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Pediatric Terrorism and Disaster Preparedness

Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

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Radiological and Nuclear Terrorism

Nuclear and radiological weapons pose a significant terrorist threat. In the past, terrorists have attacked discrete locations with explosive materials that are not inherently toxic. However, the tactics and technological sophistication of terrorists are continually evolving. Future attacks with radiological devices are a real possibility that is outside the experience of most local emergency and health officials. Radiological terrorism could include detonation of one or more nuclear weapons, deployment of a radiation-producing device or other isotopic weapon (e.g., "dirty bomb"), or simply placement of a radioactive source (e.g., nuclear waste material) in a public location. The probability and nature of injuries depend on the type of disaster involved.

There are several key public health and safety considerations in managing radiological incidents. These include the potential for both immediate and long-term health effects, depending on the specific radionuclide(s) and method of dispersal involved. Other concerns include protection of first responders (including forensic investigators) and the general public, casualty triage, decontamination, treatment, and management of emotional distress and fear associated with possible exposure to radiation. Key decision points include evacuation versus sheltering-in-place, and potential restrictions on food and water consumption. Initial response capabilities will be limited unless appropriate expertise, specialized equipment, and supplies are readily available.

Nuclear Weapons

The so-called "dirty bomb" disperses radioactive material and is relatively simple to deploy. A nuclear weapon would be much more difficult to deploy. Nevertheless, the potential for detonation of a nuclear weapon in a major city cannot be dismissed. The destructive action of nuclear weapons is mainly due to blast and heat, as in conventional explosives, but nuclear explosions are hundreds to millions of times more powerful than conventional explosives. 

Medical providers need to be prepared to adequately treat injuries complicated by ionizing radiation exposure and radioactive contamination. Medical facilities in the immediate area will be nearly unusable due to heavy physical damage. Medical facilities in adjacent areas may be severely compromised by downed power and phone lines; probable loss of all city utilities; and damage to electronics, communications, and HVAC control induced by the electromagnetic pulse produced by a nuclear blast. Patients requiring more than basic medical care will require transport to functioning medical facilities well outside the immediate area of destruction.

Radiological Dispersal Devices

A radiological dispersal device is designed to spread radioactive material through detonation of conventional explosives or other (non-nuclear) means. These so-called "dirty bombs" blast radioactive material into the area around the explosion, exposing people and buildings. The purpose of a dirty bomb is to frighten people and make buildings or land unusable for a long period of time.

Medical and Industrial Sources of Radiation

Radioactive materials used in medical or industrial settings can produce irradiation or contamination from accidental or intentional misuse. Powerful industrial radiography sealed sources used in the nondestructive testing of oil and water pipelines have caused severe exposures. They are potential terrorist weapons and could present a serious localized radiation threat. Another important medical/industrial source is Cs-137, which is an important decay product resulting from the fission of uranium and plutonium fuels. This isotope is used in both industrial sealed-gamma sources as well as medical therapeutic sealed sources. 

Nuclear Power Plants

The United States has 104 nuclear reactors licensed to provide electric power, as well as 36 reactors licensed for other uses. The U.S. Nuclear Regulatory Commission has stringent physical protection requirements against sabotage covering both plant design and security protection features. Unlike the design of some foreign reactors, designs for power reactors operating in the United States incorporate a layered system of physical shields and walls, including a potentially pressurized containment vessel. Consequently, there have been relatively few mishaps involving American-designed power reactors.

The primary down-wind hazard from destruction or sabotage of a nuclear reactor is the venting of radioactive iodine gas. Power reactors cannot detonate like a nuclear bomb because reactor fuel does not contain the highly enriched uranium needed for detonation.

Pediatricians may be asked about the safety of consuming milk and other foods after a reactor accident. Iodine-131 fallout on vegetation has an effective half-life of about 5 days. An infant consuming 1 L of milk per day contaminated with 1 microCurie (µCi)/L would receive a total cumulative dose to the thyroid of about 16 rem. Therefore, locally produced milk, fruit, and vegetables should be declared fit for consumption only after clearance by appropriately trained health inspectors.

External Contamination

External contamination with radionuclides can occur in the same settings and situations that cause internal contamination. Any person who passes through a contaminated area without appropriate personal protective equipment or is injured in a contaminated area will become externally contaminated. The largest amount of fallout is on the surface of the ground, so children and crawling infants are particularly prone to pick up this material on their bare skin. However, up to 95 percent of contamination is on the outer clothing and shoes. The body surfaces most likely to be contaminated include the hands, face, lower legs, and oral and nasal cavities.

External contamination with radioactive agents is unlikely to cause acute injury, so emergency resuscitation and treatment of injuries come first. This is in contrast to external contamination with chemical agents, in which rapid decontamination may be more important.

Medical Treatment Unique to Pediatrics

The clinical manifestations of radiation injury in children are generally similar to those in adults. However, a number of characteristics render the pediatric patient uniquely sensitive to the effects of radiation exposure. For example:

  • Children have a greater body surface area to weight ratio than adults and skin that is more permeable and less keratinized, making them more vulnerable to both thermal and radiation burns.
  • Young children may be unable to shield their eyes, making them more susceptible to ocular injury from blast, radiation, and thermal effects.
  • Children have a higher baseline respiratory rate than adults and also exist in a lower breathing zone, making them more vulnerable to both generalized inhalation exposure and particulate exposure from radioactive fallout.
  • Children have a lower intravascular volume reserve than adults, making them more susceptible to dehydration from the gastrointestinal losses encountered in acute radiation syndrome.
  • Infants and young children are more likely to come in close contact with radioactively contaminated materials in their environment.
  • Radioiodine, a common byproduct of nuclear reactor activity, is efficiently transmitted through both human breast milk and cow's milk, which are staples of the childhood diet.

Long-term Susceptibility

The well-documented long-term effects of radiation exposure to the fetus and child are potentially of even greater concern for the more broadly exposed pediatric population. These effects can occur anywhere from months to years after initial exposure and include:

  • Increased incidence of thyroid and hematologic malignancies.
  • Increased incidence of breast cancer.
  • Higher incidence of mental retardation, microcephaly, and postnatal growth retardation from fetal exposure to radiation.

Psychological Vulnerability

Children involved in a radiation-related incident will be particularly vulnerable to psychological trauma, as in any disaster or terrorist event. Depending on the child's stage of development, this increased vulnerability can manifest as generalized fear and anxiety, developmentally regressive behavior, sleep and appetite problems, altered play, school problems, or greater dependence on caregivers. This latter problem may be exacerbated by physical separation from parents in the chaos of the event. Repetitive television and news broadcasts relating to the event may even traumatize children in areas remote from the actual disaster, convincing them that they also are at risk. Children also experience stress by witnessing the reactions of their parents. Any treatment plan for children exposed to radiation must take these unique vulnerabilities and parental reactions into account.

Immediate Care

The first priority during the care of anyone exposed to radiation is to treat life-threatening injuries before addressing radiation exposure and contamination. In general, evolving injuries such as burns, lacerations, and fractures need to be stabilized before decontamination and subsequent transport to facilities where radiation-specific injuries are to be managed. In most instances, radiation levels will not be known and survey instruments may not be available. Contamination risks to medical responders will be minimal in most cases, unlike biological and chemical exposures. However, simple precautions such as wearing gloves and wrapping victims in sheets or blankets to reduce the spread of contamination should be taken before transport.

Followup Care and Risk of Carcinogenesis

Children are particularly susceptible to the transforming effects of ionizing radiation. This is true for children exposed to radioactive fallout, release of radioactive materials from nuclear power plants, and external beam radiation therapy for medical conditions. External beam radiation therapy, used, for example, in the treatment of Hodgkin's disease or tumors of the central nervous system, is associated with an increased risk of second malignancies, particularly solid tumors arising in the radiation field.

Thyroid nodules and cancers are one of the most frequent late complications of ionizing radiation. Although generally uncommon in children, they are very frequent 10-20 years after radiation exposure. Stable iodine prophylaxis can reduce the risks of thyroid cancer after nuclear disasters or accidents but has no effect against external beam radiation therapy because the latter does not involve radioactive iodine. The World Health Organization and the U.S. Food and Drug Administration recommend stable iodine prophylaxis for exposed populations stratified according to age. Thyroid function tests should be monitored in infants to allow early recognition and treatment of hypothyroidism.

In general, radiation-induced thyroid cancers appear to be more aggressive than spontaneous thyroid cancers and are frequently multifocal. Exposed children should be monitored by serial ultrasound examinations, and suspicious lesions should be removed by total thyroidectomy to eliminate other microscopic foci of disease.

Due to the increased incidence of leukemia in children exposed to high doses of radiation, close followup with regular physical examinations and complete blood counts is warranted. The incidence of breast cancer is also increased in young women, so regular breast examinations should be emphasized. Abnormalities should be evaluated with a high level of suspicion. Enrollment in a high-risk breast clinic may be indicated. The latency period (i.e., the time interval between irradiation and appearance of a malignancy) is shortest for leukemia (5-7 years) but can extend to 45 years or more for solid tumors.

Environmental Issues

The environmental damage from a terrorist incident involving radiation has many potential consequences for children. Response planning should include actions that may be taken to minimize exposure both immediately after and during recovery from a terrorist incident, for example, whether to shelter-in-place or evacuate.

Evacuation is an effective countermeasure to the presence of radiation and may prevent exposure to children. The decision to evacuate should take into account the potential disruption and actual risk. Area evacuations can result in increased risk of exposure if a plume already exists or if evacuation is to a higher risk location. Also, casualties can result from the evacuation process, and negative psychological effects can occur. Ideally, the evacuation would begin before the passage of any radioactive material carried in a dispersal cloud. Evacuation is almost always indicated if the projected average effective dose is likely to be >0.5 Sv (50 rem) within a day.

Sheltering-in-place for protection from radioactive fallout is also an effective countermeasure with little negative impact for short periods of time (hours) and may be done in a fallout shelter, an underground area, or in the middle of a large building. Sheltering generally reduce exposures to external and internal contamination by 5 to 10 times. Sheltering is almost always justified if it will prevent exposures of 0.050 Sv (5 rem) or more.

Earlier recommendations by the Environmental Protection Agency for evacuation were written for a nuclear power plant accident in which the release of radioactive material would occur hours after the initial accident, allowing the population to be evacuated in a plume-free environment. However, a terrorist attack is more likely to release a plume within minutes rather than hours of the event. Therefore, sheltering is likely to be more protective in response to a radiological terrorist event. Sheltering should be performed whenever it is more protective than evacuation.

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Blast Terrorism

A 1997 report by the Department of Justice presented an abundance of evidence suggesting that given intent, the knowledge required to build bombs is readily available in print and on the World Wide Web. The raw materials for explosive devices are routinely found in areas of farming and mining activities. Due to the public accessibility of explosive materials and bomb-building knowledge, a domestic terrorist attack would probably take the form of a conventional explosive munitions attack.

Both blast trauma and conventional trauma have aspects of blunt, penetrating, burn, crush, and inhalational injuries. However, victims of a blast may suffer all of these injuries simultaneously, with additional injury caused by the blast wave itself, that is, primary blast injury. Primary blast injuries are lethal, unique, and often subtle.

Many mechanisms of injury are involved in blast injuries:

  • Primary blast injury refers to tissue damage by the blast wave itself.
  • Secondary injury refers to penetrating or blunt injury that results from the acceleration of shrapnel or debris.
  • Tertiary injuries result from acceleration-deceleration forces imposed as the blast wind propels the victim.
  • A fourth injury mechanism includes flash and flame burns, inhalational injury, and crush injuries incurred from fires and structural collapse.

Trauma Systems

The medical response to blast terrorism is built on the foundation of the regional trauma system. About 98 percent of all terrorist events worldwide, of which approximately 75 percent are due to blast trauma, involve physical trauma. Therefore, regional emergency management, public safety, and public health agencies should include not only regional child health care experts, but also regional pediatric trauma professionals in planning for mass casualty events that affect children.

Most trauma hospitals are full-service general hospitals that provide the highest level of health care service in their communities. However, modern trauma system design does not rely solely on such hospitals but integrates all health facilities within the region to the level of their resources and capabilities. Thus, the complete trauma system should consist of an integrated network of health care facilities within a region, designed for safe and rapid transport of injured patients to the health care facilities that best meet their medical needs. Many stand-alone pediatric hospitals also serve as pediatric trauma centers.

Planning and Mitigation

Regional trauma system planning should consider the special needs of children who are injured due to blast terrorism and the special resources necessary to care for them. Children and young adults are at higher risk of serious injury than adults for several reasons. Although blast tolerances in children are poorly defined, there is good reason to believe that children may absorb more blast energy per unit of body mass than adults after blast trauma. This predisposes children to morbidity and mortality rates higher than those of adults as compressive shock waves passing through the body are compacted into a smaller total body mass.

Reports in the literature point out the inadequate state of emergency preparedness for disasters that involve children. They also describe the common problems in pediatric disaster planning and management, such that pediatric professionals involved in disaster planning will be knowledgeable about these problems and can seek to anticipate and avoid them in future disasters. For example, no children were injured in the terrorist attack on the Pentagon on September 11, 2001, principally because the Pentagon daycare center was located on the opposite side of the building from the location of attack. However, issues were subsequently raised on children's hospital disaster preparedness.

Immediately after the attack, the hospital disaster plan was invoked, resulting in the discharge of more than 50 patients and the cessation of all nonurgent activities. Although hospital staff had conducted disaster drills in preparation for Y2K, hospital leaders continued to question their actual state of readiness. Further, emergency preparations were complicated by the fact that all of their news came not from official sources, but from local television, leaving hospital leaders unsure about what to expect.

These experiences highlight the importance of planning and preparedness and raise a number of vitally important issues regarding blast terrorism mitigation in children:

  • After a blast, injuries in children are to be expected with most children injured in closed or confined spaces, which greatly increases the magnitude of forces of injury.
  • As with blast injuries in adults, most children will either die at the scene or sustain minor injuries. Only a small number of children in the "penumbra" of the blast wind who sustain major injuries will survive to require hospital care. They typically will not begin to arrive at the trauma center until 30-60 minutes after the blast event.
  • Most surviving children with major injuries will require early surgery and subsequent care in a pediatric critical care unit, followed by lengthy hospitalization and rehabilitation, both physical and psychological.

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Mental Health Issues

Pediatricians and other health professionals who care for children will play many critical roles in identifying and addressing the mental health needs of children and families in a disaster or terrorist event. Indeed, for many, if not most, children affected by a critical event, pediatricians and other health care providers for children will be the first responders. Therefore, pediatricians need to be able to identify psychological symptoms, perform timely and effective triage of mental health complaints, initiate brief supportive interventions, and make appropriate referrals when necessary.

Because children's adjustment depends to a great extent on their parents' own ability to cope with the situation, pediatricians should also attempt to identify parents who are having difficulties adjusting to the event and encourage them to seek support for themselves. Pediatricians can also help families identify and access appropriate supportive or counseling services, and they can help support families who are reluctant to seek mental health services because of misunderstandings related to the nature of the treatment or associated stigma.

Trauma-Related Disorders

Exposure to disasters and terrorism can be direct, interpersonal, or indirect. Children who are physically present during an incident or are an eyewitness to it are directly exposed.  Interpersonal exposure occurs when relatives or close associates are directly affected. Indirect exposure occurs through secondary negative consequences of an event such as chaos and disruption in daily activities. Children who are far away from an incident may be remotely affected with fear and generalized distress as they perceive the societal impact of these experiences.

Children may develop psychiatric symptoms and disorders—including posttraumatic stress disorder (PTSD), anxiety, depression, and behavioral problems—after exposure to disasters or terrorist incidents. Grief in these situations can be compounded by the traumatic circumstances associated with the loss. The following factors are associated with an increased risk of posttraumatic symptoms and other adjustment difficulties:

  • Children or others close to them are direct victims.
  • Children directly witness the event.
  • Children perceived during the event that their life was in jeopardy.
  • Event results in separation from parents or other caregivers.
  • Event results in disruption of regular environment.
  • Children have a history of prior traumatic experiences or prior psychopathology.
  • Parents have difficulty coping with the aftermath of the event.
  • Family lacks a supportive communication style.
  • Community lacks the resources to support children after the event.

The essential feature of PTSD is the development of characteristic symptoms after exposure to a traumatic event that arouses intense fear, helplessness, or horror or that leads to disorganized or agitated behavior. Signs and symptoms are categorized into three clusters:

  1. Persistent intrusive re-experiencing (e.g., unwanted memories, nightmares).
  2. New onset and persistent avoidance and numbing (e.g., avoiding thoughts about the experience, amnesia).
  3. New onset persistent hyperarousal (e.g., sleep difficulties, exaggerated startle response).

Other conditions, especially anxiety and affective disorders, are common after crisis events and may occur independently or together with PTSD. Signs of trauma may be evident in children's behavior, mood, and interactions, and traumatized children may adopt behavior more appropriate of younger children. Girls are more likely to express anxiety and sadness, while boys tend to exhibit more behavior problems.

Although grief is not a mental disorder, it may require professional attention, especially if it is complicated by depression or PTSD. Traumatic deaths are of particular concern, and referral to a pediatric mental health professional is often indicated in these situations.

Assessment and Treatment

Assessment and treatment of children after a disaster vary depending on characteristics of the disaster and the child's exposure, the setting, and the length of time since the event. In the acute-impact and early post-impact phases, supportive interventions should:

  • Ensure the child's safety and protection from additional harm.
  • Address immediate physical needs.
  • Provide reassurance.
  • Minimize exposure to traumatic aspects of the event.
  • Validate experiences and feelings.
  • Restore routine.

Children benefit from accurate information, but it should be age-appropriate and measured. Pediatric mental health professionals may be able to help other health professionals and family members with the process of death notification when needed. Reuniting family members is a priority.

Assessment should include a history of the child's exposure and reactions. When children or their close family members have been directly exposed, the children may require more comprehensive assessment, but children with less direct exposure may also need attention. Observation and the use of projective techniques, such as play and art, aid in assessment and are useful in treatment as well. Children generally should not be forced or coerced to recount the event through repetitive questioning, or to act out the event, or to share their feelings before they are ready.

Treatment should be guided by the child's exposure and reactions. Directly traumatized and bereaved children should be seen individually, but groups are useful for identifying children in need of more comprehensive evaluation and treatment. Cognitive behavioral therapy and educational information provide structure and support and may be used in individual or group sessions after disasters. Medication is rarely indicated in children after disasters but might be appropriate for those with severe reactions. Consultation with a child psychiatrist is recommended when medication is considered. 

The family has a major role in the child's adjustment to trauma, and parents should be included in treatment. Helping parents resolve their own emotional distress can increase their perceptiveness and responsiveness to their children.

School-Based Interventions

Schools are an excellent setting in which to deliver mental health services to children and families after a disaster. They provide access to children, encourage normalcy, and minimize stigma.

PTSD and associated symptoms are likely to emerge in the school setting. For example, intrusive thoughts and difficulty concentrating may interfere with academic performance and social adaptation. Therefore, school consultation about the consequences of trauma and the recovery process may be indicated. School-based interventions, which can include curricular materials and activities, should be appropriate for the setting and should not supplant efforts to identify and refer children in need of more intensive individual evaluation and treatment.

Explaining Death to Children

Children's understanding of death may be very different from that of adults. Children have had far less personal experience of loss and have accumulated less information about death. They also may have difficulty understanding what they have seen and what they have been told, unless they are helped to understand the basic concepts related to death.

When providing explanations to children, use simple and direct terms. Be sure to use the words "dead" or "died" instead of euphemisms that children may find confusing. If young children are told that the person who died is in "eternal sleep," they may expect the deceased to later awaken and be afraid to go to sleep themselves. Religious explanations can be shared with children of any age, but adults should appreciate that religious explanations are generally very abstract and therefore may be difficult for young children to comprehend. It is best to present both the facts about what happens to the physical body after death (e.g., "After a person dies, the body stops working, and the person no longer can see or hear or feel pain, which is why the body can be buried"), as well as the religious beliefs that are held by the family.

Children's Reactions to Personal Loss

Similar to adults, children may be reluctant to talk about a death. They may at first be shocked by the news or fail to understand its implications. Even in the setting of a natural disaster or terrorist event, children may still wonder if they were in some way responsible for the death. After a traumatic death, such guilt feelings may increase posttraumatic symptoms and complicate the grieving process. Often such feelings of guilt are irrational. "If only I hadn't gone to school that day, my dad would never have gone to the office and wouldn't have been killed by the bomb," "I was mean to my father yesterday, and that's probably why he died," and so on. Children often are reluctant to share their guilt feelings with adults, and adults may not anticipate these feelings (or be burdened with their own guilt feelings). It may therefore be helpful to reassure children of their complete lack of responsibility, even if they do not express feelings of guilt and there is no logical reason why you might anticipate they would feel guilty.

At the time of a traumatic loss, children often think first about their own needs. Parents should be warned that this self-centeredness is not a sign that children are selfish. More likely, it is a sign that they are under considerable stress and in need of more support and assistance.

Indications of the Need for Referral

Not every child who has experienced the death of a family member or friend requires professional counseling and, in the setting of a major disaster or terrorist event, such resources are unlikely to be available. It is generally helpful though for children who have experienced the death of a family member or friend to speak with someone outside of the immediate family who understands child development and can attend to the child's needs without being burdened with his or her own grief. This person may be their pediatrician or a school counselor or social worker. When a community disaster or crisis has occurred, it is important to help establish access to supportive services within community sites, such as schools, to provide services to larger numbers of children.

Children who have extreme reactions (e.g., anxiety, posttraumatic symptoms, depression, or thoughts of suicide), atypical reactions (e.g., appearing happy or disinterested), or prolonged reactions (e.g., prolonged sleep problems or somatization) should be evaluated by their pediatrician and likely referred to a mental health professional experienced in the management of pediatric bereavement. Children who are having difficulty returning to their normal daily routines several weeks after the death or are demonstrating the new onset or worsening of problems in interacting with peers should also be referred.

School Crisis Response

Most children will benefit from receiving supportive services in the aftermath of a disaster or terrorist attack. Pediatricians can play a vital role in advocating for, consulting for, and actively participating in school crisis response teams to ensure that such supportive services can be provided to children within schools and other community sites.

School administrators, teachers, and other school staff will be affected by the same crisis event that is affecting their students. During such times, organizing and implementing an effective crisis response can be difficult if not impossible. It is therefore imperative that schools begin planning for potential crisis events before they occur, to avert disasters whenever possible and to decrease the negative impact on students and staff when disasters cannot be prevented.

The school crisis response plan should include generic protocols for the following:

  • Notification of team members, school staff, students, and parents of a crisis event.
  • Delivery of psychoeducational services and brief crisis-oriented counseling, such as through support rooms or short-term support groups.
  • Memorialization and commemoration.
  • Follow up to ensure appropriate steps are taken.

In addition, the crisis response plan should include guidelines on the following:

  • Crisis team membership and roles of members.
  • Protocols for delivery of crisis intervention services.
  • Specific guidelines for responding to unique situations, such as large-scale natural disasters or a terrorist attack.
  • Physical safety and security.
  • Rapid dissemination of accurate and appropriate information.
  • Attention to the emotional impact of the events and the crisis response.

The structure provided by a preexisting plan can be very comforting in times of crisis and helps to ensure that key issues are considered, appropriate steps are taken, and necessary resources are in place.

Delivery of supportive services to children during a crisis can be demanding work for school staff and community mental health providers working within the schools. Community groups such as the American Red Cross and the Salvation Army have programs that can be brought into schools to assist in this effort. Plans should also include mechanisms to ensure that supportive services for staff are included as a key component of crisis response.

Impact on Health Care Providers

Very often, first responders and other adult service providers show signs of distress and emotional disruption after responding to stressful situations involving trauma, disaster, or a terrorist event. Pediatricians may be approached by a colleague, a fellow worker, or any health care provider in distress. Apply some basic common sense rules to help:

  • Make psychological contact.
  • Assess the individual's level of coping.
  • Explore possibilities for getting further help.
  • Assist in taking action.
  • Provide followup.

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