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Pediatric Terrorism and Disaster Preparedness

Public Health Emergency Preparedness

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

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Chapter 10. Working with Government Agencies


The challenge of dealing with the threat of terrorism in the United States is daunting not only for disaster planners, but also for our medical system and health professionals of all types, including pediatricians. All possible forms of terrorism should be considered, including chemical, biological, explosive, radiological, and nuclear events. Pediatricians need to be able to answer concerns of patients and families, recognize signs of possible exposure to a weapon of terror, understand first-line response to such attacks, and sufficiently participate in disaster planning to ensure that the unique needs of children are satisfactorily addressed in the overall process.

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Community, Government, and Public Health Preparedness

Emergency preparedness is important at many levels—personal, family, community, regional, State, and Federal—with the State and Federal Governments having pivotal roles. The Federal Government provides significant funding for disaster preparedness and response and to a large extent establishes the framework that is then followed by States, regions, and communities. In disaster response, the funding and planning tends to be top down, while the response and use of resources tends to be from the bottom up. In other words, as resources are exhausted at the local level, assistance is requested from the next level, such as the State, which then requests Federal assistance.

Volunteer organizations, such as the Red Cross and Salvation Army, also have key roles in disaster response. Recent concepts of disaster and aftermath response and planning include the involvement of neighborhoods and families and have begun to include needs at the individual level. A successful response to a disaster requires the interaction of personnel and resources from multiple agencies in an organized and coordinated manner according to a well-formulated plan. While this planning has increased in recent times, the attention to the unique needs of children and the inclusion of pediatric expertise in the planning phases is still insufficient and deserves much more attention.

Community Response

Local governments are the first line of defense in emergencies and are primarily responsible for managing the response to most disasters. The primary responsibility for the protection of citizens belongs to such local elected officials as mayors, city councils, and boards of commissioners. When a local government receives a warning that an emergency could be imminent, its first priorities are to warn citizens and to take whatever actions are needed to minimize damage and protect life and property. If necessary, an evacuation may be ordered. The emergency operations plan is at the center of comprehensive emergency planning. This plan spells out the scope of activities required for community response. It should be a living document that accurately describes what the community can realistically do. Historically, these documents usually do not address pediatric considerations and in only the rarest of cases have pediatricians been part of the planning process.

State Government

All States have laws that describe the responsibilities of the State government in emergencies and disasters. These laws provide governors and State agencies with the authority to plan for and carry out the necessary actions to respond to and recover from emergencies. State emergency management legislation describes the duties and powers of the governor, whose authority includes the power to declare a state of emergency and to decide when to terminate this declaration.

Performing and maintaining the provisions of emergency management legislation is generally the responsibility of the State emergency management offices (some municipalities also have offices of emergency management). These offices are organized in a number of ways and have different names. Emergency managers are responsible for preparing for emergencies and for coordinating the activation and use of resources controlled by the State government when they are needed to help local governments respond to and recover from emergencies and disasters. In its coordinating role, the State emergency management office is involved in virtually all serious emergencies, terrorist events, and natural or manmade disasters.

Using procedures specified in the State emergency operations plan, the State emergency management organization coordinates deployment of personnel and resources to the affected areas. Again, pediatric concerns are rarely considered. The emergency operations plans of many States do not include child-specific guidelines. Pediatricians need to be involved in the State emergency planning committees to ensure that pediatric considerations are included in State plans and become part of the plans of each State agency and part of funding for disaster and terrorism preparation. This pediatrician involvement can be accomplished through both grassroots efforts and involvement in local chapters.

Federal Government

The authority for Federal involvement in disasters is based on provisions of the Stafford Act.1 This Act establishes the presidential declaration process for major disasters and emergencies, provides for the implementation of disaster assistance, and sets forth the various disaster assistance programs. FEMA's role is to coordinate the delivery of Federal assistance by managing its own programs and by coordinating disaster assistance from other Federal departments and agencies. FEMA coordinates these activities using the interagency Federal response system, also called the Federal Response Plan (FRP). The FRP describes the basic mechanisms and structures by which the Federal Government mobilizes resources and conducts activities to augment State and local response efforts. To facilitate the provision of Federal assistance, the FRP uses a functional approach to group the types of Federal assistance that a State is most likely to need under the 12 Emergency Services Functions (ESFs). Each ESF is headed by a primary agency that has authorities, resources, and capabilities in the particular functional area. Other agencies have been designated as support agencies for one or more ESFs based on their resources and capabilities to support the functional area. The FRP is also important in that most States use it as a base for the structure and some content of their emergency operations plans. In turn, local emergency operations plans are based on the State plans. (For more information, go to Chapter 2, Systems Issues.)

One of the major functions physicians will be involved with and should become familiar with is Emergency Services Function Number 8 (ESF #8), the Health and Medical Services Function. ESF #8 provides assistance to supplement State and local resources for public health and medical care needs during a disaster. In a federally declared disaster, the U.S. Public Health Service (USPHS), a component of the U.S. Department of Health and Human Services (HHS), forms a Crisis Action Team and activates the National Disaster Medical System (NDMS) as needed to provide health and medical care assistance. A Disaster Medical Assistance Team (DMAT) is a deployable unit of 35 physicians, nurses, technicians, equipment, and supplies for austere medical care. A Management Support Unit (MSU) manages field health and medical resources of deployed DMATs. A Disaster Mortuary Assistance Team (DMORT) provides a temporary morgue facility, victim identification, processing, preparation, and disposal of remains. A Metro Medical Strike Team (MMST) provides assistance in the medical treatment/management of chemical, biological, or radiological incidents resulting from deliberate or accidental acts. In some cities, there are Metropolitan Medical Response Teams that provide additional medical response capability. The parent agency of all of these groups is the USPHS, with assistance from the Department of Homeland Security (DHS).

Public Health Preparedness

On a larger scale, we should also recognize the need for public health preparedness. This requires the existence of a strong public health system. To allow for rapid and efficient response, we need both central organization as specified by Federal planning and State implementation and decentralization of some resources, such as diagnostic capabilities.

It is important for pediatricians to understand the importance of public health and their relationship to departments of health. This includes their role in public health, reporting requirements and mechanisms, and mechanisms for receiving and soliciting information from departments of health.

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Advocating for Children and Families in Preparedness Planning

To ensure that children are included in government and community planning and preparedness activities, informed and motivated pediatricians should advocate for children at all levels. This advocacy can take several forms. Grassroots advocacy can include efforts to ensure legislation and funding to support an emphasis on children in disaster planning at every level. Pediatricians can also serve as expert advisors to local, State, and Federal agencies and committees. Often, this activity can be through involvement in professional organizations such as the American Academy of Pediatrics, its chapters, and special committees and task forces.

Pediatricians as the experts in the care of children should:

  • Advocate for inclusion of the needs of children in all Federal, State, and local disaster planning.
  • Advocate for research on the pediatric aspects of biological, chemical, and radiological terrorism, including mechanisms, pathophysiology, and treatments. This includes the availability of appropriate medications and antidotes.
  • Work with DMATs to ensure that they are equipped and trained for the care of children.
  • Assist in developing a hospital disaster plan that provides for the proper care of children.
  • Provide on-site emergency and primary health care at emergency shelters.
  • Be involved in emergency medical services (EMS), e.g., develop proficiency in cardiopulmonary resuscitation and first aid, train first responders in pediatric assessment, assist in development of prehospital pediatric protocols, help establish protocols for consent to treat and identification of minors, and ensure the availability of pediatric resources.

At the local and community level, pediatricians should:

  • Work with local police, fire, and EMS departments to ensure that their plans and equipment address the needs of children.
  • Be involved with local and community emergency preparedness task forces and committees.
  • Work with schools, child care centers, and other locations where children spend their time to ensure that they have adequate emergency plans.

Similarly, at the State level, pediatricians should:

  • Ensure that State emergency management, department of health, and EMS advisory committees have pediatric expertise as part of their membership.
  • Advocate for all State disaster and terrorism education and funding to require inclusion of provisions for children.

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Resources Available from Government Agencies

A number of State and Federal Government agencies have information, tools, electronic media, and other materials to assist physicians, including pediatricians, and other health care providers in disaster planning, preparedness, and response. Many of these resources can be found in the bibliographies that follow chapters in this report.

Another Federal agency, the Agency for Healthcare Research and Quality (AHRQ), has provided support for research on bioterrorism preparedness and response and the development of materials to improve the Nation's capacity to respond to bioterrorism and other disasters. AHRQ's multimillion dollar investment in bioterrorism research recognizes that community clinicians—including pediatricians—have a vital role to play in disaster planning, preparedness, and response at the Federal, State, and local levels. Hospitals, health care systems, professional organizations, and other groups also have essential roles in the public health infrastructure and need evidence-based information and tools to help them respond appropriately in the event of a disaster.

To inform and assist these groups in meeting the health care needs of the U.S. population in the face of bioterrorist threats and other disasters, AHRQ-supported research has focused on the following:

  • Emergency preparedness of hospitals and health care systems for bioterrorism and other rare public health events.
  • Technologies and methods to improve the linkages between the personal health care system, emergency response networks, and public health agencies.
  • Training and information needed to prepare community clinicians to recognize the manifestations of bioterrorist agents and manage patients appropriately.

AHRQ contracted with the American Academy of Pediatrics to develop this report to ensure that the needs of children are an integral part of disaster planning and preparedness activities.

AHRQ has developed a number of other reports, tools, and other materials that focus on disaster planning, preparedness, and response. They are available online at the Agency's Web site (, and in many cases, print copies are available from the AHRQ Publications Clearinghouse. Information about print availability is also online.

1 Robert T. Stafford Disaster Relief and Emergency Assistance Act, Public Law 93-288, Sections 5121-5206, et seq of Title 42 United States Code.

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