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Disaster Care: Public Health Emergencies and Children

Murray, John Stephen PhD, RN, CPNP, CS, FAAN

AJN, American Journal of Nursing: December 2009 - Volume 109 - Issue 12 - pp 28-29,31
doi: 10.1097/01.NAJ.0000365175.55331.a1
Feature Articles

New guidelines offer an opportunity to be better prepared.

Recent guidelines provide health care practitioners with the tools they need to create emergency care plans designed specifically for children.

John Stephen Murray is a colonel in the United States Air Force and the director of education, training, and research at the Joint Task Force National Capital Region Medical, Bethesda, MD. The views expressed are those of the author and do not reflect the official policy or position of the United States Air Force, Department of Defense, or the government.

Contact author:

Disaster Care is coordinated by Mary W. Chaffee, PhD, RN, FAAN:

How prepared is the United States to assist children during a public health emergency? The nonprofit organization Save the Children reported in June that only seven states—Arkansas, Maryland, Hawaii, New Hampshire, Massachusetts, Alabama, and Vermont—"are meeting crucial minimum standards to ensure that schools and child-care facilities are prepared to respond to the needs of children during a disaster."1 The terror attacks of September 11, 2001, Hurricane Katrina, and other worldwide calamities such as floods, earthquakes, and tsunamis have made it clear that nurses and other health care providers must be prepared to care for children during public health emergencies. Children are one of the most vulnerable groups during disasters or terrorist attacks, yet most health care facilities don't have pediatric emergency care plans in place, and many schools lack comprehensive procedures. Recent guidelines from the Agency for Healthcare Research and Quality (AHRQ) address the needs of children during these events, emphasizing their vulnerability and supplying health care providers with the tools they need to create emergency care plans designed specifically for this population.

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Distinctive physiologic, anatomic, developmental, and psychosocial considerations help to determine a child's vulnerability to injury and response to disasters.2, 3 Physiologic and anatomic differences put children at greater risk for exposure to biological and chemical agents, and to dust particles from collapsed structures. Their increased respiratory rate means they may inhale larger amounts of potentially lethal toxins.4 Their small size and subsequent proximity to the ground puts them closer to where deadly gases such as sarin (an extremely toxic chemical weapon used as a lethal nerve gas) and chlorine, which are heavier than oxygen, build up.2 Children have less connective tissue flexibility and less adipose tissue than adults, and their abdominal organs are closer to the thoracic cavity, factors that place them at greater risk for multiorgan system injury as a result of blasts, flying debris from hurricanes and tornados, or falling rubble from earthquakes. Internal abdominal injuries can go unrecognized in children, with detection occurring only when their health has significantly declined.

Cognitive development plays a critical role in how children respond to a disaster.5 A toddler who's separated from her or his caretaker during an emergency will be unable to understand what's happening and may respond fearfully by crying, fussing, or becoming irritable. Older children will be better able to understand the implications and complexity of the situation.

Children's psychosocial needs are frequently overlooked during and after a disaster. Treating children appropriately is especially challenging because children can have varied reactions to emergencies. A child's response is contingent on a number of factors, including the type and severity of the disaster, the child's exposure to the event itself and resultant media coverage, the child's personality, and the degree to which parents and other adult caretakers are affected.2 Moreover, adults may not recognize the intensity of a child's distress in response to a disaster. This may be because the adult assumes the child can handle the situation or because the adults themselves are having difficulty coping.6 Preschoolers may respond to a disaster by regressing, displaying extreme forms of helplessness, or by developing persistent fears; adolescents, on the other hand, may react by acting out and engaging in risk-taking behaviors.3

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The world has experienced several public health emergencies since the attacks of September 11, all of which have significantly affected children. According to the United Nations Children's Fund in the Russian Federation, of the 331 people who died during the 2004 school hostage crisis in Beslan, Russia, 186 were children. Just three months later, the December 26 earthquake and ensuing tsunami that affected South and Southeast Asia killed more than 220,000 people and displaced another 1.5 million; it's estimated that up to 40% of the casualties were children.7 In the aftermath of Hurricane Katrina, which struck on August 29, 2005, the National Center for Missing and Exploited Children reported that it had reunited 2,526 families who were separated during that public health emergency.8 Dolan and Krug point out that caring for hospitalized pediatric patients in the New Orleans area—which was difficult because of the extensive damage caused by the storm—was further hindered by inadequate disaster planning that led, for example, to mandatory evacuations of structurally intact hospitals.9

Simply modifying disaster-response protocols developed for adults would be ineffective and inappropriate, considering the many physical, developmental, and psychosocial differences between adults and children.4 Clinicians and researchers have identified a critical need for a framework to improve the care delivered to children during public health emergencies.5, 10

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In March, the AHRQ announced the release of two highly anticipated publications aimed at providing guidance on sheltering and caring for children who are attending school or hospitalized during a public health emergency.

School-Based Emergency Preparedness: A National Analysis and Recommended Protocol fills a major gap in disaster preparedness for children by providing a national model for public health preparedness in our schools.11 Created by researchers at the Center for Biopreparedness, part of the Division of Emergency Medicine at Children's Hospital Boston, this protocol provides an overview of an emergency response plan for school systems. One key feature is a detailed guide to creating a comprehensive school emergency response plan based on the best practices of approximately 20 school systems across the country. The Center for Biopreparedness solicited copies of the emergency response plans used by these systems, analyzed them, and developed a response plan specifically for the Brookline, Massachusetts, school system, which was used as a pilot testing site. School nurses were educated and trained in the principles of school-based emergency preparedness, and an emergency response manual was developed.

The result is a compilation of best practices that U.S. school systems can use to develop extensive emergency response plans in their districts. These guidelines are evidence based, but are also informed by lessons learned in the field during public health emergencies. For more information, go to

Pediatric Hospital Surge Capacity in Public Health Emergencies, developed by the Center for Biopreparedness at Children's Hospital Boston and the Department of Emergency Medicine at the University of Massachusetts Medical Center, Worcester, Massachusetts, addresses the special medical needs of children as well as pediatric hospital systems during a mass casualty incident.12 It responds to the long-standing concerns about hospitals' preparedness to care for large numbers of children during a public health emergency and aims to assist hospital EDs in the development of plans to care for an influx of pediatric mass casualties.

These guidelines include advice on how to expand day-to-day operations in pediatric hospitals from standard operating capacity to a larger "surge capacity" that can handle mass casualties during outbreaks of communicable airborne and food-borne illnesses. They outline how facilities can activate a surge capacity plan, including delineating the role and responsibilities of the ED as well as of all other units and departments within the hospital system. Since a stress-management plan is also recommended for personnel involved in a disaster response, the guidelines address the potential special needs of the health care personnel caring for large numbers of pediatric patients. Stress reactions such as anxiety and difficulty sleeping are common following a disaster. To encourage healthy adjustment and stress reduction among personnel, it's recommended that meetings or debriefings occur soon after the event, and that participants be encouraged to share their feelings about the outbreak or disaster. For more information, go to

Nurses working with children and families during a public health crisis must have the appropriate tools to care for these vulnerable populations. All nurses should become familiar with the AHRQ guidelines and work with their facilities or employers to incorporate them into practice. These guidelines can also be used to help create emergency response checklists to be used during a disaster. They offer an unprecedented opportunity to improve our schools' and hospitals' emergency preparedness response and to better meet the needs of the pediatric population.

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1. Save the Children. Save the Children report reveals government unprepared to protect children during disasters [press release]. 2009 Jun 17.
2. American Academy of Pediatrics. The youngest victims: disaster preparedness to meet children's needs. 2002.
3. Murray JS. Addressing the psychosocial needs of children following disasters. J Spec Pediatr Nurs 2006;11(2):133–7.
4. Fox L, Timm N. Pediatric issues in disaster preparedness: meeting the educational needs of nurses—are we there yet? J Pediatr Nurs 2008;23(3):145–52.
5. Murray JS. Understanding the effects of disaster on children: a developmental-ecological approach to scientific inquiry. J Spec Pediatr Nurs 2006;11(3):199–202.
6. La Greca AM. Helping children cope with disasters and terrorism. Washington, DC: American Psychological Association; 2002.
7. Harrison M. Children and the tsunami aftermath. Sydney NSW, Australia: Children's Rights International; 2005.
8. National Center for Missing and Exploited Children. Last of unaccompanied children in Katrina shelters reunited with families [press release]. 2005 Oct 10.
9. Dolan MA, Krug SE. Pediatric disaster preparedness in the wake of Katrina: lessons to be learned. Clin Pediatr Emerg Med 2006;7(1):59–66.
10. Mohr WK. Understanding children in crisis: the developmental ecological framework. In: Zubenko WN, Capozzoli JA, editors. Children and disasters: a practical guide to healing and recovery. New York City: Oxford University Press; 2002. p. 72–84.
11. Chung S, et al. School-based emergency preparedness: a national analysis and recommended protocol. Rockville, MD: Agency for Healthcare Research and Quality; 2009.
12. Boyer EW, et al. Pediatric hospital surge capacity in public health emergencies. Rockville, MD: Agency for Healthcare Research and Quality; 2009.
© 2009 Lippincott Williams & Wilkins, Inc.