Ensuring the health security of America's children

TY - JOUR

T1 - Ensuring the health security of America's children

AU - Lurie, Nicole

AU - Khan, Ali S.

N1 - Funding Information: Nicole Lurie MD, MSPH 1 ∗ [email protected] Ali S. Khan MD, MPH, FAAP 2 1 US Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, Washington, DC 2 US Department of Health and Human Services, Centers for Disease Control and Prevention, Atlanta, GA ∗ Reprint requests: Nicole Lurie, MD, MSPH, Assistant Secretary for Preparedness and Response, 200 Independence Avenue SW, 638G, Washington, DC 20201. AAP American Academy of Pediatrics CDC Centers for Disease Control and Prevention HHS US Department of Health and Human Services MCM Medical countermeasures NDMS National Disaster Medical System The US Department of Health and Human Services (HHS) has made ensuring the safety and well-being of the nation's children in the wake of disasters and public health emergencies a priority. More than one-quarter of the US population is younger than 20 years of age, 1 and addressing the unique physiologic and developmental needs of children must be an explicit part of preparedness and response activities. The American Academy of Pediatrics (AAP) and the National Commission on Children and Disasters (2008-2011) have advocated for comprehensive planning and policies regarding emergency preparedness for children. Indeed, the experience of children in disasters can be seen as a harbinger of the overall resilience and recovery of impacted communities. 2 It is important to not only consider the needs of children as survivors, but also how youth can contribute to a whole community response and recovery. Attending to the unique health security needs of children requires a strategy and priority commensurate with their numbers, vulnerability, and importance to our society. Foremost, we need a meaningful focus on children as a bellwether for understanding the impacts of any event and to ensure their inclusion as an integral element of our planning process. To this end, HHS established a Children's HHS Interagency Leadership on Disasters Working Group ( http://phe.gov/Preparedness/planning/abc/Documents/2011-children-disasters.pdf ) to identify ongoing activities and gaps related to children and disasters and to recommend priority actions to improve children's disaster preparedness. We describe progress in public health emergency preparedness in 4 specific areas highlighted by this group: (1) the provision of acute, lifesaving care for children in disasters; (2) the development and stockpiling of medical countermeasures (MCMs) for children; (3) the behavioral and psychological needs of children in disasters; and (4) issues related to child care and welfare. The National Disaster Medical System (NDMS) is a federally coordinated system that augments the nation's medical response capability during domestic disasters. In past disasters, including Hurricane Katrina and the 2010 Haiti earthquake, the composition of NDMS teams has not always been well matched to the needs of impacted children; for instance, few pediatrics-trained providers served on response teams. Recently, a pediatrician with specialty training in emergency medical services and disaster medicine was named to lead the NDMS, and the program is actively recruiting, through strong collaborative efforts with the AAP, the Children's Hospital Association, and others, additional medical officers with training in pediatrics. Pediatric patients and topics are now included in all NDMS field training experiences and in online training modules. The goal is to ensure that any time a team operates in the field, it brings with it the capability to deliver competent and compassionate pediatric care. As was the case during the response to the Haiti earthquake, NDMS staff can now analyze data from the system's electronic health record in near real-time to ensure that the mix of pediatric-capable providers is appropriate to care for the population in need. NDMS deployed more than 20 teams during the response to Superstorm Sandy; each team was capable of providing competent pediatric care. Many states have used HHS' Hospital Preparedness Program funds for pediatric-specific initiatives. For example, Utah, which has the greatest percentage of children in the US, has established Pediatric Strike Teams to increase its capacity to deploy mobile medical personnel and equipment during a disaster. Similarly, the Centers for Disease Control and Prevention (CDC) has supported recommendations for pediatric emergency mass critical care 3 to mirror similar recommendations for adults. 4 The development and stockpiling of appropriate MCMs for use during chemical, biological, radiological, and nuclear events is another preparedness priority. Explicitly considering the needs of at-risk populations (including children) is one of the 4 goals of the congressionally mandated new 5-year Public Health Emergency Medical Countermeasures Enterprise strategy and implementation plan. 5 HHS, through the Biomedical Advanced Research and Development Authority, is supporting advanced development and research to address pediatric formulations, dosing, safety, efficacy, and Food and Drug Administration approval of several MCMs for children. Examples include safe and effective pediatric formulations of Prussian blue for the treatment of radiation poisoning in infants ages newborn to 2 years of age; midazolam autoinjectors and multidose vials to treat persons of any age exposed to chemical nerve agents; a full-capability, closed-loop, portable ventilator that will be appropriate for most infants and children; and formulation studies for crushing and mixing antibiotics if needed for mass distribution. As we move forward, new Project BioShield procurement contracts will include support for the development of pediatric formulations. The Strategic National Stockpile 6,7 holds pediatric formulations, strengths, and sizes of MCMs and ancillary supplies. The formulary undergoes an annual review process, and pediatric MCMs are specifically examined to identify any existing gaps. The CDC has also integrated children's issues into its preparedness and response activities. For example, during the 2009 H1N1 influenza pandemic, CDC established a child health team and procured pediatric doses of antivirals. The team collaborated with experts from the AAP, pediatric nursing associations, pediatric hospitals, and outpatient clinics to develop and refine guidance for providers and parents. 8 The CDC and the Food and Drug Administration worked closely to allow use of the antiviral drug oseltamivir in infants younger than 1 year of age through an Emergency Use Authorization and to develop communication materials for pharmacists regarding the emergency compounding of oseltamivir suspension when commercially manufactured suspension was unavailable. Similarly, capsule-opening guidance for parents was posted on the CDC Web site. 9 In December 2012, the Food and Drug Administration expanded the approved use of oseltamivir to treat children as young as 2 weeks old who have shown symptoms of influenza for no longer than two days. The National Biodefense Science Board, which was established to provide guidance on prevention, preparedness, and response efforts in connection with the public health effects of chemical, biological, radiological, and nuclear events, includes representatives from the pediatric community. It most recently advised on preparedness activities related to the use of anthrax vaccine adsorbed in pediatric populations as postexposure prophylaxis after an anthrax attack. Similarly, CDC and the AAP Disaster Preparedness Advisory Council 10 and Anthrax Workgroup jointly sponsored a clinical guidance meeting about anthrax therapeutics in children in November 2012. Finally, in 2011, HHS established a Pediatric and Obstetric Integrated Program Team to provide ongoing expert guidance on pediatric and obstetric MCM needs across the entire Public Health Emergency Medical Countermeasures Enterprise. Children often experience psychological distress after disasters, and HHS has prioritized the development of mitigation strategies. For example, all NDMS responders are now being trained in techniques for psychological first aid. The tornado that devastated Joplin, Missouri, in May 2011 left many children and adolescents with unresolved symptoms of anxiety, distress, and heightened worry for the safety of themselves and others. “Healing Joplin After the Storm,” a crisis counseling program administered through the HHS Substance Abuse and Mental Health Services Administration with Federal Emergency Management Agency funding, bolstered existing behavioral health services by sending workers trained in trauma, disaster, and psychological first aid (including for children) into the community. These workers were able to provide direct outreach, education, and supportive interventions to individuals at their local businesses and schools. Recovery efforts for these and other young disaster survivors will continue as HHS assumes the lead for the new Health and Social Services Recovery Support Function under the National Disaster Recovery Framework. More generally, HHS now has an operational plan designed to provide coordination and guidance for HHS federal-level behavioral health disaster preparedness, response, and recovery. Children's issues are integral to this plan. By clearly defining roles, responsibilities, procedures, and processes for use during public health crises and by sharing best practices for behavioral health preparedness and response across states and communities, HHS aims to help mitigate or prevent more serious behavioral health problems in disaster survivors and responders and promote individual and community resilience. This effort is especially true for children with special health care needs. This segment of the population is particularly vulnerable within the larger pediatric population. They represent 16% of the population of children up to age 17 years, but represented more than 50% of the pediatric influenza-associated deaths during the H1N1 pandemic. Children with special health care needs and/or disabilities may have additional cognitive, social, or physical reasons which place them at increased risk. More than 11 million children younger than 5 years of age participate in child-care programs every week, 11 and maintaining their safety during major disasters requires advanced planning. HHS Administration for Children and Families has issued guidance to states in developing, exercising, and maintaining written emergency preparedness and response plans for child care. The guidance addresses 5 key elements: planning for continuation of services, coordination with emergency management agencies and other key partners, regulatory requirements, provision of temporary services, and rebuilding after a disaster. It also includes a checklist specifically tailored to the needs of state child care programs as they work to develop and refine emergency preparedness plans. Plans to further enhance pediatric preparedness are in the works. The NDMS recruits pediatric clinicians to serve on its teams (see www.phe.gov for information), and a pilot program has been established to ensure that the NDMS has access to pediatric subspecialists to augment the standard team configurations. In addition to federal work, there are various opportunities for involvement at the local, state, and regional level, either on response teams or as vital components of disaster planning boards and committees. Pediatricians wishing to volunteer can do so through their local Medical Reserve Corps 12 or the Emergency System for Advanced Registration of Volunteer Health Professionals system. 13 The National Center for Disaster Medicine and Public Health is in the process of identifying core competencies in pediatric disaster medicine, the first step in developing metrics by which to gauge disaster response and recovery systems for their ability to deliver pediatric-capable care. 14 Recently, the Office of Preparedness and Emergency Operations under the Assistant Secretary for Preparedness and Response held 2 meetings with national-level stakeholders concerning the medical evacuation of pediatric disaster victims. Developing a national (as opposed to a federal) system that can deliver an adequate amount of pediatric-capable care during mass medical evacuation is a significant but necessary challenge, primarily because most of the national capability to conduct mass patient care movement exists for adult patients only. Finally, the focus on healthcare coalitions through the Hospital Preparedness Program should serve as the basis for additional involvement of children's hospitals and clinics in both community- and regional-level planning. The Department will continue to build on efforts to ensure that the needs of families and children in disasters are well met. We embrace the Federal Emergency Management Agency's perspective that planning and response to disasters must involve the “whole community” including children. It is important to not only consider the needs of children as survivors but how youth can be empowered to be part of a whole community response. Receipt of information and instruction is critical in disasters. In many families, children are, for example, the only English speakers, and serve as sources of information for several generations of family members. Youth are more often early adopters of social media; numerous recent events have shown how text messaging and programs such as Facebook and Twitter provide information as well as material and psychological support during disasters 15 —creating the potential for a savvy public health communicator in every household. We look forward to our continued collaboration with advocates for children as we continue to build a prepared and resilient nation—ready for all health threats. We thank Drs Dan Sosin, Nicki Pesik, Steve Redd, Sue Gorman, and Georgina Peacock (CDC), and Dr Dan Dodgen, Dr Andrew Garrett, Ms Olivia Sparer, and Ms Melissa Harvey (Office of the Assistant Secretary for Preparedness and Response) for technical suggestions and review of the manuscript.

PY - 2013

Y1 - 2013

UR - http://www.scopus.com/inward/record.url?scp=84879416062&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84879416062&partnerID=8YFLogxK

U2 - 10.1016/j.jpeds.2013.01.035

DO - 10.1016/j.jpeds.2013.01.035

M3 - Comment/debate

C2 - 23485032

AN - SCOPUS:84879416062

SN - 0022-3476

VL - 163

SP - 274

EP - 276

JO - Journal of Pediatrics

JF - Journal of Pediatrics

IS - 1

ER -