CHAPTER 83

Disaster Preparedness

Ireal Johnson Fusco, MD, FAAP, and Katherine E. Remick, MD, FACEP, FAEMS, FAAP

Disaster preparedness has become an increasingly relevant topic for children and their families. Although natural disasters, war, and pandemic infections have always threatened human populations, increasing population density, global warming, international trade, and terrorist threats have heightened our awareness of disasters and the need for preparedness. State and federal systems are an essential component of disaster preparedness, but significant delays in the delivery of resources can occur. Because of a growing need to address the availability of resources and inherently delayed response times of the state and national systems, disaster preparedness is important for families and local communities. Recent major disasters, whether human-induced events, such as the 2013 bombing during the Boston Marathon, or natural events, such as Hurricane Harvey, which devastated Houston, Texas, in 2017, demonstrate the vulnerability of communities and the need for extensive local preparation. In the first hours to days after a disaster, community response is vital to well-being, and the community needs to be prepared to play a greater role than was historically anticipated. As frontline health care providers and advocates for children, pediatricians have a particular responsibility to maintain a baseline understanding of chemical, biological, and radioactive exposures as well as emerging pandemic infections to provide guidance to families in the event of such disasters.

In addition to large-scale disasters, incidents in which local emergency medical services (EMS) are overwhelmed by the number and severity of casualties, termed mass casualty incidents, also have the potential to overwhelm community resources. These may include catastrophic events, such as multiple-vehicle collisions, mass shootings, and hazardous materials spills. Patients must be quickly triaged, treated, and transported. Typically, local government facilitates the initial response in accordance with emergency preparedness policies and procedures. This may include coordinating efforts with surrounding communities as per regional preparedness plans, along with additional assistance as necessary from state government. A public health emergency is declared only when an event exceeds the ability of local, regional, and state resources to provide routine care as the result of any incident that poses substantial risk for human fatalities or long-term disabilities. Preparedness experts suggest evaluating public health emergencies from what is called an all-hazards approach, which focuses on the key elements necessary to ensure the provision of routine care during any type of disaster or mass casualty incident. Specific scenarios that occur rarely, such as chemical or radiation exposure, require access to specialized resources that may be impractical to stockpile or are limited in availability. From a practical standpoint, the all-hazards approach is more effective.

Multiple factors make children more vulnerable than adults during a disaster. In the United States, children make up approximately 25% of the population. Younger children, especially, are reliant on others for food, shelter, and, importantly, psychological support. Their unique nutritional needs put them at risk for malnourishment if specific dietary requirements are not available. Additionally, children often have less mature immune systems. In a setting of physical stress and unreliable sanitation, children are at increased risk for infection. Moreover, decreased fluid reserves make children more susceptible to blood loss or dehydration from agents that cause diarrhea and vomiting. In the setting of a blast or fall, children are at increased risk for traumatic brain injury because of their large head-to-body ratio. Their more pliable skeleton also increases the likelihood for internal organ injury. Furthermore, children are at increased risk for exposure from chemical, biological, and radiation disasters because of their unique physiology. Infants and children have higher minute ventilation, resulting in increased inhalation of aerosolized agents. Their smaller height increases their exposure to high-vapor density agents, which are in higher concentrations closer to the ground. Additionally, the skin of infants and children is more permeable because of lesser keratinization compared with adults, and infants and children have a larger surface area-to-body mass ratio. As a result, exposed children receive a higher dose of transdermally absorbed toxins than adults exposed under identical circumstances. This larger surface area-to-body mass ratio also complicates treatment, because children are at increased risk for hypothermia during the decontamination process. Finally, the psychological effect of being separated from family and experiencing other disaster-related trauma can be devastating in the short- and long-term.

The 4 phases that the pediatrician should understand when it comes to disaster preparedness and the importance of advocating for children at each of these steps are planning, rescue, recovery, and mitigation. Planning includes training and education as well as identifying specific local risks. For example, some communities might need to anticipate hurricanes and flooding, whereas others are more concerned about earthquakes or blizzards. This is a key area in which the pediatrician can intervene and both work with families to develop disaster plans and interact with the local disaster response community to improve the capacity to care for children. Rescue refers to the actions taken during a disaster, and this is typically what receives the most attention in the media and by the public. Recovery is the process that begins immediately after the disaster occurs—often simultaneously with the rescue phase— in which the community works toward returning to normal routines. This is also the phase during which mental health problems begin to emerge. Mitigation is an important and often overlooked phase in which individuals and the community learn from the response to the disaster to prevent future occurrences or improve on the response to decrease the effect of future disasters.

Unfortunately, many disaster response teams lack pediatric training, protocols, and equipment. Recently, various public health and disaster organizations have lobbied for states to mandate disaster preparedness regulations for children. Specifically, many states lack basic emergency preparedness regulations for schools and child care facilities. The developmental vulnerabilities of infants, toddlers, and young children make them physically less able to escape a disaster scene and cognitively less able to recognize the need to flee and follow directions from authorities. Children with special health care needs, whether because of physical or cognitive disabilities, require specific attention. The pediatrician can assist schools and child care centers in developing disaster preparedness plans. All child care facilities should have a plan in place that addresses all-hazards safety, medical needs, evacuation and transportation, and reunification with families. The idea of family-centered care that seeks to keep family units together even as care is needed for individual members is important for the immediate physical health and long-term mental health of children during and after disasters.

The Role of the Pediatrician With Families

The pediatrician serves as an important resource for disaster preparedness planning for families. The pediatrician should consider assessing a family’s level of readiness for a disaster and then tailor anticipatory guidance accordingly. Families must stay informed and realize that everyone is susceptible to some type of disaster. The pediatrician can also ensure that families understand the importance of preparation and the special needs of children during a disaster. The US Federal Emergency Management Agency (FEMA) offers a free smartphone application (www.fema.gov/smartphone-app) that includes specific information on various types of natural disasters, how to build a disaster kit, resources for victims of disasters, and a disaster reporting feature. Families should prepare an emergency kit that provides up to 3 days of basic necessities, including food, water, and clothing. Families of newborns and infants must include formula and diapers as well as any daily medications for all family members. Copies of immunization and general medical information are useful as well as pictures of family members in case the family unit is separated. Parents must be prepared to handle nonemergent problems, because formal medical care may be limited to the seriously ill and injured during a disaster. If a family needs acute medical care, it may be necessary to treat children in adult facilities; alternatively, for the family unit to remain together it may be necessary for adults within the family to undergo treatment in pediatric facilities. The more information families can provide about any medical conditions requiring attention, the easier it will be to receive appropriate care in a disaster.

Families of children with special needs are especially vulnerable after a disaster because access to routine medical care may not be available. Experience in Japan during the 2011 earthquake and subsequent tsunami showed increased mortality among children with special needs and increased hospitalizations for children who were technology dependent. Not only should families have a sufficient supply of medication, they should have a surplus of necessary medical equipment and nutritional supplements. Common supplies, such as a feeding tube or catheters, may be in short supply or unavailable during a disaster. Families with a child on a ventilator or one who is oxygen dependent should notify local utilities to flag their address for priority status during power outages. They should consider the benefits of backup battery units and a backup generator at their home. These families would also benefit from notifying their local EMS agency and hospital of their child’s medical needs, because some EMS systems keep a registry of children with special needs. Some communities have developed systems in which posters are disseminated for placement in a window of the home specifying if any occupant may require special services from EMS in the event of a disaster or terrorist attack. Additionally, the American Academy of Pediatrics (AAP) and American College of Emergency Physicians offer an emergency information form that can be completed with the pediatrician and should be part of the emergency preparedness kit. The emergency information form contains information on diagnoses, procedures, medications, common presenting problems, and suggested medical management (see Online Resources). The family of a child with special needs can also contact the National Organization on Disability (www.nod.org) or Family Voices (www.familyvoices.org) for more detailed information on preparing for a disaster.

During the recovery phase after a disaster, children and adolescents may develop chronic medical problems as a result of injuries sustained during the event. Beyond physical injuries, all disasters have a psychological effect on children. The experiences and effects of disaster are unique to each patient, and the pediatrician must individualize treatment accordingly. Multiple studies of various types of disasters demonstrate the increase in mental health symptoms among children and adolescents exposed to a disaster. This is true even if a family is not directly affected by the disaster but is exposed to the event within the community, on television, or through the internet and social media. A child may present with somatic symptoms, such as headaches and abdominal pain, or may not want to participate in his or her normal activities. Long-term effects include depression, anxiety, aggression, and substance abuse. Age-appropriate discussions should be encouraged along with validation of the child’s concerns while assuring the safety of the individual child. Posttraumatic stress disorder should be considered in the differential diagnosis of the patient with persistent symptoms that do not respond to family support. Families and health professionals can obtain further information through the AAP (www.aap.org) and the Substance Abuse and Mental Health Services Administration (www.samhsa.gov).

The Role of the Pediatrician in the Community

Many state and regional disaster preparedness plans are tailored for an adult population and may not consider the special needs of children. The pediatrician can participate in the development of a community-wide disaster preparedness plan (eg, identifying emergency meeting locations) as well as surveillance to identify potential disasters as part of the planning phase of disaster response. From an operational standpoint, it is more effective to have 1 plan that can take into consideration the needs of multiple vulnerable populations rather than a separate disaster preparedness plan for each population. The pediatrician should serve as a consultant about local preparation and provide guidance about the unique medical, nutritional, and psychological needs of children. For example, increased staffing needs should be anticipated when caring for younger children and infants. Depending on availability of human milk, newborns and infants may require formula and a sterile water supply. The food needs of young children differ from those of adults. Stockpiling of medications for biological, chemical, or radiation disasters must take into consideration dosing differences for children compared with adults. It is necessary to make available suspensions of medications in addition to pill forms. Furthermore, many recommended antidotes and treatments are not approved for use in the pediatric population, and policies on the risks and benefits of their use in disasters should be established.

Emergency medical services systems are charged with the initial and rapid triage of all victims. Various well-known triage algorithms are available, including sort, assess, lifesaving interventions, treatment/transport (SALT) and simple triage and rapid treatment (START). Common to all is the rapid sorting of patients based on ability to ambulate followed by assessment of respiratory status, circulation/perfusion, and motor skills. Although multiple triage tools exist, the physiologic parameters and mental status assessments used in adult-based algorithms may not be suitable for children of all ages. Triage systems must take into account physiological differences of children as well as their psychological response to strangers. For example, young children may not be able to communicate their complaint, and because their vital signs are normally different from those of adults, medical personnel accustomed to working with adults may misinterpret physical findings and overtriage children. JumpSTART is a widely recognized pediatric-specific disaster triage tool that parallels START but is customized to address a child’s developmental ability and age-appropriate vital signs. However, it fails to capture children who are dependent on technology or those with special health care needs. Whether or not a triage tool is readily available, clinical decision making can be relied on to help sort and triage victims in a disaster.

Ideally, children should remain with their caregiver as part of family-centered disaster care. If this is not possible, it is necessary for a child advocate to be with the child at all times, although the nature of disaster response may make this challenging if not planned in advance. Additionally, incorporation of child life specialists and techniques for distraction during medical procedures should be encouraged. Children may not respond well to new environments and disaster protocols. The simple process of decontamination can be devastating to a young child without the presence of a parent or other familiar caregiver. A child may have concerns about being sprayed with water or may refuse to disrobe in front of strangers, which may affect the success of decontamination for children and adolescents. It is assumed that adults will comply with protocols, but such compliance is less predictable in a pediatric population. A child may be afraid of strangers or may simply wander off before triage is complete. Nonmedical personnel or bystanders may be called on to assist with supervising ambulatory children.

Facility-based issues must also be addressed in regional disaster preparedness plans. These include providing for increased staffing in adult facilities caring for children as well as the need for stockpiling of pediatric supplies at those facilities. Similarly, parents may be triaged with their children, so pediatric facilities should be prepared to manage adult victims as well. Additionally, facilities need to plan for children arriving without a caregiver and establish an identification system that allows children to be reunited with their families. This was a significant problem for children displaced during Hurricane Katrina. Strategies to address this include using digital cameras to photograph children on arrival with their original clothing as a means of facilitating family reunification.

The Role of the Pediatrician in Disaster Surveillance and Management

Pediatricians function as key public health workers. Their knowledge and diligence aids in local and regional surveillance for potential chemical, biological, and radiation disasters. Families may seek care from their pediatrician rather than an emergency department for early symptoms during and after a disaster. Although it is beyond the scope of this chapter to provide details about signs and symptoms after every type of disaster, important concepts in identifying and treating patients with exposures to chemical and biological agents as well as radiation are highlighted herein.

Chemical exposures usually result in immediate symptoms and require special protection for emergency personnel as well as decontamination for the victims. These exposures can occur from terrorism as well as (more commonly) industrial accidents. Insecticides, herbicides, and nerve gases are organophosphates that inhibit the enzyme acetylcholinesterase. This results in the accumulation of acetylcholine and excessive cholinergic stimulation at muscarinic and nicotinic receptors. Symptoms include the muscarinic SLUDGE toxidrome (increased salivation, lacrimation, urination, diaphoresis, gastric distress, and emesis) as well as the MTWHF nicotinic toxidrome (mydriasis, tachycardia, weakness, hypertension, and fasciculation). Vesicant exposure, such as mustard gas and lewisite, causes irreversible damage to mucous membranes, skin, and the respiratory system soon after exposure. Cyanide is another common chemical agent, known for its bitter almond taste. Cyanide inhibits cellular metabolism and causes rapid hypotension, coma, seizures, and death. Agents other than nerve agents usually do not result in severe mortality but rather incapacitate the victim. Many other chemical agents from industrial accidents can cause a variety of skin and pulmonary symptoms.

Biological agents include bacteria, viruses, and preformed toxins. These agents may be easy to disperse and can affect large populations. Unlike in chemical exposures, the onset of symptoms is delayed by hours to days, and symptoms are more difficult to distinguish from common ailments. Secondary transmission of the infection is also of concern with some agents. Management of biological disaster requires detailed surveillance and containment of exposed populations.

Although there are too many biological agents to discuss in any detail in this brief chapter, a few of particular relevance to disaster planning are mentioned here. Anthrax, from Bacillus anthracis, is a gram-positive sporulating rod. When used as a bioterrorism agent in its inhaled form, victims present with severe influenza-like symptoms with an associated high fatality rate. Fever and dyspnea associated with a widened mediastinum are common and may progress to shock. Ciprofloxacin and doxycycline are recommended for prophylaxis and treatment among adults. Despite the risks to bone and cartilage that generally restrict its use to healthy children, ciprofloxacin is approved by the US Food and Drug Administration (FDA) for use in children with inhalational anthrax exposure. Doxycycline should generally be avoided in children younger than 8 years, although it may be considered on a case-by-case basis. The physician must consider consulting with experts to assist in assessing the risks and benefits associated with using these medications. Among the viruses, variola, more commonly known as smallpox, is an agent of concern. After its global eradication in 1980, children were no longer immunized, leaving all children and most adults susceptible to the virus. Similar to varicella (ie, chickenpox), it presents with vesicles with umbilicated centers but is associated with a higher mortality rate of 3% to 30% among nonimmunized individuals. Exposure to the potent botulinal toxin results in cranial nerve disturbances, descending paralysis, and respiratory distress. Ricin, which is derived from the castor bean, is another potent toxin. Inhalation results in fever, cough, and pulmonary edema, often resulting in death within days. Ingestion presents with severe vomiting and diarrhea, resulting in hypovolemic shock. For a complete list of biological agents, presenting symptoms, and potential treatment or prophylaxis, physicians should consult the Centers for Disease Control and Prevention.

Radiation exposure may occur as a result of damage to a facility containing nuclear material, detonation of a nuclear weapon, or dispersal of nuclear material by a radioactive dispersal device. Ionizing radiation presents the greatest health risk because of its high- frequency energy. It causes chromosomal breaks in cells that can cause long-term damage and increased risk of cancer. The 5 types of ionizing radiation with specific characteristics, behaviors, and toxicities are alpha particles, beta particles, gamma rays, x-rays, and neutrons. Alpha particles have limited ability to penetrate but when inhaled or ingested can cause internal damage. Beta particles are most commonly found in a medical setting, and they have greater penetration than alpha particles. Beta particles can cause skin damage as well as damage when ingested. Gamma rays and x-rays are part of the elec-tromagnetic spectrum. Gamma rays are high energy and cause significant damage. This type radiation would be seen after a nuclear detonation or from radioactive materials. Much less common are neutrons, which induce radioactivity. Exposure to radiation is classified as external, internal, whole body, and partial body. The effects of radiation can directly damage the target tissue, or the effects can be indirect, caused by the creation of free radicals. Tissue sensitivity is based on the cellular rate of division and level of differentiation. The most sensitive to least is as follows: lymphoid, gastrointestinal, reproductive, dermal, bone marrow, nervous system. The severity of exposure is also dependent on the dose of radiation, type of radiation, and age of the victim.

Radiation exposure is quantified by the amount of energy absorbed (ie, rad [radiation absorbed dose]) and the relative biological effectiveness of doses (RBE) based on the type of ionizing radiation. The rem is the product of the rad and RBE. Under the International System of Units, the rad and rem are being replaced by the gray (1 Gy = 100 rad) and sievert (1 Sv = 100 rem). Typically, doses for common radiation exposures are given in millisieverts (1 mSv = 0.001 Sv). Radiation exposure from common radiographic procedures can range from 0.1 mSv for a chest radiograph to 2 to 20 mSv for a computed tomography scan.

Symptoms associated with radiation exposure depend on the total exposure. Nausea and vomiting can present with exposures of 0.75 to 1 Gy and lymphoid and bone marrow suppression with exposures of 1 to 6 Gy. The mean lethal dose, the radiation dose for which one-half of the population is expected to die within 60 days, is 4 Gy. Long-term effects of radiation include increased incidence of cancer and psychological distress. Evacuation is the ideal intervention to decrease exposure, but this may not be feasible in a timely fashion in highly populated areas.

Seeking shelter can greatly decrease the level of exposure, with large cement structures providing the best protection. The use of potassium iodide is effective in exposures to radioactive iodine, which is associated with nuclear power facilities. It can be dispensed in a pill and in suspension form. Dosage is based on level of radiation exposure and patient age, and physicians should consult the FDA (www.fda.gov) or the US Nuclear Regulatory Commission (www.nrc.gov) to determine the appropriate dosage of potassium iodide depending on the level of radiation exposure. For individuals seeking medical care, containment and decontamination are essential. Removal of clothing and washing the skin with warm water is quite effective. Supportive medical care is essential in managing patients with radiation exposure. Radiation results in significant immune suppression, neutropenia, and lymphocytopenia, which last for weeks and need close monitoring. The physician should be aggressive in managing infections and consider treatments to increase bone marrow regeneration. Expert consultation in radiation sickness would be prudent.

In addition to caring for patients, pediatricians need to take into consideration the well-being of their own family as well as that of office staff. During a disaster, office staff may not be able to get to work. For those able to report to work, extra supplies of food and water must be available in case staff cannot return to their homes. An office disaster plan should be implemented with emergency contacts and preparation for the staff ’s basic needs. Basic medical supplies should be available to care for patients during a disaster. Depending on the type and severity of the disaster, access to the office facility may be prohibited. Plans for backing up patient medical records should be implemented as well as for alternative sites in which medical services can be delivered.

Physicians need to review their medical liability policies addressing the provision of care in a disaster situation. Most policies only provide coverage for care that is provided in the office setting. Good Samaritan laws vary in each state about what level of protection is provided to the health professional. The AAP recommends that during a disaster situation, pediatricians who volunteer do so under the auspices of an official disaster agency or recognized relief organization to ensure the greatest protection from liability.

Conclusion

The pediatrician has a vital role in predisaster, disaster, and postdi-saster management on the local, regional, state, and national level, not only as a medical service professional but also as an advocate for the special needs of children and their families. The essential components of disaster management are to provide for all basic human requirements, reduce an individual’s vulnerability to disasters, and, after a disaster has occurred, reduce the exposure risk. The pediatrician can educate and assist families in preparing for disasters. Additionally, the pediatrician can guide communities in their disaster preparedness planning to accommodate the particular vulnerabilities of children. As with other health professionals, pediatricians can also contribute to the essential medical and public health work-force during a disaster. Pediatricians can access the most current guidelines and recommendations through multiple professional and governmental resources. It is imperative for the physician to have easy access to telephone numbers and websites specific to pediatric disaster preparedness and response for the relevant local, state, and federal agencies.

Stay updated, free articles. Join our Telegram channel

Join