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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 2. Systems Issues

Types of Disasters

Disasters are sudden calamitous events that can result in great damage, loss, injury, and death. They can occur naturally, such as floods, earthquakes, hurricanes, tornados, tsunamis, or wildfires, or they can be caused by human error or intervention. The widespread injury and disruption associated with disasters can pose difficult problems for health care providers including triage of mass casualties, disruption of infrastructure (e.g., loss of power and fresh water), and the need to deal with the mental anguish associated with uncertainty and the loss of loved ones.

The degree of injury, death, and damage caused by disasters is influenced by many factors, including population location and density, timing of the event, and community preparedness (e.g., emergency response infrastructure, local building codes, etc). Similarly, recovery after a disaster is influenced by resources (e.g., savings, insurance, and relief aid), preexisting conditions (e.g., season, local infrastructure, etc), experience, and access to information. In almost all cases, disasters are associated with mental and physical stress (both during and after the event) that can increase morbidity and mortality over and above that caused directly by the event itself.

Natural Disasters

Natural disasters usually occur suddenly and are often uncontrollable. However, they frequently cluster temporally or geographically, and therefore are somewhat predictable. In the United States and other developed countries, most natural disasters tend to cause extensive damage and social disruption with comparatively little loss of life. The most frequent types of natural disasters experienced in the United States are floods, earthquakes, hurricanes, tornados, and fires.


The most common natural disaster is flood, which accounts for roughly 30% of disasters worldwide. Approximately 25-50 million Americans live or work in floodplains, and another 110 million live in coastal areas. The frequency of flooding is increasing, due in part to increasing habitation in flood-prone areas and in part to deforestation and changing land-use patterns, which can increase the degree of flooding.

Flash floods are especially hazardous and occur during sudden heavy rains, tidal surges, or when dams or levees give way. Most of the deaths during flash floods are caused by drowning, usually from people wading or driving through moving water. The hazards posed by rapidly moving water are often unrecognized. A gallon of water weighs 8 pounds; hundreds of gallons of rushing water represent thousands of pounds of force. As little as 2 feet of rushing water can carry a vehicle away, trapping the passengers.

Except for flash flooding, floods generally are not directly associated with significant loss of life. However, flooding results in considerable destruction and disruption, and has the potential for widespread disease. Floodwaters frequently contain human or animal waste from sewage or agricultural systems that can lead to epidemics of infectious disease. Drinking water must be disinfected through boiling and/or chlorination, or an alternative clean water supply (e.g., bottled water) must be identified and made accessible. Water supplies and household surfaces can also become contaminated with petroleum products (e.g., fuel oil or kerosene), household chemicals, and molds.

Contamination of floodwaters also poses a hazard to those participating in the clean up. Rubber boots and gloves should be worn, and open wounds and sores protected. Hands should be washed frequently, especially when handling food or food containers. Foods that may have been contaminated should be discarded. Eating utensils should be thoroughly washed with soap and hot water and disinfected with a solution of 1 cup bleach to 1 gallon water. All inside surfaces, especially those used for food preparation, should be similarly cleaned. Likewise, all child play areas need to be cleaned and disinfected, along with all toys, clothing, etc. Materials that cannot be readily disinfected should be discarded.


Earthquakes are a potential hazard throughout the continental United States, especially within the tectonically unstable areas of California, Idaho, Utah, and the Pacific Northwest. Only part of the destruction caused by earthquakes and their aftershocks occurs during the event. Subsequent events triggered by the quake, such as fires, tidal waves, and so on, can cause significant destruction.

The force of an earthquake is measured on the Richter scale, which estimates the energy imparted by the quake or aftershock. Every increasing Richter unit represents an increase in energy by an order of magnitude. Richter units can be used as an estimate of earthquake probability/frequency, with an order of magnitude decrease in likelihood with every unit increase. For example, on average approximately 2 earthquakes of magnitude 8 are expected worldwide per year, 20 quakes of magnitude 7, and 200 quakes of magnitude 6.

Although earthquakes cannot be prevented, much of the injury and damage they produce can. Improvements in emergency response and health infrastructure can speed up response time and lessen death and disability. Perhaps most importantly, structures built under improved building codes and with stronger construction materials can survive earthquakes with less damage. Also, as with all natural disasters, damage can be mitigated considerably through simple preventive measures, such as turning off utilities, securing appliances, and taping windows.

Hurricanes and Tornados

Hurricanes and tornados are similar weather events that differ in magnitude and location. Both involve rotating masses of air associated with severe weather. Tornados usually measure only a few hundred meters across and travel over only a few kilometers of land, while hurricanes can stretch over hundreds of kilometers. Both can have winds of up to 200 mph, but hurricanes are associated with much more energy and have much more potential for destruction. Tornados develop primarily over landmasses, especially those within the Midwestern and Southwestern United States, while hurricanes are associated with the coastal United States, primarily the East and Gulf coasts.

Although hurricanes are associated with high winds, much of the destruction they cause is from the so-called "storm surge" and subsequent flooding. High winds and low pressure can cause water to pile up in coastal areas up to 14 meters above normal sea level. This can result in all the problems noted above for flooding, including the risk of drowning, electrocution, and disease associated with contaminated drinking water.

Much of the risk associated with these severe weather events can be mitigated through advanced warning and preparation. This is especially true for tornados, because of their sudden onset. Redundant warning systems should be developed, and everyone should be encouraged to practice tornado drills. Special outreach efforts should be made to those with special needs or disabilities, including designation of a "buddy" who knows the individual's needs and can ensure that they are prepared for an emergency. Each person/family should have a tornado shelter (e.g., cellar, basement, etc) that is equipped with an appropriate emergency kit.

Most of the injury and death associated with hurricanes is through failure to heed warnings. Individuals may refuse to evacuate or seek shelter, may not properly secure their property, and may ignore guidelines on food and water safety and injury prevention. Therefore, effective risk communication is important both in preparation for the event and during cleanup and mitigation efforts.


Underwater earthquakes can result in the formation of gigantic waves that can cross thousands of miles of ocean at speeds up to 500 mph. These waves are often no taller than wind-generated waves, but they are much more dangerous. Tsunamis have long wavelengths up to several hundred miles, making them more like prolonged flood waves than normal surf. The waves slow as they reach shallow water, causing them to crest at heights up to 100 feet. When the waves break, they can destroy piers, buildings, and human life far inland. There is little warning as a tsunami wave front approaches the coast, allowing few life-saving preventive actions. Therefore, the best hope for protecting human life is prediction and advance warning through seismology, wave gauges, etc.


Brush or forest fires can disrupt communities and cause substantial property damage, displacement, serious burns, and death. In addition, smoke from wildfires can result in irritation and respiratory difficulties, especially among those with preexisting medical conditions or impairment. As with other natural disasters, serious injury and death often result from failure to evacuate or otherwise heed warnings. Official agencies need to make provisions for those with disabilities to ensure that they are evacuated and that their special needs are addressed.

Manmade and Technological Disasters

Anthropogenic disasters are explosions, chemical releases, etc, directly associated with human action. They can be caused by accidents or deliberate malicious activities or when industrial facilities are disrupted by natural disasters. Examples of accidental anthropogenic disasters include the Bhopal chemical release and the Three-Mile Island nuclear accident. Intentional disasters include arson and terrorist attacks, such as the events of September 11, 2001. Anthropogenic disasters share many of the characteristics of natural ones but are typically less predictable.

Accidental Anthropogenic Disasters

Accidental anthropogenic disasters include a broad range of incidents that vary with the nature of the industry involved. These include hazardous material releases of various types (e.g., caustic agents, asphyxiants, radioactive materials), fires, explosions, structural collapses, transportation failures, and many more. The medical and public health responses to such events depend on the incident and type of hazardous material involved.

Although less predictable than natural disasters, accidental disasters are more preventable. Basic safety procedures and equipment, adequate training, and proper maintenance can go a long way toward preventing accidents. Emergency response training, safety drills and simulations, and medical training in appropriate responses to hazardous agents can greatly limit subsequent injury and death when accidents occur.

Intentional Anthropogenic Disasters

Intentional manmade disasters are the least predictable, with no restrictions other than the limits of the imagination of a deviant mind. The nature of these disasters can vary from simple arson or sabotage, to release of chemical or biological agents, or even to detonation of a primitive nuclear device. These disasters are associated with most of the hazards described for accidental, and sometimes even natural, disasters. However, the malicious nature of the event and the fear associated with biological, chemical, and nuclear agents result in even greater stress and social disruption.

Terrorists do not consider the age of victims, only the impact of their act on furthering a cause. Children have been and will be victims of terrorist acts. Schools, gyms, sporting events, concerts, amusement parks, shopping malls, or any other place where there are mass gatherings are all potential terrorist targets. Release of a product into the ventilation system of a local school or any of the other sites could result in rapid spread of an agent throughout a community.

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Many deaths are possible in the aftermath of a disaster. Because considerable injury and destruction can be associated with any disaster, management after a disaster is critically important. The disruption caused by disasters can result in widespread disease from unhygienic conditions. Fuel leaks, live wires, and other hazards can cause injury or start fires. The physical and emotional stress associated with the event and cleanup can result in heart attacks, musculoskeletal injuries, mental illness, and other stress-related disorders. Displaced wildlife can hamper relief efforts and endanger workers. Injuries can also result from improper use of chain saws or other mechanical equipment involved in clean-up efforts. Children are especially prone to injury or poisoning through access to debris, chemicals, equipment, and other agents discovered while exploring in the aftermath of the disaster.

When returning to a building or structure after a disaster, occupants need to check for structural damage, gas leaks, downed power lines, or other potentially hazardous situations. Sites should be inspected during daylight so that hazards are visible, and only battery-powered flashlights or lanterns should be used for auxiliary light, rather than candles, gas lanterns, or other open-flame devices.

Immediately after a disaster, governments and community organizations will be called upon to provide safe (e.g., bottled) drinking water, as well as shelter, food, clothing, and medical care for displaced people. Victims will also look to these organizations for other services, including counseling and assistance with insurance claims and other sources of emergency funds.

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Federal Response

The United States has established a robust emergency medical support infrastructure to respond to disasters at local, State, regional, and Federal government levels. Many response resources are deployable and can be relocated to accommodate varying disaster scenarios. Other response resources are integral to established health and medical systems in our country and provide health care to Americans and others on a daily basis. Populations with specific emergency medical needs in disasters—such as neonatal, pediatric, or adolescent populations—have limited support that is quickly available and specifically designed for to meet their urgent life-sustaining needs.

Response resources dedicated to pediatric populations continue to be inadequate for most emergency medical response activities related to disasters, even though victims often include children. Many children were injured or killed during the attacks on the World Trade Center in New York City and the Federal Building in Oklahoma City, and countless more witnessed these events. These experiences highlight the need to include pediatric and other special populations in local, State, regional, and Federal disaster medical planning. Table 2.1 depicts the types of disasters that may require Federal assistance.

Centers for Disease Control and Prevention

The Department of Health and Human Services (HHS) is the lead Federal agency for public health issues. The Centers for Disease Control and Prevention (CDC), one of 12 HHS agencies, provides support to the Department in carrying out its mission. CDC priorities include disease prevention and control, environmental health, and health promotion and education activities.

Within CDC, the Director's Emergency Operations Center (DEOC) operates 24 hours a day, 7 days a week to provide emergency consultation and assistance to clinicians, State and local health agencies, and citizens. The DEOC can be reached at 770-488-7100. The Clinician Information Line (877-554-4625) is available to clinicians 24 hours a day to provide guidance on the management of patients suspected of having bioterrorism-related illnesses and, when necessary, can refer pediatricians to agent-specific subject matter experts.

Pediatricians can register to receive real-time CDC updates about preparing for (and possibly responding to) terrorism and other emergency events at .

For more information about CDC's organization and overall mission, see

Department of Homeland Security

Within the last decade, because of the severity of manmade disasters and their devastating effects on life and safety, as well as the increased threat of terrorism, the Federal Government has positioned itself to respond promptly to any future terrorist events that may occur in the United States. A key step was creation of the Department of Homeland Security (DHS) in 2002. One of its missions is to minimize damage and assist in recovery from terrorist attacks that occur within the United Sates.

State and local governments share the primary responsibility for protecting their citizens from disasters, and for helping them recover when a disaster strikes. In some cases, a mass disaster is beyond the capabilities of State and local governments to respond, and the Federal sector is called upon to provide assistance.

The DHS now comprises 22 agencies, including the Federal Emergency Management Agency (FEMA). DHS is responsible for the comprehensive National Strategy for Homeland Security, which is focused on six key areas:

  • Intelligence and warning.
  • Border and transportation security.
  • Domestic counterterrorism; protecting critical infrastructure.
  • Defending against catastrophic threats.
  • Emergency preparedness and response.

To learn more about DHS and its role in disaster preparedness and response, go to

Federal Response Plan

The Federal Response Plan (FRP) was initially developed as the central document for the delivery of assistance to State and local governments in disasters or emergencies. It is a signed agreement among Federal departments and agencies that identifies actions that will be taken in the overall Federal response to disasters or emergencies. It is to be implemented in anticipation of an event that is likely to require Federal assistance and in response to an actual event requiring Federal disaster or emergency assistance. The FRP also may be implemented in response to a request made by a governor to the president for Federal assistance.

Federal response operations are coordinated with State, local, and regional officials and include positioning of a Federal coordinating officer, and deployment of emergency response teams, regional support teams, and emergency support teams to operations centers near the incident site and at the regional and national operations centers. Figure 2.1 is a graphic depicting the FRP; go to (PDF Help) for more detailed information.

Preserving lives and safety of victims are main priorities of disaster response. One component of the FRP, known as Emergency Support Function #8 (ESF #8), Health and Medical Services, is led by the Department of Health and Human Services (HHS). This function is supported by 15 Federal and non-Federal agencies and provides coordinated Federal assistance to augment State and local resources after a major disaster or during the development of an anticipated public health and/or medical emergency. Assistance is also provided when State, local, or tribal public health or medical assets are overwhelmed and Federal support has been requested through proper authorities or when pending disasters are expected to overwhelm State, local, or tribal resources. Federal support also can be provided when these public health resources are not able to address all public health needs.

The scope of ESF #8 is broad and involves supplemental health and medical assistance to meet the needs of victims of a major disaster, emergency, or terrorist attack. In the FRP, this support is categorized in the following functional areas:

  • Assessment of health/medical needs.
  • Health surveillance.
  • Medical care personnel.
  • Health/medical equipment and supplies.
  • Patient movement/evacuation.
  • Patient care.
  • Safety and security of human drugs, biologics, medical devices, veterinary drugs, etc.
  • Blood and blood products.
  • Food safety and security.
  • Agriculture safety and security.
  • Worker health/safety.
  • All-hazard public health and medical consultation, technical assistance, and support.
  • Behavioral health care.
  • Public health and medical information.
  • Vector control.
  • Potable water/wastewater and solid waste disposal.
  • Victim identification/mortuary services.
  • Protection of animal health.

Federal resources that supplement regional, State, and local response are primarily from within HHS and ESF #8 support agencies. However, other non-Federal sources such as major pharmaceutical suppliers, hospital supply vendors, the National Foundation for Mortuary Care, and certain international disaster response organizations and international health organizations also provide support.

Department of Defense

The Department of Defense (DOD) has many capabilities through which it can provide assistance to lead Federal agencies in response to a disaster. DOD medical and support capabilities include the following:

  • Triage and medical treatment.
  • Displaced populations support.
  • Hospital personnel augmentation.
  • Epidemiologic support.
  • Stress management.
  • Preventive medicine support.
  • Veterinary support.
  • Prophylaxis and immunization augmentation.
  • Mortuary affairs.
  • Medical logistics.
  • Transportation.
  • Communication.
  • Technical augmentation (e.g., modeling).
  • Surveying and monitoring the incident site.
  • Facility decontamination.

For more information about DOD and its capabilities, go to

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Federal assistance has been used successfully for many years to respond to the emergent medical requirements of victims of natural disasters throughout the United States. Recent terrorist attacks within the United States have increased the Nation's investment in homeland security through increased State, local, and regional health and medical resource development and acquisition in response to events involving weapons of mass destruction. Federal assistance is provided through the lead and supporting agencies designated within the National Response Plan (NRP), including DoD.

While Federal response assets are robust, timely management focused on the needs of at-risk groups is paramount to victim survival and positive medical outcome. Pediatric patients are among the populations gaining national attention regarding the need for appropriate medical support, including appropriate supplies and equipment, during a disaster. Historical data on disaster response, including the personal experiences of health care providers and victims, reinforce the medical requirements of pediatric populations. All sectors—Federal, State, regional, and local—must continue to be prepared to provide medical resources to a disaster, but these entities also must give attention to the needs of specific populations, including children. This is the best way to improve morbidity and mortality in response to mass casualty events.

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Centers for Disease Control and Prevention. About CDC. Available at: Accessed August 17, 2006.

Centers for Disease Control and Prevention. Biological and chemical terrorism: strategic plan for preparedness and response. Recommendations of the CDC Strategic Work Group. MMWR 2000;49(No. RR-4):1-14.

Centers for Disease Control and Prevention. PHIN's Early Event Detection Component.

Centers for Disease Control and Prevention. CDC's Disease Surveillance System Efforts: Testimony of Joseph M. Henderson, Director, Centers for Disease Control and Prevention, Before the Select Committee on Homeland Security, Subcommittee on Emergency Preparedness and Response, U.S. House of Representatives, September 24, 2003. Available at: Accessed August 17, 2006.

Centers for Disease Control and Prevention. CDC Clinician Registry. Available at: Accessed August 7, 2006.

Centers for Disease Control and Prevention. Epidemic Intelligence Service. Available at Accessed August 17, 2006.

Centers for Disease Control and Prevention. Laboratory Response Network. Available at: Accessed August 17, 2006.

Centers for Disease Control and Prevention. CDC Clinician Registry for Terrorism and Emergency Response Updates and Training Opportunities. Available at: Accessed August 17, 2006.

Centers for Disease Control and Prevention. Strategic National Stockpile. Available at: Accessed August 17, 2006.

Department of Homeland Security Home Page. Available at: Accessed September 13, 2006.

Department of Homeland Security. National Response Plan. Available at: (PDF Help). Accessed July 7, 2006.

Homeland Security Act, Public Law 107-296, 6 U.S.C. 101 et seq. November 25, 2002.

Homeland Security Presidential Directive-1. Organization and Operation of Homeland Security Council. October 29, 2001. Available at: Accessed August 17, 2006.

Homeland Security Presidential Directive-2, Combating Terrorism Through Immigration Policies, October 29, 2001. Available at: Accessed August 17, 2006.

Hughes JM, Gerberding JL. Anthrax bioterrorism: lessons learned and future directions. Emerg Infect Dis 2002;8(10):1013-14.

Hutwagner L, Thompson W, Seeman GM, et al. The bioterrorism preparedness and response Early Aberration Reporting System (EARS). J Urban Health. 003;S1;80(2):89-96.

Landesman LY. Public Health Management of Disasters: The Practice Guide. Washington, DC: American Public Health Association; 2001.

National Advisory Committee on Children and Terrorism. Recommendations to the Secretary. June 2003. Available at: Accessed August 17, 2006.

National Archives and Records Administration. Public Health Security and Bioterrorism Preparedness and Response Act of 2002. Available at: Accessed August 17, 2006.

Perkins BA, Popovic T, Yeskey K. Public health in the time of bioterrorism. Emerg Infect Dis 2002;8(10):1015-1018.

Public Health Security and Bioterrorism Preparedness and Response Act of 2002, Public Law 107-188, U.S.C. 247d and 300hh, June 12, 2002, Draft National Response Plan. February 25, 2004. Department of Homeland Security. Available at: Accessed August 17, 2006.

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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