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Strategies and Tools for Meeting the Needs of Children

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Transcript of Web Conference

This Web Conference, broadcast January 11, 2006, explored some of the key issues surrounding the preparedness planning for the care of children. It highlighted innovative research, tools and models that can be used in developing effective preparedness strategies for addressing the unique needs of children.

The Agency for Healthcare Research and Quality (AHRQ) developed and sponsored the program.

Moderator—Cindy DiBiasi: Good afternoon. Welcome to our program, Public Health Emergency Preparedness: Strategies and Tools for Meeting the Needs of Children. Today's 90-minute event will focus on preparing and providing for the special needs of children during a public health emergency.

This Web conference has been designed to help policymakers, program administrators, health systems, school systems, health care providers, child care providers, and other preparedness decision makers by providing information about the latest research, tools and models available in this topic area.

It's sponsored by the U.S. Department of Health and Human Service's Agency for Healthcare Research and Quality, often referred to by the acronym A-H-R-Q or AHRQ. I'm Cindy DiBiasi, and I'll be your moderator for today's program. Before we introduce our panelists for today's discussion, I'd like to give you background on why we're holding this event.

The reason for today's conversation is clear and compelling. The events of September 11th, 2001; subsequent anthrax attacks; threats of avian flu outbreak; and large-scale regional national disasters have emphasized the need for U.S. health care organizations and public health care agencies to be prepared to respond to public health emergencies. At the Federal level, the United States Department of Health and Human Services has developed a strategic plan to strengthen our Nation's emergency preparedness system to respond to a bioterrorist attack or other mass casualty event.

Many HHS agencies, such as the Office of Public Health Emergency Preparedness, Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the Agency for Healthcare Research and Quality, have played important roles in preparedness efforts. Many States, health care organizations, and systems have also developed preparedness plans that include strategies and tools for responses to such events. However, these strategies often focus on general population needs and may not address the unique needs of vulnerable populations like children.

To meet the needs of all infants, children, adolescents, and young adults, it's critical that our community preparedness efforts involve pediatric health care experts as well as facilities, institutions, and agencies that care for children. Within HHS's strategic framework for emergency preparedness, AHRQ's objectives are to develop and assess alternative approaches to ensuring health care surge capacity, models that address training and information needs, alternative uses of information technology and electronic communication networks, and protocols and technologies to enhance interoperability among health care systems. In addition, recognizing the importance of identifying effective strategies and tools to address the needs of children, AHRQ has expanded its bioterrorism preparedness research portfolio.

It now also focuses on integrating the special needs of children into Federal, State, regional, and local preparedness planning for public health emergencies. Today's program will highlight key issues and share important information, insights, and tools in this area.

Before we begin, let me introduce you to an interesting interactive feature of this Web conference. I am going to ask for your feedback throughout the Web conference by polling the audience. Please join me now as we practice using this feature. Let's take a poll to see where everyone is joining us from.

To participate, please answer the following question that will appear on your screen in a few seconds.

The question: "I'm participating in this Web conference from the following Region of the United States." And for the Northeast, select A. For the Northwest, select B. For the Southwest, select C. For the Southeast, select D. For the Midwest, select E. For the Mid-Atlantic, select F. And for outside of the United States, select G. While you're answering this question, I'll introduce today's panelists.

In the studio, I have Dr. Irwin Redlener, the Director of the National Center for Disaster Preparedness, Columbia University, Mailman School of Public Health; Dr. George Foltin, Director, Center for Pediatric Emergency Medicine at Bellevue Hospital; Dr. Michael Shannon, Director for the Center of Biopreparedness and Professor and Chair of the Division of Emergency Medicine at Children's Hospital, Harvard Medical School; and Dr. David Markenson, Chief, Pediatric Emergency Medicine at Maria Fareri Children's Hospital at Westchester Medical Center. Welcome, everyone. And now let's take a look at the results from our practice poll.

And as we are looking at the results, we see that—oh, most of the people by far are coming to us from the Northeast. No, a lot of people from the Midwest represented as well. Wonderful, but we have good representation throughout the United States and even have people from outside the United States. So welcome to everyone.

Okay, now let's go to another question, and the next question is, "I most closely represent the following organization." And if you represent State or local government, select A. If you most closely represent schools or child care setting, select B. For health care systems, select C. Researcher, select D. For clinical, E. And for all others, F.

And while you're answering this question, I'll explain how the program will work. First, we'll talk with each of our four panelists and then open up the line to take your questions. You'll be given instructions on how to send in questions to us later on in the program. And although we don't think you'll have any technical problems, I'm going to give you a few tips on dealing with them just in case.

If you have Web-related technical difficulties, or if it appears that the slides are not advancing in synch with the audio, you may need to restart your browser and log in again. If you're on the phone, dial star-0 to be connected to technical assistance. If you have any trouble with the audio stream or have an uncomfortable lag time between the streamed audio and the video, you may access the audio through your phone by dialing 1-877-407-0831. The password is "children."

And if technical problems cause you to miss part of the conference, at the end of our 90 minutes today, we'll let you know how to access an archive of this conference at a later time.

And now we're waiting for the results of our second poll question, to find out what areas most of our people are in. And an overwhelming majority are from State or local government, and we have a strong showing from health care systems, but again we have representation throughout—from all the sectors. That's great. Well, I think we are now ready to discuss today's topic, and we're going to start with Dr. Irwin Redlener. Dr. Redlener is here to talk about the specific vulnerabilities of children and report on the lessons learned regarding the care and support for children following recent Hurricane Katrina. Thank you for being with us today. We appreciate it.

Dr. Redlener: Happy to be here.

Cindy DiBiasi: Could you begin by describing for our audience what is it is that makes children so unique with respect to exposure to chemical, biological, nuclear, or explosive materials?

Dr. Redlener: This is an interesting question, because one of the biggest challenges that we have may be surprising for children, but a lot of people that are involved in emergency planning are actually not familiar with the fact that, as pediatricians are, for example, that children are very different from adults. They're not just little adults, and there are many aspects of a child's anatomy and physiology and medical and health responses that are very different from that of adults. And all these factors need to be included and incorporated as we're discussing what preparations need to be made, in order to ensure children coming through whatever kinds of exposure might be faced as optimally as possible. So to start with some of the features that make children different that we're aware of, think about how children breathe and where children breathe, since their breathing mechanism, their nose and mouth, is much closer to the ground than for adults. This makes sense. But what happens is many of the agents that we're worried about with children that might be concentrated to the ground will pose a much greater threat to children because of the—they'll be absorbed at a greater quantity and greater speed, not to mention the fact that children have to breathe more rapidly than adults, and all of these factors make them much more vulnerable to those kinds of agents.

Secondly, there are differences in how children absorb certain agents through the skin. The skin of small children is different than that of adults in terms of coarseness, permeability, so agents that might come in through the body through that mechanism also might be different.

Other differences in terms of how children respond medically, certain kinds of exposures, in terms of the propensity to develop dehydration, and shock are all very important, and of course we are all familiar, hopefully, with the fact that the dosages of medication and antidotes and antibiotics for children need to be very different. In fact, some of the antidotes or antibiotics may not be appropriate at all for children, so talking about different kinds of (indiscernible).

Perhaps one of the more important differences—there's categories of differences—have to do with the social issues that affect children and as well as their development. Children are strikingly dependent on adults for everything in terms of responding appropriately to emergency need. They cannot do much independently, obviously, and the smaller, the younger the child, the less capable they are of acting independently. So we have to worry about systems that might be relatively simple for adults are highly complicated, difficult, for children. And finally, the mental health consequences, which we'll talk about more later, can be very different for children and very much dependent on the child's age and developmental stage.

Cindy DiBiasi: You mentioned where children breathe. Do you have some examples of how children get exposed to these different types of materials?

Dr. Redlener: Yes. This is also an interesting question, and I think for many of us, this is worth thinking about. So the question would be, "How do children get exposed to the kinds of things that we are worried about in terms of disasters, particularly terrorism?" But more generally, we worry about how children would potentially get exposed to toxic materials—materials such as chlorine gas, for example—or other kinds of noxious materials or disasters that might have very serious effects on them. And so, on the slide, people will see how we break down the possible ways in which children might be affected by these agents, and unintentionally, we have all kinds of the problems that might turn into major disasters that affect the industries that may be important and may be proximal to where large numbers of children either live or go to school. And in a chemical plant where there's chlorine gas, for example, even without terrorism, could expose children and others to massive amounts of exposure to noxious agents.

All kinds of natural disasters, including what we witnessed in the Gulf Region from Hurricane Katrina, it has incredible—it wasn't just the force of the storm, by the way, but it was the exposure to toxic elements in the environment after the storm itself that also posed problems for children. Those are unintentional. And inadvertently, children might be in harm's way during a terrorist act such as we saw in Oklahoma City. There wasn't an intent to harm the children in the day care setting in the building, but the fact that (indiscernible) there and again, inadvertently, secondarily resulted in terrorist attack.

Then indirect consequences have to do a lot with psychological outcomes from children who may be exposed to terrorism even on television and a great deal of this after 9/11, when children all over the country were being affected by the images of the airplanes crashing into the building. But the final point I want to make is that unfortunately, children have often, throughout history, been the direct and specific target of terrorists. This is probably the most uncomfortable thought for many of us, as pediatricians, as workers in government, and as parents, to understand that children may be in fact preferential targets of terrorists looking to do ill in societies for whatever purposes they have in mind. And unfortunately, as we saw, for example, not long ago, in fact in September of 2004, the attack by al-Qaeda-influenced rebels, Chechen rebels, attacking the Beslan School No. 1 a year and a half ago, or year ago now, was extremely difficult to observe for all of us, but the fact of the matter is that many, many children were injured intentionally and specifically by rebels who had obviously other kind of political goals in mind. But this is a fact of life, and that has serious implications for our own planning in this country for what we need to think about in getting ready for disasters and terrorism.

Cindy DiBiasi: And clearly we have plans for emergency preparedness for the general population. But is there really a difference in how you plan for public health that may affect children?

Dr. Redlener: Yes, and there are quite a few things that we have to pay attention to when we're planning to deal with children that might be affected by any kind of disaster or certainly any kinds of terrorist attack. Some of the issues relate to what we talked about initially, having to do with the differences of children between children and adults, and different antidotes, different ways in which agents affect them, et cetera. But even as we look carefully at what happened at Beslan, there were very interesting things that are germane to planners who are worried about children. And one of the things that happened was that the Russian government was able to move, in essence, a pediatric field hospital right to the site of that attack on that school. Which was extremely helpful, because they were able to do triage and treatment on site with pediatric prep specialists that knew what they were doing with children, and that probably had a beneficial effect on the survival. Even though a huge number of children were killed, over 180, a number of kids did survive because the pediatric expertise was there on site. And I think as we're thinking about what we're doing, in terms of planning for whether it's pandemic flu or terrorism or any kinds of natural or industrial accident, we need to make sure that we've inserted in very specific plans that can optimize our ability to handle large number—large numbers should they be in harm's way.

Cindy DiBiasi: In terms of preparing children for the possibility of this, how should parents and professionals speak to children about terrorism or the possibility that they could be involved in a major public health emergency?

Dr. Redlener: Keep in mind here that one of the main things that we want to do is not let terrorism terrorize us to the point where we, as families and communities, become unable to do the things we normally do. And this is very, very important for the psyche of the country and for its future. But the question of how children become resilient and how people in general and families in particular cope with the images of terrorism or even images of industrial accidents or natural disasters, what is it that we need to suggest to parents in terms of managing these kinds of crisis—crises that become visible on television in our now-24/7 coverage of such events.

And one of the main pieces of advice has to do really with some common sense, and I think most parents actually get this. But it's good to reinforce the notion of parents being available to their children, being around, even when words aren't spoken. It's important to the extent that children—and I don't think small children should be allowed to be exposed to any more than absolutely necessary on television—but to the extent that any child of any age is exposed, to have their adults, the people who care for them, who care about them, present concerning the children who witness these things is very important. And we're talking about physical closeness here. We also try to reinforce the notion of parents really thinking about the family routines that are important and stabilizing and make children feel secure. So having dinner with kids, doing the weekend plans you're going to do anyway, making sure there's plenty of playing time and reading time is all very good. These are the kinds of general advice that we give to parents, including—well, the question that comes up all the time is, "Should we be volunteering information, or should we wait until the questions are asked?" And this is very important also. And a lot of this depends on obviously how old and what development stage the child is in. How we deal with our 14-year-old is very different—and I don't have to tell this to any parents, obviously; it's no secret—than what we tell our 4-year-old or 5-year-old that may be witnessing something. Sometimes, in order to get teenagers to talk, you resort to all sorts of tricks like taking them for a car ride and not making eye contact, trying to engage them in conversation—"How are the other kids in your school dealing with what we just saw at 9/11?", for example—not ask them a direct question. And—but if you're worried about the fact they may be thinking about this, to try to draw them out. For younger children, we want to simply and directly answer questions without providing an overly abundant amount of information and just try to be honest, direct, and simple and move on.

But the biggest thing, I think, that we have to deal with—we have to talk to parents about—is how to know when your child is experiencing more than you should be able to handle as a parent. So when do you need to get the advice of a pediatrician or social worker, a clergy person, or somebody else in general? And that differentiation between those things that you can deal with by reassurance versus those things where you really do need professional help are important guidelines that we need to give parents. Those guidelines are available in a variety of places, but we can talk about those, too, if we have time.

Cindy DiBiasi: Okay. I know you were recently involved in the response effort to Hurricane Katrina. Would you share with us your observations on how children in Mississippi and Louisiana fared during and after the hurricane and also in the flooding of New Orleans?

Dr. Redlener: The impact of Hurricane Katrina was extraordinary. Ninety thousand square miles of the Gulf Coast were affected by these really ferocious killer storms that devastated, literally devastated, and flattened communities from Alabama through almost into Texas. And some of the more dramatic things that we all witnessed—for example, the flooding of New Orleans, plus the general devastation from the winds and storms—have created an unbelievable environment both in the immediate aftermath, as far as children are concerned—lots and lots of children terrified by the events that unfolded around them—but also the ongoing trauma that continues to this day with children who are being now—who are living now for prolonged periods of time in displacement camps and shelters, in FEMA trailer parks and other places where we don't even know where they are. There were 128,000 children, for example, living in New Orleans at the end of August and then probably in the vicinity of 20,000 children there today. Where are those kids? Many from affluent families are relocated in other States and other places and are probably doing okay. But tens of thousands of children from non-affluent families, from poor families who were struggling before Katrina, are now experiencing extraordinary trauma in terms of disconnection from medical care, educational resources—families' livelihoods are in question and a very, very difficult time.

So what we saw and are seeing is probably the greatest concentrated crisis for children in the United States in a very, very long time. Not since the Dust Bowl in the 1930s and the Civil War before that did we actually see so many families displaced in America. And this is a big challenge for pediatricians and others to take care of kids.

Cindy DiBiasi: We will come back to talk to you more about this, because it's a very compelling story and issues that it raises. Just a reminder to the audience: you'll also be able to ask Dr. Redlener questions following the other panelists' presentation, but I'd like to turn to our next panelist, Dr. George Foltin. Dr. Foltin is the Principal Investigator on the project to develop the Pediatric Terrorism and Disaster Preparedness Resource. George, could you start by describing the resource?

Dr. Foltin: Yes, thank you; it's a pleasure to be here today. The Pediatric Terrorism and Disaster Preparedness Resource, or the PTDPR, is a comprehensive pediatric reference on preparedness for acts of terrorism, naturally occurring disasters, and public health emergencies. And for example, all this excellent information Dr. Redlener has outlined is actually in this resource in terms of identifying how children are different, how we can—how we can work with systems to address these issues, how to deal with the psychological implications and the mental health issues, and in fact there's also a chapter on Katrina and its implications for children. So it's a place to get information. The content was developed from experts from around the country and even around the world who are recruited to develop specific materials in their areas of expertise. It covers not only clinical materials but also policy issues. It's critical to the success of planning of all levels, including government and health care systems, that children's needs, as Dr. Redlener pointed out, are implanted into those plans right from the start.

It's designed to allow access to this critical and essential information, and it should save time when facilitating planning efforts.

Cindy DiBiasi: And why was it so important for a resource like this to be created?

Dr. Foltin: Somewhat surprisingly, there really is a lack of available pediatric-specific resources or clinical guidelines, and that kinds of work, for instance, is being addressed by Dr. Markenson in the consensus conference and by Dr. Shannon in the work he does, and we're all busy trying to correct this, but in fact this material is not something that public health workers, physicians, other health care workers, emergency managers had easy—or have easy reference to. It's not even really available on the community on the Internet, which is where we all go these days to try to get information. So we felt that by compiling this, analyzing it, and bringing it all together, we would save time and allow people to have access to this information to facilitate pediatric planning and efforts.

Cindy DiBiasi: As we discussed earlier, it's a one-stop shop for health care professionals. Can you talk a little about what the resource covers, give people a picture what have they would get in it?

Dr. Foltin: Sure. For instance, there's a chapter on how children are different. There's a large chapter on system issues, preparedness for the pediatrician and for others. It addresses government preparedness; EMS [Emergency Medical Services] preparedness; hospital preparedness; surge capacity; how the national response plan is organized, for those who may be—are experts in child health care issues but not experts in emergency management and vice versa; a chapter on biological terrorism; a chapter on chemical weapons and terrorism; nuclear terrorism; bioterrorism; a large section on mental health issues; and chapters on integrating this resource into one's practice.

Cindy DiBiasi: And how did the idea for this come about?

Dr. Foltin: I'm going to tell that you in a second. I also would like to mention that within the resource, it's organized such that there are key points for each section—that throughout our tips and algorithms for care, materials for pediatricians to teach non-pediatricians, handouts, and many key references as well as a glossary.

Cindy DiBiasi: Okay.

Dr. Foltin: The way that it came about was that this was a project that the American Academy of Pediatrics developed and AHRQ then wisely decided to take on this project and allowed us to go forward, and so the Academy partnered with our Center for Pediatric Emergency Medicine, and I was a lead editor along with David Schonfeld and Michael Shannon, and the three of us compiled this wonderful resource, which is really wonderful, because probably the hundred experts who are willing to contribute materials to it, and we delivered those materials to AHRQ on November 30th, and we're working now to figure out distribution.

Cindy DiBiasi: And who do you envision using the resource?

Dr. Foltin: Well, it was designed for all the pediatricians in America, but we also knew that it would be designed to be used by any health care professional, any emergency manager who is going to need to think about and deal with terrorism disaster public health needs of children. So I think it's going to have a broad audience.

Cindy DiBiasi: You just alluded to the fact that it's being edited and you're trying to figure out distribution, but for those who are interested, how ultimately are they going to be able to get a copy?

Dr. Foltin: What I suggest they do, because I think it will be ready very shortly, is to go to the AHRQ Web site, and that will be where the information will be available in order to obtain copies of this resource.

Cindy DiBiasi: Okay. Are there similar resources to help general hospitals help prepare to handle these mass pediatric casualties?

Dr. Foltin: So, again, leading off on something that Irwin mentioned was that, unfortunately, we can think that the schools might be a soft target for terrorism, for example, or that natural disasters of public health emergencies could affect large populations of children, and the thing that we have to remember is that children are gathered during the daytime and therefore in any community they're in one place out of proportion to their percentage of the population. And the more rural a setting you have, the higher this imbalance is that the children are really in much larger concentrations, so that if something happens and they go to their local health care facilities, it's likely those facilities will not have the resources or the planning to deal with a large number of suddenly ill or injured children. Interesting, a study by Marion Garche (ph) last year demonstrated 90 percent of emergency care of children in America is delivered at general hospitals and in fact not at children's hospitals. That might be surprising. And yet, if we think about who is preparing most for large numbers of events in children, it's likely that general hospitals are not as well-prepared as they should be. So the New York City Department of Health and Mental Hygiene appropriately worked with the pediatric disaster advisory group, which is a part of the hospital preparedness program out of HRSA [Health Resources and Services Administration] to develop a pediatric disaster toolkit, which is really a resource for general hospitals to start to prepare in a meaningful way for the unlikely and hopefully never occurring event of having a large number of suddenly ill or injured children. I'd like to tell you the kinds of materials that are in this toolkit that would be useful to the hospital. And this is—not only is there a chapter materials on staffing, pharmacy, decontamination, training, space, and equipment, which you would expect, but we also thought we should have material on dietary—if you're a general hospital, you may not know what to feed children of all ages—and to deal with security that, if you had a school event, that you would probably have a large number of children who were brought to school who weren't necessarily injured; where would they be put, and how would we identify them and get them connected to their parents; and the psychosocial/ethical issues. This material is available at the Department of Health and Mental Hygiene, New York City Web site.

Cindy DiBiasi: That's where all the—of the information on this project—is that the place for people to go?

Dr. Foltin: On the pediatric disaster toolkit, yes.

Cindy DiBiasi: Okay. We'll come back to you, because I'm sure we'll have a lot of questions about the resource and the toolkit.

Dr. Foltin: This last slide is a list of Web sites that the listeners could visit to get more information on a variety of topics.

Cindy DiBiasi: Okay. And we will show that again, people.

Now let's turn to Dr. Michael Shannon. Good afternoon, Michael. Although much has been accomplished over the last 5 years with respect to emergency preparedness issues as they involve, what would you say are the unmet needs, the needs that still exist?

Dr. Shannon: Let me first thank you for inviting me here today, Cindy.

Let me begin by emphasizing that despite 5 years of large-scale, unprecedented effort across our Nation, there is still many unmet needs when it comes to preparing for large-scale disasters involving children.

I've listed six on my slide that I'd like to briefly elaborate on. First, we still, to this day, need a comprehensive school-based emergency preparedness protocols. We need in every one of the 5,100 acute care hospitals in our country, protocols to care for children who are involved in a public health emergency. We need plans in place in every hospital that permit us to take care of surge events such that it is as easy to take care or at least as effective taking care of 50 children as it is 5 children. We need to make sure that all clinicians, prehospital care, or hospital clinicians who might be called upon to care for pediatric casualties to be educated and trained on the unique issues involving children; for example, meeting the developmental needs of children by understanding each of the developmental stages that go with each age. We need to engage the community, meaning that schools, public safety officials, public health agencies need to sit at the same table in order to create these comprehensive plans. And then finally, as we'll talk about, I think, in a few minutes, I hope for me a new concept of really planning effectively on how we will identify and reunite children with their parents when there are large-scale events occurring and large numbers of unidentified children arrive at a health care facility.

Cindy DiBiasi: Now, in your work, you stress the importance of education and training for the pediatric aspects of disaster response. Can you tell us why you think it's so important and what are the key issues to consider when specifically discussing education and training?

Dr. Shannon: It should go without saying that education and training are key to preparation and having an effective response. I would posit that if we view the status quo, this is what we would currently find. We would find that many first responders and first receivers remain inadequately trained in pediatric aspects of disaster response. We would find that training programs in emergency response, even though they're proliferating around the Nation, are providing feeble segments on children and pediatric response, if anything. And I think we would also find that we have not taken advantage of DVDs and videos as training tools, even though video is so far superior to other teaching techniques such as lecture or articles or even PowerPoint® presentations.

Cindy DiBiasi: And in fact you brought and we'll be reviewing a clip from a training video that was produced by the Center for Biopreparedness called The Decontamination of Children. Can you describe a little bit for us what this video is and what we're going to be seeing?

Dr. Shannon: Yes. We created this video, again entitled The Decontamination of Children, for the express purpose of providing a step-by-step demonstration of the process of decontaminating a child in real time, again taking advantage of the fact that what a video can provide other than a lecture or PowerPoint® presentation is the visual image, the movement, and really can bring the student, in this case, into the scene much better than any other teaching method.

Again, it is designed to be a training tool for any first responders and first receivers, and I think what we're going to see is a short segment from this video that shows the actual process of decontaminating in this case an infant. I have to tell a quick anecdote that in creating this video, we created it in November in Boston in our ambulance bay, and a lot of people arose to the occasion, including one of our employees, who was willing to let us use her 3-month-old infant to create this video, because she, like those among our team, knew the importance, could appreciate the importance of creating something like this. So I think what you'll see is that tiny segment of decontaminating a 3-month-old.

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