Janet M. Berreman and Linda Rudolph
THE ROLE OF THE HEALTH CARE SECTOR
Health care involvement in disaster preparedness in its current form grew out of the September 11, 2001, attack on the World Trade Center and the subsequent postal anthrax dissemination. In the wake of Hurricane Katrina, and with growing international concern about an impending influenza pandemic, preparation for terrorist and bioterrorist attacks has broadened to an “all-hazards” approach, including preparedness for natural and infectious disasters.
Disaster is “a sudden calamitous event bringing great damage, loss, or destruction.”1 In preparedness circles, any event in which needs exceed local capacity is considered a disaster. Disaster preparedness covers a wide range of threats, varying from the commonplace to the hypothetical.2
Pediatricians have a significant role in disaster preparedness: as trusted resources for parents; as experts on the unique needs and vulnerabilities of infants, children, and adolescents; as advocates for the pediatric population; and as skilled first responders. Without pediatric input at all phases of a disaster, children’s unique vulnerabilities mean that they will bear a disproportionate burden of disaster consequences. By being part of disaster planning, pediatricians can improve disaster response and recovery and pediatric outcomes.3
Children’s physiologic and developmental characteristics put them at greater risk of harm in a disaster. They inhale and ingest larger quantities of potentially contaminated air, food, and water for their weight than do adults; they absorb toxins more readily because of increased skin permeability and greater proportionate body-surface area; they are smaller in size, stature, and muscle mass than adults; they are more exposed to toxins that collect near ground level; they have less fluid reserve; they are less able to recognize and flee danger and less skilled at self-preservation.2,4 These susceptibilities, as well as the extent to which children are dependent on adults, vary with age and developmental stage. In addition, there are many gaps in knowledge regarding issues such as pediatric doses and formulations for disaster response medications, posttraumatic stress disorder management in pediatrics, appropriate prioritization of vaccines and drugs, and implications of school or childcare dismissal.
Disaster preparedness requires a basic understanding of the Incident Command System, a standard structure for disaster response that facilitates efficient coordination and mobilization of resources across agencies, sectors, and regions. Disaster response relies on the availability of “mutual aid,” accessed through the Incident Command System, to augment local capacity.5-8 The Incident Command System is a departure from the normal chain of command, especially for health care professionals accustomed to autonomous decision making.
In the United States, state and local health departments receive funding for preparedness work from the federal Department of Health and Human Services. The Hospital Preparedness Program funds health care facility emergency preparedness.9 The Centers for Disease Control, through its Public Health Emergency Preparedness Cooperative Agreement, provides funding for public health department preparedness.10,11
Disaster preparedness requires planning and coordination at the international, national, state, and local levels. Sectors of particular relevance to pediatric issues are health care facilities and professionals, public health authorities, emergency medical services, communities (in particular schools and child care providers), and families.
Disaster-related activities include four phases: preparedness, response, recovery, and mitigation.2 Pediatrics and pediatricians have substantial contributions to make in each area.12,13 eTable 8.1 provides examples of disaster-related activities in each phase for health-related sectors. This discussion focuses on actions pediatricians and the pediatric profession can take in each phase: as clinicians, researchers, policymakers, child advocates, employers, and community members.
Preparedness consists of developing formal plans for response to a disaster and of practicing or “exercising” those plans. Pediatric preparedness must take place on multiple levels. The first is personal preparedness and preparedness of one’s staff and workplace. Well-prepared essential service providers are more effective and focused disaster responders. Office-based pediatricians should address both the internal operations of the practice (eg, emergency supplies, staff contact lists) and communication and coordination with local health departments and emergency response agencies.14,15
Second, pediatricians must be professionally prepared to provide care in a wide variety of disaster situations. This includes understanding the basics of medical management of children exposed to agents such as those in Table 8-1and becoming familiar with triage systems, such as JumpSTART,16 for mass casualty incidents Pediatricians should also familiarize themselves with the preparedness activities and plans of local health departments, hospitals, and emergency responders, including participation in drills and exercises.17 Pediatric participation is important in medical volunteer registries, Medical Reserve Corps, and federal disaster medical assistance teams (DMATs).14,18
Third, pediatricians can help prepare patients and their families by incorporating preparedness information into routine anticipatory guidance. Family preparedness materials from local health departments or state and federal agencies can be distributed and displayed at practice sites.19,20 Patients on chronic prescription medications should be assisted with maintaining an adequate supply of those medications. Disaster plans should be reviewed in detail with families of children with special needs, especially those who are dependent on technology. Anticipatory guidance that helps parents talk to their children about the violence, death, and disaster that are part of our daily environment may increase the resilience of children and families and give them skills they can use in the event of a disaster. Pediatricians can address community groups on the subject of disaster preparedness, first aid, and emergency medical services.
Table 8-1. Disaster Categories and Agents
Finally, the pediatric voice is important at the higher levels of disaster preparedness to ensure that the unique needs of children are addressed in school district, city, county, state, and federal public health and emergency preparedness programs. The availability of medications and supplies in doses and formulations appropriate for infants and children in local, state, and national stockpiles needs to be assured. Child-appropriate non-pharmaceutical supplies are also a priority, as is response staff with adequate pediatric training and experience. Pediatricians should work with hospital and EMS planners to ensure that children’s needs are met. Community pediatricians can organize to allow their efficient mobilization in a local response. Pediatricians can participate in the development and distribution of protocols for emergency procedures such as decontamination, case identification, prophylaxis, and triage.
Disaster response is dealing directly with a disaster: assessment of the situation, containment or limitation of its impact, triage and treatment of victims, and mobilization of additional resources as needed. The fate of children in a disaster depends both on whether their needs are adequately addressed in the preparedness phase and on the availability of pediatric expertise in the response. Pediatricians must receive and respond to disaster notifications, work within the Incident Command System structure, and provide their services where they are most needed. Well-meaning but disorganized or fragmented response adds confusion to inherently stressful and complex response operations. Pediatricians who are familiar with the preparedness plans of their communities and health care facilities are able to optimize the management of children: triage, treatment, mental health, family reunification, and children with special needs. They can also supply ongoing medical assessment of any disaster-specific risks to children. Table 8-1 categorizes disasters by type and agent and gives specific response and pediatric considerations.
Recovery from disaster, the return to normalcy, begins immediately following the acute event and continues for days to years. Recovery includes assessment of the preparation and response activities: How well did we do? What could we have done better? What unanticipated challenges arose? Lessons learned from actual disasters are an opportunity to improve preparedness and response for future disasters.
Primary care pediatricians will see families in the aftermath of disaster and have a major role in the recovery process for those families: assessing mental health needs, resuming routine health care, caring for orphaned or displaced children, aiding in the adaptation or rehabilitation of those with traumatic or other disabilities, and monitoring the long-term impact of disaster on child growth and development. Posttraumatic stress disorder (PTSD) can occur among health care professionals as well as children and their families.21-23 Pediatricians should identify and refer those in need of mental health services.
Disaster mitigation refers to actions taken before a disaster to minimize vulnerability to future disasters. While preparedness improves the ability to respond, mitigation aims to reduce the need to respond. Mitigation most frequently refers to structural soundness, and pediatric practice sites certainly should be constructed and located to resist disaster damage as much as possible. Pediatricians can also mitigate future disasters by nonstructural measures. Fully immunizing all children reduces the population susceptibility to infectious disease outbreaks. Routinely practicing and teaching cough etiquette and hand-washing can limit the spread of infectious agents, including pandemic influenza. Attentive surveillance and prompt reporting of suspected outbreaks or reportable conditions allows public health authorities to respond before an outbreak reaches disaster proportions or to minimize its extent.
An influenza pandemic is a global disease outbreak occurring when a new influenza virus emerges for which people have little or no immunity. The disease spreads easily from person to person, may cause serious illness, and can sweep across the country and around the world in a very short time. The continued spread of the highly pathogenic avian influenza A (H5N1 virus) raises concerns about a potential human pandemic.24,25
An influenza pandemic poses special challenges for children, families, and pediatricians. Children shed flu viruses for longer and in higher quantities than do adults and are efficient and prolific transmitters of influenza.26 Thus, schools and childcare facilities will likely be closed and gatherings of children severely restricted during a pandemic.27 A flu pandemic is expected to occur in multiple waves over a period of a year or more. Pediatricians must participate in planning for the prophylaxis of susceptible children and the care of ill children during a pandemic and will play a major role in triage and community and home management of affected children when hospital surge capacity is overwhelmed. Because a pandemic will involve most if not all of the country, it is unlikely that mutual aid will be a reliable resource. Pediatric input is also essential in planning for the supervision, care, education, and well-being of healthy children whose daily lives will be disrupted for weeks to months at a time. Creative strategies for reducing the impact of an influenza pandemic may come from pediatricians, accustomed as they are to being on the front lines both of child well-being and infectious disease outbreaks.
Disaster preparedness and response bring to mind vivid images of the aftermath of Hurricane Katrina and the enormous inequities of the disproportionate burden born by the poor and African American populations of New Orleans. Disaster preparedness must actively address these inequities if this scenario is not to be repeated. Multiple vulnerable groups are at risk of being overlooked: the poor; the chronically ill; the mentally, developmentally, or physically disabled; and the socially or linguistically isolated. Disasters necessitate the allocation and distribution of scarce resources. Developing parameters for the ethical use and prioritization of limited resources is a challenging yet fundamental part of disaster preparedness. Following those parameters in the response, recovery, and mitigation phases is equally challenging and equally essential. Pediatricians, as advocates for the health of children, must assure that children in general, and vulnerable subpopulations of children, are reached and accounted for in all phases of disaster-related activities.
Disaster preparedness reference materials abound and can be overwhelming in their volume and detail. It is an axiom of preparedness work that “all disasters are local,” so starting with the materials from one’s local and state health departments, hospitals, emergency medical services, and/or emergency preparedness offices is appropriate. The references included here are national, with links to local tools and resources.19,20,28-30 Many of the references listed on DVD contain links to online resources that link to local tools and resources.