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PDLS © : Children in Disaster: Public Health Considerations and Disaster Mitigation.

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Presentation on theme: "PDLS © : Children in Disaster: Public Health Considerations and Disaster Mitigation."— Presentation transcript:

1 PDLS © : Children in Disaster: Public Health Considerations and Disaster Mitigation

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3 Preparing for the Public Health consequences of disaster involving children should occur at the Community, State and Federal levels. The benefits of this type of planning have been proven many times over

4 Identify personnel, equipment and infrastructure for pediatric disaster preparedness Identify personnel, equipment and infrastructure for pediatric disaster preparedness Learn the principles of family disaster planning Learn the principles of family disaster planning Recognize which potential biological disasters may be mitigated by public health measures Recognize which potential biological disasters may be mitigated by public health measures Consider public health implications of chemical and radiation attacks Consider public health implications of chemical and radiation attacks Understand the components of disaster mitigation Understand the components of disaster mitigation Objectives

5 Community Resources Pediatric emergency and trauma centers Pediatric emergency and trauma centers Pre-hospital care providers, including EMS, fire departments and police Pre-hospital care providers, including EMS, fire departments and police Social services Social services Schools Schools Local health clinics Local health clinics Departments of Health Departments of Health Government Government Local and national media Local and national media Photo Courtesy of FEMA

6 Emergency Medical Services for Children (EMS-C) in a Disaster A program of Health Resources and Services Administration (HRSA) A program of Health Resources and Services Administration (HRSA) - Education and grant funding for development pre-hospital pediatric care Provides designations for pediatric disaster centers Provides designations for pediatric disaster centers - Emergency Department Approved for Pediatrics (EDAP) - Pediatric Critical Care Center (PCCC) - Stand-by Emergency Department Approved for Pediatrics (SEDP)

7 Plans for Surge Capacity Facilities Hospitals without formal pediatrics services Hospitals without formal pediatrics services Community health centers Community health centers Rehabilitation hospitals Rehabilitation hospitals Urgent care centers Urgent care centers Physicians’ offices Physicians’ offices Nursing homes Nursing homes School-based health centers School-based health centers Field hospitals in gymnasiums, warehouses, arenas and convention centers Field hospitals in gymnasiums, warehouses, arenas and convention centers Religious or faith-based facilities Religious or faith-based facilities

8 Healthcare Providers Coursework Available coursework for pediatric clinician disaster preparedness: Basic and Advanced Disaster Life Support (BDLS, ADLS) Basic and Advanced Disaster Life Support (BDLS, ADLS) Disaster Preparedness for School Nurses Disaster Preparedness for School Nurses Pediatric Advanced Life Support (PALS) Pediatric Advanced Life Support (PALS) Advanced Pediatric Life Support (APLS) Advanced Pediatric Life Support (APLS) Emergency Nursing Pediatric Course (ENPC) Emergency Nursing Pediatric Course (ENPC) Pediatric Education for Pre-hospital Professionals (PEPP) Pediatric Education for Pre-hospital Professionals (PEPP) Advanced Trauma Life Support (ATLS) Advanced Trauma Life Support (ATLS)

9 Equipment Necessary for Pediatric Disaster Preparedness Airway equipment Airway equipment IV access devices ( intravenous lines, intraosseous needles) IV access devices ( intravenous lines, intraosseous needles) Warming blankets Warming blankets Radiant warmers Radiant warmers Normal saline Normal saline Pediatric nutrition supplies Pediatric nutrition supplies - Formula, - G-tube feeds, - Child-friendly non-perishable items Laryngeal Mask Airway

10 Vectors of Transmission of Infectious Diseases Affected by Disaster Airborne Airborne - Crowded habitation Waterborne Waterborne - Contaminated water supply - Children most susceptible Foodborne Foodborne - Problems with proper storage Insect and Animal borne Insect and Animal borne - Decrease disease transmission control

11 Consider the Needs of Children in Family Preparedness Planning Listing of key phone numbers Listing of key phone numbers Create an emergency kit Create an emergency kit - Prescription medications - OTC medications - Formula/Food - Diapers - Clothes Create a list of trusted adults and a safety “password” Create a list of trusted adults and a safety “password” Comfort objects and foods Comfort objects and foods

12 Family Disaster Planning (focus on the safety of the children): Safe sites within the home Family communication – reassembly plan (children at school parents at work) Stored disaster supplies (water, food, cooking equipment, heat sources) Conduct drills for common disasters (tornado, earthquake) In reality few families have done any planning

13 Pets in Disaster Planning Case study-Katrina Case study-Katrina

14 Family Disaster Planning Preparation: Home Create and discuss disaster plan for family Create and discuss disaster plan for family Acquaint all family members with first aid equipment in home Acquaint all family members with first aid equipment in home Route of egress from home Route of egress from home Meeting place outside Meeting place outside Conduct drills Conduct drills

15 Preparation: Home Preparation: Home Keep disaster stores of food, meds, diapers, etc. Keep disaster stores of food, meds, diapers, etc. Have “disaster containers” in home and car Have “disaster containers” in home and car Special needs children Special needs children - Early evacuation plans, etc

16 Pharmaceutical/Medical Supply Stockpiles The Centers for Disease Control and Prevention (CDC) provide a Strategic National Stockpile (SNS) The Centers for Disease Control and Prevention (CDC) provide a Strategic National Stockpile (SNS) - Developed in 1999 for anthrax - Point of delivery (POD) system for local distribution, with supplementation by state and national sources within 48 hours States should plan on being self-sufficient for 72 hours before SNS arrives States should plan on being self-sufficient for 72 hours before SNS arrives Instructions for accessing PODS Instructions for accessing PODS - Use of United States Postal Service for distribution - Security considerations - Available media used to disseminate distribution point locations

17 Pre-event Public Health Planning Issues: Evacuation of populations at risk. Evacuation of populations at risk. Provide temporary shelter and protection from the environment. Provide temporary shelter and protection from the environment. Provide food, water and clothing. Provide food, water and clothing. Plan for adequate personnel hygiene (toilets, showers, etc.). Plan for adequate personnel hygiene (toilets, showers, etc.). Backup plans for communications, transportation and activities for children. Backup plans for communications, transportation and activities for children. Plan for management of children with special needs. Plan for management of children with special needs.

18 Post-event Public Health Response Issues: Finding and extracting individuals who refused to evacuate Finding and extracting individuals who refused to evacuate Manage neglected chronic medical issues (diabetes, heart disease, etc.) Manage neglected chronic medical issues (diabetes, heart disease, etc.) Provide for medical emergencies and childbirth Provide for medical emergencies and childbirth Keeping confined children healthy (medical & psychological). Keeping confined children healthy (medical & psychological).

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27 Public Health Issues: Infectious Disease Outbreaks Type Airborne illnesses: Airborne illnesses: Vector borne illnesses: Vector borne illnesses: Water-borne illnesses: (oral-fecal transmission) Water-borne illnesses: (oral-fecal transmission) Food borne illnesses: Food borne illnesses:Examples Influenza, tuberculosis Avian flu, malaria, dengue, tick related Cholera, salmonella, shigella, norovirus, cryptosporidiosis Fungi, E-Coli

28 Influenza Influenza, a common viral respiratory virus with a long history of periodic pandemics Influenza, a common viral respiratory virus with a long history of periodic pandemics Mutations in strains of influenza including bird flu pose risk of widespread outbreak Mutations in strains of influenza including bird flu pose risk of widespread outbreak Risk of death increases with secondary bacterial infections Risk of death increases with secondary bacterial infections Highly contagious, spread via droplet and contact routes Highly contagious, spread via droplet and contact routes

29 Influenza: Treatment and Prevention Amantadine is used for influenza A in children > 12 months Amantadine is used for influenza A in children > 12 months - Useful if given within 2 days of symptoms Oseltamivir (Tamiflu) is approved for children > 12 months Oseltamivir (Tamiflu) is approved for children > 12 months - Prevents release of viral particles from infected cells - Efficacious for influenza A and B - Given orally bid for 5 days Both agents approved for chemotherapy, theoretically useful as prophylaxis Both agents approved for chemotherapy, theoretically useful as prophylaxis

30 Influenza: Treatment and Prevention Indications for immunoprophylaxis (protection from influenza A and B) Indications for immunoprophylaxis (protection from influenza A and B) - Children less than 9 years receiving influenza immunization for the first time require two doses one month apart The following children require immunization: The following children require immunization: - Persons aged 2-18 years with comorbid conditions - Children aged 6-59 months - Pregnant adolescents - Household contacts and out-of- home caregivers of children aged <6 months

31 Viral Hemorrhagic Fevers Viral hemorrhagic fevers, a group of diseases carried by animals and characterized by bleeding Viral hemorrhagic fevers, a group of diseases carried by animals and characterized by bleeding - More likely to be fatal in children Examples include Argentine Hemorrhagic Fever, Ebola, Lassa, Hanta and Nipah viruses Examples include Argentine Hemorrhagic Fever, Ebola, Lassa, Hanta and Nipah viruses Usually spread via contaminated body fluids, mosquitoes and ticks Usually spread via contaminated body fluids, mosquitoes and ticks Rarely airborne Rarely airborne Few antiviral drugs/chemotherapy available Few antiviral drugs/chemotherapy available Mosquito and Tick Photos Credit: CDC

32 Viral Hemorrhagic Fevers: Treatment and Prevention Most have no specific treatment Most have no specific treatment Supportive care Supportive care Two Exceptions Two Exceptions - Argentine hemorrhagic fever convalescent serum - Ribavirin is an antiviral drug useful for Lassa virus Ribavirin

33 Smallpox A delayed cutaneous infection spread via respiratory route A delayed cutaneous infection spread via respiratory route Acute, contagious and sometimes fatal disease caused by the variola virus (an orthopoxvirus) Acute, contagious and sometimes fatal disease caused by the variola virus (an orthopoxvirus) Historically important disease Historically important disease - Speculation about availability as WMD Photos: CDC Photo Credit: CDC

34 Smallpox: Treatment and Prevention Pre-exposure vaccination not currently recommended in children Pre-exposure vaccination not currently recommended in children Vaccine is effective in decreasing disease severity within 4 days of exposure Vaccine is effective in decreasing disease severity within 4 days of exposure Ring vaccination strategy recommended in event of an outbreak Ring vaccination strategy recommended in event of an outbreak Contraindications include eczema and immunodeficiency Contraindications include eczema and immunodeficiency Vaccinia immune globulin (VIG) is immunotherapy stockpiled by CDC for complications of vaccine Vaccinia immune globulin (VIG) is immunotherapy stockpiled by CDC for complications of vaccine Edward Jenner

35 Tularemia Tularemia, a disease of rabbits and rodents, spread to people by contact with these animals or the ticks and mosquitoes that feed on them Tularemia, a disease of rabbits and rodents, spread to people by contact with these animals or the ticks and mosquitoes that feed on them Caused by Francisella tularensis Caused by Francisella tularensis - Can be aerosolized and used as a weapon - No immunization is widely available

36 Tularemia: Treatment and Prevention Antibiotics Antibiotics - First line agents include gentamicin for 10 days - streptomycin and amikacin good alternatives - Doxycycline and fluoroquinolones are second line agents, with risk of adverse effects Doxycycline

37 Brucellosis A disease usually caused by contact with infected animals and animal products A disease usually caused by contact with infected animals and animal products Examples include cows and milk Examples include cows and milk - Caused by Brucella bacteria - Can be aerosolized and used as a weapon - No immunization is widely available

38 Brucellosis: Treatment and Prevention Indications for antibiotics Indications for antibiotics - Recommendation for post- exposure prophylaxis - Rifampicin and trimethoprim- sulfamethoxazole (TMP-SMX) for 3-6 weeks - May be given by mouth - May use quinolones, doxycycline in children over 8

39 Plague Caused by Yersinia pestis, a bacterium found in rodents and their fleas in many areas around the world Caused by Yersinia pestis, a bacterium found in rodents and their fleas in many areas around the world Forms: Bubonic, Septicemic and Pneumonic Forms: Bubonic, Septicemic and Pneumonic Can be aerosolized and used as a weapon Can be aerosolized and used as a weapon

40 Plague: Treatment and Prevention A plague vaccine is not currently available for use in the United States A plague vaccine is not currently available for use in the United States Antibiotics must be given within 24 hours of first symptoms Antibiotics must be given within 24 hours of first symptoms Streptomycin 30 mg/kg/day divided in two doses Streptomycin 30 mg/kg/day divided in two doses Streptomycin

41 Anthrax Anthrax, a disease of animal handlers and those who encounter contaminated animal products Anthrax, a disease of animal handlers and those who encounter contaminated animal products Inhalational most likely weapon Inhalational most likely weapon - Used in 2001 anthrax mail contamination - Highly lethal - Initial flu-like illness for 2-5 days - Followed by intra-thoracic bleeding, dyspnea, pleural effusions and widened mediastinum

42 Anthrax Delayed symptoms Delayed symptoms - Oral-gastrointestinal - Cutaneous - Hemorrhagic meningitis

43 Lesion of Cutaneous Anthrax Associated With Microangiopathic Hemolytic Anemia and Coagulopathy in a 7-Month-Old infant

44 Cutaneous Anthrax Pediatric case: Pediatric case: - systemic illness seen transient DIC renal dysfunction - unique susceptibility?

45 Anthrax Decontamination Decontamination - Undress, soap/shower. Use 0.5% diluted household bleach for gross or visible contamination - Environment: 0.5% bleach

46 Anthrax: Treatment and Prevention BioThrax immunization for animal handlers and military BioThrax immunization for animal handlers and military Limited data support intramuscular doses at 0, 2 and 4 weeks after exposure Limited data support intramuscular doses at 0, 2 and 4 weeks after exposure - No human studies showing efficacy in post-exposure prophylaxis - Prevents cutaneous anthrax in humans - Animal studies show prevention of inhalation disease Not licensed by FDA for post-exposure prophylaxis Not licensed by FDA for post-exposure prophylaxis

47 Anthrax: Treatment and Prevention Initial prophylaxis with either fluoroquinolone or tetracycline Initial prophylaxis with either fluoroquinolone or tetracycline - Ciprofloxacin (10-15 mg/kg/dose po q 12 hrs) not to exceed 1 gram per day or - Doxycycline - up to and including 8 years or over 8 years and less than or equal to 45 kg (2.2 mg/kg/dose po BID) Benefit of protecting children outweighs risks of medication exposure Once susceptibility of organism established, change to amoxicillin, clindamycin or vancomycin Treat for 60 days to allow time for spores to germinate and be killed

48 Botulism Botulism, a paralytic disease caused by the toxin of Clostridium botulinum Botulism, a paralytic disease caused by the toxin of Clostridium botulinum - Can be aerosolized and used as a weapon - Non-terrorist cases caused by contaminated food - No antibiotic/chemotherapy treatment exists Clostridium Botulinum Photo Credit: CDC

49 Botulism: Treatment and Prevention Suspected cases require supportive care Suspected cases require supportive care - Respiratory support - Intravenous nutrition Botulinum antitoxin is available Botulinum antitoxin is available - Should be used in symptomatic cases before laboratory confirmation - Approved for use in children by FDA - Manufactured by California Department of Health Services

50 Case Study – Rapid Displacement Rwandan Civil War – 1994 Disaster Type: Rapid displacement of a large improvished population (aka – complex humanitarian disaster) Medical Issues:Epidemics of infectious disease such as: cholera, hepatitis, exposure, nutritional needs of children

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52 Public Health Issues – Airborne Toxins Smothering construction materials, fuels, freon Smothering construction materials, fuels, freon Examples: Silica, asbestos, h2g, CO, Lead, etc. Examples: Silica, asbestos, h2g, CO, Lead, etc.

53 Public Health Issues – Airborne Radiation

54 “In some respects, major radiation exposure due to a terrorist attack should be easier to manage than chemical or biological attacks. An important resource is the tens of thousands of persons who deal with radiation daily at hospitals, universities, military units, national laboratories, and government agencies”. NEJM 2002 Radiation Exposure

55 Radiation Characteristics TypePenetrateComments AlphaNo Inhale, ingest, open wound BetaSuperficial Electrons, a few centimeters GammaDeep Easy penetration X-RayDeep

56 Severity None Death Nausea Vomiting Diarrhea Hypotension Confusion Seizures Coma

57 ED MD Response Seal ED with police-security Seal ED with police-security Get Radiation Safety to ED STAT Get Radiation Safety to ED STAT Create decontamination area Outside Create decontamination area Outside Don’t Contaminate ED Don’t Contaminate ED Wear gowns, gloves, radiation detectors Wear gowns, gloves, radiation detectors

58 Public Health Issues – Personal & Intrapersonal Violence and Abuse Child abuse, PTSD, partner abuse, suicide, substance abuse Child abuse, PTSD, partner abuse, suicide, substance abuse

59 What is Disaster Mitigation? What is Disaster Mitigation? Steps taken prior to and after a disaster to minimize morbidity and mortality Steps taken prior to and after a disaster to minimize morbidity and mortality Examples include: Examples include: - disaster plans: community, school, and home - pre-designated shelters - clean water stores, food stores - post disaster emotional support

60 Examples of Disaster Mitigation Activities: Community wide influenza vaccination programs Community wide influenza vaccination programs Enforcement of engineering codes for construction projects Enforcement of engineering codes for construction projects Avoidance of construction in disaster prone areas Avoidance of construction in disaster prone areas Stockpiling of supplies in safe places Stockpiling of supplies in safe places

61 Disaster Mitigation: Planning for Mass Gathering (particularly those involving children): Concerns: fire, riot-stampede, major accidents (stage collapse), inclement weather Concerns: fire, riot-stampede, major accidents (stage collapse), inclement weather Specifics: onsite EMS deployment; triage plan from site to available medical facilities Specifics: onsite EMS deployment; triage plan from site to available medical facilities

62 Preparation: School Makes disaster plan known to all Makes disaster plan known to all Routes of egress from school Routes of egress from school Meeting place Meeting place Drills Drills

63 Hospital Interface Work with local and state officials to create disaster management plan Work with local and state officials to create disaster management plan Local EMS plans for all schools & daycares Local EMS plans for all schools & daycares Practice interface between school, EMS, and hospital with drills at least once a year Practice interface between school, EMS, and hospital with drills at least once a year

64 Recovery Phase: Initial Shelters should be “kid friendly” Shelters should be “kid friendly” Keep families together Keep families together Personnel to organize area for orphaned and separated children until families reunited Personnel to organize area for orphaned and separated children until families reunited Create children's groups in shelter, plenty of toys, books, etc.. Create children's groups in shelter, plenty of toys, books, etc..

65 Recovery Phase: Long-term Psychological services early Psychological services early Be attentive to children's needs, consider educational resources for long-term sheltering. Be attentive to children's needs, consider educational resources for long-term sheltering. Aberrant behavior may be manifestation of emotional trauma Aberrant behavior may be manifestation of emotional trauma

66 Recovery Phase: Long-term Children must feel safe in home, community and school; encourage this Children must feel safe in home, community and school; encourage this Learn from mistakes Learn from mistakes

67 Disaster Mitigation: What you can do Emergency physicians, Pediatric EM physicians, Pediatricians, Nurses, other health care professionals: Emergency physicians, Pediatric EM physicians, Pediatricians, Nurses, other health care professionals: - Preparation before disaster - Action during disaster - Recovery phase

68 Before Disaster Strikes Involve yourself in the local EMS and area disaster plan: help to develop systems that keep children's’ needs in mind Involve yourself in the local EMS and area disaster plan: help to develop systems that keep children's’ needs in mind Work with schools, daycares and local hospitals to develop integrated disaster plans Work with schools, daycares and local hospitals to develop integrated disaster plans Act as an advisor to your patients for home disaster planning Act as an advisor to your patients for home disaster planning

69 Before Disaster Strikes Arrange disaster response drills Arrange disaster response drills Promote community awareness addressing pediatric needs Promote community awareness addressing pediatric needs

70 During A Disaster Be active!! Be active!! Institute disaster plans in your facility Institute disaster plans in your facility Participate in the community response to disaster Participate in the community response to disaster

71 Disaster Recovery Provide medical care to shelters Provide medical care to shelters Assume basic community services will be disrupted for some time Assume basic community services will be disrupted for some time Attend to emotional needs of the pediatric population effected Attend to emotional needs of the pediatric population effected

72 Summary Pediatric disaster public health issues require the right people, places, tools and plans Pediatric disaster public health issues require the right people, places, tools and plans Disaster preparedness includes planning, training, and acquisition of appropriate medications and equipment Disaster preparedness includes planning, training, and acquisition of appropriate medications and equipment Disaster mitigation begins before the event Disaster mitigation begins before the event Photo Credit: FEMA


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