A Child’s Health Is the Public’s Health: Progress and Gaps in Addressing Pediatric Needs in Public Health Emergencies

Abstract

Children are the most prevalent vulnerable population in US society and have unique needs during the response to and recovery from public health emergencies. The physiological, behavioral, developmental, social, and mental health differences of children require specific attention in preparedness efforts. Despite often being more severely affected in disasters, children’s needs are historically underrepresented in preparedness.

Since 2001, much progress has been made in addressing this disparity through better pediatric incorporation in preparedness planning from national to local levels. Innovative approaches, policies, and collaborations contribute to these advances. However, many gaps remain in the appropriate and proportional inclusion of children in planning for public health emergencies.

Successful models of pediatric planning can be developed, evaluated, and widely disseminated to ensure that further progress can be achieved.

Children younger than 18 years constitute approximately 25% of the US population and, as is often said, 100% of our future. In the context of disasters and public health emergencies, they are the most prevalent vulnerable population and have age-specific vulnerabilities that heighten their risks and magnify their unique needs during response and recovery.¹ These include physiological vulnerability to a variety of pathogens, toxins, radioactive isotopes, and harsh conditions. Increased skin permeability, faster metabolism, more active cell division, higher respiratory rate, and higher surface area–to–mass ratio can all contribute to greater susceptibility to physical threats.¹ Behavioral differences in children based on their stages of development, such as more hand-to-mouth contact, underdeveloped sense of self-preservation, more time spent outdoors and on the ground, and difficulty communicating symptoms, can make them more likely to be exposed to a hazard or less able to protect themselves from its effects.² Beyond this, children have substantially more daily person-to-person social contact than adults, making them especially vulnerable to contagious threats.³ Children in disasters may develop mental health problems, including acute stress disorders, posttraumatic stress disorder, and depression. Children’s vulnerability can vary according to individual factors as well; some children live with disabilities or are dependent on medical technology, and more than 30% of all US children live below poverty levels.⁴

DISPROPORTIONATE REPRESENTATION

Children can be more severely affected in public health emergencies. New strains of influenza and other emerging infections often disproportionately attack the young, who have no immunity to earlier circulating strains with similar antigenic properties.⁵ In natural disasters, children’s vulnerabilities are equally evident. As many as one third of the causalities in the 2004 Indian Ocean tsunami were children, many of whom were likely not strong enough to resist the force of the water.⁶ In the 2010 magnitude 7.0 Haiti earthquake, an estimated 220 000 people lost their lives, and more than 300 000 were injured; one study estimated that almost half of the injured were children.⁷

Unfortunately, intentional disasters and terrorist attacks greatly affect and have sometimes specifically targeted children because of the elevated emotional effect and enduring damage that the loss of children inflicts on society.² The deliberate destruction of the child care center of the Oklahoma City, Oklahoma, federal building bombed in 1995 (19 children killed); the 2004 school siege in Beslan, Russia (1200 hostages, with 186 children killed); and the 2012 massacre (20 children killed) at Sandy Hook Elementary School in Newtown, Connecticut, are grim examples of this pattern. War and conflict also highlight the vulnerability of children, causing disproportionate morbidity and mortality. Examples include chemical agent attacks, such as those occurring during the Syrian Civil War (more than 400 children killed in a single day), in which inhalation of toxic gases is potentiated in children who are closer to the ground and breathe with faster respiratory rates.^1,8

Despite heightened vulnerability, children and their needs are historically underrepresented in preparedness efforts in both public health and medical communities.¹ In public health, progress has been limited in formulating, approving, and stockpiling medical countermeasures for use in children.¹ Several elements of a public health response, such as evacuation, decontamination, and sheltering, require special consideration of children to successfully address their needs; however, these needs are frequently not modeled in exercises or included in planning. Public health guidance documents for response and recovery often lack information about children, and public health responders may not recognize children’s different vulnerabilities. In the medical community, all hospitals, not just children’s hospitals, may be called on to care for children in a public health emergency, and without advanced planning, they may not be able to cope with a surge in pediatric patients. A recent report highlighted that only 47% of hospitals have disaster plans that address pediatric-specific needs.⁹ These gaps indicate a disconnect between the spheres of public health preparedness and pediatric medicine: children’s providers are often unaware of what preparedness steps are being taken in their communities, and public health professionals are not clear on what roles pediatric institutions would play in the event of a public health emergency.

PROGRESS AND ACCOMPLISHMENTS

Ongoing pediatric emergency and disaster preparedness efforts, including those by the American Academy of Pediatrics and by the Emergency Medical Services for Children program of the Health Resources and Services Administration, predate the September 11, 2001, terrorist attacks in the United States; however, many important actions to promote disaster preparedness for children have occurred since then.^10,11 At a national level, concerns about the state of pediatric readiness were raised to prominence with the watershed report by the National Commission on Children in Disasters.¹² The commission’s executive summary stated that

One year ago [2009], the Commission offered a sobering assessment of the national state of disaster and emergency preparedness for children. As expected, we found serious deficiencies in each functional area, where children were more often an afterthought than a priority.

It went on to state,

In our final analysis, meeting the needs of children in disaster planning and management is a national responsibility lacking not only sufficient funding, but also a pervasive concern, a sustained will to act, and a unifying force.¹²

The commission made more than 80 specific recommendations to the president of the United States and Congress, including adoption of a national strategy on children in disasters. Federal agencies incorporated some of these recommendations into their preparedness efforts.⁹ The US Department of Health and Human Services (HHS) created the Office of the Assistant Secretary for Preparedness and Response (ASPR) in 2006, which houses a Division for At-Risk Individuals, Behavioral Health, and Community Resilience that addresses the needs of children in disaster preparedness. This office coordinates the Children’s HHS Interagency Leadership on Disasters Working Group, established in 2010, to facilitate interagency cooperation on pediatric-focused preparedness efforts.¹³ Collaborative work included the creation of a Pediatrics and Obstetrics Integrated Program Team to provide expert guidance to the HHS Public Health Emergency Medical Countermeasures Enterprise and prioritize gaps related to pediatric and obstetric medical countermeasure needs.¹³ Additionally, individual federal agencies took actions that complemented these cross-agency efforts. The Centers for Disease Control and Prevention (CDC) launched a Children’s Preparedness Unit in 2012 to address children’s needs in the context of infectious disease outbreaks and other public health emergencies.¹⁴ That same year, the Federal Emergency Management Agency formed a Youth Preparedness Council to bring together youth leaders to advocate for preparedness efforts in their own communities.¹⁵

The Pandemic and All-Hazards Preparedness Reauthorization Act, passed and signed in March 2013, specifically addressed the need for children’s issues to be incorporated into preparedness activities.⁹ Following enactment of the Pandemic and All-Hazards Preparedness Reauthorization Act, the HHS secretary, in consultation with the secretary of the US Department of Homeland Security, established the National Advisory Committee on Children and Disasters in 2014. Its purpose is to provide advice and consultation to HHS and ASPR with respect to the medical and public health needs of children in disasters.⁹ The National Advisory Committee on Children and Disasters produced reports and recommendations on pediatric surge capacity (to improve preparedness for pediatric mass casualty incidents) and health care preparedness (focusing on coalitions, workforce development, and medical countermeasures). Forthcoming reports on youth resiliency, postdisaster support strategies (such as child care, domestic violence programs, psychological first aid, and research), and pediatric inclusion in preparedness funding strategies are expected.

In November 2015, more than 200 people attended the first National Pediatric Disaster Coalition Conference. Recommendations were made targeting important gaps in pediatric disaster preparedness. Conference organizers and attendees resolved to create the National Pediatric Disaster Coalition with the mission to advance community preparedness, mitigation, response, and recovery for newborns, infants, children, and their families in disasters. Coalition participants include representatives from the American Academy of Pediatrics, ASPR, CDC, Department of Homeland Security, Emergency Medical Services for Children, Federal Emergency Management Agency, and Health Resources and Services Administration. Efforts to widely disseminate available information about pediatric disaster medicine include the ASPR Technical Resources, Assistance Center, and Information Exchange and the Department of Homeland Security–sponsored Pediatric Disaster Resilience Group. In 2016, the Office of the ASPR released new Health Care Preparedness and Response Capabilities for 2017 to 2022, including a focus on coalitions, which include pediatric disaster preparedness in the context of overall preparedness.¹⁶

These efforts yielded policy changes to potentially improve pediatric response in future incidents. Examples include the development of new medications and medical countermeasures for children by the Biomedical Advanced Research and Development Authority within the Office of the ASPR, as well as the adoption of new processes and protocols by the US Food and Drug Administration and CDC for approval and emergency or investigational use of certain therapeutics in children, such as botulism antitoxin and anthrax vaccine, during a mass event.¹ The CDC also has integrated a children’s health team into its Emergency Operations Center structure, beginning in 2009 with the H1N1 influenza pandemic and including responses to influenza A variant virus (H3N2v) in 2012, Ebola virus in 2014 to 2015, Zika virus in 2016 to 2017, and Flint, Michigan, water contamination in 2016.

The local efforts of children’s hospitals, community-based organizations, and the small but growing numbers of pediatric disaster coalitions are improving pediatric preparedness as well. Initiatives include pediatric-focused training for disaster response, child-focused triage tools and transport capabilities, pediatric surge and evacuation planning for hospitals and health systems (including space, staffing, and equipment needs), and family reunification following a sudden disruptive event.¹⁷

Some of the lessons learned and progress made in children’s preparedness are direct consequences of recent public health emergency responses. The 2001 anthrax incident and the 2009 to 2010 H1N1 influenza pandemic led to the development of better disaster communications tools and surge preparedness for children. The reactor meltdowns at the Fukushima Nuclear Power Plant in 2011 raised important issues related to the decontamination and treatment of children exposed to radiation.¹ The complex topic of parental presence for a child infected with a dangerous and transmissible pathogen was considered at length during the recent historic Ebola outbreak from 2014 to 2015, leading to specific guidance from the American Academy of Pediatrics.¹⁸ The ongoing Zika virus outbreak since 2016 brought many child-focused public health efforts not typically involved in emergency responses into the spotlight, such as birth defects surveillance, and raised awareness that affected children can have substantial needs long after the immediate emergency itself has passed.

REMAINING GAPS

Important progress is ongoing, but many gaps remain to meet the needs of children during public health emergencies. Ensuring appropriate and proportional inclusion of children in all exercises and other preparedness activities for natural, accidental, and intentional disasters is critical. A 2015 report by Save the Children emphasized that only 17 of the National Commission on Children in Disasters’ recommendations were fully met, with 44 still in progress and 20 not addressed at all, stating that “of every $10 in federal emergency preparedness grants, less than one cent is directed toward activities targeting children’s safety.”¹⁹ Although national resources and strategies to prepare for children’s needs during public health emergencies improved overall, pediatric planning is not consistently adopted at national, regional, state, and local levels. The purpose and operation of pediatric disaster coalitions within the context of overall preparedness must be addressed and informed by existing successful models. Gaps remain in the available medical countermeasures and in knowledge of disaster-related pediatric physiology and pharmacology, pediatric surge capacity, and first responder and overall training in pediatric protocols. The Emergency Medical Services for Children’s Pediatric Readiness Project identified the lack of specific emergency department readiness, which highlights the need for viable solutions to the care of children in nonpediatric emergency departments.²⁰ Federal disaster medical assistance team functions can improve by including obstetric, newborn, and pediatric services, equipment, and supplies. Functional and full-scale disaster preparedness exercises, whether local, regional, or national, will better meet children’s developmentally appropriate needs when they include a pediatric component and facilitate improved connections with pediatric practitioners. Collection of pediatric-specific epidemiology and surveillance information during a public health emergency can help direct resources to meet the needs of children more effectively. Protocols for emergency or investigational use of medical countermeasures, when not licensed for children, will require detailed implementation plans, which are most effective if available before the emergency.

Additionally, mental health considerations for children in disasters require more attention and better understanding. Although children can be incredibly resilient, unattended mental health problems can be quite damaging and cause avoidable long-term disability. Children may have great difficulty coping with traumatic events, as was apparent in the aftermath of the September 11 terrorist attacks and Hurricane Katrina. These events showed that in such situations, children can be expected to reflect their caregivers’ mental health problems and that they are highly susceptible to media influence.^21,22 Six months after the September 11 event, 29% of schoolchildren in New York City in grades 4 through 12 had at least one anxiety or depressive disorder, and 15% of the children from families in Hurricane Katrina’s path were found to have a “serious emotional disturbance,” compared with 4% to 7% in communities nationally.^23,24 By integrating children’s mental health needs into planning and response efforts, national planners, hospitals, outpatient departments, community-based health care providers, schools, and child care centers can improve pediatric and family outcomes during and after disasters. A resource needs assessment of available mental health provider assets is essential to defining the parameters of an appropriate response and then developing an operations plan to be adopted and implemented. The work of programs such as the National Child Traumatic Stress Network, established by Congress in 2000, can facilitate raising the standard of care while increasing access to pediatric mental health services.²⁵

CONCLUSIONS

In recent public health emergencies, such as the water contamination in Flint, Michigan, and the Zika virus outbreak in the Americas, the specific threat to children’s health and development is at the forefront of the crisis and the prime indication for full-scale response. Such events are now increasing awareness of the wide-ranging effect of disasters on children and the responsibility of stakeholders to address children’s preparedness, response, and recovery needs regardless of the public health emergency. Successful models for children’s preparedness can be developed and disseminated widely within collaborative networks and accessible platforms, alongside strategies to persuade and incentivize uptake. Evaluation of these models should indicate effectiveness, cost efficiency, and areas in which further innovation is required. These efforts will be strongest when including the unique needs of children and their families in the context of overall disaster preparedness and increased community resiliency. Ultimately, success in pediatric preparedness will not be judged by events that are witnessed but by poor outcomes that are avoided. Although this will take no small effort, the children of our communities are worth the investment.