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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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A Resource for Pediatricians


This summary and the full report are designed to be practical resources that pediatricians can consult in planning for and responding to natural disasters and bioterrorist events. The report was prepared by the American Academy of Pediatrics (AAP) for the Agency for Healthcare Research and Quality (AHRQ).

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Children Are Not Small Adults
Systems Issues
Responding to a Disaster
Biological Terrorism
Chemical Terrorism
Radiological and Nuclear Terrorism
Blast Terrorism
Mental Health Issues
Integrating Terrorism and Disaster Preparedness Into Your Pediatric Practice
Terrorism and Disaster Preparedness for Hospital-Based Pediatricians
Working with Government Agencies
Advocating for Children and Families in Preparedness Planning
Additional Resources
Acknowledgments and Disclaimers
AHRQ's Bioterrorism Research Portfolio


This summary presents highlights from a report prepared by the American Academy of Pediatrics for Agency for Healthcare Research and Quality (AHRQ). The purpose of the report is to enhance the role and capabilities of pediatricians in planning for and responding to natural disasters and bioterrorist events. The goal is to ensure that the special needs of children are considered and incorporated into local, State, regional, and Federal disaster preparedness planning and response. A list of resources is provided at the end of this summary to help readers access additional information on each of the topics discussed here.

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A disaster is a calamitous event that affects a large population and generally results in injury, death, and destruction of property. A disaster can also be thought of as any occurrence that taxes or overwhelms local response resources, including law enforcement, transportation, shelters, and so on. Local resources can be overwhelmed by natural disasters or other events that result in multiple casualties such as earthquakes, fires, large motor vehicle crashes, and terrorist incidents.

Disasters caused by terrorism or accidents (e.g., a multiple car crash on an interstate highway) can occur without warning. In other types of disasters, such as hurricanes, there usually is some time for warning and preparation. Some disasters end quickly, while others can affect large populations over an extended period of time (e.g., a humanitarian disaster involving famine). Disasters can have physical, mental, and emotional effects on a large number of people without regard to age or other factors. 

Terrorism is a reality in the United States, and bombs, germs, toxic gases, and the forces of nature do not discriminate between children and adults. Despite our best efforts to shelter and protect them, children remain among the most vulnerable victims of terrorism and natural disasters. 

This resource is intended primarily to educate, inform, increase awareness among, and assist pediatricians in recognizing and fulfilling their important roles in disaster preparedness and response. Families and communities turn to pediatricians for anticipatory guidance on all issues involving children. In turn, pediatricians can help families plan their response to disaster and, when disaster strikes, refer them to available resources. Based on their traditional roles in prevention, anticipatory guidance, and advocacy, pediatricians can make a difference in ensuring comprehensive public health planning for disaster.

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Children Are Not Small Adults

Many important differences distinguish children from adults and are the origin of the oft-used truism "you can't treat children as small adults." Some of these differences are:

  • Anatomic differences (e.g., size, more pliable skeleton).
  • Physiologic differences (e.g., age-related variations in vital signs, higher relative metabolism).
  • Immunologic differences (e.g., immature immunologic system, higher risk of infection).
  • Developmental differences (e.g., inability to vocalize symptoms or localize pain, dependence on others for necessities of life).
  • Psychological differences (e.g., age-related response to trauma, vulnerability to major psychiatric disorders such as depression).

These differences affect children's vulnerability to injury and response in a disaster. Failure to account for these differences in triage, diagnosis, and management of children is most often due to lack of knowledge or experience or both. Unfortunately, grave errors can result, increasing the child's risk of serious harm and even death.

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Systems Issues

The widespread injury and devastation associated with disasters can pose difficult problems for health care providers, including triage of mass casualties, disruption of the 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, disaster planning, etc.). Similarly, recovery after a disaster is influenced by resources—for example, insurance and relief aid—and by experience, access to information, and preexisting environmental factors, such as season, local infrastructure, and so on. 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.

Usually, there are many deaths and widespread injury and destruction in the aftermath of a disaster. For example:

  • 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 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 equipment involved in clean-up efforts.

Children are especially prone to injury or poisoning through exposure to debris, chemicals, equipment, and other agents in the aftermath of a disaster. Thus, management after a disaster is critically important to minimize further injuries and destruction.

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Responding to a Disaster

There are four basic phases of response to a disaster. They are:

  1. Preparedness (including prevention and planning).
  2. Actual response to the event.
  3. Mitigation.
  4. Recovery (short- and long-term).


Although we usually cannot predict disasters, we often can exert some control over their impact through prevention and planning efforts. Prevention through preparedness is probably the most important phase of response in emergency management. During the preparedness phase, governments, organizations, and individuals develop plans to save lives, minimize disaster damage, and enhance disaster response. Such efforts include:

  • Preparedness and evacuation planning.
  • Emergency exercises and training.
  • Warning systems.
  • Emergency communication systems.
  • Public information and education.
  • Development of resource inventories, personnel contact lists, and mutual aid agreements.

Physicians participate in preparedness and prevention in many different ways, including:

  • Immunization programs.
  • Dietary advice.
  • Health education.
  • Safety precautions and planning.

As participants in an emergency action plan, physicians need to help formulate ways of preventing incidents from occurring or limiting the consequences from an incident that has already occurred. Physicians need to know what will be expected of them and their hospital in the case of a potential infectious disease outbreak. They should also be prepared with the knowledge and resources needed to help identify the etiology of a problem and to provide timely treatment.

Pediatricians should be proactive in providing input regarding the unique needs of children during disasters and ensure that children's issues are included in all preparedness activities. 

Actual Response to an Event

Response activities provide emergency assistance for casualties and speed recovery. They include:

  • Activating public warning systems.
  • Notifying public authorities.
  • Mobilizing emergency personnel and equipment.
  • Providing emergency medical assistance.
  • Manning emergency operation centers.
  • Declaring disasters.
  • Evacuating the public.
  • Mobilizing security forces.
  • Providing search and rescue operations.
  • Suspending some laws on an emergency basis.


Mitigation includes actions taken to stop the incident from doing any further damage and to stabilize the situation. Examples include putting out a fire or plugging a leak in a hazardous material incident. Mitigation also plays a role in preparedness through measures such as building codes, tax incentives, zoning and land use management, safety codes, and so on.


The objective is to return things to normal or near normal as quickly as possible. Depending on the scope of the incident, the recovery period can range from hours to years. Short- and long-term recovery measures include:

  • Returning vital life-support systems to minimum operating standards.
  • Reconstruction.
  • Temporary housing.
  • Ongoing medical care.
  • Public information, health and safety education, and counseling. 

Regional Response to a Disaster

Although each area of the country differs somewhat in the way emergency responses are handled, all agencies involved in emergency response use some form of an incident management system. Almost all use the National Incident Management System with unified command. Communication and information sharing are key parts of successful incident management—both before and during an actual event. Regional physicians should review community emergency response plans, as well as the collaborative efforts between responders and planners, to ensure that they know what will be expected of them in the event of a disaster and where they can turn for assistance. For example:

  • Emergency medical services (EMS). In recent years, the addition and expansion of initial and continuing education in prehospital pediatric trauma care, as well as the provision of expert pediatric medical direction, has greatly enhanced the capabilities of most regional EMS systems. In most regions, injured children can now receive emergency medical assistance comparable to that provided to injured adults.
  • Hospitals. In mass casualty incidents, including those involving release of biological or chemical agents, both children and adults are likely to be significantly affected. Indeed, children are likely to be disproportionately affected by such an incident, so pediatricians should assist in planning coordinated responses for local hospitals that may have limited pediatric resources. Health care facilities could also be a primary or secondary target. At the very least, hospitals will be caring for large numbers of anxious and worried individuals, including children and parents. In addition, hospitals may be overwhelmed by numerous victims who appear at the facilities without benefit of EMS triage and transport.
  • Surge capacity. Most of our medical systems are already operating at near capacity, so pre-event planning is essential to develop local capacity to expand health care resources. Surge capacity expressed in terms of beds is not specific enough. Specific pediatric surge capacity that is somewhat intervention-specific is preferable. For example, there may be 1,000 hospital beds available in a large community but only 10 pediatric intensive care unit beds. Regional response to a disaster may involve crossing State lines and tapping emergency services from many different jurisdictions. Thus, surge capacity needs to be considered from several perspectives, including local, State-wide, and regional facilities and services.
  • High-acuity pediatric patients. In large urban areas, there are likely to be multiple pediatric hospitals within a short distance of each other. However, many smaller communities have access to only one regional facility that is capable of handling high-acuity pediatric cases. This means that surge capacity for pediatric disaster victims may be critically limited. Transporting pediatric patients to facilities outside of the region may be required (particularly if a pediatric facility is damaged or incapacitated). Pediatricians should educate and advocate regarding this type of planning. This is similar to the situation for high-end pediatric cardiac surgery, organ transplantation, and burn unit care for which pediatricians already refer to resources outside their region.
  • Other facilities. It may be necessary to use facilities other than hospitals to care for unaccompanied but medically stable children or for children with social but no serious physical issues. This will not occur unless pediatricians help the responsible agencies/facilities prepare in advance.

Pediatricians as Planners

There are many ways that pediatricians can participate in regional hospital and community planning to ensure optimum care for children in the event of a disaster. Some examples include:

  • Meet with hospital planners to ensure children's needs can be met.
  • Help organize the response of community pediatricians to ensure appropriate distribution of pediatric expertise.
  • Participate in developing education and assistance packets for family preparedness.
  • Work with hospitals and schools to develop decision trees for the initial steps to be taken in decontamination, further triage, transport, and so on.
  • Help hospitals develop color-coded triage systems for patients who arrive without previous triage to ensure appropriate levels of care and that children are not separated from their caregivers in a chaotic situation.
  • Assist hospital disaster planning teams in developing a protocol for managing pediatric victims who have been separated from their primary caregivers during a disaster.

Triage to the appropriate facility can be critical for a child. Pediatricians should work to ensure that a mass casualty plan is in place that considers the unique needs of children, as well as the importance of not overloading one local facility (whenever possible). While there should be designated facilities for referral of critically injured children, each facility should be able to care for and at least initially stabilize both children and adults. Pediatric skills and equipment should be maintained at all facilities.

Emergency departments and hospitals may be called upon to provide for the both the physical and the medical needs of pediatric patients. They may need to provide children, for the short-term at least, with shelter, clothing, food, supervision, and entertainment, as well as protection from the media in the critical period immediately after a disaster. These nontraditional functions should be addressed during development of disaster plans.

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Biological Terrorism

Biological terrorism is the deliberate use of any biological agent against people, animals, or agriculture to cause disease, death, destruction, or panic for political or social gains.  A bioterrorist agent may be a common organism, such as influenza or Salmonella, or a more exotic organism such as Ebola virus or variola virus. The following biological agents pose the greatest potential for use in a bioterrorist attack and have been designated as Category A agents:

  • Variola major (smallpox).
  • Bacillus anthracis (anthrax).
  • Yersinia pestis (plague).
  • Francisella tularensis (tularemia).
  • Botulinum toxin (botulism).
  • Filoviruses and arena viruses (viral hemorrhagic fevers [VHFI]).

When there is no other explanation for an outbreak of illness, it may be reasonable to investigate bioterrorism as a possible source. There are a number of clues that should arouse suspicion of a bioterrorist event. Some examples include:

  • Disease caused by an uncommon organism (e.g., smallpox, anthrax, or VHF).
  • A disease identified in a geographic location where it is not usually found (e.g., anthrax in a non-rural area, or plague in the United States).
  • Antiquated, genetically engineered, or unusual strains of infectious agents.
  • An unexplained increase in incidence of an endemic disease that previously had a stable incidence rate.
  • A large number of people presenting with similar illnesses in noncontiguous regions (may be a sign that there have been simultaneous releases of an agent).


Rapid reporting of a suspected bioterrorist event is essential, since all public health and medical responses to bioterrorism begin at the local level. Pediatricians are front-line health care providers in every community and may become front-line responders in the event of a bioterrorist attack. It is impossible to predict where a child or parent may first seek care for an illness caused by a bioterrorist agent, so primary care pediatricians, as well as those working at secondary and tertiary care facilities, must be prepared to promptly diagnose and isolate a patient who is contaminated or infected with a communicable disease. If the illness is potentially related to bioterrorism, the proper authorities must be notified promptly.

After the initial history and physical examination have been completed, if the pediatrician suspects a disease related to bioterrorism, he or she must notify the proper authorities, including the infection-control practitioner (if one is available at the facility) and local public health authorities. Each local public health system is organized slightly differently, so pediatricians should know which local public health agency to contact and have the correct phone number at hand.

Laboratory Support

Collecting the appropriate clinical laboratory specimens when a bioterrorism-related illness is suspected is critical for the medical care of the patient, as well as for public health and legal investigations. Specimen collection varies by the agent suspected and should be done in consultation with public health authorities. Local and State public health authorities can advise on specific specimen collection and shipping in each case, and they can consult with the Centers for Disease Control and Prevention (CDC) as needed. 

Limiting Spread

Rapid identification and isolation of patients with a communicable illness related to bioterrorism are essential to prevent transmission in health care settings. When such an illness is suspected, the patient should be placed on contact precautions and airborne infection isolation, in addition to standard precautions, until preliminary test results are available and the transmissibility of the infection can be reevaluated.

Agents of bioterrorism generally are not transmitted from person to person. The release of an agent is most likely from a point source. However, smallpox, VHFs, and pneumonic plague may be highly transmissible from person to person via respiratory droplet and, in some cases, by aerosol spread.

All patients in a health care facility and all patients suspected of infection with a Category A bioterrorist agent (anthrax, botulinum toxin, plague, smallpox, tularemia, and VHFs) should be cared for using standard precautions, as well as contact precautions and airborne infection isolation (the highest level of precaution) until preliminary test results are available and the transmissibility of disease can be reevaluated. Standard precautions prevent direct contact with blood, other body fluids, secretions, excretions, nonintact skin/rashes, and mucous membranes; they should be observed during all aspects of patient care.

Contact precautions ensure that health care workers and others do not come into direct contact with the patient's skin or indirect contact with surfaces or patient-care items in the patient's environment. Airborne infection isolation requires the patient's room to have certain features (private, negative air pressure room with 6 to 12 air exchanges per hour and other features), places limits on who can enter the room, and necessitates confinement of the patient to his or her room except when it is absolutely necessary to transport the patient to another area of the facility.

Equipment and Supplies

The type of equipment and supplies necessary to diagnose and treat a patient suspected of being infected with a bioterrorist agent varies by the level of care that will be provided at a particular facility. An office-based primary care pediatrician may need to be concerned only with short-term isolation and preliminary stabilization of a patient. Such limited care would require a relatively short list of supplies, usually available in the well-stocked pediatric medical office. Hospital-based pediatricians may be providing longer term and more complex care to patients and should consult with and advise their hospital administration regarding the hospital's bioterrorist response plan and the response plans of State and local health authorities. Hospital-based pediatricians should know how to access the Strategic National Stockpile in the event of a bioterrorist event.

Pediatric Practices

Community-based pediatricians and their staffs should keep the office running smoothly and provide care to the best of their abilities during and after a bioterrorist event. The first step is for every staff member to have a personal family emergency plan. Once staff members are assured that they and their family members are safe, they will be better able to focus on their professional duties.

Second, every office needs an emergency plan. This plan should include details for handling an emergency, both in the office and in the community. Items that should be included in an in-office emergency plan include the following:

  • Isolation of the patient and family.
  • Personal protective equipment for staff.
  • Backup and safe storage of medical records.
  • Plans for a secondary office/practice site.
  • Contact information for local public health authorities.
  • Phone numbers and instructions for emergency patient transport.

Items that should be included in a plan for an emergency in the community include the following:

  • Information sheets and hotline telephone numbers.
  • Telephone triage protocols.
  • Back-up staffing schedules.

Depending on the situation, dedicated staff may be needed just to handle anxious or worried parents.

The community-based pediatrician should have the following items readily available to evaluate children suspected of having an illness related to bioterrorism:

  • An examining room with a door that closes, in which to isolate a patient and accompanying family members.
  • Surgical masks.
  • Clean, nonsterile gowns.
  • Clean, nonsterile disposable gloves.
  • Eye protection equipment, such as goggles and face shields.
  • The 24/7 phone numbers of local and State public health authorities.

Managing Patients

Treatment consists of supportive care (e.g., fever management, fluid management, nutritional supplementation, ventilatory support, and emotional care) and medical treatment (antibiotics and antitoxins) specific to the bioterrorist agent implicated.

The Department of Health and Human Services (HHS) has stockpiled vaccine for potential use in an outbreak of smallpox or anthrax. Although these vaccines are not available to the public before a bioterrorist event, they could be made rapidly available to high-risk populations in the event of an attack.

Strategic National Stockpile

The Strategic National Stockpile (SNS) was established in 1999 and is managed by HHS. The SNS is a national repository of antibiotics, chemical antidotes, antitoxins, vaccines, life-support medications, and other medical and surgical items. The SNS maintains a stock of supplies that are specific for the medical needs of children and has received guidance from academic and public health experts in general pediatrics, pediatric infectious diseases, pediatric pharmacology, and pediatric critical care medicine.

The SNS is designed to supplement and re-supply State and local public health agencies in the event of a national emergency anywhere and at any time in the United States or its territories. The SNS is prepared for immediate response by having push packs strategically positioned across the United States. Push packs provide medical supplies for an initial response to a broad range of emergencies and can arrive on site within 12 hours of deployment. If additional supplies are required, they can be shipped within 24-36 hours through vendor-managed inventory. SNS supplies will be dispensed when the governor of an affected State makes a request to CDC or HHS.

Information for Families

In the event of a bioterrorist attack, one of the most important and challenging roles for the local pediatrician will be providing information to families with children. During the anthrax attacks of 2001, public health and medical facilities were inundated with requests for information and medical evaluation. As a result, these same agencies have prepared communication messages and information sheets that can be shared with families before and during a crisis. Parents will want information that is age-appropriate for their children, as well as suggestions for ways to answer their children's questions. Pediatricians may want to consider accessing some of these materials and having them available before an emergency occurs. Go to the list of resources (including the HHS, AHRQ, and CDC Web sites) at the end of this summary for further information.

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Chemical Terrorism

Chemical terrorism is the intentional use of toxic chemicals to inflict mass casualties and mayhem on an unsuspecting civilian population, including children. Such an incident could potentially overwhelm the capacity of regional emergency medical services and pose extraordinary medical management challenges to pediatricians.

Chemical terrorism often refers to the use of military chemical weapons that have been illicitly obtained or manufactured de novo. However, additional concerns might include the intentional explosion of an industrial chemical factory, a tanker car, or a transport truck in proximity to a civilian residential community, school, or worksite. These events underscore the need for all pediatricians to expand their working knowledge of the approach to mass casualty incidents involving traditional military chemical weapons and other toxic chemicals that might be used as "weapons of opportunity."

Chemical weapons can be categorized based on the predominant symptoms they cause:

  • Neurologic (nerve agents or cyanide).
  • Respiratory (phosgene or chlorine, high-dose riot-control agents, or sulfur mustard with a delay of several hours from time of exposure).
  • Mucocutaneous syndromes (vesicants).

Casualties will occur almost immediately after an incident involving chemical terrorism, and the attack will likely be recognized rapidly. First responders will be EMS, police, fire, and paramedic personnel. Decontamination and initial care of small children on-scene will pose enormous management issues for personnel wearing bulky personal protective gear. In addition, many exposed, but not critically injured children, will undoubtedly be taken by parents to hospitals and pediatricians' offices without prior on-scene decontamination—thus posing similar challenges for and possibly personal risk to pediatric care providers themselves.

Specific Pediatric Vulnerabilities to Chemical Agents

Children have inherent physiologic, developmental, and psychological differences from adults that may enhance susceptibility and worsen prognosis after a chemical agent exposure. Briefly, such physiologic differences include:

  • Higher minute ventilation.
  • Increased skin permeability.
  • Greater body surface area to weight ratio (plays a key role in degree of contamination and in the ability to maintain thermal homeostasis after decontamination).
  • Less intravascular volume reserve in defense of hypovolemic shock.
  • Shorter stature (which places children nearer to the greatest gas vapor density at ground level). 

Children who are pre-ambulatory or pre-verbal or have special needs are less able to evade danger or seek attention effectively. A chaotic atmosphere compounded by rescuers wearing unfamiliar garb may frighten children of all ages and potentially increase the posttraumatic response to stress. Those providing care for children are faced with additional complexities posed by developmental, age, and weight considerations beyond the general scope of the already enormous challenge.

Initial Approach, Decontamination, and Triage

The general treatment of contaminated victims begins with extrication, triage, resuscitation as needed, and decontamination performed by rescue workers or health care providers wearing appropriate personal protective equipment. Even if decontamination has been done in the field, hospitals are likely to repeat decontamination procedures to protect the facility from contamination. Decontamination to limit secondary exposures is especially important in exposures to nerve agents and vesicants. Children and their parents or caregivers should be kept together during decontamination whenever possible.

After decontamination, ambulatory, asymptomatic victims may be able to be discharged from the scene, while those with minimal symptoms may be directed toward local shelters (e.g., American Red Cross stations, local schools, or other sites designated by local or State health departments) for medical observation. These shelters may also serve as sites for reuniting children and families who have become separated, keeping track of all victims, and communicating with law enforcement agencies.

Community Preparedness

In today's world of heightened awareness, many agencies are collaborating to provide coordinated care of pediatric victims, and all pediatricians are encouraged to participate in disaster management training. The need to stock appropriate antidotes, practice decontamination strategies, and learn the use of personal protective equipment is apparent. Although perhaps not every practicing pediatrician needs to be competent in all aspects of disaster response, all in the community should work together to optimize the overall capacity for providing disaster care to chemically exposed children. Successful planning and response to events involving chemical terrorism require strong collaboration and integrated functioning of many agencies and facilities in the public and private sectors.

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