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violence, and disaster preparedness in the home are common. Pediatricians should be ready to provide accurate answers. The AAP Web site includes information, created by the AAP Task Force on Terrorism, on disaster preparedness to meet the needs of children (www.aap.org/disaster), as well as links to many other sources of information. Pediatricians enjoy a high degree of public trust as expert sources of information and support on matters involving the health and well-being of children and families. Therefore, their roles in disaster preparedness and management are extremely important. For example, pediatricians act as first responders and care providers when the emergency medical system and emergency departments become rapidly overwhelmed in the recovery and mitigation phases of incidents of terrorism or disasters. Pediatricians, especially in instances of bioterrorism (such as the case of anthrax in an infant in New York City), could be the first to see victims and determine a diagnosis. This means that pediatricians should acquire further knowledge of infections and the effects of exposure to toxins that most likely they have never seen. Residency training in pediatrics has been limited on subjects such as biological and chemical terrorism, as well as nuclear exposure, and it should be broadened accordingly. Children’s hospitals, which serve many communities, should also generate and implement this information. The pediatric office could also be involved in the first response phase after a disaster. A good first step for the pediatrician is preparation of an office disaster plan that is periodically updated and practiced (see also Chapter 9, Integrating Terrorism and Disaster Preparedness into Your Pediatric Practice). As the office plan is prepared, pediatricians should consider other roles they might have in the community disaster response and familiarize themselves with liability and licensure issues. Working with an agreement with local/state government agencies to provide disaster services affords the best liability coverage and often allows reimbursement. For a discussion of their liability, pediatricians should review the AAP Policy Statement (reaffirmed in 2004) Pediatricians’ Liability During Disasters (see http://aappolicy.aappublications.org/cgi/content/full/pediatrics;106/6/1492). Recommendations include the following: • Familiarity with State statutes and protections afforded while providing emergency care during a disaster. • Familiarity with individual liability insurance coverage outside of the usual practice settings when providing urgent and routine care. • Working in concert with response agencies when providing disaster relief. Parents turn to pediatricians for help, guidance, support, treatment, and referral regarding mental health issues in the recovery and mitigation phases of disaster. A wide range of reactions can be expected, from anxiety to adjustment reactions and posttraumatic stress disorder (PTSD). The effects can be direct or indirect, affecting children who were not actually involved in the disaster. Parents will turn to pediatricians with many questions regarding how to explain the reasons for disaster, whether to let their children watch the events on television, and what to say about loved ones or acquaintances who have been 3
injured or killed (see also Chapter 8, Mental Health Issues). Pediatricians should be able to recognize potential symptoms of adjustment reactions and PTSD and to give parents coping strategies and referrals. The role of pediatricians in the mental health care of children after terrorism and disasters is described in a recent article, “Psychosocial implications of disaster or terrorism on children: A guide for the pediatrician,” which is available at http://www.pediatrics.org/cgi/content/full/116/3/787. The pediatrician’s perspective is well-suited to assist in the community planning process. Pediatricians have an appreciation for children as part of families that comprise communities that become regions, States, and so on. This perspective is valuable, but pediatricians may have limited knowledge and skill in planning and response. Pediatricians should educate themselves, acknowledge their limitations, and/or obtain outside expert input. The role of the pediatrician has been comprehensively described and defined in the AAP Policy Statement The Pediatrician’s Role in Disaster Preparedness prepared by the Committee on Pediatric Emergency Medicine (http://pediatrics.aappublications.org/cgi/content/full/99/1/130). Pediatricians are respected advocates for children. In this role, pediatricians should advocate for resources and products that currently do not exist for children, especially for children with special health care needs (including the chronically ill and technologically dependent). For example, children cannot always be decontaminated in adult decontamination units. Skin decontamination showers that are safe for adults may cause hypothermia in children unless warming equipment (e.g., heating lamps) is provided. Decontamination systems should be designed for use with children of all ages, for the child unaccompanied by a parent, for the nonambulatory child, and for the child with special health care needs. Little protective gear is available for children; when its use has been attempted, such as with gas masks, mishandling has led to fatalities from suffocation. Vaccines for anthrax and plague are not approved for use in children. The frequency of serious complications after administration of smallpox and yellow fever vaccines is higher in children than in adults; development and approval of safer vaccines are needed (see also Chapter 4, Biological Terrorism). Antidote kits for use after nerve agent exposure such as the Mark-1 kit (for adults) have only recently been developed for children (see Chapter 5, Chemical Terrorism). Common systems for determining drug dosages in children do not include dosages for antidotes. Recently, a liquid preparation of potassium iodide (65 mg/cc) has come on the market for use in preventing radiationinduced thyroid effects after radiation exposure (see also Chapter 6, Radiological and Nuclear Terrorism and the AAP Policy Statement on Radiation Disasters and Children at www.aap.org/policy/s040208.html). Planning and preparation for terrorism and disasters can be both daunting and challenging. For all, but especially for children, there are many recognized gaps in knowledge, resources, and professional education. This resource has been provided to increase pediatric expertise of those taking on the challenge of preparation and planning. This resource will be invaluable, not only for pediatricians, but also for other pediatric 4
Page 1 and 2: Bioterrorism and Other Public Healt
Page 3 and 4: Contents Chapter 1. Introduction ..
Page 5 and 6: Q Fever............................
Page 7 and 8: Basic Principles...................
Page 9 and 10: Chapter 9. Integrating Terrorism an
Page 11 and 12: Table 5.4 Nerve agent triage and do
Page 13: There are many gaps in knowledge, e
Page 17 and 18: Head injury is common in children.
Page 19 and 20: In situations of disaster, caregive
Page 21 and 22: maintaining and securing the airway
Page 23 and 24: • Schonfeld DJ. In times of crisi
Page 26 and 27: Types of Disasters Chapter 2. Syste
Page 28 and 29: problems noted above for flooding,
Page 30 and 31: Federal Response The United States
Page 32 and 33: The scope of ESF #8 is broad and in
Page 34 and 35: • Centers for Disease Control and
Page 36: Table 2.1 Types of disasters, hazar
Page 39 and 40: Medical staffs need to know what wi
Page 41 and 42: information, health and safety educ
Page 43 and 44: y private physicians. Approximately
Page 45 and 46: even required (particularly if a pe
Page 47 and 48: ICS structure is hierarchical. For
Page 49 and 50: • Provide community education so
Page 51 and 52: • Provide for crisis counseling.
Page 53 and 54: incident command officer is most of
Page 55 and 56: Figure 3.1 National Response Plan D
Page 58 and 59: Background History of Bioterrorism
Page 60 and 61: Epidemiology of a Terrorist Attack
Page 62 and 63: and may be watery, purulent, or blo
Page 64 and 65:
fluid in these vesicles. A painless
Page 66 and 67:
determined to be due to an agent of
Page 68 and 69:
cared for using standard precaution
Page 70 and 71:
may be providing longer term and mo
Page 72 and 73:
The vaccine has a number of common
Page 74 and 75:
Vaccination Large-scale vaccination
Page 76 and 77:
cutaneous lesions; however, previou
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common food source is identified du
Page 80 and 81:
treated people experience some degr
Page 82 and 83:
treatment for plague meningitis. An
Page 84 and 85:
Smallpox is spread most commonly in
Page 86 and 87:
focal, intensely suppurative necros
Page 88 and 89:
Control measures. Some viruses that
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Control measures. Person-to-person
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Signs and symptoms. The incubation
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currently used for individuals trav
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Accessed July 12, 2006. • Centers
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• Roffey R, Tegnell A, Elg HF. Bi
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Figure 4.2. Neurological signs, bot
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Figure 4.4. Physical distribution o
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Figure 4.6. Varicella lesions Note:
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Figure 4.8a. Febrile rash illness a
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Table 4.1. Early clinical signs and
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Table 4.2. Infection control transm
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Table 4.3. Diagnostic procedures, i
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Table 4.4a. Diagnostic tests for an
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Table 4.6. Treatment recommendation
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Introduction Chapter 5. Chemical Te
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likely manifest as an acute onset o
Page 122 and 123:
exposures (Table 5.3). For an in-de
Page 124 and 125:
Neuromuscular effects. At the neuro
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children. Finally, routine administ
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Treatment Management of cyanide poi
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Sulfur mustard is stockpiled both i
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decontamination is therefore extrem
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Pulmonary Agents Toxic industrial c
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Type I agents, the significance of
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After dispersal of riot control age
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• Kales SN, Christiani DC. Acute
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• Gray EA, Love JW, Arnold JL. CB
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Table 5.2. Chemical weapons - Summa
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Table 5.3 Representative classes of
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Table 5.4. Nerve agent triage and d
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Table 5.5. Clinical effects from su
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Table 5.7. Medical treatment of rio
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Chapter 6. Radiological and Nuclear
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from ground zero. For weapons large
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(1000 rem), resulting in four fatal
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cooling systems at Mayak exploded,
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pediatric practices. This put infan
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energy, releasing two photons of ex
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need to be shielded, although the a
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adioactive isotope of potassium. Ba
Page 170 and 171:
An integrated, interactive human bo
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Biodosimetry and Radiological Terro
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primitive/progenitor cells and othe
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permits bacterial translocation and
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To assess radiation dose, a researc
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status? 4. Conduct an initial surve
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explosion, when it is concentrated
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Skin pathway. Although intact skin
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personnel should also take a wipe s
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• Geiger-Mueller or G-M counters
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• Protective clothing— Disposab
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Decontamination priorities are as f
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These effects can occur anywhere fr
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manifestations of ARS may range fro
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Neutropenia: Viral and Fungal Infec
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The main reason for targeting pregn
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No significant side effects from it
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axilla, groin, and skin folds. Radi
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Followup Care, Including Risk of Ca
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artificial because followup in almo
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adioactive material in an accident.
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131, canned milk or other milk prod
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home immediately after the incident
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• National Council on Radiation P
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• U.S. Nuclear Regulatory Commiss
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Radiation Detection, PPE, Monitorin
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• National Council on Radiation P
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• Peter RU, Gottlober P. Manageme
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Recommendations for State and Local
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Figure 6.2. Environmental exposure
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Figure 6.4. Bone marrow irradiated
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Figure 6.6. Classic Andrews diagram
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Figure 6.8. Examples of radiation s
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Figure 6.10. Localized radiation ef
Page 238 and 239:
Table 6.2. Biodosimetry based on ac
Page 240 and 241:
Table 6.4. Diagnostic steps in acut
Page 242 and 243:
Table 6.6. Dose assessment summary
Page 244 and 245:
Table 6.8. Antibiotics for treatmen
Page 246 and 247:
Table 6.10. Radionuclide specific t
Page 248 and 249:
Introduction Chapter 7. Blast Terro
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Spalling effect. When a blast wave
Page 252 and 253:
Clinical findings and diagnosis. Cl
Page 254 and 255:
highest position. Because of the pr
Page 256 and 257:
perilymph in the membranous labyrin
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• Hemoptysis. • Subcutaneous em
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management and immediately involve
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considered (see Chapter 4, Biologic
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• Circumstances (weather conditio
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Bibliography Explosives, Incendiary
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Trauma Systems and Planning/Mitigat
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Table 7.2 Spectrum of primary blast
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Table 7.3 Principles of Advanced Tr
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Determine the severity of the burn
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Chapter 8. Mental Health Issues Men
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• Amnesia for important parts of
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Treatment. Treatment should be guid
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• Before notifying the family, br
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• Be conscious of nonverbal commu
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sadness, anger, guilt, or a sense o
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was mean to my father yesterday and
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these roles, they should work close
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• Lack of availability of trauma-
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The structure provided by a preexis
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necessarily meet the children’s n
Page 298 and 299:
Make Psychological Contact Tune in
Page 300 and 301:
A communications goal of “educati
Page 302 and 303:
• Schonfeld D. Crisis interventio
Page 304 and 305:
Chapter 9. Integrating Terrorism an
Page 306 and 307:
Chain of command. A chain of comman
Page 308 and 309:
The chain of command established by
Page 310 and 311:
Advice for families of children wit
Page 312 and 313:
Quarantine procedures. Quarantine p
Page 314 and 315:
Chapter 10. Working with Government
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need under the 12 Emergency Service
Page 318 and 319:
ecognizes that community clinicians
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Chapter 11. Conclusion This report
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Planning for special medical needs
Page 324 and 325:
Table 11.1 Environmental constraint
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Table 11.2 Pediatric medical compla
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• The post-storm environment is h
Page 330 and 331:
Acronyms AAP American Academy of Pe
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RIA RTG SCIWORA SEB SI SNS SSRI STA
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Appendix A. Pediatric Terrorism and
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1. List which biological agents (mi
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19. Identify chemical terrorism tox
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39. Provide followup care, being mi
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Learning Objectives: At the end of
Page 344 and 345:
Lead Editors Appendix B. List of Co
Page 346 and 347:
James Tsung, MD, FAAP Attending Phy
Page 348 and 349:
Gerald S. Braley, PhD Major, United
Page 350 and 351:
Kobi Peleg, PhD Michael Stein, MD J
Page 352 and 353:
Lou E. Romig MD, FAAP, FACEP Childr
Page 354:
Maternal & Child Health Bureau Dan
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