The National Advisory Committee The National Advisory Committee on Children and Terrorism and on Children and Terrorism and Current U.S. Changes in How Current U.S. Changes in How

Preparedness is EvaluatedPreparedness is EvaluatedPeter D. Rumm, MD, MPH, FACPMPeter D. Rumm, MD, MPH, FACPMDirector, Center for Public Health Director, Center for Public Health

Readiness and CommunicationReadiness and CommunicationDrexel School of Public HealthDrexel School of Public Health

pdr26@drexel.edupdr26@drexel.edu or 215-762-1652or 215-762-1652

Most Famous Anthrax Disaster: Most Famous Anthrax Disaster: SverdlovskSverdlovsk

In late April of 1979, an outbreak of pulmonary In late April of 1979, an outbreak of pulmonary anthrax occurred in Sverdlovsk (now anthrax occurred in Sverdlovsk (now Yekaterinburg) in the former Soviet Union. Yekaterinburg) in the former Soviet Union.

While, originally, the outbreak was described as While, originally, the outbreak was described as being due to ingestion of infected meat, it was being due to ingestion of infected meat, it was later discovered that the cause was from an later discovered that the cause was from an accidental release of anthrax in aerosol form accidental release of anthrax in aerosol form from the Soviet Military Compound 19, a huge from the Soviet Military Compound 19, a huge Soviet bioweapons facility. Soviet bioweapons facility.

Residents living downwind from this compound Residents living downwind from this compound developed high fever and difficulty breathing, developed high fever and difficulty breathing, and a large number died. The final death toll and a large number died. The final death toll was estimated at the time to be between 200 was estimated at the time to be between 200 and 1,000.and 1,000.

www.dermatologyabout.comwww.dermatologyabout.com

Cutaneous Anthrax (day 5)Cutaneous Anthrax (day 5)

CDC, EID Vol 7 No 6 Nov-Dec 2001CDC, EID Vol 7 No 6 Nov-Dec 2001

Anthrax Inhalation Cases (10) and their Anthrax Inhalation Cases (10) and their TimelineTimeline

                                                                                                                                                                                    

                                                                                                                                                                                    

                                                                                                                                                                                    

                                                                                                                                                                                    

The “Challenge of Bioterrorism”The “Challenge of Bioterrorism”

Biological weapons are a formidable Biological weapons are a formidable challenge. The use of a bioagent as a challenge. The use of a bioagent as a weapon is a multidimensional problem weapon is a multidimensional problem because of the diversity of bioagents, because of the diversity of bioagents, the large number of vulnerable targets, the large number of vulnerable targets, and the varied routes of dissemination. and the varied routes of dissemination.

Terrorists using biological warfare can Terrorists using biological warfare can decimate a large population, inflict decimate a large population, inflict enormous psychological and economic enormous psychological and economic hardship, and incite political unrest by hardship, and incite political unrest by merely attacking small populations in merely attacking small populations in multiple sites over a long period of multiple sites over a long period of time.time.

US Postal CasesUS Postal Cases In October 2001, anthrax spores were sent In October 2001, anthrax spores were sent

through the U.S. mail and caused 18 through the U.S. mail and caused 18 confirmed cases of anthrax (11 inhalation, 7 confirmed cases of anthrax (11 inhalation, 7 cutaneous). Five individuals with inhalation cutaneous). Five individuals with inhalation anthrax died; none of the cutaneous cases anthrax died; none of the cutaneous cases was fatal.was fatal.

One of the cutaneous cases was a child that One of the cutaneous cases was a child that did well.did well.

We learned a lot about the potential We learned a lot about the potential vulnerability of children, the aged and other vulnerability of children, the aged and other populations.populations.

Soviet Union and RussiaSoviet Union and Russia

Although the former Soviet Although the former Soviet Union was a signatory to the Union was a signatory to the Biological Weapons Biological Weapons Convention, their Convention, their development of biological development of biological weapons only intensified weapons only intensified after the accord and after the accord and continued with full steam continued with full steam into the 1990s. into the 1990s.

Overlooked PopulationsOverlooked Populations

Many groups of people are Many groups of people are frequently overlooked in frequently overlooked in response plans, including those response plans, including those regarding mental health, and the regarding mental health, and the needs of children, elderly, needs of children, elderly, disabled, and ethnic minority disabled, and ethnic minority groups that are vulnerable to groups that are vulnerable to backlash or hate crimes.backlash or hate crimes.

Some ResourcesSome Resources

American Academy of PediatricsAmerican Academy of PediatricsChildren, Terrorism and Disasters: DisasterChildren, Terrorism and Disasters: Disaster Preparedness to Meet Children’s Needs Preparedness to Meet Children’s Needs

Columbia University Mailman School Columbia University Mailman School of Public Healthof Public HealthThe National Center for Disaster The National Center for Disaster Preparedness, Program for Pediatric Preparedness, Program for Pediatric PreparednessPreparedness

American Red CrossAmerican Red CrossChildren and DisastersChildren and Disasters

Other PopulationsOther Populations Disabled: American Red CrossDisabled: American Red Cross

Special Needs & Concerns: Disaster Special Needs & Concerns: Disaster Preparedness for People with Disabilities Preparedness for People with Disabilities

Hate crimes: Council on American-Islamic Hate crimes: Council on American-Islamic RelationsRelationsMuslim Community Safety KitMuslim Community Safety Kit

Seniors: International Longevity CenterSeniors: International Longevity CenterEmergency Preparedness for Older Emergency Preparedness for Older People People

Mental Health: American Psychological Mental Health: American Psychological AssociationAssociationBriefing Sheet: The Psychological Impact Briefing Sheet: The Psychological Impact of Terrorism on Vulnerable Populationsof Terrorism on Vulnerable Populations

Children may be most vulnerable Children may be most vulnerable population, at home or in schoolspopulation, at home or in schools

A survey by the National Safety A survey by the National Safety Resource Officers in Schools in 2003 Resource Officers in Schools in 2003 stated that 68% of schools stated that 68% of schools unprepared for a disaster or act of unprepared for a disaster or act of terrorism.terrorism.

Children have special vulnerabilities Children have special vulnerabilities both physiologically and mentally.both physiologically and mentally.

According to the WHO in 2002 most According to the WHO in 2002 most casualties of both man made and casualties of both man made and natural disasters were children.natural disasters were children.

Purpose of the NACCTPurpose of the NACCT

Created by joint legislation Created by joint legislation introduced first by Senator Hillary introduced first by Senator Hillary Clinton in 2001.Clinton in 2001.

The objective of the National Advisory The objective of the National Advisory Committee on Children and Terrorism Committee on Children and Terrorism (NACCT) as specified in the legislation (NACCT) as specified in the legislation was to assess and provide was to assess and provide recommendations for Health and recommendations for Health and Human Services Secretary Tommy Human Services Secretary Tommy ThompsonThompson

Public Health Security and Public Health Security and Bioterrorism Preparedness and Bioterrorism Preparedness and

Response Act of 2002Response Act of 2002

Established a National Advisory Established a National Advisory Committee on Children and Committee on Children and Bioterrorism; assured that our national Bioterrorism; assured that our national system of responding and countering system of responding and countering bioterrorism.bioterrorism.

Provided training to health professionals Provided training to health professionals on the special needs of children;on the special needs of children;

Promoted 211 hotlines and other Promoted 211 hotlines and other communications systems.communications systems.

Background InformationBackground Information

There are more than 70 million There are more than 70 million children under the age of 18 in the children under the age of 18 in the United States today, and more than United States today, and more than 22 million are ages five and younger. 22 million are ages five and younger.

In the event of a terrorist attack, In the event of a terrorist attack, these children would be among the these children would be among the most vulnerable populations in our most vulnerable populations in our society society

As recently as 1997, data collected by As recently as 1997, data collected by FEMA showed that no state disaster FEMA showed that no state disaster plans had pediatric components. plans had pediatric components.

Reports ConsensusReports Consensus

Children are not simply small adults. Children are not simply small adults. Children breathe faster and have faster Children breathe faster and have faster heart rates than adults, making them heart rates than adults, making them more vulnerable to aerosolized more vulnerable to aerosolized biological and chemical agents. biological and chemical agents.

Children metabolize drugs differently, Children metabolize drugs differently, requiring different dosages of drugs requiring different dosages of drugs and different antidotes to many and different antidotes to many agents, as well as specially sized agents, as well as specially sized equipment to administer many equipment to administer many treatments. treatments.

Classic Presentation of a Severe Classic Presentation of a Severe Case about 1 Week, 10 DaysCase about 1 Week, 10 Days

Committee ConsensusCommittee Consensus

Ill and injured children react differently Ill and injured children react differently than adults to stress, and their than adults to stress, and their psychological vulnerabilities in the psychological vulnerabilities in the aftermath of disasters and aftermath of disasters and emergencies are still only imperfectly emergencies are still only imperfectly understood. understood.

On every level, physical, medical, On every level, physical, medical, psychological, emotional and social, psychological, emotional and social, children have unique needs and children have unique needs and vulnerabilities that must be taken into vulnerabilities that must be taken into account.account.

Focus AreasFocus Areas Primary Care Pediatricians, Office-Based Primary Care Pediatricians, Office-Based

Practice & Urgent Care CentersPractice & Urgent Care Centers Community InvolvementCommunity Involvement Children’s School and ChildcareChildren’s School and Childcare Research and DataResearch and Data TrainingTraining Mental Health Response PhaseMental Health Response Phase Children with Special Health Care NeedsChildren with Special Health Care Needs Mental Health Recovery and Mitigation PhaseMental Health Recovery and Mitigation Phase Hospital PreparednessHospital Preparedness Public Health Departments Public Health Departments Pre-Hospital and Critical CarePre-Hospital and Critical Care

MethodsMethods

Each of 12 members began Each of 12 members began working with 3-4 CDC staff and working with 3-4 CDC staff and consultants wrote a 30-50 page consultants wrote a 30-50 page draft report on their focus area draft report on their focus area that they led. This involved a that they led. This involved a massive literature review and massive literature review and seeking out expert opinions.seeking out expert opinions.

Four meetings were held in two Four meetings were held in two places (DC, Atlanta)places (DC, Atlanta)

Methods ContinuedMethods Continued Over a 3-4 month time we each spent Over a 3-4 month time we each spent

hours working with the CDC and HHS hours working with the CDC and HHS senior staff and other staff to senior staff and other staff to compose report. compose report.

Report is available on line at Report is available on line at www.bt.cdc.govwww.bt.cdc.gov and a supplement has and a supplement has also been published at:also been published at:

J Sch Health. 2004 Feb;74(2):39-J Sch Health. 2004 Feb;74(2):39-51.51.Schools and terrorism. A supplement to the Schools and terrorism. A supplement to the report of the National Advisory Committee on report of the National Advisory Committee on Children and Terrorism.Children and Terrorism.

Key RecommendationKey Recommendation

1.3 Conduct a national survey 1.3 Conduct a national survey of Federal, state and local of Federal, state and local terrorism and disaster plans terrorism and disaster plans that includes a specific that includes a specific assessment of preparedness assessment of preparedness and training for the medical and training for the medical and psychological effects of and psychological effects of terrorism on children.terrorism on children.

Key Recommendation of This CommitteeKey Recommendation of This Committee

1.2 Assure that the unique 1.2 Assure that the unique physical and mental health physical and mental health needs of children are needs of children are recognized and resources recognized and resources provided for in all DHHS provided for in all DHHS terrorism preparedness and terrorism preparedness and response funding initiatives, response funding initiatives, strategic plans and priority strategic plans and priority setting activities.setting activities.

History of Bioterrorism = Not New!History of Bioterrorism = Not New! Before the era of modern microbiology Before the era of modern microbiology

brought the prospect of germ warfare to the brought the prospect of germ warfare to the world of the 21st century, ancient armies world of the 21st century, ancient armies used filth, cadavers, animal carcasses and used filth, cadavers, animal carcasses and contagion as weapons against each other. contagion as weapons against each other.

They knew that fear of infectious diseases They knew that fear of infectious diseases could rapidly demoralize and dismantle could rapidly demoralize and dismantle enemy forces.enemy forces.

During the North American colonization, During the North American colonization, British forces purposely spread smallpox British forces purposely spread smallpox among the native Indian population by among the native Indian population by sending smallpox-infested blankets as sending smallpox-infested blankets as "gifts"; to Indian tribes who resisted British "gifts"; to Indian tribes who resisted British authority.authority.

Key RecommendationKey Recommendation

1.6 Expand the State Children's 1.6 Expand the State Children's Health Insurance Program Health Insurance Program (SCHIP) to provide financial (SCHIP) to provide financial mechanisms for States to mechanisms for States to support post-disaster physical support post-disaster physical and mental healthcare to all and mental healthcare to all children. children.

Key Recommendation – focus on Key Recommendation – focus on mental health and resiliencymental health and resiliency

3.1 Conduct research relating 3.1 Conduct research relating to identifying patterns of child to identifying patterns of child trauma, resilience, coping and trauma, resilience, coping and recovery in the aftermath of recovery in the aftermath of disasters and terrorism.disasters and terrorism.

This research should include This research should include studying the topic of resiliency.studying the topic of resiliency.

Key Recommendations on Risk Key Recommendations on Risk Communication and “Translational Communication and “Translational

Research”Research”

9.1-3 Implement risk communication 9.1-3 Implement risk communication strategies to positively affect the nation strategies to positively affect the nation as a whole during times of elevated threat as a whole during times of elevated threat levels and actual terrorist events, in light levels and actual terrorist events, in light of the special effects these threats and of the special effects these threats and events have on children.events have on children.

Develop clear, concise and situation-Develop clear, concise and situation-specific guidance for parents, caregivers specific guidance for parents, caregivers and teachers concerning helping children and teachers concerning helping children to cope with terrorism and disasters, and to cope with terrorism and disasters, and ensure that consistent information is ensure that consistent information is disseminated by all DHHS agencies. disseminated by all DHHS agencies.

Public Health Ramps Up for TerrorismPublic Health Ramps Up for Terrorism The CDC over the last four years has spent approximately The CDC over the last four years has spent approximately

1.2 billion per year on terrorism preparedness.1.2 billion per year on terrorism preparedness.

They use about 150 million per year internally to improve They use about 150 million per year internally to improve internal terrorism preparedness and the syndrome internal terrorism preparedness and the syndrome biosurveillance initiative.biosurveillance initiative.

The rest of the money is distributed primarily to state The rest of the money is distributed primarily to state agencies and US territories through annual appropriations agencies and US territories through annual appropriations (some goes directly to large cities)(some goes directly to large cities)

The U.S. DHHS has also spent billions on hospital and The U.S. DHHS has also spent billions on hospital and medical training primarily through the Human Resources medical training primarily through the Human Resources Services Administration.Services Administration.

www.cdc.gov/fmo.fmofybudget.htmwww.cdc.gov/fmo.fmofybudget.htm

Future etc?Future etc?

Former members of the NACCT Former members of the NACCT believe that funding for children believe that funding for children and special populations is and special populations is increasing for this usage but is increasing for this usage but is not enough per recent not enough per recent conference calls. conference calls.

Will the Committee be Will the Committee be reinstated?reinstated?

Red Cross and Special Red Cross and Special PopulationsPopulations

During emergencies and disasters, it During emergencies and disasters, it is especially important to provide is especially important to provide assistance to those people with assistance to those people with special needs. These include the special needs. These include the elderly and disabled and people with elderly and disabled and people with limited English proficiency (LEP). limited English proficiency (LEP).

The Red Cross has developed The Red Cross has developed materials to assist these individuals. materials to assist these individuals.

http://www.redcross.org/services/ http://www.redcross.org/services/ disaster/beprepared/disability.htmldisaster/beprepared/disability.html

FEMA (Federal Emergency FEMA (Federal Emergency Management Agency)Management Agency)

Promotes self-help networks = are Promotes self-help networks = are arrangements of people who agree to arrangements of people who agree to assist an individual with a disability assist an individual with a disability in an emergency. Discuss with the in an emergency. Discuss with the relative, friend or co-worker who has relative, friend or co-worker who has a disability what assistance he or she a disability what assistance he or she may need. may need. (http://www.fema.gov/rrr/assistf.shtm)(http://www.fema.gov/rrr/assistf.shtm)

A Renowned Local EffortA Renowned Local Effort One of the best is in the San Francisco One of the best is in the San Francisco

area that was spurred by the earthquake area that was spurred by the earthquake during the 1997 baseball World Series.during the 1997 baseball World Series.

PrepareNow.org “provides the tools, PrepareNow.org “provides the tools, expertise and access to resources to expertise and access to resources to assist anyone engaged in disaster assist anyone engaged in disaster planning for individuals with special planning for individuals with special needs. needs.

http://www.preparenow.org/purpose.htmlhttp://www.preparenow.org/purpose.html

Past Measures to Past Measures to Gauge PreparednessGauge Preparedness

Centered around U.S CHC and HRSA Centered around U.S CHC and HRSA guidance that dealt with focus areas.guidance that dealt with focus areas.

Centered on Capacity – several Centered on Capacity – several instruments done on volunteer basisinstruments done on volunteer basis

National BTAIP by ASTHO revealed a National BTAIP by ASTHO revealed a nation better but still under—nation better but still under—prepared in workforce, information prepared in workforce, information systems and surveillance.systems and surveillance.

Billions for What?Billions for What? Sidell and Cohen others blast wasted Sidell and Cohen others blast wasted

spending since 9’11” and anthrax attacks.spending since 9’11” and anthrax attacks. Rumm and others challenge that spending Rumm and others challenge that spending

has at least improved our public health has at least improved our public health system and especially our laboratories.system and especially our laboratories.

Trust for America Report continues to Trust for America Report continues to blast some state efforts and calls for blast some state efforts and calls for common metrics.common metrics.

Gursky calls for a Force Protection Gursky calls for a Force Protection Agency.Agency.

Gaskin and Rumm StudyGaskin and Rumm Study

Over 50 assessments, few on children Over 50 assessments, few on children and special needs.and special needs.

Continuing lack in some sectors in Continuing lack in some sectors in training, communications, training, communications, surveillance systems and most surveillance systems and most importantly in workforce.importantly in workforce.

Has been substantial improvement in Has been substantial improvement in laboratory capacity and some laboratory capacity and some improvement in hospital surge improvement in hospital surge capacitycapacity..

Today Movement toward Metrics – away Today Movement toward Metrics – away from capacity toward capability!from capacity toward capability!

CPHRC leadership on the Lehigh Valley CPHRC leadership on the Lehigh Valley Study and the Federal Regional Study and the Federal Regional Preparedness Metrics.Preparedness Metrics.

Commonality of metrics coming under Commonality of metrics coming under the leadership of the U.S. DHS Disaster the leadership of the U.S. DHS Disaster Response Plan and Target Capabilities.Response Plan and Target Capabilities.

CDC and other Capability studies CDC and other Capability studies including those by RAND – is this a including those by RAND – is this a good thing?good thing?