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Federal Response The United States has established a robust emergency medical support infrastructure to respond to disasters at local, State, regional, and Federal government levels. Many response resources are deployable and can be relocated to accommodate varying disaster scenarios. Other response resources are integral to established health and medical systems in our country and provide health care to Americans and others on a daily basis. Populations with specific emergency medical needs in disasters—such as neonatal, pediatric, or adolescent populations—have limited support that is quickly available and specifically designed for to meet their urgent life-sustaining needs. Response resources dedicated to pediatric populations continue to be inadequate for most emergency medical response activities related to disasters, even though victims often include children. Many children were injured or killed during the attacks on the World Trade Center in New York City and the Federal Building in Oklahoma City, and countless more witnessed these events. These experiences highlight the need to include pediatric and other special populations in local, State, regional, and Federal disaster medical planning. Table 2.1 depicts the types of disasters that my require Federal assistance. Centers for Disease Control and Prevention The Department of Health and Human Services (DHHS) is the lead Federal agency for public health issues. The Centers for Disease Control and Prevention (CDC), one of 12 DHHS agencies, provides support to the Department in carrying out its mission. CDC priorities include disease prevention and control, environmental health, and health promotion and education activities. Within CDC, the Director’s Emergency Operations Center (DEOC) operates 24 hours a day, 7 days a week to provide emergency consultation and assistance to clinicians, State and local health agencies, and citizens. The DEOC can be reached at 770-488-7100. The Clinician Information Line (877-554-4625) is available to clinicians 24 hours a day to provide guidance on the management of patients suspected of having bioterrorism-related illnesses and, when necessary, can refer pediatricians to agent-specific subject matter experts. Pediatricians can register to receive real-time CDC updates about preparing for (and possibly responding to) terrorism and other emergency events at http://www.bt.cdc.gov/clinregistry/index.asp. For more information about CDC’s organization and overall mission, see http://www.cdc.gov/aboutcdc.htm. Department of Homeland Security Within the last decade, because of the severity of manmade disasters and their devastating effects on life and safety, as well as the increased threat of terrorism, the Federal Government has positioned itself to respond promptly to any future terrorist events that may occur in the United States. A key step was creation of the Department of Homeland Security (DHS) in 2002. One of its missions is to minimize damage and assist in recovery from terrorist attacks that occur within the United Sates. 19
State and local governments share the primary responsibility for protecting their citizens from disasters, and for helping them recover when a disaster strikes. In some cases, a mass disaster is beyond the capabilities of State and local governments to respond, and the Federal sector is called upon to provide assistance. The DHS now comprises 22 agencies, including the Federal Emergency Management Agency (FEMA). DHS is responsible for the comprehensive National Strategy for Homeland Security, which is focused on six key areas: • Intelligence and warning. • Border and transportation security. • Domestic counterterrorism; protecting critical infrastructure. • Defending against catastrophic threats. • Emergency preparedness and response. To learn more about DHS and its role in disaster preparedness and response, go to http://www.dhs.gov/dhspublic/theme_home2.jsp. Federal Response Plan The Federal Response Plan (FRP) was initially developed as the central document for the delivery of assistance to State and local governments in disasters or emergencies. It is a signed agreement among Federal departments and agencies that identifies actions that will be taken in the overall Federal response to disasters or emergencies. It is to be implemented in anticipation of an event that is likely to require Federal assistance and in response to an actual event requiring Federal disaster or emergency assistance. The FRP also may be implemented in response to a request made by a governor to the president for Federal assistance. Federal response operations are coordinated with State, local, and regional officials and include positioning of a Federal coordinating officer, and deployment of emergency response teams, regional support teams, and emergency support teams to operations centers near the incident site and at the regional and national operations centers. See Figure 2.1 for a graphic depicting the FRP or go to http://www.dhs.gov/dhspublic/interweb/assetlibrary/NRP_Brochure.pdf for more detailed information. Preserving lives and safety of victims are main priorities of disaster response. One component of the FRP, known as Emergency Support Function #8 (ESF #8), Health and Medical Services, is led by the Department of Health and Human Services (DHHS). This function is supported by 15 Federal and non-Federal agencies and provides coordinated Federal assistance to augment State and local resources after a major disaster or during the development of an anticipated public health and/or medical emergency. Assistance is also provided when State, local, or tribal public health or medical assets are overwhelmed and Federal support has been requested through proper authorities or when pending disasters are expected to overwhelm State, local, or tribal resources. Federal support also can be provided when these public health resources are not able to address all public health needs. 20
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 and 14: There are many gaps in knowledge, e
Page 15 and 16: injured or killed (see also Chapter
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 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
Page 78 and 79: 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
Page 90 and 91:
Control measures. Person-to-person
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Signs and symptoms. The incubation
Page 94 and 95:
currently used for individuals trav
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Accessed July 12, 2006. • Centers
Page 98 and 99:
• 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
Page 104 and 105:
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
Page 118 and 119:
Introduction Chapter 5. Chemical Te
Page 120 and 121:
likely manifest as an acute onset o
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exposures (Table 5.3). For an in-de
Page 124 and 125:
Neuromuscular effects. At the neuro
Page 126 and 127:
children. Finally, routine administ
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Treatment Management of cyanide poi
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Sulfur mustard is stockpiled both i
Page 132 and 133:
decontamination is therefore extrem
Page 134 and 135:
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
Page 144 and 145:
Table 5.2. Chemical weapons - Summa
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Table 5.3 Representative classes of
Page 148 and 149:
Table 5.4. Nerve agent triage and d
Page 150 and 151:
Table 5.5. Clinical effects from su
Page 152 and 153:
Table 5.7. Medical treatment of rio
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Chapter 6. Radiological and Nuclear
Page 156 and 157:
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,
Page 162 and 163:
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
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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
Page 206 and 207:
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
Page 218 and 219:
• U.S. Nuclear Regulatory Commiss
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Radiation Detection, PPE, Monitorin
Page 222 and 223:
• National Council on Radiation P
Page 224 and 225:
• Peter RU, Gottlober P. Manageme
Page 226 and 227:
Recommendations for State and Local
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Figure 6.2. Environmental exposure
Page 230 and 231:
Figure 6.4. Bone marrow irradiated
Page 232 and 233:
Figure 6.6. Classic Andrews diagram
Page 234 and 235:
Figure 6.8. Examples of radiation s
Page 236 and 237:
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
Page 250 and 251:
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
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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
Page 264 and 265:
• Circumstances (weather conditio
Page 266 and 267:
Bibliography Explosives, Incendiary
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Trauma Systems and Planning/Mitigat
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Table 7.2 Spectrum of primary blast
Page 272 and 273:
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
Page 278 and 279:
• Amnesia for important parts of
Page 280 and 281:
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
Page 288 and 289:
was mean to my father yesterday and
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these roles, they should work close
Page 292 and 293:
• Lack of availability of trauma-
Page 294 and 295:
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
Page 316 and 317:
need under the 12 Emergency Service
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ecognizes that community clinicians
Page 320 and 321:
Chapter 11. Conclusion This report
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Planning for special medical needs
Page 324 and 325:
Table 11.1 Environmental constraint
Page 326 and 327:
Table 11.2 Pediatric medical compla
Page 328 and 329:
• The post-storm environment is h
Page 330 and 331:
Acronyms AAP American Academy of Pe
Page 332 and 333:
RIA RTG SCIWORA SEB SI SNS SSRI STA
Page 334 and 335:
Appendix A. Pediatric Terrorism and
Page 336 and 337:
1. List which biological agents (mi
Page 338 and 339:
19. Identify chemical terrorism tox
Page 340 and 341:
39. Provide followup care, being mi
Page 342 and 343:
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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