1. PDLS © : Children in Disaster: Public Health Considerations and Disaster Mitigation Dr. Jim Courtney Assistant Professor of Emergency Medicine

2. Preparing for the Public Health consequences of a disaster involving children should occur at the local, regional and national levels. The benefits of this type of planning have been proven many times over

3. Pre-event Public Health Planning Issues: Evacuation of populations at risk. Evacuation of populations at risk. Provide temporary shelter and protection from the environment. Provide temporary shelter and protection from the environment. Provide food, water and clothing. Provide food, water and clothing. Plan for adequate personnel hygiene (toilets, showers, etc.). Plan for adequate personnel hygiene (toilets, showers, etc.). Backup plans for communications, transportation and activities for children. Backup plans for communications, transportation and activities for children. Plan for management of children with special needs. Plan for management of children with special needs.

4. Post-event Public Health Response Issues: Finding and extracting individuals who refused to evacuate Finding and extracting individuals who refused to evacuate Manage neglected chronic medical issues (diabetes, heart disease, etc.) Manage neglected chronic medical issues (diabetes, heart disease, etc.) Provide for medical emergencies and childbirth Provide for medical emergencies and childbirth Keeping confined children healthy (medical & psychological). Keeping confined children healthy (medical & psychological).

6. Post Event Case Study: Hurricane ↑ insect bites especially among children ↑ insect bites especially among children Easy transmission of viral illnesses amongst shelter co-inhabitants Easy transmission of viral illnesses amongst shelter co-inhabitants Lack of regular medications (inhalers) Lack of regular medications (inhalers) Many lacerations and infected wounds Many lacerations and infected wounds Poor hygiene leading to gastrointestinal illnesses (Cholera Outbreak – Katrina) Poor hygiene leading to gastrointestinal illnesses (Cholera Outbreak – Katrina)

12. Public Health Issues: Infectious Disease Outbreaks Type Airborne illnesses: Airborne illnesses: Vector borne illnesses: Vector borne illnesses: Water-borne illnesses: (oral-fecal transmission) Water-borne illnesses: (oral-fecal transmission) Food borne illnesses: Food borne illnesses:Examples Influenza, tuberculosis Avian flu, malaria, dengue, tick related Cholera, salmonella, shigella, norovirus, cryptosporidiosis Fungi, E-Coli

13. Public Health Issues – Airborne Toxins Smothering construction materials Smothering construction materials Fuels Fuels Freon Freon Stored toxic gases Stored toxic gases Stored pesticides Stored pesticides

14. Case Study: World Trade Center

15. Med station

16. Med Station 1

17. patients2

18. Med Station 2

19. Heading in

20. GZ

21. Med Station 3

22. Crushed engine

23. Med station

24. Patients

25. Public Health Issues – Terrorism Related: Biological –Chemical-Radiation Risks Type Biological: Biological: Chemical: Chemical: Radiation: Radiation:Examples Anthrax, smallpox, plague Organophosphorus compounds (pesticides, sarin) Dirty bombs, food contamination

26. Case Study: NYC Anthrax

27. Five cases of cutaneous anthrax diagnosed in NYC Five cases of cutaneous anthrax diagnosed in NYC Occurred between September 22 and October 11, 2001. Occurred between September 22 and October 11, 2001. No cases of Inhalation anthrax No cases of Inhalation anthrax Problem:

28. Cutaneous Anthrax Begins as painless, pruritic papule Begins as painless, pruritic papule Surrounding by enlarging vesicles Surrounding by enlarging vesicles Gelatinous edema surrounds lesion Gelatinous edema surrounds lesion Vesicles rupture and coalese Vesicles rupture and coalese Black eschar forms Black eschar forms

29. Inhalational Anthrax: Observations from 10 cases 7- Positive Blood Cultures 7- Positive Blood Cultures 10- Abnormal CXR 10- Abnormal CXR - 8 Pleural effusions - 7 Wide mediastinum - 7 Infiltrates 9- Minimal non- productive cough 9- Minimal non- productive cough 8- Severe fatigue and malaise 8- Severe fatigue and malaise 7- Shortness of breath 7- Shortness of breath

30. Inhalational Anthrax: Observations from 10 cases 5- Abdominal pain, nausea, vomiting 5- Abdominal pain, nausea, vomiting 5- Chest discomfort 5- Chest discomfort 2- Sore throat 2- Sore throat 1- Rhinorrhea 1- Rhinorrhea Incubation period- 7days (5-11days) Incubation period- 7days (5-11days) Survival= 6/10 Survival= 6/10

31. Lesion of Cutaneous Anthrax Associated With Microangiopathic Hemolytic Anemia and Coagulopathy in a 7-Month-Old infant

32. Cutaneous Anthrax Pediatric case: Pediatric case: - systemic illness seen transient DIC renal dysfunction - unique susceptibility? Freedman A, Afonja O, Chang MW et al. Cutaneous anthrax associated with microangiopathic hemolytic anemia and coagulopathy in a 7-month-old infant. JAMA. 2002;287:869-864.

33. Anthrax Decontamination Decontamination - Undress, soap/shower. Use 0.5% diluted household bleach for gross or visible contamination - Environment: 0.5% bleach

34. Public Health Issues: Disaster Mitigation Definition: Steps taken to minimize the impact on humans (including children of disastrous events – whether expected or unexpected) Definition: Steps taken to minimize the impact on humans (including children of disastrous events – whether expected or unexpected)

35. Examples of Disaster Mitigation Activities: Community wide influenza vaccination programs Community wide influenza vaccination programs Enforcement of engineering codes for construction projects Enforcement of engineering codes for construction projects Avoidance of construction in flow – prove great Avoidance of construction in flow – prove great Stockpiling of supplies in safe places Stockpiling of supplies in safe places

36. Family Disaster Planning (focus on the safety of the children): Safe sites within the home Safe sites within the home Family communication – reassembly plan (children at school parents at work) Family communication – reassembly plan (children at school parents at work) Stored disaster supplies (water, food, cooking equipment, heat sources) Stored disaster supplies (water, food, cooking equipment, heat sources) Conduct drills for common disasters (tornado, earthquake) Conduct drills for common disasters (tornado, earthquake) In reality few families have done any planning

37. Disaster response personnel should become active in developing health care policy regarding disaster Be sure children are represented

38. What is Disaster Mitigation? What is Disaster Mitigation? Steps taken prior to and after a disaster to minimize morbidity and mortality Steps taken prior to and after a disaster to minimize morbidity and mortality Examples include: Examples include: - disaster plans: community, school, and home - pre-designated shelters - clean water stores, food stores - post disaster emotional support

39. Family Disaster Planning Preparation: Home Create and discuss disaster plan for family Create and discuss disaster plan for family Acquaint all family members with first aid equipment in home Acquaint all family members with first aid equipment in home Routes of escape from the home Routes of escape from the home Meeting place outside Meeting place outside Conduct drills Conduct drills

40. Preparation: Home Preparation: Home Keep disaster stores of food, medications, diapers, etc. Keep disaster stores of food, medications, diapers, etc. Have “disaster containers” in home and car Have “disaster containers” in home and car Special needs children Special needs children - Early evacuation plans, etc

41. Preparation: School Makes disaster plan known to all Makes disaster plan known to all Routes of escape from the school Routes of escape from the school Predetermined meeting place Predetermined meeting place Drills Drills

42. Lack of Preparation

43. Hospital Interface Work with local and state officials to create disaster management plan Work with local and state officials to create disaster management plan Local EMS should have plans for all schools, Daycares, etc.. in area Local EMS should have plans for all schools, Daycares, etc.. in area Practice interface between school, EMS, and hospital with drills at least once a year Practice interface between school, EMS, and hospital with drills at least once a year

44. Management of Resources Children require unique supplies Children require unique supplies Hospital pediatric resuscitation equipment should be adequately stocked Hospital pediatric resuscitation equipment should be adequately stocked Oral fluids, small gauge IV sets, diapers, etc. should be stockpiled nearby Oral fluids, small gauge IV sets, diapers, etc. should be stockpiled nearby Children's toys, books, etc. should be accessible Children's toys, books, etc. should be accessible

45. Management of Resources Know total number of pediatric floor and ICU beds in area Know total number of pediatric floor and ICU beds in area Be prepared to transport patients and or supplies large distances Be prepared to transport patients and or supplies large distances

46. Premature Twins Evacuated

47. Recovery Phase: Initial Shelters should be “kid friendly” Shelters should be “kid friendly” Keep families together Keep families together Personnel to organize area for orphaned and separated children until families reunited Personnel to organize area for orphaned and separated children until families reunited Create children's groups in shelter, plenty of toys, books, etc.. Create children's groups in shelter, plenty of toys, books, etc..

49. Recovery Phase: Long-term Psychological services early Psychological services early Be attentive to children's needs, consider educational resources for long-term sheltering. Be attentive to children's needs, consider educational resources for long-term sheltering. Aberrant behavior may be manifestation of emotional trauma Aberrant behavior may be manifestation of emotional trauma

50. Activities for Children

51. Recovery Phase: Long-term Children must feel safe in home, community and school; encourage this Children must feel safe in home, community and school; encourage this Learn from mistakes Learn from mistakes

52. Disaster Mitigation: What you can do Emergency physicians, Pediatric EM physicians, Pediatricians, Nurses, other health care professionals: Emergency physicians, Pediatric EM physicians, Pediatricians, Nurses, other health care professionals: - Preparation before disaster - Action during disaster - Recovery phase

53. Before Disaster Strikes Involve yourself in the local EMS and area disaster plan: help to develop systems that keep children's’ needs in mind 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 Work with schools, daycares and local hospitals to develop integrated disaster plans Act as an advisor to your patients for home disaster planning Act as an advisor to your patients for home disaster planning

54. Before Disaster Strikes Arrange disaster response drills Arrange disaster response drills Promote community awareness addressing pediatric needs Promote community awareness addressing pediatric needs

55. During A Disaster Be active!! Be active!! Institute disaster plans in your facility Institute disaster plans in your facility Participate in the community response to disaster Participate in the community response to disaster

56. Disaster Recovery Provide medical care to shelters Provide medical care to shelters Assume basic community services will be disrupted for some time Assume basic community services will be disrupted for some time Attend to emotional needs of the pediatric population effected Attend to emotional needs of the pediatric population effected

57. Destruction of Resources

58. Emotional Problems: What To Expect Acting out Acting out Depression Depression Apathy, lack of expression Apathy, lack of expression Difficulty sleeping Difficulty sleeping Fear of thunder, wind, etc. Fear of thunder, wind, etc. Somatic complaints Somatic complaints

59. Apathy

60. Acting Out

61. Who Is Most At Risk For Emotional Problems? Children most directly affected by the disaster: injured themselves, family members killed or injured Children most directly affected by the disaster: injured themselves, family members killed or injured Children with prior emotional problems Children with prior emotional problems Children suffering a disruption in their family Children suffering a disruption in their family

62. Disaster Mitigation...... Plan For The Children!