PDLS©:
Children in Disaster: Public
Health Considerations and
Disaster Mitigation
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Preparing for the Public Health
consequences of disaster involving
children should occur at the Community,
State and Federal levels.
The benefits of this type of planning have
been proven many times over
Objectives
Identify personnel, equipment and infrastructure for pediatric
disaster preparedness
•
• Learn the principles of family disaster planning
• Recognize which potential biological disasters may be
mitigated by public health measures
• Consider public health implications of chemical and radiation
attacks
• Understand the components of disaster mitigation
Community Resources
 Pediatric emergency and trauma centers
 Pre-hospital care providers, including EMS, fire departments
and police
 Social services
 Schools
 Local health clinics
 Departments of Health
 Government
 Local and national media
Photo Courtesy of FEMA
Emergency Medical Services for
Children (EMS-C) in a Disaster
 A program of Health Resources and
Services Administration (HRSA)
-
Education and grant funding for
development pre-hospital pediatric care
 Provides designations for pediatric
disaster centers
-
Emergency Department Approved for
Pediatrics (EDAP)
Pediatric Critical Care Center (PCCC)
Stand-by Emergency Department
Approved for Pediatrics (SEDP)
Plans for Surge Capacity Facilities
 Hospitals without formal pediatrics services
 Community health centers
 Rehabilitation hospitals
 Urgent care centers
 Physicians’ offices
 Nursing homes
 School-based health centers
 Field hospitals in gymnasiums, warehouses, arenas and
convention centers
 Religious or faith-based facilities
Healthcare Providers Coursework
Available coursework for pediatric
clinician disaster preparedness:
 Basic and Advanced Disaster Life
Support (BDLS, ADLS)
 Disaster Preparedness for School Nurses
 Pediatric Advanced Life Support (PALS)
 Advanced Pediatric Life Support (APLS)
 Emergency Nursing Pediatric Course
(ENPC)
 Pediatric Education for Pre-hospital
Professionals (PEPP)
 Advanced Trauma Life Support (ATLS)
Equipment Necessary for Pediatric
Disaster Preparedness
 Airway equipment
 IV access devices ( intravenous lines,
intraosseous needles)
 Warming blankets
 Radiant warmers
 Normal saline
 Pediatric nutrition supplies
-
Formula,
G-tube feeds,
Child-friendly non-perishable items
Laryngeal Mask Airway
Vectors of Transmission of Infectious
Diseases Affected by Disaster
 Airborne
-
Crowded habitation
 Waterborne
-
Contaminated water supply
Children most susceptible
 Foodborne
-
Problems with proper storage
 Insect and Animal borne
-
Decrease disease transmission control
Consider the Needs of Children in
Family Preparedness Planning
 Listing of key phone numbers
 Create an emergency kit
-
Prescription medications
OTC medications
Formula/Food
Diapers
Clothes
 Create a list of trusted adults and a
safety “password”
 Comfort objects and foods
Family Disaster Planning (focus on the
safety of the children):
 Safe sites within the home
 Family communication – reassembly plan
(children at school parents at work)
 Stored disaster supplies (water, food, cooking
equipment, heat sources)
 Conduct drills for common disasters (tornado,
earthquake)
In reality few families have done any planning
Pets in Disaster Planning
 Case study-Katrina
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Family Disaster Planning
Preparation: Home
 Create and discuss disaster plan for family
 Acquaint all family members with first aid
equipment in home
 Route of egress from home
 Meeting place outside
 Conduct drills
Preparation: Home
 Keep disaster stores of food, meds, diapers,
etc.
 Have “disaster containers” in home and car
 Special needs children
- Early evacuation plans, etc
Pharmaceutical/Medical Supply
Stockpiles
 The Centers for Disease Control and Prevention (CDC) provide a Strategic
National Stockpile (SNS)
-
Developed in 1999 for anthrax
Point of delivery (POD) system for local distribution, with supplementation by state
and national sources within 48 hours
 States should plan on being self-sufficient for 72 hours before SNS arrives
 Instructions for accessing PODS
-
Use of United States Postal Service for distribution
Security considerations
Available media used to disseminate distribution point locations
Pre-event Public Health Planning
Issues:
 Evacuation of populations at risk.
 Provide temporary shelter and protection from
the environment.
 Provide food, water and clothing.
 Plan for adequate personnel hygiene (toilets,
showers, etc.).
 Backup plans for communications,
transportation and activities for children.
 Plan for management of children with special
needs.
Post-event Public Health Response
Issues:
 Finding and extracting individuals who
refused to evacuate
 Manage neglected chronic medical issues
(diabetes, heart disease, etc.)
 Provide for medical emergencies and
childbirth
 Keeping confined children healthy
(medical & psychological).
Public Health Issues: Infectious
Disease Outbreaks
Type
Examples
• Airborne illnesses:
Influenza, tuberculosis
• Vector borne
illnesses:
Avian flu, malaria,
dengue, tick related
• Water-borne
illnesses: (oral-fecal
transmission)
Cholera, salmonella,
shigella, norovirus,
cryptosporidiosis
• Food borne illnesses: Fungi, E-Coli
Influenza
 Influenza, a common viral
respiratory virus with a long
history of periodic pandemics
 Mutations in strains of
influenza including bird flu
pose risk of widespread
outbreak
 Risk of death increases with
secondary bacterial infections
 Highly contagious, spread via
droplet and contact routes
Influenza: Treatment and
Prevention
 Amantadine is used for influenza A
in children > 12 months
- Useful if given within 2 days of
symptoms
 Oseltamivir (Tamiflu) is approved
for children > 12 months
- Prevents release of viral particles
-
from infected cells
Efficacious for influenza A and B
Given orally bid for 5 days
 Both agents approved for
chemotherapy, theoretically useful
as prophylaxis
Influenza: Treatment and
Prevention
 Indications for immunoprophylaxis
(protection from influenza A and B)
- Children less than 9 years receiving
influenza immunization for the first
time require two doses one month
apart
 The following children require
immunization:
- Persons aged 2-18 years with
-
comorbid conditions
Children aged 6-59 months
Pregnant adolescents
Household contacts and out-ofhome caregivers of children aged <6
months
Viral Hemorrhagic Fevers
Viral hemorrhagic fevers, a group
of diseases carried by animals
and characterized by bleeding
-
More likely to be fatal in
children
Examples include Argentine
Hemorrhagic Fever, Ebola,
Lassa, Hanta and Nipah viruses
Usually spread via contaminated
body fluids, mosquitoes and ticks
Rarely airborne
Few antiviral
drugs/chemotherapy available
Mosquito and Tick
Photos Credit: CDC
Viral Hemorrhagic Fevers:
Treatment and Prevention
Most have no specific
treatment
 Supportive care
Two Exceptions
- Argentine hemorrhagic
fever convalescent serum
- Ribavirin is an antiviral
drug useful for Lassa
virus
Ribavirin
Smallpox
 A delayed cutaneous
infection spread via
respiratory route
 Acute, contagious and
sometimes fatal disease
caused by the variola virus
(an orthopoxvirus)
 Historically important disease
- Speculation about
availability as WMD
Photos: CDC
Photo Credit: CDC
Smallpox: Treatment and
Prevention
 Pre-exposure vaccination not currently
recommended in children
 Vaccine is effective in decreasing
disease severity within 4 days of
exposure
 Ring vaccination strategy
recommended in event of an outbreak
 Contraindications include eczema and
immunodeficiency
 Vaccinia immune globulin (VIG) is
immunotherapy stockpiled by CDC for
complications of vaccine
Edward Jenner
Tularemia
 Tularemia, a disease of rabbits
and rodents, spread to people
by contact with these animals
or the ticks and mosquitoes
that feed on them
 Caused by Francisella
tularensis
- Can be aerosolized and used
as a weapon
- No immunization is widely
available
Tularemia: Treatment and
Prevention
 Antibiotics
- First line agents include
gentamicin for 10 days
- streptomycin and amikacin
good alternatives
- Doxycycline and
fluoroquinolones are
second line agents, with
risk of adverse effects
Doxycycline
Brucellosis
 A disease usually caused
by contact with infected
animals and animal
products
 Examples include cows
and milk
- Caused by Brucella
bacteria
- Can be aerosolized and
used as a weapon
- No immunization is widely
available
Brucellosis:
Treatment and Prevention
 Indications for antibiotics
- Recommendation for postexposure prophylaxis
- Rifampicin and trimethoprimsulfamethoxazole (TMP-SMX)
for 3-6 weeks
- May be given by mouth
- May use quinolones,
doxycycline in children over 8
Plague
 Caused by Yersinia
pestis, a bacterium
found in rodents and
their fleas in many
areas around the world
 Forms:
Bubonic, Septicemic
and Pneumonic
 Can be aerosolized and
used as a weapon
Plague: Treatment and Prevention
 A plague vaccine is not
currently available for use in
the United States
 Antibiotics must be given
within
24 hours of first symptoms
 Streptomycin 30 mg/kg/day
divided in two doses
Streptomycin
Anthrax
 Anthrax, a disease of animal handlers
and
those who encounter contaminated
animal products
 Inhalational most likely weapon
- Used in 2001 anthrax mail contamination
- Highly lethal
- Initial flu-like illness for 2-5 days
- Followed by intra-thoracic bleeding,
dyspnea,
pleural effusions and widened
mediastinum
Anthrax
 Delayed symptoms
- Oral-gastrointestinal
- Cutaneous
- Hemorrhagic meningitis
Lesion of Cutaneous Anthrax Associated With
Microangiopathic Hemolytic Anemia and
Coagulopathy in a 7-Month-Old infant
Cutaneous Anthrax
 Pediatric case:
- systemic illness seen
transient DIC
renal dysfunction
- unique susceptibility?
Anthrax
 Decontamination
- Undress, soap/shower.
Use 0.5% diluted
household bleach for gross or visible
contamination
- Environment:
0.5% bleach
Anthrax: Treatment and Prevention
 BioThrax immunization for animal
handlers and military
 Limited data support intramuscular
doses at 0, 2 and 4 weeks after
exposure
-
-
No human studies showing
efficacy in post-exposure
prophylaxis
Prevents cutaneous anthrax in
humans
Animal studies show prevention of
inhalation disease
 Not licensed by FDA for
post-exposure prophylaxis
Anthrax: Treatment and Prevention
 Initial prophylaxis with either fluoroquinolone or tetracycline
-
Ciprofloxacin (10-15 mg/kg/dose po q 12 hrs) not to exceed
1 gram per day or
-
Doxycycline - up to and including 8 years or over 8 years and less
than or equal to 45 kg (2.2 mg/kg/dose po BID)
Benefit of protecting children outweighs risks of medication exposure
Once susceptibility of organism established, change to amoxicillin,
clindamycin or vancomycin
Treat for 60 days to allow time for spores
to germinate and be killed
Botulism
 Botulism, a paralytic disease
caused by the toxin of
Clostridium botulinum
- Can be aerosolized and
used as a weapon
- Non-terrorist cases caused
by contaminated food
- No antibiotic/chemotherapy
treatment exists
Clostridium Botulinum
Photo Credit: CDC
Botulism:
Treatment and Prevention
 Suspected
cases require supportive
care
-
Respiratory support
Intravenous nutrition
Botulinum antitoxin is available
- Should be used in symptomatic
cases before laboratory
confirmation
- Approved for use in children by
FDA
- Manufactured by California
Department of Health Services
Case Study – Rapid Displacement
Rwandan Civil War – 1994
Disaster Type: Rapid displacement of a large
improvished population
(aka – complex humanitarian disaster)
Medical Issues: Epidemics of infectious
disease such as: cholera, hepatitis,
exposure, nutritional needs of
children
Public Health Issues – Airborne Toxins
 Smothering construction materials, fuels,
freon
 Examples: Silica, asbestos, h2g, CO,
Lead, etc.
Public Health Issues – Airborne
Radiation
Radiation Exposure
“In some respects, major radiation exposure
due to a terrorist attack should be easier to
manage than chemical or biological attacks. An
important resource is the tens of thousands of
persons who deal with radiation daily at
hospitals, universities, military units, national
laboratories, and government agencies”.
NEJM 2002
Radiation Characteristics
Type
Penetrate
Comments
Alpha
No
Beta
Superficial
Gamma
Deep
Inhale, ingest,
open wound
Electrons, a few
centimeters
Easy penetration
X-Ray
Deep
Easy penetration
Severity
None
Death
ED MD Response
 Seal ED with police-security
 Get Radiation Safety to ED STAT
 Create decontamination area Outside
 Don’t Contaminate ED
 Wear gowns, gloves, radiation detectors
Public Health Issues – Personal &
Intrapersonal Violence and Abuse
 Child abuse, PTSD, partner abuse, suicide,
substance abuse
What is Disaster Mitigation?
 Steps taken prior to and after a disaster to
minimize morbidity and mortality
 Examples include:
- disaster plans: community, school, and home
- pre-designated shelters
- clean water stores, food stores
- post disaster emotional support
Examples of Disaster Mitigation
Activities:
 Community wide influenza vaccination
programs
 Enforcement of engineering codes for
construction projects
 Avoidance of construction in disaster
prone areas
 Stockpiling of supplies in safe places
Disaster Mitigation: Planning for Mass
Gathering (particularly those involving children):
 Concerns: fire, riot-stampede, major
accidents (stage collapse), inclement
weather
 Specifics: onsite EMS deployment; triage
plan from site to available medical
facilities
Preparation: School
 Makes disaster plan known to all
 Routes of egress from school
 Meeting place
 Drills
Hospital Interface
 Work with local and state officials to create
disaster management plan
 Local EMS plans for all schools & daycares
 Practice interface between school, EMS, and
hospital with drills at least once a year
Recovery Phase: Initial
 Shelters should be “kid friendly”
 Keep families together
 Personnel to organize area for orphaned and
separated children until families reunited
 Create children's groups in shelter, plenty of
toys, books, etc..
Recovery Phase: Long-term
 Psychological services early
 Be attentive to children's needs, consider
educational resources for long-term
sheltering.
 Aberrant behavior may be manifestation of
emotional trauma
Recovery Phase: Long-term
 Children must feel safe in home, community
and school; encourage this
 Learn from mistakes
Disaster Mitigation: What you can do
 Emergency physicians, Pediatric EM
physicians, Pediatricians, Nurses, other
health care professionals:
- Preparation before disaster
- Action during disaster
- Recovery phase
Before Disaster Strikes
 Involve yourself in the local EMS and area
disaster plan: help to develop systems that
keep children's’ needs in mind
 Work with schools, daycares and local
hospitals to develop integrated disaster plans
 Act as an advisor to your patients for home
disaster planning
Before Disaster Strikes
 Arrange disaster response drills
 Promote community awareness addressing
pediatric needs
During A Disaster
 Be active!!
 Institute disaster plans in your facility
 Participate in the community response to
disaster
Disaster Recovery
 Provide medical care to shelters
 Assume basic community services will be
disrupted for some time
 Attend to emotional needs of the pediatric
population effected
Summary
 Pediatric disaster public health
issues require the right people,
places, tools and plans
 Disaster preparedness
includes planning, training, and
acquisition of appropriate
medications and equipment
Photo Credit: FEMA
 Disaster mitigation begins
before the event