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Pediatric Critical Care Medicine:
doi: 10.1097/PCC.0b013e318234a906
Recommendations

The reality of pediatric emergency mass critical care in the developing world

Burkle, Frederick M. Jr MD, MPH, DTM, FAAP, FACEP; Argent, Andrew C. MB, BCh, MMed(Paeds), FCPaeds(SA), FRCPCH(UK); Kissoon, Niranjan MD, FRCP(C), FAAP, FCCM, FACPE; for the Task Force for Pediatric Emergency Mass Critical Care; Task force members in alphabetical order: Terry Adirim, MD, MPH, Department of Homeland Security, Washington, DC; Michael Anderson, MD, FAAP, Rainbow Babies and Children's Hospital, Cleveland, OH (Steering Committee); Andrew Argent, MD, University of Cape Town Red Cross War Memorial Children's Hospital, Cape Town, South Africa; Armand H. Antommaria, MD, PhD, University of Utah School of Medicine, Salt Lake City, UT; Carl Baum, MD, Yale-New Haven Children's Hospital, Woodbridge, CT; Nancy Blake, RN, MN, American Association of Critical Care Nurses, Los Angeles, CA; Desmond Bohn, MB, The Hospital for Sick Children, Toronto, Ontario, Canada (Steering Committee); Dana Braner, MD, Oregon Health and Science University, Portland, OR; Debbie Brinker, RN, MSN, American Association of Critical Care Nurses, Spokane, WA (Steering Committee); James Broselow, MD, University of Florida, Hickory, NC; Frederick Burkle, MD, MPH, DTM, FAAP, FACEP, Harvard School of Public Health, Cambridge, MA (Steering Committee); Jeffrey Burns, MD, MPH, Children's Hospital Boston, Boston, MA (Steering Committee); Michael D. Christian, MD, FRCP(C), University of Toronto, Toronto, Ontario, Canada (Steering Committee); Sarita Chung, MD, Children's Hospital Boston, Boston, MA; Edward E. Conway Jr, MD, MS, FAAP, FCCM, Beth Israel Medical Center, New York, NY (Steering Committee); Arthur Cooper, MD, MS, FACS, FAAP, FCCM, FAHA, Columbia University Medical Center, New York, NY; Steven Donn, MD, FAAP, CS Mott Children's Hospital, Ann Arbor, MI (Steering Committee); Andrew L. Garrett, MD, MPH, Department of Health and Human Services, Washington, DC; Marianne Gausche-Hill, MD, FACEP, FAAP, Harbor-UCLA Medical Center, Torrance, CA (Steering Committee); James Geiling, MD, VA Medical Center, White River Junction, VT; Robert Gougelet, MD, New England Center for Emergency Preparedness, Lebanon, NH; Robert K. Kanter, MD, SUNY Upstate Medical University, Syracuse, NY (Steering Committee); Niranjan Kissoon, MD, FRCP(C), The British Columbia Children's Hospital, Vancouver, BC (Steering Committee, Chair); Steven E. Krug, MD, FAAP, Northwestern University's Feinberg School of Medicine, Chicago, IL (Steering Committee); Maj. Downing Lu, MD, MPH, FAAP, Walter Reed Army Medical Center, Washington, DC; Robert Luten, MD, University of Florida, Jacksonville, FL; Lt Col (USAFR) Michael T. Meyer, MD, FAAP, Wilford Hall Medical Center, Lackland AFB and Medical College of Wisconsin, Milwaukee, WI; Jennifer E. Miller, MS, Bioethics International, New York, NY (Steering Committee); W. Bradley Poss, MD, University of Utah, Salt Lake City, UT; Tia Powell, MD; Montefiore-Einstein Center for Bioethics and Einstein-Carodoz Masters of Science in Bioethics, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY; Dave Siegel, MD, National Institutes of Health, Bethesda, MD; Paul Sirbaugh, DO, Texas Children's Hospital, Houston, TX; Ken Tegtmeyer, MD, FAAP, FCCM, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (Steering Committee); Philip Toltzis, MD, Rainbow Babies and Children's Hospital, Cleveland, OH (Steering Committee); Donald D. Vernon, MD, University of Utah, Salt Lake City, UT (Steering Committee); Jeffrey S. Upperman, MD, University of Utah, Salt Lake City, UT (Steering Committee); Jeffrey S. Upperman, MD; Children's Hospital Los Angeles, Los Angeles, CA (Steering Committee).

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Author Information

From the Harvard Humanitarian Initiative (FMB), Harvard School of Public Health, Cambridge, MA; Division of Pediatric Critical Care (ACA), Red Cross War Memorial Children's Hospital, University of Cape Town, Rondebosch, Cape Town, South Africa; Vice President, Medical Affairs (NK), British Columbia Children's Hospital and Sunny Hill Health Centre; BCCH and UBC Global Child Health, Department of Paediatrics and Emergency Medicine, University of British Columbia, Child and Family Research Institute, Vancouver, British Columbia, Canada.

The Pediatric Emergency Mass Critical Care Task Force was supported, in part, by the Centers for Disease Control and Prevention.

Disclaimer: The views expressed in this article are those of the authors and do not represent the official position of the Centers for Disease Control and Prevention.

The authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: fburkle@hsph.harvard.edu

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Abstract

Introduction: Public health emergencies resulting from major man-made crises and large-scale natural disasters severely impact developing countries, causing unprecedented rates of indirect mortality and morbidity, especially in children and women. Concomitantly, the state of children's health in the least-developed countries is the worst since the 1950s before the Declaration of Alma Ata. Worldwide decline in public health protections, infrastructures, and systems, and a health worker crisis primarily in Africa and Asia, limit the delivery of intensive and critical care services.

Methods: In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations.

Steering Committee members established subgroups by topic area and performed literature reviews of MEDLINE and Ovid databases. The Steering Committee produced draft outlines through consensus-based study of the literature and convened October 6–7, 2009, in New York, NY, to review and revise each outline. Eight draft documents were subsequently developed from the revised outlines as well as through searches of MEDLINE updated through March 2010.

The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29–30, 2010. Feedback on each manuscript was compiled and the Steering Committee revised each document to reflect expert input in addition to the most current medical literature.

Task Force Recommendations: Using pandemics as a model of public health emergencies, steps to improve care to the most vulnerable of populations are outlined, including mandates under the International Health Regulations Treaty of 2007 and World Health Organization guidelines. Recommendations include an emphasis on first improving primary care, prevention, and basic emergency care, where possible. Advances in care should move incrementally without compromising primary care resources. A first step in preparing for a pandemic in developing countries involves building capacity in public health surveillance and proven community containment and mitigation strategies. Given the severe lack of healthcare workers in at least 57 countries, the Task Force also supports World Health Organization's recommendations that planning for a public health emergency include means for health workers to collaborate with staff in the military, transport, and education sectors as well as international healthcare workers to maximize the efficiency of scarce human resources. Rapid response teams can be augmented by international subject matter experts if these do not exist at the country level.

“Medicine is the only world-wide profession, following everywhere the same methods, actuated by the same ambitions, and pursuing the same ends. This homogeneity, its most characteristic feature, is not shared by the law, and not by the Church, certainly not in the same degree.” - — Sir William Osler, Bt, MD, FRS, Aequanimitas, 1906

Osler's words apply today. The aspirations of providing the best “opportunity to survive” to all the world's population is a shared ambition among healthcare professionals. Professor Osler would, in his treatise on “Teaching and Thinking” written on the eve of the first World War, further observe that, despite “boasted enlightenment,” the “enormous increase in the comfort of each individual's life,” and the “multiplication of the nations,” “joys have not been increased” in the world he knew (1). Absent the lofty language, healthcare providers at the onset of the 21st century share awareness that, whereas blatant inequities and gaps in health between the “have and have-not” continue, there are overall trends of improvement (Tables 1 and 2). In developed countries, there has been a dramatic drop in the incidence of infectious disease and trauma, with a progressive decrease in under-age-5 mortality rates (U5MRs). In other parts of the world, especially in developing and least-developed countries, the U5MR ranges in both absolute numbers and in rate of reduction and availability of resources differ greatly, as do the economic indicators (Table 3). Encouragingly, and despite some areas where U5MRs are increasing, the overall trend is a substantial drop in U5MR.

Table 1
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Table 2
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Table 3
Table 3
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Yet, despite this trend, we cannot be lulled into a false sense of optimism when in the least-developed countries, children have not fared well in the last 3 decades of almost constant war and conflict. With advanced weaponry, modern wars most commonly result in violent deaths, long-term physical and emotional disabilities in a large number of civilians, and a total destruction of the protective public health infrastructure and systems (2). Many postconflict nations, despite “declarations of peace,” experience a rise in mortality during the transition phase that may exceed those from the war itself and primarily affect the most vulnerable of children and women. Because of a pattern of economic stagnation, worsening health indices, poor governance, corruption, and the ever-present availability of weaponry, 47% of postconflict countries return to war within a decade, a rate that is 60% in Africa (3). A tragic similarity observed from wars of the last 3 decades is that health and public health facilities and resources are the first to be destroyed and the last to be recovered (4). As such, the world has entered the 21st century with an absence or decline of aged public health and agricultural infrastructure and capacity. This is especially severe in the least-developed countries, which have much worse health, compounded by very low income, high inflation, high rates of debt reduction, and corruption. This year, for the first time, the number of people experiencing hunger, defined as “lack of food for basic health,” exceeded 1 billion.

The term public health emergencies denotes crises and disasters that adversely impact the public health system and its protective infrastructure (water, sanitation, shelter, food, and health). A common thread of public health emergencies is seen in wars, pandemics, and other large-scale natural and man-made disasters (5). The public health infrastructure or system can be destroyed (e.g., war), overwhelmed (e.g., Hurricane Katrina, Indian Ocean tsunami), not maintained or recovered (e.g., southern Iraq after the 1992 Persian Gulf War), or denied to populations by those in political control (e.g., ethnic, religious, or other minority groups in internal nation-state complex humanitarian emergencies, and in Palestine and Sudan) (6). Classic consequences, all preventable, emerge: outbreaks of communicable disease, food shortages leading to undernutrition and eventual malnutrition, inevitably resulting in worsening vulnerability and insecurity, population displacement, loss of livelihoods, and poverty. Public health emergencies occur more often in the least-developed countries where public health infrastructure and systems, adequate numbers of health sector workers, and basic medications and equipment are lacking or nonexistent.

It is difficult to see how these least-developed countries will be able to mobilize or increase healthcare capacity when faced with a crisis or disaster that results in a public health emergency. This difficulty is further underlined by the fact that women and children bear the brunt of most disasters worldwide.

This manuscript is an attempt to review the literature and highlight issues that may be pertinent to responding to public health emergencies in the poorest countries. This review addresses conditions that apply to all major public health emergencies. However, it highlights the major problems of pandemics, which have the potential to cause unprecedented excess mortality and morbidity.

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State of the World's Children

Nearly 99% of all child deaths occur in low- and middle-income countries (7). Sub-Saharan Africa (with 51% of all child deaths) and South Asia (with 42%) are well behind other regions on most indicators (7). According to the United Nations Children's Fund's 2009 State of the World's Children, 24,000 children under the age of 5 yrs die every day from largely preventable causes (8). The 50 least-developed countries still have very high child mortality rates, nearly four times higher than the rate that existed in industrialized countries in 1960. Half of U5MRs occur in six countries with large populations: India, Nigeria, Democratic Republic of Congo, Ethiopia, Pakistan, and China (7). For newborns, the greater risks for death (86%) are severe infections, asphyxia, and preterm births (8). Discouragingly, countries with the highest U5MRs also have the highest infant mortality rates and maternal mortality rates, and the 60 countries with U5MRs that exceed 50 deaths per 1000 live births have increased this rate by 13% in the last decade (5). The crisis itself first produces direct effects on individuals resulting in death and injury, while indirect mortality and morbidity begin to escalate postcrisis and may even exceed the direct rates. All indirect consequences are preventable, yet public health and its workforce face “enormous challenges” that, in the least-developed countries, they are ill-equipped to meet. Public health emergencies, such as pandemics, require short-term, lifesaving resources and support from national governments and international agencies, and eventually long-term solutions that will contribute to the development of essential “infrastructure, human security, and management” (9).

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Critical, Primary, Emergency, and Intensive Care in the Developing World

Arguably, the acute phase of response to an epidemic or physical disaster requires skills of rapid organization of available resources and an established resource-based triage process. The initial phases of the care of critically ill or injured children depend on the resources available. Essentially, developing the capacity to respond to a disaster (in resource-limited settings) must depend on development of local resources (particularly human resources) that will improve overall care on a daily basis, not only during disasters. In this context, the training of mothers, village healthcare workers (10–13), or prehospital emergency services personnel and/or professional drivers is very relevant (14, 15). Once the acute disaster has passed, public health is the primary concern, but demand for emergency care is likely to increase as well. Therefore, as systems are redeveloped, there should be an emphasis on ways to incorporate principles of emergency and critical care into the infrastructure and systems, and education of healthcare providers and public health professionals alike.

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Critical Care.

The World Federation of Pediatric Intensive and Critical Care adopted the definition of critical care as “the treatment of the child with a life-threatening illness or injury in its broadest sense, without regard for the location and including prehospital and emergency and intensive care” (16). Thus, “critical care” for children includes all interventions: early antibiotic therapy for neonatal infections; increased availability of oxygen monitoring and therapy for children with pneumonia; improved care for sick children at district hospitals; improved structure and organization of acute care services for children; development of triage and management systems; and innovative training programs in prehospital trauma care (16). Essential resource components of pediatric critical care are listed in Table 4.

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Primary Care.

The large majority of deaths in the developing world are related to the lack of access to or availability of primary care. Nurses, paramedical workers, and nonspecialist physicians provide care to critically ill children in most of the world, but with resources and support that are inadequate (17). In many situations, hospitals have no hand soap, no disinfectant to clean operating rooms, no latex gloves, no masks, and limited essential medications. In some cases, only one health worker may serve an entire clinic. In a 2002 Uganda study, only 20% of clinics surveyed had electricity, only 66% had an onsite water source, and only 40% had infection control provisions (18). However, with the introduction of World Health Organization (WHO) guidelines, accompanied by training of nurses and paramedical personnel and auditing of quality improvement measures, case fatality rates have fallen substantially (19).

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Emergency Care.

Developing countries' health priorities are public-health focused and are not traditionally aimed at emergency medical care needs, nor have they been traditionally part of health sector reform (8). Among 21 hospitals in seven developing countries, 14 indicated that the public health system has never focused on emergency care and therefore lacked any adequate system for triage and initial assessment (20). If a form of emergency care exists it is found at larger hospitals and clinics, primarily in urban settings (21).

Most facility-based health in developing countries is provided at clinics and hospitals. Healthcare staff in clinics close to communities can often cope with uncomplicated emergencies; however, diagnosis and treatment by physicians primarily occurs at district hospitals. A Kenya study in 2005 found that many sociopolitical issues prevented basic health care (both preventive and curative) from reducing child mortality and called for more clear delivery by district hospitals and pediatricians (22). Countries emerging from poverty and poor development may attempt to provide a basic “package” of prevention and emergency services (23). Emergency care comprises care at the community level, care during transportation, and care at the access point to the health system facility (24). A significant number of deaths arise at the community level from failures of health workers and birth attendants to recognize serious complications. Lack of transportation, appropriate vehicles, and bad roads lead to many avoidable deaths (15). In community surveys in Pakistan, respondents were not satisfied with care, perceiving a lack of proper emergency care, lack of medicines, and nonavailability of medical officers. With emergencies involving children, 35% of respondents preferred a private hospital and 25% preferred a district hospital (25).

Seamless and well-organized emergency services for children that provide triage and timely and effective management will lead to decreased mortality (26). Achieving these goals and strengthening the commonly weak emergency and critical care services in low-income countries will meet the United Nation's Millennium Development Goal 4 in reducing U5MR by two thirds by 2015 (27).

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Intensive Care.

Issues regarding the role of tertiary care, intensive care specialists, and district and referral hospitals in developing countries are complex. Although intensive care is recommended by WHO in hospitals that do surgical procedures, the definition of intensive care varies widely. Studies suggest that 10% to 20% of patients seen during the WHO Integrated Management of Childhood Illness process should appropriately be referred to district hospitals (28). However, there is evidence that a substantial proportion of children presenting to hospitals for care across the world receive suboptimal care. More than half of the children seen in 21 hospitals in Kenya were inappropriately or inadequately treated with antibiotics, fluids, and oxygen (20, 28, 29). Similar data are available for hospitals in Angola, Brazil, Cambodia, Indonesia, and elsewhere (30). Emphasis therefore must be placed on how communities integrate the care of critically ill patients; if this is done correctly at the time of first presentation at the local level, many patients will never need intensive care.

The relationship between available resources and the level of complexity of care that can be provided must be addressed. For example, many developing countries can afford some intensive care for critically ill or injured children (Figs. 1 and 2), factors that must be taken into account when considering critical care responses to crises, such as pandemics.

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Referral Hospitals.

Many developing countries (excluding the poorest), provide nondistrict-level referral hospitals where more complex clinical care, that resembles Western-based critical care, occurs. Referral hospitals are often linked to universities where medical students are trained. If a country can justify training its own physicians, then it will have a referral hospital (31). This also enables and facilitates the functioning of lower-level health services, such as support of functions that provide population-based public health. The most frequent barrier to establishing referral hospital care in developing countries is the “inappropriate utilization of higher-level facilities and the apparent failure of most referral hospitals in developing countries to function as intended” (31). Researchers suggest that if “primary healthcare and district hospital services are weak, cutting resources for referral hospitals without destabilizing the system will be more difficult” (31). Therefore, lower-level quality primary care must receive priority.

Patients feeling “crowded out” at the primary care level because of long lines and filled beds at the district level will inappropriately self-refer to referral hospitals (22, 31). This is seen most often in countries with a high prevalence of human immunodeficiency virus/acquired immunodeficiency syndrome. Some pediatric intensive care unit practitioners in developing countries, in anticipating a fatal outcome, have excluded children known to have human immunodeficiency virus/acquired immunodeficiency syndrome (32). Although human immunodeficiency virus/acquired immunodeficiency syndrome cases may well require hospitalization, “only a small proportion of cases require specialized tertiary care” (33). Decision makers must be aware that similar patterns will rapidly occur with other pandemics when the “human wave of primary care” accelerates, making referral hospitals that have critical care less efficient (31, 34). Factors that affect access to both primary and critical care lead to skewed benefits and inequity (35).

Furthermore, referral facilities in Ethiopia and Nigeria repeatedly show favor for urban rather than rural dwellers. A “steep distance-decay” function occurs where individuals seeking clinical care will be less likely to access that service the farther away from the referral center they live (23, 36). Other factors that impact decisions to seek advanced care in unfamiliar urban settings include transportation costs and perceived cultural and linguistic differences. In contrast, Latin American countries have strongly favored the poor populations when distributing referral hospital assets (31).

Existing critical care services in Nigeria and West Africa have been hampered by recent economic reversals resulting in low wages, manpower flight overseas, government apathy toward funding of hospitals, and endemic corruption. Debt cancellation by Western countries has helped the situation but the chronic lack of human investment by governments makes recovery and sustainability slow (37). Mortality rates in the general intensive care unit population in two studies from Nigeria and Uganda were 35.1% and 25%, respectively, compared to 12% to 17% in the United States (38).

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Preparedness and Response for Complex Public Health Emergencies

Clearly, if the health system routinely is overburdened, then planning for possible disasters will be very limited. Arguably, a reasonable approach would be to see how interventions can be made to improve daily quality of care and preparedness for disasters at the same time. In the context of a pandemic, social-distancing strategies to prevent crowding, rapid triage, treatment, and medication distribution provide basic and well-tested community mitigation of disease transmission, rather than pretending that services can offer intensive care. A functioning organizational structure is as crucial as medication, oxygen, and other essential resources in terms of critical care. For example, to ensure procurement of oxygen, medications, supplies, monitoring, and teaching of necessary clinical skills, practitioners, administrators, and planners must work as a cohesive team.

Molyneux et al (39) showed that a key component of the Emergency Triage Assessment and Treatment courses is that problems in health service delivery can be solved successfully through a systematic process of simple, low-cost, locally available and effective training, which also improves patient flow and collaboration between inpatient and outpatient services. These results were reproduced in Cambodia, Indonesia, Kazakhstan, Kenya, Solomon Islands, and Timor Leste, among others (40).

Preparedness for a “disaster event” can be viewed at multiple levels:

1) At the level of first response, the constraints are resources, skills, geographical situation; safety and stability of infrastructure; and level of integration of services.

2) As one moves from an immediate event, it becomes a public health issue. At that level, the pediatric issues are underlying levels of nutrition, immunization, education of mothers/caretakers, access to basic health professionals, and access to more advanced healthcare resources. These issues are compounding in their effects.

3) With major epidemics, issues relate to overcrowding, processes for access to immunization (if available), and access to basic healthcare. Even with influenza, many deaths are related to bacterial coinfection, and early access to relatively inexpensive antibiotics may be more effective than overcoming the limited access to expensive antiviral medications and intensive care.

4) Preparedness must focus on staff training in self-protection. The risk in developing countries is that the limited number of healthcare staff will be decimated very rapidly.

5) Underlying all these is the issue of optimizing the organizational resources that are available within a geographic area. Here, logistic challenges may dominate.

The occurrence of natural disasters is increasing (Figs. 3 and 4). Concomitantly, there are concerns that demands for preparedness for a large-scale public health emergency, such as a highly pathogenic influenza pandemic, will lead to a “sudden shift of public health focus” in Africa and Asia away from other priorities. Fledgling surveillance and control activities “must work within the already strained capacity of health infrastructure” (41). A massive shift of resources could damage existing public health programs but would strengthen both human and veterinary surveillance in the long term. Thailand's system, facing similar preparedness demands, benefited from previous experience with severe acute respiratory syndrome that led to greater public confidence and cooperation (42). A study of 53 African country preparedness plans found that detection and containment plans were robust. By contrast, the healthcare sector is ill-prepared. “Case management, triage procedures, identification of healthcare facilities for patient management, including home care and provisions for distribution and administration of pharmaceuticals, are poorly addressed,” as are plans to maintain essential services (43).

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Clinical Management in Resource-Poor Settings.

Because the most common cause of death among children under age 5 yrs is pneumonia (44), most resource-poor countries will have intravenous crystalloids and antibiotics, with fewer having means to concentrate oxygen, a generator, and a vehicle for transportation (45). Supplies will be limited and will not be able to surge with high-patient volumes (46). Oxygen shortages are common owing to the cost and complex logistics of transporting it in cylinders. Most hospitals do not have pulse oximetry, and hence, healthcare providers may not be able to recognize clinical signs of hypoxemia.

In these settings, basic delivery of antibiotics should be launched along with full immunization; if the setting can afford oxygen, then supplies should be available as needed. If ventilation services are available, it is critical that children who can potentially survive with reasonably limited intensive care resources be ventilated.

In studies of >11,000 children with pneumonia in Papua New Guinea, a combined pulse oximetry and oxygen concentrators approach was able to alleviate oxygen shortages, reduce mortality, improve quality of care, and be cost effective (47). In a Gambian study, because electrical power costs may be prohibitive, cylinders are preferred if transportation is available (48). Solar-operated systems, despite the initial investment, become cost effective, especially where 6 hrs of sunlight per day can be guaranteed, and rural hospital needs exceed 6 treatment days of oxygen per month (49). Another study found that all low-flow methods (e.g., nasopharyngeal catheters, nasal catheters and prongs) were effective in oxygenation of sick children. Nasopharyngeal and nasal catheters are less expensive. Nasal prongs were favored in small hospitals (50).

Clinical care strategies must focus on reducing all-cause premature mortality. WHO's Integrated Management of Childhood Illness (51) and Integrated Management of Adolescent and Adult Illness (52) for triage and management at the primary care level should be followed and implemented at all levels of care. Decentralization of antiviral medications in primary care settings, even in limited supply, is important to reach at-risk and disadvantaged populations. Key principles of management include: basic symptomatic care; early use of antiviral medications for high-risk populations, if available; antimicrobials for coinfections; and proactive observation for progression of illness. Hospital care requires early supplemental oxygen therapy to correct hypoxemia, with saturation monitoring at triage and during hospitalization, if possible, careful fluid replacement, antimicrobials, and other supportive care. Patients with severe hypoxemia will need high-flow oxygen delivered by face mask and options listed previously. Medical oxygen in some countries will not be available; in these situations, industrial oxygen can be used.

Severe respiratory distress requires mechanical ventilation and intensive support. Again, some countries may not offer mechanical ventilation (53). Clinical management and triage may be altered because of severity of the novel viral pathogen and particulars within the case definition, such as age and comorbidity. Additionally, healthcare providers must consider the impact of malnutrition and chronic micronutrient deficiency (especially vitamin A and zinc) on mortality, morbidity, and duration of diarrhea and pneumonia (54–59).

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International Response Mechanisms
International Health Regulations and Treaty.

International health regulations have existed for years for cholera, smallpox, and yellow fever, but with the severe acute respiratory syndrome pandemic in 2005, WHO's authority and surveillance capacity was expanded to all infectious diseases of international concern. This new international health regulation became a treaty in 2007 and applies to all public health emergencies of international concern. It ensures maximum security against the international spread of diseases while addressing the need to mitigate the economic tragedy that prevails with any pandemic. Fragile states and ungoverned spaces (which by definition have little or no public health protections) may forgo international health regulation measures and represent an ideal home for future viral mutation and propagation (60). Obligations under the 2007 treaty are three-fold (61):

1) All countries are required to report to WHO all events within their respected territories that may constitute a public health emergency of international concern (Article 6.1). This includes governments of fragile states or those with ungoverned territories.

2) One provision (Article 9.1) allows WHO to receive reports of disease events from sources other than governments, such as nongovernmental organizations or the media, and to seek verification of these reports. The international health regulation (Article 9.2) requires a state party to report within 24 hrs evidence that it receives of a disaster event occurring within the territory of another state party, which could produce reports of “a public health-risk” occurrence in fragile and ungoverned areas.

3) A first step in assisting a country comes from building capacity in public health surveillance and proven community containment and mitigation strategies (e.g., social distancing, respiratory etiquette, and hand washing [62, 63]) as an incentive for fragile states to accept improvements in basic governance.

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WHO Regional Organizations.

As an example of how WHO Regional Organizations provide resources to developing countries, the Pan American Health Organization focused their aid on providing technical assistance for crisis management and coordination, surveillance, and investigation of cases in the Americas during the 2009 Influenza A/H1N1 Pandemic. The Pan American Health Organization immediately activated its Emergency Operations Center, which serves as the center for strategic coordination, analysis, and decision making during a pandemic. The Center provided point-of-contact services and improved communication with country and field offices and other regional offices. It provided the logistic support to deploy technical experts to the field and to ensure timely shipment of oseltamivir antiviral medication (1 million doses were sourced), personal protective equipment, and other supplies needed by countries. The Pan American Health Organization/WHO also monitored laboratories in member states and distributed diagnostic kits, revised manuals, reagents, laboratory equipment, and Internet-based self-learning programs (64).

Rapid response teams within a country can be mobilized to carry out the following tasks:

* Conduct a rapid assessment of a possible outbreak

* Confirm the existence of an epidemic

* Assess the impact on health

* Assess the local response capacity and immediate needs

* Present results of the investigation to the department of health services and other relevant authorities (e.g., Minister of Health, local population for action)

Each rumor/report must be investigated immediately (within 24 hrs) after contacting health personnel and community leaders of the affected district or subdistrict.

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Partnerships.

As a partner, the U.S. Agency for International Development provided the Pan American Health Organization with 25,000 personal protective kits, and the U.S. Agency for International Development and Centers for Disease Control and Prevention provided 220,000 antiviral treatments in response to urgent requests made by those countries with the highest number of confirmed cases. Additional partnerships were made with the Canadian International Development Agency and the Spanish Agency for International Cooperation and Development (64).

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Promoting Health Capacity
Barriers.

Over 57 countries, primarily from Africa and Asia, are experiencing a severe healthcare worker crisis. Africa alone is short 4.2 million health workers and loses 20,000 skilled health workers per year. Sub-Saharan Africa and Southeast Asia together have 53% of the global burden of disease but only 15% of the world's healthcare workers (65–67). Specialty trained physicians and nurses are “expected” to emigrate, with countries such as Canada, the United States, the United Kingdom, and Australia exacerbating the crisis through active recruitment of qualified health workers. Only recently has this practice been considered a crime (68).

Severe imbalances exist throughout the world and are made more severe by inequities within countries, with rural areas suffering the most. These countries cannot meet the Millennium Development Goals, and many are slipping further as the health worker shortage worsens (69). WHO emphasizes that concerns over emerging and re-emerging diseases, including novel influenzas, have drawn greater attention to this crisis by alerting countries to what the consequences would be with a devastating global pandemic. A state of even “minimal preparedness” does not exist (70).

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WHO's Strategy to Improve Healthcare Capacity.

The WHO's program includes:

* More direct investment in the training and support of health workers

* A national plan for the health workforce and an increase in the number of health workers in all countries with serious shortages

* More efficient use of the existing health workforce

* Task-shifting, or the process where some simple healthcare tasks now assigned to highly skilled personnel are delegated to less skilled workers able to deliver them competently

* Protection and fairer treatment of health workers

* Access to effective human immunodeficiency virus prevention and treatment for all health workers

* Encouragement of women to enter health professions

* Decreased incentives for early retirement

* Comprehensive preparedness plans in every country for a workforce response to outbreaks and emergencies

* Reassignment of health workers during times of conflict to areas in need

* Orientation of health worker training and development of career incentives to encourage service in rural and disadvantaged areas

* Better strategies to more actively engage communities and patients in their own health care

In pandemics, WHO recommends that plans include means for health workers to collaborate with staff in the military, transport, and education sectors to maximize the efficiency of scarce human resources. In addition, WHO's Code of Practice for the Recruitment of International Health Personnel encourages countries that receive emigrant healthcare workers to assist in improving working conditions in source countries. Faculty from the University of British Columbia emphasize that countries benefiting from the healthcare worker migration have a “genuine responsibility to reciprocate with resources of their own” (71). Intensified efforts are needed in ensuring better working conditions and in integrating worker safety with patient safety.

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Education, Training, Research, and Advocacy

Aside from the least-developed countries with environments commonly referred to as unstable, fragile, and nonpermissive due to human insecurity, Stidham and Novick (72) suggest that assistance from the developed world may best come in the form of “intensive care services which can serve as a foundation for further assisted development.” Specifically, they cite promoting increased access to donated equipment and supplies, basic on-site critical care training, intermittent training that elevates the level of services provided for short periods of time, building sequentially on each learning experience, development of “intellectual connections” that provide an immediate source of telephone consultation, and the potential future in computer-assisted telecommunications (72).

The World Federation of Pediatric Intensive and Critical Care Societies is based on the premise that, through educational, scientific, research, and charitable means, ways will be found to improve the care of critically ill children throughout the world, and in doing so, disseminate that knowledge available to those who care for children (73). The Federation has over 25 national, international, and regional member societies representing over 10,000 pediatric and neonatal critical care physicians, nurses, and allied healthcare workers. The Federation collaborates with the Society of Critical Care Medicine to publish the journal Pediatric Critical Care Medicine, with abstracts published in seven languages (73). Specialty societies, such as the American Academy of Pediatrics, provide a database of qualified professionals for future disasters. A similar database is appropriate for critical care specialists to provide either field expertise or subject-matter telecommunications from a distance.

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SUMMARY

The Task Force Recommends the Following:

* The definition of pediatric critical care should include “the treatment of the child with a life-threatening illness or injury in its broadest sense, without regard for the location and including prehospital, emergency, and intensive care.”

* Responses to disasters in developing countries have to take into account the available resources. Realistically, intensive care is simply not possible in these countries. However, major impacts can be achieved using local people, simple remedies, community mitigation strategies (e.g., social distancing), and basic training. The response in these countries needs to be tailored to the particular stage of development of the health services and resources.

* In the least-developed countries, emphasis must be placed on first improving primary care, prevention, and basic emergency care, where possible. Advances in care should move incrementally without compromising primary care resources.

* A first step in preparing for a pandemic in a developing country comes from building capacity in public health surveillance and proven community containment and mitigation strategies (e.g., social distancing, respiratory etiquette, and hand washing).

* Clinical care strategies must focus on reducing all-cause premature mortality and the United Nations Children's Fund/WHO guidelines and algorithms for Integrated Management of Childhood Illness and Integrated Management of Adolescent and Adult Illness. Key principles of management include: basic symptomatic care; decentralization of antiviral medications in primary care settings, even in limited supply, to reach at-risk and disadvantaged populations; antimicrobials for coinfections; and proactive observation for progression of illness.

* International assistance is provided to resource-poor countries during pandemics through mandates provided by the International Health Regulations Treaty of 2007 and the WHO Regional Organization emergency response capabilities and their partnerships.

* In public health emergencies, the WHO recommends that country plans include means for health workers to collaborate with staff in the military, transport, and education sectors as well as international healthcare workers to maximize the efficiency of scarce human resources. Rapid response teams can be augmented by international subject matter experts if these do not exist at the country level.

* Partnerships through the WHO Regional Organization with international donors, such as U.S. Agency for International Development, Australian Agency for International Development, Canadian International Development Agency, Department for International Development (United Kingdom), Japan's International Cooperation Agency, and others, will expedite the deployment of scarce resources.

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ACKNOWLEDGMENTS

The Pediatric Emergency Mass Critical Care Task Force thanks the American Academy of Pediatrics and its Disaster Preparedness Advisory Council for their review and contributions to this issue.

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Keywords:

children; developing countries; disasters; emergencies; emergency mass critical care; global health; pandemics; pediatric critical care; pediatrics; public health emergencies

©2011The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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