
infection with a Category A bioterrorist agent (anthrax, botulinum
toxin, plague, smallpox, tularemia, and VHFs) should be cared for using
standard precautions, as well as contact precautions and airborne
infection isolation (the highest level of precaution) until preliminary
test results are available and the transmissibility of disease can be
reevaluated. Standard precautions prevent direct contact with blood,
other body fluids, secretions, excretions, nonintact skin/rashes, and
mucous membranes; they should be observed during all aspects of patient
care. Contact precautions ensure that health care workers and others do
not come into direct contact with the patient's skin or indirect contact
with surfaces or patient-care items in the patient's environment.
Airborne infection isolation requires the patient's room to have certain
features (private, negative air pressure room with 6 to 12 air exchanges
per hour and other features), places limits on who can enter the room,
and necessitates confinement of the patient to his or her room except
when it is absolutely necessary to transport the patient to another area
of the facility.

# Equipment and Supplies

The type of equipment and supplies necessary to diagnose and treat a
patient suspected of being infected with a bioterrorist agent varies by
the level of care that will be provided at a particular facility. An
office-based primary care pediatrician may need to be concerned only
with short-term isolation and preliminary stabilization of a patient.
Such limited care would require a relatively short list of supplies,
usually available in the well-stocked pediatric medical office.
Hospital-based pediatricians may be providing longer term and more
complex care to patients and should consult with and advise their
hospital administration regarding the hospital's bioterrorist response
plan and the response plans of State and local health authorities.
Hospital-based pediatricians should know how to access the Strategic
National Stockpile in the event of a bioterrorist event (see following
section on Strategic National Stockpile).

# Pediatric Practices

Community-based pediatricians and their staffs should keep the office
running smoothly and provide care to the best of their abilities during
and after a bioterrorist event. The first step is for every staff member
to have a personal family emergency plan. Once staff members are assured
that they and their family members are safe, they will be better able to
focus on their professional duties.

Second, every office needs an emergency plan. This plan should include
details for handling an emergency, both in the office and in the
community. Items that should be included in an in-office emergency plan
include the following:

-   Isolation of the patient and family.

-   Personal protective equipment for staff.

-   Backup and safe storage of medical records.

-   Plans for a secondary office/practice site.

-   Contact information for local public health authorities.

-   Phone numbers and instructions for emergency patient transport.

Items that should be included in a plan for an emergency in the
community include the following:

-   Information sheets and hotline telephone numbers.

-   Telephone triage protocols.

-   Back-up staffing schedules.

Depending on the situation, dedicated staff may be needed just to handle
anxious or worried parents.

The community-based pediatrician should have the following items readily
available to evaluate children suspected of having an illness related to
bioterrorism:

-   An examining room with a door that closes, in which to isolate a
    patient and accompanying family members.

-   Surgical masks.

-   Clean, nonsterile gowns.

-   Clean, nonsterile disposable gloves.

-   Eye protection equipment, such as goggles and face shields.

-   The 24/7 phone numbers of local and State public health authorities.

# Managing Patients

Treatment consists of supportive care (e.g., fever management, fluid
management, nutritional supplementation, ventilatory support, and
emotional care) and medical treatment (antibiotics and antitoxins)
specific to the bioterrorist agent implicated.

The Department of Health and Human Services has stockpiled vaccine for
potential use in an outbreak of smallpox or anthrax. Although these
vaccines are not available to the public before a bioterrorist event,
they could be made rapidly available to high-risk populations in the
event of an attack.

# Strategic National Stockpile

The Strategic National Stockpile (SNS) was established in 1999 and is
managed by the Department of Health and Human Services (HHS). The SNS is
a national repository of antibiotics, chemical antidotes, antitoxins,
vaccines, life-support medications, and other medical and surgical
items. The SNS maintains a stock of supplies that are specific for the
medical needs of children and has received guidance from academic and
public health experts in general pediatrics, pediatric infectious
diseases, pediatric pharmacology, and pediatric critical care medicine.

The SNS is designed to supplement and re-supply State and local public
health agencies in the event of a national emergency anywhere and at any
time in the United States or its territories. The SNS is prepared for
immediate response by having push packs strategically positioned across
the United States. Push packs provide medical supplies for an initial
response to a broad range of emergencies and can arrive on site within
12 hours of deployment. If additional supplies are required, they can be
shipped within 24--36 hours through vendor-managed inventory. SNS
supplies will be dispensed when the governor of an affected State makes
a request to CDC or HHS.

## Information for Families

In the event of a bioterrorist attack, one of the most important and
challenging roles for the local pediatrician will be providing
information to families with children. During the anthrax attacks of
2001, public health and medical facilities were inundated with requests
for information and medical evaluation. As a result, these same agencies
have prepared communication messages and information sheets that can be
shared with families before and during a crisis. Parents will want
information that is age-appropriate for their children, as well as
suggestions for ways to answer their children's questions. Pediatricians
may want to consider accessing some of these materials and having them
available before an emergency occurs. See the list of resources
(including the HHS, AHRQ, and CDC Web sites) at the end of this summary
for further information.

## Chemical Terrorism

Chemical terrorism is the intentional use of toxic chemicals to inflict
mass casualties and mayhem on an unsuspecting civilian population,
including children. Such an incident could potentially overwhelm the
capacity of regional emergency medical services and pose extraordinary
medical management challenges to pediatricians.

Chemical terrorism often refers to the use of military chemical weapons
that have been illicitly obtained or manufactured *de novo*. However,
additional concerns might include the intentional explosion of an
industrial chemical factory, a tanker car, or a transport truck in
proximity to a civilian residential community, school, or worksite.
These events underscore the need for all pediatricians to expand their
working knowledge of the approach to mass casualty incidents involving
traditional military chemical weapons and other toxic chemicals that
might be used as "weapons of opportunity."

Chemical weapons can be categorized based on the predominant symptoms
they cause:

-   Neurologic (nerve agents or cyanide).

-   Respiratory (phosgene or chlorine, high-dose riot-control agents, or
    sulfur mustard with a delay of several hours from time of exposure).

-   Mucocutaneous syndromes (vesicants).

Casualties will occur almost immediately after an incident involving
chemical terrorism, and the attack will likely be recognized rapidly.
First responders will be EMS, police, fire, and paramedic personnel.
Decontamination and initial care of small children on-scene will pose
enormous management issues for personnel wearing bulky personal
protective gear. In addition, many exposed, but not critically injured
children, will undoubtedly be taken by parents to hospitals and
pediatricians' offices without prior on-scene decontamination---thus
posing similar challenges for and possibly personal risk to pediatric
care providers themselves.

**Specific Pediatric Vulnerabilities to Chemical Agents**

Children have inherent physiologic, developmental, and psychological
differences from adults that may enhance susceptibility and worsen
prognosis after a chemical agent exposure. Briefly, such physiologic
differences include:

-   Higher minute ventilation.

-   Increased skin permeability.

-   Greater body surface area to weight ratio (plays a key role in
    degree of contamination and in the ability to maintain thermal
    homeostasis after decontamination).

-   Less intravascular volume reserve in defense of hypovolemic shock.

-   Shorter stature (which places children nearer to the greatest gas
    vapor density at ground level).

Children who are pre-ambulatory or pre-verbal or have special needs are
less able to evade danger or seek attention effectively. A chaotic
atmosphere compounded by rescuers wearing unfamiliar garb may frighten
children of all ages and potentially increase the posttraumatic response
to stress. Those providing care for children are faced with additional
complexities posed by developmental, age, and weight considerations
beyond the general scope of the already enormous challenge.

# Initial Approach, Decontamination, and Triage

The general treatment of contaminated victims begins with extrication,
triage, resuscitation as needed, and decontamination performed by rescue
workers or health care providers wearing appropriate personal protective
equipment. Even if decontamination has been done in the field, hospitals
are likely to repeat decontamination procedures to protect the facility
from contamination. Decontamination to limit secondary exposures is
especially important in exposures to nerve agents and vesicants.
Children and their parents or caregivers should be kept together during
decontamination whenever possible.

After decontamination, ambulatory, asymptomatic victims may be able to
be discharged from the scene, while those with minimal symptoms may be
directed toward local shelters (e.g., American Red Cross stations, local
schools, or other sites designated by local or State health departments)
for medical observation. These shelters may also serve as sites for
reuniting children and families who have become separated, keeping track
of all victims, and communicating with law enforcement agencies.

**Community Preparedness**

In today's world of heightened awareness, many agencies are
collaborating to provide coordinated care of pediatric victims, and all
pediatricians are encouraged to participate in disaster management
training. The need to stock appropriate antidotes, practice
decontamination strategies, and learn the use of personal protective
equipment is apparent. Although perhaps not every practicing
pediatrician needs to be competent in all aspects of disaster response,
all in the community should work together to optimize the overall
capacity for providing disaster care to chemically exposed children.
Successful planning and response to events involving chemical terrorism
require strong collaboration and integrated functioning of many agencies
and facilities in the public and private sectors.

**Radiological and Nuclear Terrorism**

Nuclear and radiological weapons pose a significant terrorist threat. In
the past, terrorists have attacked discrete locations with explosive
materials that are not inherently toxic. However, the tactics and
technological sophistication of terrorists are continually evolving.
Future attacks with radiological devices are a real possibility that is
outside the experience of most local emergency and health officials.
Radiological terrorism could include detonation of one or more nuclear
weapons, deployment of a radiation-producing device or other isotopic
weapon (e.g., "dirty bomb"), or simply placement of a radioactive source
(e.g., nuclear waste material) in a public location. The probability and
nature of injuries depend on the type of disaster involved.

There are several key public health and safety considerations in
managing radiological incidents. These include the potential for both
immediate and long-term health effects, depending on the specific
radionuclide(s) and method of dispersal involved. Other concerns include
protection of first responders (including forensic investigators) and
the general public, casualty triage, decontamination, treatment, and
management of emotional distress and fear associated with possible
exposure to radiation. Key decision points include evacuation versus
sheltering-in-place, and potential restrictions on food and water
consumption. Initial response capabilities will be limited unless
appropriate expertise, specialized equipment, and supplies are readily
available.

**Nuclear Weapons**

The so-called "dirty bomb" disperses radioactive material and is
relatively simple to deploy. A nuclear weapon would be much more
difficult to deploy. Nevertheless, the potential for detonation of a
nuclear weapon in a major city cannot be dismissed. The destructive
action of nuclear weapons is mainly due to blast and heat, as in
conventional explosives, but nuclear explosions are hundreds to millions
of times more powerful than conventional explosives.

Medical providers need to be prepared to adequately treat injuries
complicated by ionizing radiation exposure and radioactive
contamination. Medical facilities in the immediate area will be nearly
unusable due to heavy physical damage. Medical facilities in adjacent
areas may be severely compromised by downed power and phone lines;
probable loss of all city utilities; and damage to electronics,
communications, and HVAC control induced by the electromagnetic pulse
produced by a nuclear blast. Patients requiring more than basic medical
care will require transport to functioning medical facilities well
outside the immediate area of destruction.

**Radiological Dispersal Devices**

A radiological dispersal device is designed to spread radioactive
material through detonation of conventional explosives or other
(non-nuclear) means. These so-called "dirty bombs" blast radioactive
material into the area around the explosion, exposing people and
buildings. The purpose of a dirty bomb is to frighten people and make
buildings or land unusable for a long period of time.

**Medical and Industrial Sources of Radiation**

Radioactive materials used in medical or industrial settings can produce
irradiation or contamination from accidental or intentional misuse.
Powerful industrial radiography sealed sources used in the
nondestructive testing of oil and water pipelines have caused severe
exposures. They are potential terrorist weapons and could present a
serious localized radiation threat. Another important medical/industrial
source is Cs-137, which is an important decay product resulting from the
fission of uranium and plutonium fuels. This isotope is used in both
industrial sealed-gamma sources as well as medical therapeutic sealed
sources.

# Nuclear Power Plants

The United States has 104 nuclear reactors licensed to provide electric
power, as well as 36 reactors licensed for other uses. The U.S. Nuclear
Regulatory Commission has stringent physical protection requirements
against sabotage covering both plant design and security protection
features. Unlike the design of some foreign reactors, designs for power
reactors operating in the United States incorporate a layered system of
physical shields and walls, including a potentially pressurized
containment vessel. Consequently, there have been relatively few mishaps
involving American-designed power reactors.

The primary down-wind hazard from destruction or sabotage of a nuclear
reactor is the venting of radioactive iodine gas. Power reactors cannot
detonate like a nuclear bomb because reactor fuel does not contain the
highly enriched uranium needed for detonation.

Pediatricians may be asked about the safety of consuming milk and other
foods after a reactor accident. Iodine-131 fallout on vegetation has an
effective half-life of about 5 days. An infant consuming 1 L of milk per
day contaminated with 1 microCurie (µCi)/L would receive a total
cumulative dose to the thyroid of about 16 rem. Therefore, locally
produced milk, fruit, and vegetables should be declared fit for
consumption only after clearance by appropriately trained health
inspectors.

**External Contamination**

External contamination with radionuclides can occur in the same settings
and situations that cause internal contamination. Any person who passes
through a contaminated area without appropriate personal protective
equipment or is injured in a contaminated area will become externally
contaminated. The largest amount of fallout is on the surface of the
ground, so children and crawling infants are particularly prone to pick
up this material on their bare skin. However, up to 95 percent of
contamination is on the outer clothing and shoes. The body surfaces most
likely to be contaminated include the hands, face, lower legs, and oral
and nasal cavities.

External contamination with radioactive agents is unlikely to cause
acute injury, so emergency resuscitation and treatment of injuries come
first. This is in contrast to external contamination with chemical
agents, in which rapid decontamination may be more important.

# Medical Treatment Unique to Pediatrics

The clinical manifestations of radiation injury in children are
generally similar to those in adults. However, a number of
characteristics render the pediatric patient uniquely sensitive to the
effects of radiation exposure. For example:

-   Children have a greater body surface area to weight ratio than
    adults and skin that is more permeable and less keratinized, making
    them more vulnerable to both thermal and radiation burns.

-   Young children may be unable to shield their eyes, making them more
    susceptible to ocular injury from blast, radiation, and thermal
    effects.

-   Children have a higher baseline respiratory rate than adults and
    also exist in a lower breathing zone, making them more vulnerable to
    both generalized inhalation exposure and particulate exposure from
    radioactive fallout.

-   Children have a lower intravascular volume reserve than adults,
    making them more susceptible to dehydration from the
    gastrointestinal losses encountered in acute radiation syndrome.

-   Infants and young children are more likely to come in close contact
    with radioactively contaminated materials in their environment.

-   Radioiodine, a common byproduct of nuclear reactor activity, is
    efficiently transmitted through both human breast milk and cow's
    milk, which are staples of the childhood diet.

**Long-Term Susceptibility**

The well-documented long-term effects of radiation exposure to the fetus
and child are potentially of even greater concern for the more broadly
exposed pediatric population. These effects can occur anywhere from
months to years after initial exposure and include:

-   Increased incidence of thyroid and hematologic malignancies.

-   Increased incidence of breast cancer.

-   Higher incidence of mental retardation, microcephaly, and postnatal
    growth retardation from fetal exposure to radiation.

**Psychological Vulnerability**

Children involved in a radiation-related incident will be particularly
vulnerable to psychological trauma, as in any disaster or terrorist
event. Depending on the child's stage of development, this increased
vulnerability can manifest as generalized fear and anxiety,
developmentally regressive behavior, sleep and appetite problems,
altered play, school problems, or greater dependence on caregivers. This
latter problem may be exacerbated by physical separation from parents in
the chaos of the event. Repetitive television and news broadcasts
relating to the event may even traumatize children in areas remote from
the actual disaster, convincing them that they also are at risk.
Children also experience stress by witnessing the reactions of their
parents. Any treatment plan for children exposed to radiation must take
these unique vulnerabilities and parental reactions into account.

**Immediate Care**

The first priority during the care of anyone exposed to radiation is to
treat life-threatening injuries before addressing radiation exposure and
contamination. In general, evolving injuries such as burns, lacerations,
and fractures need to be stabilized before decontamination and
subsequent transport to facilities where radiation-specific injuries are
to be managed. In most instances, radiation levels will not be known and
survey instruments may not be available. Contamination risks to medical
responders will be minimal in most cases, unlike biological and chemical
exposures. However, simple precautions such as wearing gloves and
wrapping victims in sheets or blankets to reduce the spread of
contamination should be taken before transport.

# Followup Care and Risk of Carcinogenesis

Children are particularly susceptible to the transforming effects of
ionizing radiation. This is true for children exposed to radioactive
fallout, release of radioactive materials from nuclear power plants, and
external beam radiation therapy for medical conditions. External beam
radiation therapy, used, for example, in the treatment of Hodgkin's
disease or tumors of the central nervous system, is associated with an
increased risk of second malignancies, particularly solid tumors arising
in the radiation field.

Thyroid nodules and cancers are one of the most frequent late
complications of ionizing radiation. Although generally uncommon in
children, they are very frequent 10--20 years after radiation exposure.
Stable iodine prophylaxis can reduce the risks of thyroid cancer after
nuclear disasters or accidents but has no effect against external beam
radiation therapy because the latter does not involve radioactive
iodine. The World Health Organization and the U.S. Food and Drug
Administration recommend stable iodine prophylaxis for exposed
populations stratified according to age. Thyroid function tests should
be monitored in infants to allow early recognition and treatment of
hypothyroidism.

In general, radiation-induced thyroid cancers appear to be more
aggressive than spontaneous thyroid cancers and are frequently
multifocal. Exposed children should be monitored by serial ultrasound
examinations, and suspicious lesions should be removed by total
thyroidectomy to eliminate other microscopic foci of disease.

Due to the increased incidence of leukemia in children exposed to high
doses of radiation, close followup with regular physical examinations
and complete blood counts is warranted. The incidence of breast cancer
is also increased in young women, so regular breast examinations should
be emphasized. Abnormalities should be evaluated with a high level of
suspicion. Enrollment in a high-risk breast clinic may be indicated. The
latency period (i.e., the time interval between irradiation and
appearance of a malignancy) is shortest for leukemia (5--7 years) but
can extend to 45 years or more for solid tumors.

**Environmental Issues**

The environmental damage from a terrorist incident involving radiation
has many potential consequences for children. Response planning should
include actions that may be taken to minimize exposure both immediately
after and during recovery from a terrorist incident, for example,
whether to shelter-in-place or evacuate.

Evacuation is an effective countermeasure to the presence of radiation
and may prevent exposure to children. The decision to evacuate should
take into account the potential disruption and actual risk. Area
evacuations can result in increased risk of exposure if a plume already
exists or if evacuation is to a higher risk location. Also, casualties
can result from the evacuation process, and negative psychological
effects can occur. Ideally, the evacuation would begin before the
passage of any radioactive material carried in a dispersal cloud.
Evacuation is almost always indicated if the projected average effective
dose is likely to be \>0.5 Sv (50 rem) within a day.

Sheltering-in-place for protection from radioactive fallout is also an
effective countermeasure with little negative impact for short periods
of time (hours) and may be done in a fallout shelter, an underground
area, or in the middle of a large building. Sheltering generally reduce
exposures to external and internal contamination by 5 to 10 times.
Sheltering is almost always justified if it will prevent exposures of
0.050 Sv (5 rem) or more.

Earlier recommendations by the Environmental Protection Agency for
evacuation were written for a nuclear power plant accident in which the
release of radioactive material would occur hours after the initial
accident, allowing the population to be evacuated in a plume-free
environment. However, a terrorist attack is more likely to release a
plume within minutes rather than hours of the event. Therefore,
sheltering is likely to be more protective in response to a radiological
terrorist event. Sheltering should be performed whenever it is more
protective than evacuation.

**Blast Terrorism**

A 1997 report by the Department of Justice presented an abundance of
evidence suggesting that given intent, the knowledge required to build
bombs is readily available in print and on the World Wide Web. The raw
materials for explosive devices are routinely found in areas of farming
and mining activities. Due to the public accessibility of explosive
materials and bomb-building knowledge, a domestic terrorist attack would
probably take the form of a conventional explosive munitions attack.

Both blast trauma and conventional trauma have aspects of blunt,
penetrating, burn, crush, and inhalational injuries. However, victims of
a blast may suffer all of these injuries simultaneously, with additional
injury caused by the blast wave itself, that is, primary blast injury.
Primary blast injuries are lethal, unique, and often subtle.

Many mechanisms of injury are involved in blast injuries:

-   Primary blast injury refers to tissue damage by the blast wave
    itself.

-   Secondary injury refers to penetrating or blunt injury that results
    from the acceleration of shrapnel or debris.

-   Tertiary injuries result from acceleration-deceleration forces
    imposed as the blast wind propels the victim.

-   A fourth injury mechanism includes flash and flame burns,
    inhalational injury, and crush injuries incurred from fires and
    structural collapse.

**Trauma Systems**

The medical response to blast terrorism is built on the foundation of
the regional trauma system. About 98 percent of all terrorist events
worldwide, of which approximately 75 percent are due to blast trauma,
involve physical trauma. Therefore, regional emergency management,
public safety, and public health agencies should include not only
regional child health care experts, but also regional pediatric trauma
professionals in planning for mass casualty events that affect children.

Most trauma hospitals are full-service general hospitals that provide
the highest level of health care service in their communities. However,
modern trauma system design does not rely solely on such hospitals but
integrates all health facilities within the region to the level of their
resources and capabilities. Thus, the complete trauma system should
consist of an integrated network of health care facilities within a
region, designed for safe and rapid transport of injured patients to the
health care facilities that best meet their medical needs. Many
stand-alone pediatric hospitals also serve as pediatric trauma centers.

**Planning and Mitigation**

Regional trauma system planning should consider the special needs of
children who are injured due to blast terrorism and the special
resources necessary to care for them. Children and young adults are at
higher risk of serious injury than adults for several reasons. Although
blast tolerances in children are poorly defined, there is good reason to
believe that children may absorb more blast energy per unit of body mass
than adults after blast trauma. This predisposes children to morbidity
and mortality rates higher than those of adults as compressive shock
waves passing through the body are compacted into a smaller total body
mass.

Reports in the literature point out the inadequate state of emergency
preparedness for disasters that involve children. They also describe the
common problems in pediatric disaster planning and management, such that
pediatric professionals involved in disaster planning will be
knowledgeable about these problems and can seek to anticipate and avoid
them in future disasters. For example, no children were injured in the
terrorist attack on the Pentagon on September 11, 2001, principally
because the Pentagon daycare center was located on the opposite side of
the building from the location of attack. However, issues were
subsequently raised on children's hospital disaster preparedness.

Immediately after the attack, the hospital disaster plan was invoked,
resulting in the discharge of more than 50 patients and the cessation of
all nonurgent activities. Although hospital staff had conducted disaster
drills in preparation for Y2K, hospital leaders continued to question
their actual state of readiness. Further, emergency preparations were
complicated by the fact that all of their news came not from official
sources, but from local television, leaving hospital leaders unsure
about what to expect.

These experiences highlight the importance of planning and preparedness
and raise a number of vitally important issues regarding blast terrorism
mitigation in children.

-   After a blast, injuries in children are to be expected with most
    children injured in closed or confined spaces, which greatly
    increases the magnitude of forces of injury.

-   As with blast injuries in adults, most children will either die at
    the scene or sustain minor injuries. Only a small number of children
    in the "penumbra" of the blast wind who sustain major injuries will
    survive to require hospital care. They typically will not begin to
    arrive at the trauma center until 30--60 minutes after the blast
    event.

-   Most surviving children with major injuries will require early
    surgery and subsequent care in a pediatric critical care unit,
    followed by lengthy hospitalization and rehabilitation, both
    physical and psychological.

## 

## Mental Health Issues

Pediatricians and other health professionals who care for children will
play many critical roles in identifying and addressing the mental health
needs of children and families in a disaster or terrorist event. Indeed,
for many, if not most, children affected by a critical event,
pediatricians and other health care providers for children will be the
first responders. Therefore, pediatricians need to be able to identify
psychological symptoms, perform timely and effective triage of mental
health complaints, initiate brief supportive interventions, and make
appropriate referrals when necessary.

Because children's adjustment depends to a great extent on their
parents' own ability to cope with the situation, pediatricians should
also attempt to identify parents who are having difficulties adjusting
to the event and encourage them to seek support for themselves.
Pediatricians can also help families identify and access appropriate
supportive or counseling services, and they can help support families
who are reluctant to seek mental health services because of
misunderstandings related to the nature of the treatment or associated
stigma.

# Trauma-Related Disorders

Exposure to disasters and terrorism can be direct, interpersonal, or
indirect. Children who are physically present during an incident or are
an eyewitness to it are directly exposed. Interpersonal exposure occurs
when relatives or close associates are directly affected. Indirect
exposure occurs through secondary negative consequences of an event such
as chaos and disruption in daily activities. Children who are far away
from an incident may be remotely affected with fear and generalized
distress as they perceive the societal impact of these experiences.

Children may develop psychiatric symptoms and disorders---including
posttraumatic stress disorder (PTSD), anxiety, depression, and
behavioral problems---after exposure to disasters or terrorist
incidents. Grief in these situations can be compounded by the traumatic
circumstances associated with the loss. The following factors are
associated with an increased risk of posttraumatic symptoms and other
adjustment difficulties:

-   Children or others close to them are direct victims.

-   Children directly witness the event.

-   Children perceived during the event that their life was in jeopardy.

-   Event results in separation from parents or other caregivers.

-   Event results in disruption of regular environment.

-   Children have a history of prior traumatic experiences or prior
    psychopathology.

-   Parents have difficulty coping with the aftermath of the event.

-   Family lacks a supportive communication style.

-   Community lacks the resources to support children after the event.

The essential feature of PTSD is the development of characteristic
symptoms after exposure to a traumatic event that arouses intense fear,
helplessness, or horror or that leads to disorganized or agitated
behavior. Signs and symptoms are categorized into three clusters:

1.  Persistent intrusive re-experiencing (e.g., unwanted memories,
    nightmares).

2.  New onset and persistent avoidance and numbing (e.g., avoiding
    thoughts about the experience, amnesia).

3.  New onset persistent hyperarousal (e.g., sleep difficulties,
    exaggerated startle response).

Other conditions, especially anxiety and affective disorders, are common
after crisis events and may occur independently or together with PTSD.
Signs of trauma may be evident in children's behavior, mood, and
interactions, and traumatized children may adopt behavior more
appropriate of younger children. Girls are more likely to express
anxiety and sadness, while boys tend to exhibit more behavior problems.

Although grief is not a mental disorder, it may require professional
attention, especially if it is complicated by depression or PTSD.
Traumatic deaths are of particular concern, and referral to a pediatric
mental health professional is often indicated in these situations.

# Assessment and Treatment

Assessment and treatment of children after a disaster vary depending on
characteristics of the disaster and the child's exposure, the setting,
and the length of time since the event. In the acute-impact and early
post-impact phases, supportive interventions should:

-   Ensure the child's safety and protection from additional harm.

-   Address immediate physical needs.

-   Provide reassurance.

-   Minimize exposure to traumatic aspects of the event.

-   Validate experiences and feelings.

-   Restore routine.

> Children benefit from accurate information, but it should be
> age-appropriate and measured. Pediatric mental health professionals
> may be able to help other health professionals and family members with
> the process of death notification when needed. Reuniting family
> members is a priority.

Assessment should include a history of the child's exposure and
reactions. When children or their close family members have been
directly exposed, the children may require more comprehensive
assessment, but children with less direct exposure may also need
attention. Observation and the use of projective techniques, such as
play and art, aid in assessment and are useful in treatment as well.
Children generally should not be forced or coerced to recount the event
through repetitive questioning, or to act out the event, or to share
their feelings before they are ready.

Treatment should be guided by the child's exposure and reactions.
Directly traumatized and bereaved children should be seen individually,
but groups are useful for identifying children in need of more
comprehensive evaluation and treatment. Cognitive behavioral therapy and
educational information provide structure and support and may be used in
individual or group sessions after disasters. Medication is rarely
indicated in children after disasters but might be appropriate for those
with severe reactions. Consultation with a child psychiatrist is
recommended when medication is considered.

The family has a major role in the child\'s adjustment to trauma, and
parents should be included in treatment. Helping parents resolve their
own emotional distress can increase their perceptiveness and
responsiveness to their children.

# School-Based Interventions

Schools are an excellent setting in which to deliver mental health
services to children and families after a disaster. They provide access
to children, encourage normalcy, and minimize stigma.

PTSD and associated symptoms are likely to emerge in the school setting.
For example, intrusive thoughts and difficulty concentrating may
interfere with academic performance and social adaptation. Therefore,
school consultation about the consequences of trauma and the recovery
process may be indicated. School-based interventions, which can include
curricular materials and activities, should be appropriate for the
setting and should not supplant efforts to identify and refer children
in need of more intensive individual evaluation and treatment.

**Explaining Death to Children**

Children's understanding of death may be very different from that of
adults. Children have had far less personal experience of loss and have
accumulated less information about death. They also may have difficulty
understanding what they have seen and what they have been told, unless
they are helped to understand the basic concepts related to death.

When providing explanations to children, use simple and direct terms. Be
sure to use the words "dead" or "died" instead of euphemisms that
children may find confusing. If young children are told that the person
who died is in "eternal sleep," they may expect the deceased to later
awaken and be afraid to go to sleep themselves. Religious explanations
can be shared with children of any age, but adults should appreciate
that religious explanations are generally very abstract and therefore
may be difficult for young children to comprehend. It is best to present
both the facts about what happens to the physical body after death
(e.g., "After a person dies, the body stops working, and the person no
longer can see or hear or feel pain, which is why the body can be
buried), as well as the religious beliefs that are held by the family.

**Children's Reactions to Personal Loss**

Similar to adults, children may be reluctant to talk about a death. They
may at first be shocked by the news or fail to understand its
implications. Even in the setting of a natural disaster or terrorist
event, children may still wonder if they were in some way responsible
for the death. After a traumatic death, such guilt feelings may increase
posttraumatic symptoms and complicate the grieving process. Often such
feelings of guilt are irrational. "If only I hadn't gone to school that
day, my dad would never have gone to the office and wouldn't have been
killed by the bomb," "I was mean to my father yesterday, and that's
probably why he died," and so on. Children often are reluctant to share
their guilt feelings with adults, and adults may not anticipate these
feelings (or be burdened with their own guilt feelings). It may
therefore be helpful to reassure children of their complete lack of
responsibility, even if they do not express feelings of guilt and there
is no logical reason why you might anticipate they would feel guilty.

At the time of a traumatic loss, children often think first about their
own needs. Parents should be warned that this self-centeredness is not a
sign that children are selfish. More likely, it is a sign that they are
under considerable stress and in need of more support and assistance.

# Indications of the Need for Referral

Not every child who has experienced the death of a family member or
friend requires professional counseling and, in the setting of a major
disaster or terrorist event, such resources are unlikely to be
available. It is generally helpful though for children who have
experienced the death of a family member or friend to speak with someone
outside of the immediate family who understands child development and
can attend to the child's needs without being burdened with his or her
own grief. This person may be their pediatrician or a school counselor
or social worker. When a community disaster or crisis has occurred, it
is important to help establish access to supportive services within
community sites, such as schools, to provide services to larger numbers
of children.

Children who have extreme reactions (e.g., anxiety, posttraumatic
symptoms, depression, or thoughts of suicide), atypical reactions (e.g.,
appearing happy or disinterested), or prolonged reactions (e.g.,
prolonged sleep problems or somatization) should be evaluated by their
pediatrician and likely referred to a mental health professional
experienced in the management of pediatric bereavement. Children who are
having difficulty returning to their normal daily routines several weeks
after the death or are demonstrating the new onset or worsening of
problems in interacting with peers should also be referred.

**School Crisis Response**

Most children will benefit from receiving supportive services in the
aftermath of a disaster or terrorist attack. Pediatricians can play a
vital role in advocating for, consulting for, and actively participating
in school crisis response teams to ensure that such supportive services
can be provided to children within schools and other community sites.

School administrators, teachers, and other school staff will be affected
by the same crisis event that is affecting their students. During such
times, organizing and implementing an effective crisis response can be
difficult if not impossible. It is therefore imperative that schools
begin planning for potential crisis events before they occur, to avert
disasters whenever possible and to decrease the negative impact on
students and staff when disasters cannot be prevented.

The school crisis response plan should include generic protocols for the
following:

-   Notification of team members, school staff, students, and parents of
    a crisis event.

-   Delivery of psychoeducational services and brief crisis-oriented
    counseling, such as through support rooms or short-term support
    groups.

-   Memorialization and commemoration.

-   Follow up to ensure appropriate steps are taken.

In addition, the crisis response plan should include guidelines on the
following:

-   Crisis team membership and roles of members.

-   Protocols for delivery of crisis intervention services.

-   Specific guidelines for responding to unique situations, such as
    large-scale natural disasters or a terrorist attack.

-   Physical safety and security.

-   Rapid dissemination of accurate and appropriate information.

-   Attention to the emotional impact of the events and the crisis
    response.

The structure provided by a preexisting plan can be very comforting in
times of crisis and helps to ensure that key issues are considered,
appropriate steps are taken, and necessary resources are in place.

Delivery of supportive services to children during a crisis can be
demanding work for school staff and community mental health providers
working within the schools. Community groups such as the American Red
Cross and the Salvation Army have programs that can be brought into
schools to assist in this effort. Plans should also include mechanisms
to ensure that supportive services for staff are included as a key
component of crisis response.

**Impact on Health Care Providers**

Very often, first responders and other adult service providers show
signs of distress and emotional disruption after responding to stressful
situations involving trauma, disaster, or a terrorist event.
Pediatricians may be approached by a colleague, a fellow worker, or any
health care provider in distress. Apply some basic common sense rules to
help:

-   Make psychological contact.

-   Assess the individual's level of coping.

-   Explore possibilities for getting further help.

-   Assist in taking action.

-   Provide followup.

**Integrating Terrorism and Disaster Preparedness Into Your Pediatric
Practice**

Emergency preparedness should be exercised at all organizational levels,
and office-based physicians (either in a hospital or free-standing
practice) should understand their specific role in the general system
response to disasters. Ideally, office-based policies and procedures
should be specific to the location of the practice and its
characteristics and be consistent with the policies of affiliate
institutions and public and governmental agencies.

Preparedness for disaster by office-based physicians can be subdivided
into two broad categories:

-   Internal operations of the practice.

-   External operations related to communication and coordination with
    other agencies, institutions, and the community.

**Office Readiness**

A comprehensive, child-oriented emergency care system aligns with the
concept of systematic intervention in response to disasters while
viewing the needs of the child in the context of family and community.
This framework is particularly suited to the office-based physician who
attends to the whole child. Pediatric health care professionals possess
knowledge about responses and needs of children involved in disasters,
and they should work across public systems to deliver effective medical,
educational, and community interventions. The objective is to ensure
that the biological and psychological needs of children are addressed
before, during, and after trauma.

Office-based physicians should be aware of the particular
vulnerabilities of free-standing practice buildings based on geographic
location, and their practices should comply with strict building code
regulations and be equipped with back-ups for emergency systems. In the
event of structural damage to the practice, there should be a plan for
its relocation (e.g., by planning to share facilities with another
practice).

Offices should have pre-assembled emergency kits that contain water, a
substantial first-aid kit (including thermometer, blood pressure cuff,
and stethoscope), radios, flashlights, batteries, heavy-duty gloves,
food, sanitation supplies, and medical reference books and cards.
Emergency supplies should be located both on- and off-site. Lack of
refrigeration for medications and vaccines is a likely scenario in a
disaster. Back-up generators are important in case of outages. Back-up
communication systems---such as cellular phones, direct telephone lines
that are not part of the regular telephone system, two-way radios,
beepers, and ham radios---should be considered.

**Records**

The Health Insurance Portability and Accountability Act (HIPAA) mandates
that copies of records be stored off-site (some experts recommend at
least 50 miles away) in case of catastrophe. This includes copies of
patient charts and other vital records, even if most records are stored
electronically. In addition to patient charts, other records---such as
copies of licenses, insurance policies, and real estate leases---also
should be stored off-site

**Contact List**

A confidential contact list of all physicians, nurses, and other staff
that includes home, cell, and emergency contact phone numbers should be
kept by designated individuals. The contact list should also include
back-up providers. This confidential list should be kept in multiple
places (e.g., the practice, an outside location, and/or with the
designated individuals). Practices should consider keeping a list of
technologically dependent children who, during a disaster or emergency
situation, may need specific planning (e.g., availability of back-up
generators) and where these children and families should go in case
their equipment fails.

## Staff Responsibilities

Staff should be made aware that they have a professional responsibility
to discuss their availability in case of disasters. This would include
calling in to check where their services are needed and the feasibility
of responding based on previously discussed office-readiness plans.
Discussion with staff of their multiple responsibilities for their own
families, work, and the community will help to alleviate concerns and
anticipate problem areas. Staff should prepare a Family Emergency Plan
so that they will be assured that the needs of their own families will
be addressed while they are performing critical health care duties.

The roles of the physician, nurse, and support staff should be agreed
upon and documented. For example, everyone should know who will contact
the police or fire department, who will aid in evacuation, who will
reschedule patients, and so on. Staff members need to know where to go
to access credible and up-to-date information during a crisis. Often,
such information can be found online, and Web addresses for pertinent
sites should be identified and posted in advance for easy access.

The office-based physician may be the first contact for an individual
who is the victim of a biological agent and may be called on to treat or
answer questions with regard to chemical and radiation exposure.
Pediatricians should understand the following:

-   The classification and qualities of possible biological agents.

-   The natural history and management of biological, chemical, and
    radiological injuries and exposures.

-   Chemical agents that may be used and their properties.

-   Types of radiological terrorism.

-   Decontamination procedures, especially those specific to children.

-   Availability of antidotes and other therapeutics.

The procedure and numbers for alerting the proper authorities (e.g., the
Department of Health, CDC, etc.) should be part of the office's
preparedness plan.

Office-based physicians may be unsure of their role or feel that they do
not have a role in disaster planning or management, yet emergency
pediatricians may need to draw on community pediatricians to provide the
best possible management of children. The office-based physician may be
asked to help hospital-based pediatricians determine which pediatric
patients can be discharged or transferred to another hospital. They also
will need to triage their own patients who show up at the practice to
determine whether they need to go to the hospital or can be safely
managed without emergency care. In addition, office-based pediatricians
play a critical role in screening children and their family members for
medical and psychological distress.

**Communication and Coordination with Other Agencies**

The office-based physician should determine how the practice will link
and coordinate efforts with affiliate hospitals, schools, daycare
centers, local response teams, the local department of health, and other
entities at the city, State, regional, and Federal levels. Electronic
communication, when circumstances permit, is a useful tool for
communicating with multiple entities. The chain of command established
by the practice should include the points(s) of contact within the
organizational structure for communication with the various larger
agencies. Ideally, a list of all the relevant agencies should be
developed in advance with contact numbers listed (e.g., local and
regional hospitals, city fire department, utilities, pharmacies,
shelters, and so on).

# 

# Communicating with Children and Families

During a disaster or terrorist event, children and families will receive
good and bad information from a multitude of sources, including friends,
media, and public officials. A well-educated and available pediatrician
who can appropriately respond to numerous and varied questions can be of
great service. Families view pediatricians as their expert resource, and
most expect pediatricians to be knowledgeable in areas of concern.
Providing expert guidance entails both educating families in
anticipation of events and responding to questions during and after
actual events.

Pediatricians can play a central role in helping families develop a
disaster and terrorism preparedness plan. Family preparedness may
include training in cardiopulmonary resuscitation, rendezvous points,
lists of emergency telephone numbers, and an out-of-state friend or
relative whom all family members can contact after an event to report
their whereabouts and conditions. Family members should know the safest
place in the home, make special provisions, know community resources,
and have a plan to reunite.

Medications for chronic illness and resources for children who depend on
technological means for survival should be included in the family
preparedness plan. Pediatricians can advise parents on the need for a
power of attorney, living will, advance directive, and other important
legal documents. In addition, pediatricians should advise parents and
other family members to:

-   Notify utility companies to provide emergency support for
    technologically dependent family members during a disaster.

-   Maintain a supply of medications and equipment in case availability
    is disrupted during a disaster.

-   Know how to obtain additional medications and equipment during times
    of a disaster.

-   Learn how they can assume the role of in-home health care providers
    who may not be available during a disaster.

-   Keep an up-to-date emergency information form to provide health care
    workers with the child's medical information in case the regular
    care provider is unavailable.

-   Know back-up hospitals/providers in the region in case primary
    hospital/specialists/providers cannot be used.

# Terrorism and Disaster Preparedness for Hospital-Based Pediatricians

In mass casualty incidents, including those involving chemical and
biological agents, casualties among children and adults could be
significant. Because children are likely to become victims in most
disaster events, pediatricians should assist in preparedness planning to
ensure coordinated responses of local hospitals that in some cases may
have limited pediatric resources.

It is important to remember that health care facilities could themselves
be primary or secondary targets. Also, facilities may be overwhelmed by
massive numbers of anxious individuals and families. Pediatricians
working in or supporting hospitals can play a vital role in ensuring the
enhanced care of the pediatric disaster victim by participating in all
levels of disaster preparedness planning.

# Emergency Department Readiness

Pediatricians working in or supporting hospitals should interact with
the planning committee to ensure adequate training and preparation of
supplies and treatment areas in the emergency department. Pediatricians
working in hospitals can be key facilitators between emergency
department services, critical care services, and regular inpatient
services. Coordination with the local community should involve
primary/prehospital/infrastructure response (e.g., EMS, fire, police,
regional poison centers, and so on) with liaison planning to State and
Federal agencies and community/citizen response (e.g., schools, daycare
centers, service groups, and so on). Planners should take into
consideration the fact that usual referral patterns may not typically
include accepting pediatric patients.

# Inpatient Service Readiness

Anticipating surge capacity for inpatient care is vital in preparedness
planning and perhaps represents the greatest contribution of
pediatricians working in hospitals. Issues that should be considered
include the following:

-   Increasing the number of inpatient beds within a community (e.g., by
    converting cafeterias and meeting spaces into ward capacity or
    making arrangements with other community hospitals). Local hotels,
    school gymnasiums, etc., may be converted into low- or mid-acuity
    medical facilities with some planning. Parallel pediatric services
    have been documented to improve quality and efficiency in the care
    of children.

-   Making contingency plans for acquiring or maintaining essential
    services (e.g., water, electricity, portable oxygen, garbage
    disposal, etc.).

-   Planning for stockpiling or readily acquiring medical supplies such
    as vaccines, antitoxins, and antibiotics (in dosages, formulations,
    etc., appropriate for pediatric patients). In addition,
    pediatric-specific supplies and equipment in a full range of sizes
    to accommodate children of various ages should be available.

-   Networking community resources to organize volunteers who can become
    proxy caretakers for orphaned children.

# Hospital Infrastructure Needs

Essential components of hospital preparedness include crisis drills,
infection control plans, quarantine procedures, and staff training. For
example:

**Crisis drills:** Hospital and community-wide drills need to be done on
both a wide scale and with a narrow focus. Drills should include not
only the initial triage and decontamination stages, but also the 48-72
hours after impact to measure readiness with all provider and support
services that will be needed. Specific drills should be planned and
practiced for evacuation in response to fire or other disasters.

**Infection control plans:** These plans closely parallel quarantine
procedures in the community and on a public health basis. In-hospital
infection control plans involve quarantine or isolation and control
measures to limit spread of infection to staff and other patients.

**Quarantine procedures:** Children who become ill following a disaster
or terrorist event may require isolation to prevent spread of disease to
other patients and health care providers. The exact nature and severity
of quarantine will depend on the specific hazard involved. Close
coordination with the public health service, CDC, and local poison
control centers is essential in both the planning and execution of
quarantine procedures.

**Staff training:** Staff training should include the following:

-   Use of protective gear.

-   Orientation to all aspects of the plan from the disaster site to the
    emergency department to hospital floors, as well as to
    rehabilitation and rebuilding in the community.

-   Staff preparedness for notification, transportation to treatment
    sites, self-preparedness (e.g., emergency packages of personal
    items), strategies for coping with family demands, psychological
    demands, and plans for personal health and hygiene.

-   Support for families of health care workers so that they are
    available to provide services.

-   Mechanism for tracking resources.

-   Media/public communication issues.

## Working with Government Agencies

The challenge of dealing with the threat of terrorism in the United
States is daunting not only for disaster planners, but also for our
medical system and health professionals of all types, including
pediatricians. All possible forms of terrorism must be considered,
including chemical, biological, explosive, radiological, and nuclear
events. Pediatricians must be able to respond to concerns of patients
and families, recognize signs of possible exposure to a weapon of
terror, understand first-line response to such attacks, and sufficiently
participate in disaster planning to ensure that the unique needs of
children are satisfactorily addressed in the overall process.

The Federal government provides significant funding for disaster
preparedness and response and to a large extent establishes the
framework that is then followed by States, regions, and communities.
Volunteer organizations, such as the Red Cross and Salvation Army, also
have key roles in disaster response. A successful response to a disaster
requires the interaction of personnel and resources from multiple
agencies in an organized and coordinated manner according to a
well-formulated plan. While overall planning has increased significantly
in recent times, attention to the unique needs of children and the
inclusion of pediatric expertise in the planning phases continue to be
insufficient.

Local governments are the first line of defense in emergencies and are
primarily responsible for managing the immediate response to most
disasters. When a local government receives a warning that an emergency
could be imminent, its first priorities are to warn citizens and to take
whatever actions are needed to minimize damage and protect life and
property. The emergency operations plan is at the center of
comprehensive emergency planning. This plan spells out the scope of
activities required for community response. Historically, these
documents have not focused much attention on pediatric considerations,
and only rarely have pediatricians been part of the planning process.

All States have laws that describe the responsibilities of the State
government in emergencies and disasters. The State emergency management
office follows procedures specified in the State emergency operations
plan to respond to virtually all serious emergencies, including
disasters and terrorist events. These plans rarely include
child-specific guidelines. To remedy this, pediatricians need to be
involved in State emergency planning committees to ensure that pediatric
considerations are included in State plans and the plans of individual
agencies, as well as a component of funding for disaster and terrorism
preparedness.

At the Federal level, planning and preparedness for disasters and
terrorist events are coordinated by the Federal Emergency Management
Agency (FEMA). FEMA uses the interagency Federal response system, also
called the Federal Response Plan (FRP), to oversee and coordinate the
response and activities of other Federal departments and agencies. The
FRP describes the basic mechanisms and structures by which the Federal
Government mobilizes resources and conducts activities to augment State
and local response efforts. It is important to understand the Federal
role and the provisions of the FRP, in that most States use it as a
basis for the structure and some content of their own emergency
operations plans. In turn, local emergency operations plans are based to
some extent on State plans.

On a larger scale, we also should recognize the need for public health
preparedness. This requires the existence of a strong public health
system. To allow for rapid and efficient response, both a central
organization, as specified by Federal planning and State implementation,
and the decentralization of some resources, such as diagnostic
capabilities, are necessary. Pediatricians should understand the
importance of public health and their relationship to departments of
health at various organizational levels. This includes their role in
public health, reporting requirements and mechanisms, and mechanisms for
receiving and soliciting information from departments of health.

# Advocating for Children and Families in Preparedness Planning

Properly informed and motivated pediatricians are essential advocates
for children to ensure they receive appropriate attention in
preparedness planning at the local, State, and Federal levels. The role
of pediatricians can take several forms. Grass roots advocacy can
include efforts to ensure legislation and funding to support an emphasis
on children in disaster planning at every level. Pediatricians can serve
as expert advisors to local, State, and Federal agencies and committees.
They also can serve as strong advocates for children through their
involvement in boards, community groups, and professional associations,
including national organizations.

As experts in the care of children, pediatricians should be prepared to:

-   Advocate for inclusion of the needs of children in all Federal,
    State, and local disaster planning.

-   Advocate for research on the pediatric aspects of biological,
    chemical, and radiological terrorism, including mechanisms,
    pathophysiology, and treatment, as well as the availability of
    appropriate medications and antidotes.

-   Work with disaster medical assistance teams to ensure that they are
    equipped and trained for the care of children.

-   Assist in developing hospital disaster plans that ensure the proper
    care of children.

-   Provide on-site emergency and primary health care at emergency
    shelters.

-   Be involved in emergency medical services (e.g., develop proficiency
    in cardiopulmonary resuscitation and first aid, train first
    responders in pediatric assessment, assist in development of
    prehospital pediatric protocols, help establish protocols for
    consent to treat and identification of minors, and ensure the
    availability of pediatric resources).

[]{.mark}

At the local and community levels, pediatricians should:

-   Work with local police, fire, and EMS departments to ensure their
    plans and equipment are prepared for children.

-   Be involved with local and community emergency preparedness task
    forces and committees.

-   Work with schools, child care centers, and other facilities where
    children spend their time to ensure that they have adequate
    emergency plans.

[]{.mark}

Similarly, at the State level, pediatricians should:

-   Ensure that State emergency management, department of health, and
    EMS advisory committees have pediatric expertise as part of their
    membership.

-   Advocate to ensure that all State disaster and terrorism education
    and funding require incorporation of children's needs.

# Conclusion

This summary focuses on the very important role of pediatricians in
disaster planning. This includes advocating for the needs of children
during the development of preparedness plans, the provision of care
during and after a disaster or terrorist event, and the mitigation of
suffering in the aftermath of a disaster.

# Lessons Learned

As a Nation, we have learned some painful lessons about the need for
preparedness from recent disasters, in particular Hurricane Katrina. For
example:

-   The initial response to mitigate the impact of Katrina on New
    Orleans and surrounding areas was inadequate at many levels.

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-   A large part of the problem was insufficient coordination and
    planning for the magnitude of the destruction, the need to evacuate
    large numbers of people, and the long-term displacement of people
    from their homes and schools.

-   In disasters, State and Federal aid is always going to take some
    time to arrive.

-   Local and regional authorities, as well as individual families,
    should have an effective plan in place that includes immediate
    efforts to be undertaken before distant assistance can arrive.

-   Communities need a realistic evacuation plan that provides for
    quickly setting up emergency shelters, providing food, managing
    water sanitation, and providing medical and mental health care
    services for large numbers of people.

Following Katrina, parallel services spontaneously evolved and were
found to be readily accepted by providers, decisionmakers, and patients.
For example:

-   When a pediatrician is invited to command center meetings,
    children's issues are resolved more appropriately, efficiently, and
    effectively.

-   Well-meaning volunteers will appear, and some organization of their
    efforts is essential. Some will be untrained; they have proven to be
    helpful when appropriately managed. For professionals, emergency
    credentialing and licensing processes aided in more appropriate use
    of volunteer skills.

-   Payment issues for meaningful and necessary services need to be
    resolved.

Here are some issues for pediatricians and other planners to consider as
they develop and refine emergency response plans for their communities.
These are issues that directly affect children and families, and they
deserve attention.

# Vulnerable populations: In a disaster, the most vulnerable are going to suffer the most. Clearly, vulnerable populations include the poor, the infirm, individuals with mental illness, the elderly, and children. In addition, these situations highlight the need for including large numbers of technologically dependent patients, many of whom require highly specialized regionalized care, in planning efforts to mitigate the impact of a disaster.

# Separation of children from families: In the event of a disaster or terrorist event, it is likely that numerous children will be separated from their parents or other caregivers. Several national organizations---including the National Center for Missing and Exploited Children and the Red Cross---work to help separated family members find each other. This issue deserves more attention in preparedness and mitigation planning. For example, pre-disaster identification of children (e.g., name tags, other forms of ID, etc.) \-- especially for those who are not verbal or cannot give their own name, a parent's name, or other critical information \-- should be considered. Neonates and their mothers are purposefully given matching ID bracelets in hospitals immediately after delivery so the identity of the maternal-child pair is never in doubt. Similar identification of parent-child pairs at the time of separation (e.g., during rescue or evacuation) could greatly aid in the identification of the child and more accurately track and reunite children separated from their parents.

**Sheltering families:** The immediate first responses to a disaster may
be the need to mobilize and evacuate a community or large region.
Subsequently, those displaced from their homes, schools, and
neighborhoods will require basic necessities (e.g., food, clean water,
medical care). The unique needs of children in shelter situations
include special food needs (e.g., formula), clothing and sanitation
needs (e.g., diapers), and sleeping accommodations (e.g., cribs).
Planning for special medical needs and for mental health care that
focuses on a child's unique developmental stages is also critical.

The frustration to staff and evacuees caused by a crying infant or an
obstreperous 2-year-old is predictable and needs to be anticipated. In
addition, some shelters will not accept a pregnant female. This also
should be anticipated, and alternate arrangements should be in place in
advance of a disaster.

**Providing urgent care to large numbers of displaced children:** There
is a need for pediatric specialists in disasters, and it may be
necessary to set up a temporary pediatric clinic to care for large
numbers of injured and/or displaced children. Some lessons learned that
should be taken into consideration in future planning include:

-   Physicians and nurses who are trained and experienced in the
    emergency care of children should always be included, even at the
    most basic level, when planning for and responding to a disaster.

-   Access to local tertiary pediatric care resources should be arranged
    for in advance, and tertiary care providers should be involved in
    planning, including pharmaceutical, central supply, and respiratory
    personnel.

-   While volunteerism is essential in the event of a mass casualty,
    guaranteed staffing of medical facilities, including temporary
    clinics, should be a priority.

-   The appropriate allocation of physician and nursing resources is
    vitally important to patient flow.

-   Cooperation with regional disaster command is essential.

-   Choosing an appropriate venue for the staging of disaster response
    is critical.

-   Mental health care and social services should be made available to
    the evacuated population as early as possible.

-   A centrally located, functional phone, cell phone, and/or radio are
    crucial.

-   A command center should be designated.

-   There should always be a planned exit strategy.

# A Final Word

Timely response and appropriate medical management are essential to
minimizing injuries and maximizing survival when a disaster occurs.
Being prepared ahead of time is the key to timely and appropriate
medical care. Children and other vulnerable populations have special
needs that must be considered in the course of planning for a mass
casualty event.

Pediatricians can play a very important and unique role in advocating
for the needs of children and families who seldom receive enough
attention in disaster planning. Response resources dedicated to
pediatric populations remain unavailable or extremely limited for most
emergency medical response activities related to disasters, even though
victims often include children. To address this shortcoming, it is
vitally important that pediatricians and other representatives of
special populations take part in local, State, regional, and Federal
disaster planning to ensure appropriate care for the most vulnerable
populations.

**Additional Resources**

The following telephone and online resources are provided to assist you
in locating additional information on the topics discussed in this
summary.

# Department of Health and Human Services 

For materials to educate families about bioterrorism, go to
<http://www.os.dhhs.gov/> and select "Disasters and Emergencies."

# Agency for Healthcare Research and Quality

For a variety of resources on bioterrorism and emergency preparedness
and response, go to [http://www.ahrq.gov](http://www.ahrq.gov/) and
select "Public Health Preparedness"

**Centers for Disease Control and Prevention (CDC)**

CDC home page, which includes links to information for families at
<http://www.cdc.gov/index.htm>.

Emergency consultation and assistance to clinicians and to State and
local health agencies is available 24/7; call 770-488-7100 to reach the
Director's Emergency Operations Center.

The Clinician Information Line at 877-554-4625 operates 24/7 to provide
guidance on management of patients suspected of having
bioterrorism-related illnesses.

Physicians can go to <http://www.bt.cdc.gov/clinregistry/index.asp> to
register to receive real-time CDC updates about preparing for and
responding to terrorism and other emergency events.

For public health bioterrorism planning documents, go to
<http://www.bt.cdc.gov/>

Go to <http://www.bt.cdc.gov/stockpile/index.asp> for information on the
Strategic National Stockpile.

For a listing of State health department Web sites, go to
<http://www.cdc.gov/other.htm#states>

For a listing of State epidemiologists, see
<http://www.cste.org/members/state_and_territorial_epi.asp>

For information about infection control, go to

<http://www.cdc.gov/ncidod/dhqp/gl_isolation.html>

For a video on the history of terrorism, see
<http://www.bt.cdc.gov/training/historyofbt/index.asp>

# Health Resources and Services Administration

Go to <http://www.hrsa.gov/healthconcerns/default.htm> and select
"Emergency Preparedness" for materials related to bioterrorism and
disaster preparedness, including materials specific to children and
adolescents.

# Substance Abuse and Mental Health Services Administration

Go to [http://www.nctsnet.org](http://www.nctsnet.org/) to access
resources developed by SAMHSA's National Child Traumatic Stress Network.
Resources include materials on disaster and terrorism preparedness for
parents and caregivers, educators, professionals, and the media.

**American Academy of Pediatrics**

General information and tools, available at
<http://www.aap.org/terrorism>

Family Readiness Kit, available at
<http://www.aap.org/family/frk/frkit.htm>

Emergency Information Form for Children with Special Needs, available at
<http://www.aap.org/advocacy/blankform.pdf>

Links to Federal bioterrorism-related materials,
<http://www.aap.org/terrorism/resources/federal_resources.html>