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National Commission on Children and Disasters: 2010 Report to the President and Congress

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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3. Child Physical Health and Trauma

Recommendation 3.1: Congress, HHS, and DHS/FEMA should ensure availability of and access to pediatric medical countermeasures (MCM) at the Federal, State, and local levels for chemical, biological, radiological, nuclear, and explosive threats.
  • Provide funding and grant guidance for the development, acquisition, and stockpiling of MCM specifically for children for inclusion in the Strategic National Stockpile (SNS) and all other federally funded caches, including those funded by DHS/FEMA.
  • Amend the Emergency Use Authorization to allow the FDA, at the direction of the HHS Secretary, to authorize pediatric indications of MCM for emergency use before an emergency is known or imminent.
  • Form a standing advisory body of Federal partners and external experts to advise the HHS Secretary and provide expert consensus on issues pertaining specifically to pediatric emergency MCM.
  • Within the HHS Biomedical Advanced Research and Development Authority, designate a pediatric leader and establish a pediatric and obstetric working group to conduct gap analyses and make research recommendations.
  • Include pediatric expertise on the HHS Enterprise Governance Board or its successor and all relevant committees and working groups addressing issues pertaining to MCM.
  • Establish a partnership between the proposed MCM Development Leader and key pediatric stakeholders both within and outside government.

Children are subject to higher levels of exposure and harm following chemical and biological incidents.95 Children inhale more air and consume more water on a per-weight basis than adults.96 Therefore, if a chemical, biological, radiological, nuclear, or explosive agent enters into the environment, children are more vulnerable than adults to the agent's adverse effects. Although these considerations should warrant greater attention to children during emergencies, the quantity of pediatric medical countermeasures (MCM)97 in the Strategic National Stockpile (SNS)98 is very limited. While the SNS maintains MCM for adults for high-threat agents, comparable pediatric indications and countermeasures for children are largely unavailable or have not been approved by the Food and Drug Administration (FDA).99 It is critical that the Federal Government take all steps necessary to remedy fully and quickly these gaps in coverage for children currently present within the SNS, in addition to ensuring that MCM developed and approved in the future have pediatric indications, dosages, and formulations.

A summary report of a February 2010 workshop sponsored by the Public Health Emergency Medical Countermeasures Enterprise (PHEMCE)100 reemphasized the need for certain populations, especially children, to have immediate access to MCM.101 The workshop report discusses how incentives to develop pediatric MCM102 are impeded by the obstacles involved in conducting clinical trials of MCM on children.103 Although procurement contracts issued by the Biomedical Advanced Research and Development Authority (BARDA) for chemical, biological, radiological, and nuclear threats contain options to extend label indications to pediatric populations, the incentive is unsuitable since the participation of children in controlled trials is virtually impossible.104,105

In December 2009, in the aftermath of the H1N1 pandemic, the Department of Health and Human Services (HHS) Secretary directed the Office of the Assistant Secretary for Preparedness and Response (ASPR) to lead a thorough review of its entire MCM system and make recommendations.106 The Public Health Emergency Medical Countermeasures Enterprise Review, released in August 2010, recognizes the need to enhance the development and regulatory review of MCM for vulnerable populations, including children and pregnant women, as part of a broader effort to improve MCM regulatory science, domestic manufacturing capacity, coordination and collaboration, and financial incentives.107 While the review does not specify in greater detail the significant gaps that currently exist in our Nation's portfolio of MCM for children, the Commission supports several of the recommendations in the review because they provide promising opportunities to address the disparate challenges that are unique to children, through new mechanisms and investments.

The review appropriately recommends that HHS identify a senior leader for the MCM enterprise (MCM Development Leader). The Commission recommends that there be a partnership between this leader and key pediatric stakeholders both within and outside government. This partnership should include the Commission, but in addition, key nongovernmental organizations, such as the American Academy of Pediatrics. Furthermore, HHS reported to the Commission that it has identified research and development needs and regulatory issues surrounding pediatric MCM, yet funding is not available to address these gaps. This information should be coordinated with the MCM Development Leader and shared with the BARDA senior leadership council.

The review proposes the creation of an independent strategic investment entity for MCM innovation and development. Pediatric MCM should be a priority and therefore it is vital for this entity to have pediatric expertise. The review also calls for a reassessment of how liability protection is offered to the parties involved in MCM development, testing, manufacturing and administration. The Commission concurs, as liability concerns are perceived to be a significant barrier to pediatric labeling and the application of MCM to children.

The review recommends that the FDA be resourced with enhanced capability and capacity to work proactively with industry sponsors and researchers in targeted areas in the hope that this activity might help to expedite the development of MCM. In addition, the Commission recommends that one of the targeted regulatory science enhancement initiatives for the FDA be pediatric labeling and formulations for existing MCM in the SNS.

The review refers to the FDA's role in the Emergency Use Authorization (EUA) process but does not appear to acknowledge that the EUA (or a modified EUA mechanism) might be a useful tool in creating more timely solutions to emerging or perceived threats-and particularly so for children. Recognizing that the development of FDA-approved MCM for children may take several years, the Commission recommends that Congress amend the EUA statute to permit the FDA, at the direction of the HHS Secretary, to authorize pediatric indications of MCM for emergency use before an emergency is known or imminent. The Project BioShield Act of 2004108 established the EUA, which permits FDA to approve "the emergency use of drugs, devices, and medical products (including diagnostics) that were not previously approved, cleared, or licensed by FDA"and "the off-label use of approved products in certain well-defined emergency situations."109,110 Despite this mechanism, FDA lacks authority to authorize MCM prior to a declaration of an emergency, which prevents the stockpiling of pediatric MCM in the SNS for ready availability, which places children at an unacceptable risk. Pediatric indications should be authorized when sufficient data exist regarding the pediatric dose and administration of the MCM, and when expert consensus advises that it is prudent to stockpile the MCM for pediatric use during an emergency.

In its Interim Report, the Commission recommended that the HHS Secretary establish an advisory committee of Federal and external partners to provide expert consensus opinion on issues pertaining specifically to pediatric MCM.111 The advisory committee could review existing data and information on MCM and provide rationale and consensus-based recommendations for use with children during an emergency, ideally before an emergency occurs. The 2006 Pandemic and All-Hazards Preparedness Act112 specifically gives the HHS Secretary the authority to establish a working group of experts to "obtain advice regarding supporting and facilitating advanced research and development related to qualified countermeasures and qualified pandemic or epidemic products that are likely to be safe and effective with respect to children, [etc.]." HHS suggested to the Commission that the advisory committee be established as a standing committee within the NBSB, which has a broad scope beyond children. The Commission believes this approach is insufficient and urges Congress and the HHS Secretary to establish this advisory committee as a separate entity solely dedicated to children.

Finally, the Commission recommends that ASPR designate a pediatric leader within BARDA, supported by a pediatric and obstetric working group, to conduct gap analyses on MCM for children and pregnant women, make research recommendations and provide input to Federal procurement contracts for MCM. Also, as recommended in the Interim Report, existing committees and working groups must include pediatric experts to ensure children are represented when MCM are being prioritized for development and procurement.113 HHS reported that the PHEMCE includes pediatric subject matter experts on all of its interagency activities, such as Requirements Working Groups and Integrated Program Teams. The Commission acknowledges these positive actions and recommends that pediatric leadership also be included on PHEMCE's Enterprise Governance Board, which is proposed to be replaced by the Enterprise Senior Council (ESC). The ESC will include senior leaders of PHEMCE "to oversee and serve as the decision forum for MCM development policy and implementation."114 Appropriate pediatric leadership would ensure that pediatric MCM needs are consistently considered throughout the entire MCM development process.

Recommendation 3.2: HHS and DoD should enhance the pediatric capabilities of their disaster medical response teams through the integration of pediatric-specific training, guidance, exercises, supplies, and personnel.
  • HHS should develop pediatric capabilities within each National Disaster Medical System (NDMS) region.
  • HHS should establish a "reserve pool" of pediatric health care workers to assist in NDMS disaster response.
  • HHS and DoD should establish a Pediatric Health Care Coordinator on each disaster medical response team and develop strategies to recruit and retain team members with pediatric medical expertise.

The National Disaster Medical System (NDMS) is the Federal Government's primary system to augment disaster medical care in response to major emergencies and disasters. NDMS has three components:

  1. Medical response to a disaster area by trained and credentialed individuals, supplies, and equipment that compose teams, including Disaster Medical Assistance Teams (DMATs).115
  2. Patient movement from a disaster site to participating health care facilities.
  3. Definitive medical care at participating hospitals.116

NDMS has responded to domestic and international emergencies and disasters, including Hurricane Katrina and the 2010 earthquake in Haiti.

As highlighted in the Commission's Interim Report, NDMS' pediatric capabilities are limited, even though children constitute a substantial percentage of DMAT patients.117 For example, only two of the 53 DMATs are Pediatric Specialty Teams118 and less than 6 percent of NDMS clinical practitioners have subspecialty training in pediatrics.119 Findings from the Commission's April 2010 field visit to Florida to examine the domestic impact from the Federal response to the Haiti earthquake highlighted the need to supplement DMATs with pediatric specialty health care providers, expand NDMS' hospital network to include more pediatric health care facilities, and improve Federal capability to transport pediatric patients.120

In its Interim Report, the Commission made specific recommendations for improving NDMS' pediatric capabilities, including: adding core competencies on treatment and care of children to NDMS national credentialing standards; providing pediatric education and training to all DMAT members; equipping DMATs with appropriate pediatric supplies and equipment prior to deployments; establishing protocols for delivering care; and developing new pediatric "strike teams"for responding to disasters in which large numbers of children are injured.121

In response to the Interim Report recommendations, NDMS hired a Deputy Chief Medical Officer for Pediatric Care. Also, ASPR plans to address the recommendations by:

  1. Developing a reserve pool of qualified professionals who have the credentials and competence to provide a service, but cannot commit to "full-time"NDMS membership.122
  2. Initiating a cache development program to define a cache standard for pediatrics.
  3. Developing objectives and guidelines for a standard pediatric training curriculum for NDMS response teams.123 The Commission recommends HHS develop a detailed plan for accomplishing these objectives.

The Commission recommends that NDMS form a pre-credentialed reserve pool of pediatric professionals to supplement DMATs. DMATs often do not have members with expertise in key pediatric specialties, such as individuals who provide surgical, intensive care, nursing, or neonatology services. Difficulty in recruiting pediatric health care providers to DMATs is often due to the significant time commitment for travel, training, and exercises. As an alternative to recruiting pediatric specialists as full-time DMAT members, a reserve pool of pediatric specialists could provide individuals to supplement a DMAT if there is a high demand during an emergency for their particular expertise. For example, many health care workers, including more than 1,200 pediatricians and children's hospital personnel,124 spontaneously volunteered to work in Haiti after the 2010 earthquake. Despite their good intentions, many of these professionals could not participate because they had not been previously trained and credentialed by emergency response organizations. NDMS would identify reserve pool members before a disaster to ensure they receive proper credentials, liability coverage, and basic disaster training. NDMS is working with pediatric organizations such as the National Association of Children's Hospitals and Related Institutions and the American Academy of Pediatrics to encourage membership in DMATs and reserve pools. The NDMS should assess the current state of its network and work with stakeholder groups to further expand participation by pediatric centers. This would serve to increase the available bed capacity—and particularly critical care beds—and awareness and management of that limited resource.

The Commission also recommended that a Pediatric Health Care Coordinator be designated on each federally funded medical response team,125 with responsibility for developing strategies for enhancing pediatric medical expertise within the team. In response, the U.S. Public Health Service's Office of Force Readiness and Deployment (OFRD), which oversees U.S. Commission Corps teams126 that deploy in response to public health emergencies, established Pediatric Health Care Coordinators.127 OFRD also committed to evaluating the feasibility of expanding its Readiness and Response Program to include rostered Pediatric Strike Teams within existing resources and funding. However, OFRD noted that funding is not provided in the Fiscal Year (FY) 2011 budget request for OFRD pediatric teams or pediatric-specific field training or exercises. The Commission recommends that Congress appropriate funds to support these activities and that HHS include funds in the FY 2012 budget request. Furthermore, the Commission urges HHS and other Federal agencies, particularly the Department of Defense (DoD), to establish and appropriately resource Pediatric Health Care Coordinators on their medical response teams.

Recommendation 3.3: HHS should ensure that health professionals who may treat children during a disaster have adequate pediatric disaster clinical training.
  • The President should direct the Federal Education and Training Interagency Group for Public Health and Medical Disaster Preparedness and Response (FETIG) to prioritize the development of pediatric core competencies, core curricula, training, and research.
  • The FETIG should support the formation of a Pediatric Disaster Clinical Education and Training Working Group to establish core clinical competencies and a standard, modular pediatric disaster health care education and training curriculum.

Health professionals, whether responding to a disaster scene or treating survivors in a hospital, must have appropriate training to provide needed medical care to children. Children are a significant portion of the population and are as likely as adults, if not more likely, to sustain serious injuries during disasters. In 2009 and 2010, Federal disaster response teams were deployed to disaster sites in American Samoa and Haiti, where children constitute approximately 40 percent of the population. In Haiti, children sustained serious crushing injuries, in many cases requiring amputations.128

Emergency managers and health professionals should plan and train for an anticipated number of pediatric survivors requiring medical care after a disaster based on the demographics of their community. Pediatric training provided to emergency medical responders varies in content and quality primarily due to the absence of national standards for pediatric disaster education and training.129 As noted previously, few DMAT members have formal subspecialty training in pediatrics.130 Also, the National Guard Bureau staff reported that there is very limited pediatric training for emergency responders who are not already pediatric specialists.131

The Commission recommends that the President direct the Federal Education and Training Interagency Group for Public Health and Medical Disaster Preparedness and Response (FETIG)132 to address these deficiencies. As part of this effort, the Commission recommends that FETIG, working through the National Center for Disaster Medicine and Public Health (NCDMPH), should prioritize the development of pediatric core competencies, core curricula, training, and research in the NCDMPH's work plan. The Commission recommends that all Federal agencies represented on the FETIG, particularly HHS as the coordinating agency for Emergency Support Function (ESF) #8,133 provide the resources necessary to support the mission and continuation of the FETIG.

To complete this work, the FETIG should support the formation of a Pediatric Disaster Clinical Education and Training Working Group with appropriate pediatric subject matter experts to complete this work. The Commission's Interim Report recommended forming this working group to: establish detailed core competencies and skill sets for different types of responders and health care professionals; develop a national training curriculum based on those core competencies; review existing training materials; provide guidance on how to incorporate children into exercises and drills; and build continuing education requirements into licensing and re-certification processes.134

The importance of training is reflected in the HHS 2009 National Health Security Strategy (NHSS), which outlines actions for ensuring the Nation's health in the event of a major disaster or incident. One of NHSS' 10 strategic objectives is to "develop and maintain the workforce needed for national health security."135 The lack of training and certification standards is noted as one obstacle to achieving this objective.136 A companion NHSS Implementation Guide outlines specific activities to be accomplished in 2010, including prioritizing areas of investment and developing workforce competencies.137 The Commission recommends that HHS explicitly address the needs of children in its efforts to expand workforce training and development.

Recommendation 3.4: The Executive Branch and Congress should provide resources for a formal regionalized pediatric system of care to support pediatric surge capacity during and after disasters.
  • HHS should include pediatric surge capacity as a "Required Funding Capability" in the Hospital Preparedness Program.
  • States and hospital accrediting bodies should ensure all hospital emergency departments stand ready to care for ill or injured children through the adoption of emergency preparedness guidelines jointly developed by the American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association.138

A mass casualty event or major public health emergency involving children will rapidly overwhelm local health care response capabilities. Communities must develop pediatric medical surge plans that focus on incorporating and sharing local, regional, State, and Federal resources. Regionalization of emergency care was one of the key recommendations of the 2006 Institute of Medicine (IOM)'s Committee on the Future of Emergency Care.139 Formal regionalized pediatric systems have been associated with improvements in daily patient outcomes as well as medical surge capacity during disaster response and long-term recovery.140,141

In September 2009, Federal, State, and local policymakers and stakeholders assessed progress made since the IOM's 2006 report during a two-day workshop on regionalizing emergency care sponsored by the Emergency Care Coordination Center.142 Representatives from key Federal agencies offered comments on opportunities and challenges going forward, including the need for: data-driven approaches to measuring effectiveness and designing systems; a Congressional action plan for advancing regionalization; the establishment of roles, responsibilities, and priorities of a lead Federal agency; and consistency across all regional emergency medical services (EMS) systems.

In light of the ongoing challenges, the Commission recommends that the Executive Branch and Congress invest greater resources to assist health care systems in regionalization, compliance with the national emergency care guidelines for children, and development of pediatric medical surge capacity for disasters. The 2009 American Recovery and Reinvestment Act143 allocated funds for comparative effectiveness research, providing an opportunity to bolster research on regionalized systems of pediatric care. Additional funding for demonstration projects on regionalization was authorized in the 2010 Patient Protection and Affordable Care Act.144 The scope of this authorization includes at least four projects that will design, implement, and evaluate innovative regional emergency medical care systems. An explicit requirement is that all grantees address "pediatric concerns related to integration, planning, preparedness, and coordination of emergency medical services for infants, children, and adolescents."145 Given the potential of these projects to advance regional systems of care for children, the Commission recommends that Congress appropriate funds for this initiative.

While regional pediatric systems of care rely on the participation of the Nation's 250 children's hospitals,146 other hospitals also must be prepared to provide appropriate care for children. As noted in the Commission's Interim Report, up to 50 percent of disaster survivors will be "walk-ins,"arriving at hospital emergency departments through means other than EMS.147 However, most hospitals are not adequately prepared to treat critically ill children. Only 6 percent of hospital emergency departments have inventories of pediatric equipment and supplies that meet national guidelines.148

To support hospital preparedness regionalization efforts, the Commission recommends that the HHS Hospital Preparedness Program (HPP) include pediatric surge capacity as a "Required Funding Capability."149 Furthermore, to increase awareness of funding eligibility for pediatric initiatives, children should be specifically referenced throughout future HPP grant guidance, rather than grouped within a subset of "at-risk populations."HPP should highlight and share pediatric funded activities and best practices with hospitals and eligible health care systems. HHS reported that several States used program funding to develop pediatric specific initiatives including regionalized pediatric response, evacuation plans, improved risk communications, improved training, pediatric stockpiles, and pediatric strike teams.150

Notwithstanding the need for greater Federal support, State health care licensing bodies and the Joint Commission on Accreditation of Healthcare Organizations must be the primary drivers in promoting health care system regionalization and adoption of standards and emergency preparedness recommendations.151

Recommendation 3.5: Prioritize the recovery of pediatric health and mental health care delivery systems in disaster-affected areas.
  • Congress should establish sufficient funding mechanisms to support restoration and continuity of for-profit and non-profit health and mental health services to children.
  • The Executive Branch should recognize and support pediatric health and mental health care delivery systems as a planning imperative in the development and implementation of the National Health Security Strategy and National Disaster Recovery Framework.
  • HHS should create Medicaid and Children's Health Insurance Program incentive payments for providers in disaster areas.
  • The American Medical Association should adopt a new code or code modifier to the Current Procedural Terminology to reflect disaster medical care in order to facilitate tracking of these services and as a means for enhanced reimbursement from public and private payers.

Health and mental health care providers face significant challenges in restoring their operations in a timely manner post-disaster, which hinders the consistent provision of care to children and families during disaster recovery. Therefore, Federal, State, and local disaster recovery planning must consider existing resource gaps for the recovery of health and mental health care practices after disasters. The Robert T. Stafford Disaster Relief and Emergency Assistance Act ("Stafford Act")152 provides funds for repairs to public or nonprofit medical facilities. However, approximately 85 percent of pediatric treatment in the United States occurs in privately-owned medical practices.153 Although the Small Business Administration makes loans to support rebuilding and provide operating capital for private, for-profit businesses, many practices affected by major disasters may lack the means to qualify for or repay such loans since health care practices often experience a decline in patients and variations in health insurance reimbursements. After Hurricanes Katrina and Rita, it took nearly two years for many physicians in the New Orleans area to treat a volume of patients sufficient to sustain their practices.154

The Commission recommends that Congress establish sufficient funding mechanisms to support restoration and continuity of for-profit and nonprofit health and mental health services to children following a disaster. The National Health Security Strategy recognizes the importance of restoring access to health services following a disaster. The Strategy states that pre-event planning is fundamental to resuming service delivery in areas affected by a disaster. Such planning should address: behavioral health services for both the affected community and responders; the provision of medical services throughout the recovery period; and the rebuilding and restoration of health care delivery mechanisms, including the health care infrastructure.155

In the Interim Report, the Commission recommended the development of a National Disaster Recovery Strategy which, among several provisions, would include:

  • Continuous access to the full spectrum of pediatric medical services, including a medical home,156 pediatric specialty services, and children's hospitals.
  • Federal disaster assistance grants for all medical facilities damaged or destroyed by a disaster, such as primary medical, dental, and mental health care practices and clinics.
  • Access to appropriate crisis, bereavement, and mental health services.157

In addition, the Commission recommends that the National Health Security Strategy and the National Disaster Recovery Framework and Recovery Support Functions prioritize and support the continuity and restoration of health and mental health practices in jurisdictions affected by disasters. In addition, Federal, State, and local recovery planning must involve primary and mental health care providers at the community level.

The Commission further recommends that the Centers for Medicare & Medicaid Services create Medicaid and Children's Health Insurance Program (CHIP) incentive payments for providers in areas impacted by disasters. Following Hurricane Katrina, the Federal Government provided a 10 percent increase in Medicare reimbursements to physicians in New Orleans after designating Orleans Parish a health professional shortage area.158 However, pediatricians did not benefit from this assistance since eligible children are insured under Medicaid, not Medicare.159

Finally, the Commission recommends the creation of a unique code or code modifier to the Current Procedural Terminology (CPT)160 to report professional services provided in a declared disaster area to public and private health insurance providers. This would allow the appropriate documentation and tracking of such services in the aftermath of a disaster. Insurers may also choose to compensate health care providers with higher insurance reimbursement for services provided to disaster-affected individuals. The Commission is currently collaborating with the American Academy of Pediatrics to propose a new CPT code for "disaster-related care"to the American Medical Association's CPT Editorial Panel in 2010.161

Recommendation 3.6: EPA should engage State and local health officials and nongovernmental experts to develop and promote national guidance and best practices on re-occupancy of homes, schools, child care, and other child congregate care facilities in disaster-impacted areas.
  • EPA and HHS should expand research on pediatric environmental health risks associated with disasters.

Children may suffer serious health and wellness consequences after disasters due to environmental exposure to and inhalation of particulate matter containing asbestos, lead, cement dust, and mold.162 Following 9/11, 52.8 percent of 3,184 children enrolled in the World Trade Center Health Registry displayed a new or worsened respiratory symptom and 5.7 percent received a new diagnosis of asthma.163 More recently, a report by the National Center for Disaster Preparedness on the impact of the 2010 Gulf of Mexico oil spill disaster on children and families estimated that over 40 percent of the population living within 10 miles of the coast had experienced some direct exposure to the oil spill, and that households with children were 1.4 times more likely to report oil spill exposure than households without children.164

The Commission recommends that the Environmental Protection Agency (EPA), in collaboration with its network of Pediatric Environmental Health Specialty Units (PEHSU)165 and other pediatric experts, develop national guidance and best practices for families, caregivers, health care providers, and responsible parties to determine when it is safe for children to re-enter or re-occupy a home, school, child care facility, or other facility affected by a disaster. EPA should partner with HHS and other Federal agencies to expand existing guidance with information specific to children, including Planning Guidance for Protection and Recovery Following Radiological Dispersal Device (RDD) and Improvised Nuclear Device (IND) Incidents,166 Draft Planning Guidance for Recovery Following Biological Incidents,167 and The White House Office of Science and Technology Policy's draft Clean-up Decision-Making Guidance for Chemical Incidents, which is under development by an interagency working group.

The Commission also recommends additional research to expand the evidence base on environmental health risks to children associated with disasters. In 1997, EPA and HHS partnered with other Federal agencies to establish the President's Task Force on Environmental Health Risks and Safety Risks to Children.168 Among the Task Force's accomplishments were the development of the National Children's Study, the Federal Strategy Targeting Lead Paint Hazards, and the Healthy School Environments Assessment Tool to examine environmental threats to children's health.169 The authority for the Task Force expired in 2005, and efforts are underway to reestablish the Task Force in 2010. The Commission recommends that the Task Force prioritize research efforts on environmental health risks of children associated with disasters.170

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