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Cindy DiBiasi: And before we show it, I want to let our audience know the following is streamed video, so people on the phone will not be able to hear it. If you're receiving the audio by phone, you're going to experience about 45 seconds of silence. The video clip shown today can be viewed or downloaded from the Web site following the program.
Handling infants will be challenging with current technology, as chemical-resistant gloves lead to a significant compromise in dexterity. Special care must be taken. The showering procedure needs to be carefully controlled.
Cindy DiBiasi: Michael, are there other videos or training tools out there that would be useful for addressing the needs of children?
Dr. Shannon: Again, we have not taken advantage of videos as a teaching tool. So I think that we could easily come up with a very large number of potential topics. I've listed a few here that I would kind of prioritize if someone really were to begin a campaign of creating these teaching tools. I think that there's a desperate need to create video-based training module on responding to the mental health needs of children after disaster. I think there's need to create a video that outlines how a school or school district would create a comprehensive school-based disaster plan, and I've listed three others. I think there's very much a need to create video training modules on mass casualty incidents, management of bioterrorism and other infectious emergencies. And even management of radio logic emergencies as they involve the care of children.
Cindy DiBiasi: I understand that after Hurricane Katrina, there were 2,500 children who were separated from their parents, and the idea of a parent searching every health care facility in the area to find his or her child after a disaster like that is really a frightening thought. What are the issues involved in identifying tracking and reuniting with children after an event like this?
Dr. Shannon: Well, Cindy, as I mentioned earlier, identifying children—large numbers of children—who come to a health care facility without a name or a parent and then reuniting those children with their parents is a huge unsolved problem. We have been trying to address it at our center, and if you dissect the steps solving this problem, this is at least my view of it. I think you first have to create a means of rapidly collecting information on arriving casualties. And certainly having a digital camera that can quickly take pictures would be very useful. Equally important, though, you would need to have software that conducts some type of feature analysis of those photographs and then indexes that child by those features. You really can't, in a mass casualty incident, allow large numbers of parents, guardians, friends, and relatives into a health care facility, even though they're looking for their child. Therefore, you must—and this must be done in advance—you must have a place outside of the hospital where those parents and loved ones will come to find out if their children are in this health care facility. And then finally—and we discovered this in one of our recent disaster drills—what you can't do—and this is what I mean, unsolved problem—what you can't do is you can't take a long sequence of digital photographs of traumatized injured children and show them to parent or loved ones and saying, "Is this your child, is this your child, this your child?" Thus, the importance of creating the software that can conduct some type of feature analysis so that you only have to show that parent or guardian one or two photos and then let them know is their child until your health care facility or not. And again, one would think that we would have solved this by now, not only in responding to terrorism but to natural disasters such as Katrina. It's an unsolved problem. I don't know; it's just unspeakable importance.
Cindy DiBiasi: As you're pointing out, the technology is there.
Dr. Shannon: Well, I think the technology is there. We're currently working with collaborators in the artificial intelligence lab at MIT, and actually they're helping us to create some fairly exciting software that may solve this problem.
Cindy DiBiasi: Well, that leads us into our next polling question, so we'll come back to you. You've raised a lot of very interesting issues that I'm sure the audience wants to ask more questions about. But first I'd like to take a quick second just to poll the audience. Curious to know how many people in the audience have used pediatric-specific tools like the ones Dr. Shannon described.
If you could, please answer the following question, that will appear on your screen: "I have used or have access to emergency preparedness tools specific to the pediatric population." And please select "Yes," "No," or "Not sure." And if you could, vote now. We have one more question for our audience as you're answering the first one: "If made available to me, I would use emergency preparedness tools and models specific to meeting the unique needs of the pediatric population." Again, please select "Yes," "No," or "Not sure." And if you could answer that question now, we would appreciate it. Thanks for your input; we'll have the results shortly.
Let's move on to David Markenson. Thanks for joining us today and being patient for waiting. I understand a conference on considerations and emergency preparedness was just held. What was the reason for the conference? What were the objectives?
Dr. Markenson: There were actually two separate objectives; it was actually a two-track conference. One track dealt with pediatric preparedness, and the second tract dealt with preparedness for persons with disabilities. As many people may know, in 2003, with funding from AHRQ, we held the first Conference on Pediatric Preparedness for Children. And this conference developed the first set of national guidelines, standards, and treatment recommendations for children, which allowed a lot of people who wanted to plan for children but were unable to, because of lack of knowing what they needed to do, to actually do it. And this was a large step forward but just a first step in a process, and at the time, we knew we would need to do it again.
So in the pediatric front, the purpose of the conference was to, one, review new literature, new modalities of care, unfortunately also new data from disasters, public health emergencies that had occurred that we can incorporate to say this was good in 2003, but it can't be static; we need to move forward. So what were the new things we could do? So we had the opportunity to update the pediatric guidelines. In addition, we had the opportunity to expand the guidelines. With the first attempt, we couldn't possibly drill down into detail on every single topic, so we picked a few key in importance and knew in the future we would have more. We move on to our second.
This approach we pioneered, so to speak, showed the pediatrics of looking at the unique vulnerability of a population and marrying the experts in those unique vulnerabilities with experts in emergency management public health and coming up with guidelines with approach to be applied to other populations with unique vulnerabilities. And again, with the AHRQ's funding for this conference, we were able to do it for persons with disabilities, to bring together those people from the community, the consumers, those from the experts of persons with disabilities to talk about the unique vulnerabilities and have an exchange with people who are responsible for emergency planning and public health to talk about how we take those unique vulnerabilities and address them in appropriate emergency planning to be able to do the guidelines for persons with disabilities.
Cindy DiBiasi: Let's talk about the existing terrorism guidelines and how—what changes were made to these guidelines.
Dr. Markenson: Again, since the original guidelines came out, there were interesting changes, and there are a multitude that will be made. I want to highlight a few. We first talked about the drug treatments that were available for terrorism agents, and let's start with infectious diseases. Fluoroquinolones were in the framework of never to be used on a child. Absolutely never, don't touch it; every pediatrician knew it was a horrible thing to do. Yet it was a drug of choice for anthrax and some other of the infectious disease agents and presented a problem. We started down the road of, "Okay, maybe in special cases under special circumstances, a fluoroquinolone like Cipro would be good, but here are some alternatives, maybe not the best but good enough." Well, since that time, there's been a lot more literature showing that fluoroquinolones can be used in children. And we're using that them in other medical things for children, cancer treatments with infections, and others. So we now have to relook and say, "Maybe we don't need to be so conservative. Maybe we can use fluoroquinolones in a broader sense for children."
In addition, when we looked at chemical agents, there was something called a Mark 1 kit, the common antidote for nerve gas exposure, but there was no equivalent pediatric device, and we said, "But that's okay, because looking at the dosage, it actually works for children, and it works for children down to 3 with normal dosages and for any child," but now a new device came out. The problem was, it wasn't equivalent. It only had half of a Mark 1 kit and atropine, and although an appropriate pediatric dose, it's not out, so how do we look at that? And then in addition to those evolving changes, another example would be something that didn't exist. For smallpox, people in the adult population are talking about cidofavir, a drug that may have some utility although not proven with a lot of risks and problems, so people said, "Well, we're starting to talk about it in adult, so this time, instead of having peds as an after thought, why don't we think holistic with both pediatrics and adults?" We have new technology, new medication, and new approaches that we're able to analyze.
Cindy DiBiasi: I know this conference included some additional and expand topics that were not covered at the last conference. Can you briefly talk about what some of the topics were and why they were included?
Dr. Markenson: Again, the second half—not only do we now have the opportunity to bring the new information, but those topics that we didn't have the time and ability to drill down into detail during the first conference, we're able to really go into substantial detail this time in this conference, topics like school preparedness—Dr. Shannon spoke very good about how schools really aren't where they need to be in preparedness, overall hazards, and integrated, and so we looked at that. We also said, "Schools is a nice idea but not the only place," and we broadened the category to include child congregate facilities. These are places where a lot of children spend their days, not only at school, day care centers. Equivalent to a school maybe during the summer, I don't know if kids will think it's equivalent, but a camp. Lots of children away from their parents. We then looked at unique things such as sheltering needs, public health emergency preparedness, decontamination, because we have a lot of work done by Dr. Shannon and Foltin and others, looking at family center care and then really get into some of the special needs even within children or children with special health care needs and those that are technologically dependent.
Cindy DiBiasi: Let's talk about some of the recommendations regarding schools.
Dr. Markenson: Again, schools have been doing planning but in a very sporadic way. If you look at schools, probably you couldn't find a school in the country that doesn't have a fire safety plan. But when you ask them what their emergency plans are, all they ever do is point you to a fire safety plan, because that's been their thought process. So schools have not been really given the tools to look at the risk that they may face. A, they need to plan for all hazards, not only fire but any hazard. But B, also the risk assessment which people in emergency management can teach them such as, "Yes, you have to plan for all hazards, but based on where they're located and what your population is, you may have unique risk. You're 3 miles downwind from a chemical plant, you have a unique risk. If you have an area prone to tornadoes, you have a unique risk." So it's not only fire but really the ability to develop an all-hazards plan for school that is based on risk.
You also have to integrate those plans. Emergency management really needs to be involved with school planning, but school planning needs to be also involved in emergency management. There are—there always seems to be a disconnect. For the emergency plan, you have both sides. You have the schools planning for disaster themselves, but you also have the schools being a resource for community. One of the interesting problems that we see that's sort of funny in a planning way is, national disaster occurs. Schools have the initial reaction of an evacuating children to their home. Then somewhere—and that usually occurs during the day-- 4 to 5 hours later, the families brought back to the school at night as a shelter for the family and children. There seems to be a sort of a disconnect between "move them out" and "move them all back in." If the schools in the community were looking at the schools not only as something that needs to be planned for but how it can be used, you might say, "Why not reunite the parents in the shelter with the children instead of having the two-step plan?" That whole combining with emergency management, looking at all hazards, and looking at the risk are new guidelines and new ideas for schools.
Cindy DiBiasi: Let's talk about some of the key recommendations regarding the decontamination for children.
Dr. Markenson: Again, a lot of the recommendations come out of the work done by Dr. Shannon and Foltin and others. When we started this process, we knew a little about what to do for children. We didn't have a lot of information. Now I think there isn't tons of information, but there's more. There's information we can give people on the proper water temperature and pressure. There's information we can give them on the fact that they'll need additional personnel to deal with moving a child through; issues on how to deal with a non-ambulatory child, a child that can't walk and needs to be carried through—adult paradigm of "walk everyone through a shower" doesn't work very well for infants—and how to deal with the mental health concerns. And these are all solutions. In addition, not only do we have the information now; we can point people towards tools which we didn't have. I can now refer them to the work Dr. Shannon did with the video that's available through AHRQ we didn't have in the past. Not only do we have recommendations but tools to help them fulfill those recommendations.
Cindy DiBiasi: Were there any new recommendations for hospitals?
Dr. Markenson: Hospitals we looked at, again, and we tried to get more specific than we had in the past, and again one of the sort of disclaimers is that again the recommendations are still in their editing and finalization, so I'm going to show you some of the—what probably will be the final but not the full. The conference was just held as recently as December; it was actually put off because of the recent Katrina and other events to help bring in the most up-to-date and new information. One of the things is, how much does the hospital have to be prepared on its own? The quote and unquote, "How long can you stand on your own?" So we picked a number of 72 hours, which gives them a time that most Federal resources are promised to be present but a little safety, because in a disaster, nothing ever works as planned at the local, State, and Federal or other level.
In addition, instead of picking an arbitrary number, which is our first task, we said we should meet a higher level of planning. Hospitals should be doing risk assessments to know what their risk is. They should know what their census is and pick a percentage above their normal census that's the minimum, but it should be adjusted up as necessary based on the risk. They're in a high-risk area for large patients, then 5 percent above or 10 percent may not be enough, and it should be risk adjusted.
In addition, now that most hospitals and other entities are training, disaster drills, it now has to be not just a suggestion but a requirement that pediatrics is instituted in all training programs and hospitals. That doing a hospital drill that doesn't involve children is unacceptable and must be a requirement. So as we move forward, the level of detail and expectations of the hospitals and planning needs to move forward also.
Cindy DiBiasi: David, thank you, and thank you for all of our panelists. I know the audience is anxious. We're getting a lot of questions. And I just want to give some information before we move to Q&A, and that is, the clip from the decontamination of children can be found on line at www.ahrq.gov/research/decontam.htm. And a free single copy of the video available in DVD or VHS format may be ordered by calling 1-800-358-9295, or by sending an E-mail to firstname.lastname@example.org. And I'm sure our discussion with the panelists has given our audience a lot to think about, and we're anxious to hear those questions. Before we move into our question-and-answer session, I'd like to make you aware of the various tools has assembled to help and other public health emergencies.
The Agency for Healthcare Research and Quality, under its Bioterrorism and Emergency Preparedness Program, has a selected list of resources and tools to help communities respond to bioterrorism and other public health emergencies, and if you would like to access that list, you can go to www.ahrq.gov/path/biotrspn.htm. You may also click on the "Download Slide" link in the lower left-hand side of your screen, and here you'll find presentation materials for today's Web conference.
Now let's move on to questions from the audience. If you're participating online, please click the Q&A button, select "New," type your question in the space provided, and click "Send."
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AHRQ hopes that today's Web conference and previous events will provide a forum for a productive discussion between policymakers and researchers on these issues. We're pleased you can join us this afternoon. Some of you are joined—have joined us also for the 2004-2005 series on bioterrorism in surge capacity, and the audience is grown tremendously over the past 3 years. This tells us there's a lot of interest in this area.
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You can always E-mail our comments to—or your comments to the AHRQ User Liaison and Research Translation program at https://info.ahrq.gov. Now, before we go to questions from the audience, I'd like to share the results of the earlier poll with you. For the poll question—or the poll sentence—"I've used or have access to emergency preparedness tools specific to the pediatric population," 65 percent of you said you did not have access to those tools, 23 percent said you did, and 13 percent were unsure. So most do not.
And to the poll question 3-B, on "If made available to me, I would use emergency preparedness tools and models specific to meeting the unique needs of the pediatric population," 91 percent of you said yes, you would use them; 6 percent said you weren't sure; and only 3 percent said you wouldn't use them. So there seems like there is a great demand for this.
Now, if we could go to some of the questions from our audience. The first question is on our phone from Michelle Cochran from West Virginia. Hello, Michelle.
Caller: Hi. The question's actually from Wayne, Director of our Radiation/Indoor Air Division. Hold on just a second.
Cindy DiBiasi: Okay.
Caller: Yes, thank you. The question I have is that I'm currently involved here in the State on a statewide task force dealing with drug-endangered children. And the question of decontamination is one of the things—decontamination of children is one of the things that we're facing in trying to develop protocols. And I'm wondering if there's any advice or anything out there that we can use for this, because normally this is a little bit different type of situation. Children may have been taken from situations such as a meth lab. They need decontamination on site, and there's been a lot of criticism in the way that a lot of first responders are handling this. A lot of times, because of privacy issues... Plus, there's no parental support, because in many cases, the parents have just been arrested, and they've seen their parents arrested and taken away. The children are already traumatized, then they have to put up the decon process. Is there anything you know specifically that would fit?
Cindy DiBiasi: Michael?
Dr. Shannon: There's nothing that I know of specifically. What I would say, though, is that the principles of decontaminating children are the same regardless of why you're decontaminating them.
I would emphasize that the video we made was designed for health care facilities, not prehospital personnel, though I think it would be beneficial to prehospital providers. And its emphasis is on a large-scale incident, when you have many children, that many, many children that require decontamination. But fundamentally, the principles are the same. So I would suggest that you get a copy of the video, view it, and I suspect you'll find you can readily incorporate many of its principles into your job.
Cindy DiBiasi: Okay, thank you. Question from David McCann: "The large number of relocated children in the aftermath of Katrina are having trouble integrating in schools in their new environment. Specifically, Houston is having a tough time with fights, beatings, classroom disruption. How can we best deal with that issue?"
Dr. Redlener: This is an extraordinarily difficult problem, and it's not just for the children who are relocated out of State. Many children who have been relocated in State were moved from New Orleans into relatively small communities with very small and not terrifically robust school systems in other parts of the State. And they're coming from homes where the families themselves are feeling extremely despairing and worried about their livelihoods in the future, so you have kids coming from very emotionally labile families going to schools already overcrowded or staying there for a long time, and it's producing exactly what the questioner has been asking about. I think if you are a member of the community there, I think there's a couple things to think about. One is that this was an enormous crisis and, unfortunately, the people who were the direct victims and many people who are in the host communities are having to accommodate. And I think we need to be patient with this accommodation, and I do think we need, in the schools where these kids are going, a significant upgrading in the ability of the teachers, the school system in general, and the parents of the kids in the host communities to get guidance about how to best deal with this. I don't think this should be a case of people in the schools sort of winging it, because it's not only the fights and the aggression, but there's also a significant amount of growing depression in children and including suicidal concerns among kids. It really is an emergency. So we are hoping that in all the schools and communities where there are large numbers of relocated children, that trained counselors will be available to help the schools figure out the protocols to best deal with this, and there are a number of outside organizations, including some from my own institution at Columbia University in New York, that have been sending down highly expert individuals working with the school system to try to give tools to the teachers and the school administrators to help them figure out how to best accommodate these very significant needs.
Cindy DiBiasi: Thank you. George? Question on the PDTPR: the caller wants to know if it has any information that is specific to children with special health needs.
Dr. Foltin: Yes, thank you for bringing that up. I did not mention that section, but this is quite a bit of material that addresses that highly vulnerable and needy population.
Cindy DiBiasi: Okay. David, the caller says we need plans and protocols for special needs children, medically and technologically dependent, who are integrated with the input of communities and families. How can we share models and identify family leaders who can be helpful?
Dr. Markenson: Part of that is actually what was nice about the conference we just held. Although there were two tracks, one dealing with personal disability and one dealing with pediatrics, the middle day allowed integration of both children with special health care needs and technological needs as children as well as the unique needs as having those special medical and technological needs. And just for people to know, in those groups were parents of children with special health care needs, those who represent some of the major parent groups, the many of the groups from around technological dependencies as well as mental health and chronic health needs. So that was actually what we were able to do, and I think you'll see some of the results of the guidelines that came out. Not only will the guidelines help, but I think we started the process by allowing emergency management and public health community to know the value added by involving families, parents, and those consumers within the population that have children with special health care needs or technologically dependent in their planning process.
Cindy DiBiasi: Okay. Also, just a reminder, the Web site to obtain the pediatric disaster toolkit for hospitals is...?
Dr. Markenson: The Department of Health and Mental Hygiene of New York City. I don't have it here. It should be in front, but you can Google that and go right to it.
Cindy DiBiasi: We can do that for you, too. We also want to remind people to call in—calling with questions to press star-1, and please don't use speaker phones, because it is a bit hard for our panelists to hear them.
Michael, a question: "How do you get around confidentiality issues as well as protecting children from people who are not their parents or guardians when using a system such as photos in a mass casualty with children?"
Dr. Shannon: That's a question that is unresolved. I think that in a public health emergency, that—let me answer two ways. First, I think in a public health emergency, particularly large scale, one has to find the balance between the HIPAA that guides us on privacy issues and really trying to do the right thing by reuniting children with their parent.
I do believe that a parent—it would be difficult for someone to come pretending to be a parent who can tell you what their child was wearing, the color of their skin, their hair, their eyes, and what I envision as a process of really screening. And similarly, if that individual managed to know the child's features and make it into the health care facility to the child's bedside, there's an entire screening process that nurses, physicians, and other clinicians are going to take that individual through. Ultimately, I think it becomes very, very difficult to pretend to be someone's parent or guardian.
Cindy DiBiasi: David?
Dr. Markenson: Yeah, I think Dr. Shannon's points (loss of audio) are well taken. That the issues with HIPAA and the differences from normal situations that really needs to be thought about. When I was in college in Israel... Israel has a nationwide system of digital photographs of the victims and a Web-based system where they can identify that's available in all the hospitals, and so what they actually do is it's not only available in not in hospital but, like, the family reception area and the hospital affected. It's available nationwide, so family members who may not be in the city can find out if a family member is in the hospital. Actually a strikingly good system, but one of the first things we're met with is it would never pass the day-to-day regulatory restrictions in this country, although one of your other comments has the same problem: they have not worked out. I'm interested to hear about the artificial technology, because they do have to screen through every picture, which is exceptionally traumatizing to people looking for children or other family members.
Cindy DiBiasi: George?
Dr. Foltin: Yes. Having just looked at this before I left the Web site, there are still 400 children who are still not reunited with their family as of today. Clearly, this is a large issue that we had not focused on that everybody agrees need to be focused on, and my belief is that as we move forward, the experts in the area, government agencies, will focus on this and we will have both macro and micro solutions. At a local level, things that we could suggest right now is that, you know, public health communities could suggest that parents have a permanent marker and if there's something like Katrina, they could actually write on the children, identifying information if they get separated from them; they have it. Issues about children having ID cards in their bag, identifying who they are. We use in hospital when a baby is born—we band the mother and the baby; maybe we could have bands that we tell parents to have in their preparedness kit. I'm not bringing these up because these are the ultimate solutions, but we need to start the process of thinking of simple solutions as well as we try to do technological solutions and bring to bear the government and expert views on how to make this better.
Cindy DiBiasi: Irwin?
Dr. Redlener: Let's not forget also the prevention aspect of this and ask the question, "Why are so many children separated from their parents in the first place?" A lot of that has to do with things that we may want to think about in the planning phases to examine the factors that will increase the possibility of kids might be separated from parents. There's lots that has to do with the process of evacuation and how are people actually leaving dangerous areas, and those images that we saw of people handing their children to people and going out in buses have to do with extraordinarily important inadequacies in the planning process and how the disaster was actually managed. And I think we could have avoided the vast majority—let me put it that way—of these separations had we thought about it in advance.
One of the things—when we talk about lessons from situations like the Katrina debacle, we want to look carefully at what we're going to do in terms of planning for the next event and make sure that we don't duplicate those same things that left us in this kinds of jam. Horrible thought, as all of us are just trembling to think about the fact that parents are actually separated from their children for such a long period of time.
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