Public Health Emergency Preparedness

Introduction

Terrorism and Disasters—An Overview

On September 11, 2001, the U.S. was victim of an unprecedented terrorist attack. This was followed within a month by the intentional release of anthrax spores placed in tainted letters. These two events permanently altered the American way of life. Among the lessons learned in these and subsequent terrorist events is that domestic terrorism exists as a new part of society; gone are the days when terrorism and the release of weapons of mass destruction were focused solely on the military theater. 

Another important lesson of 9/11 and the subsequent years has been that there are five distinct forms of domestic terrorism:

• Biologic—exemplified by the release of anthrax spores, the threat of a smallpox release, and the discovery of ricin in contaminated letters.
• Chemical—exemplified by the sarin incident in Japan in 1995.
• Nuclear—as evidenced by new guidelines for community-wide distribution of potassium iodide (American Academy of Pediatrics Committee on Environmental Health, 2003).
• Explosive (Blast)—exemplified by the Okalahoma City disaster of 1995 and the World Trade Center disaster of 2001.
• Incendiary—which accompanied explosive events (e.g., the World Trade Center disaster).

Prior to 9/11, there was relatively little planning around terrorist events, leaving the U.S. unprepared and vulnerable. This exposed weakness resulted in a massive post-event effort at Federal, State, and local levels to correct deficiencies and better prepare for terrorist acts. The formation of a new Cabinet office, The Department of Homeland Security, has been the most important and symbolic product of these efforts. 

Initial terrorist response activities by public health agencies were reactive and fragmentary. This was quickly recognized as an inefficient use of resources and expenditures and led to expansion of the "all hazards" approach, a principle that had been created years before but was not initially used in terrorism response and planning. Emergency response planners began to appreciate the value of a "dual-functionality" infrastructure that could be employed in both terrorism response and public health emergencies (e.g., natural disasters).

Emergency preparedness plans around both terrorism and unintentional disasters (natural, such as hurricanes and floods, or manmade, such as plane crashes or hazardous materials releases) have now been created and promulgated by both homeland security and public health agencies. However, across the Nation, the needs of children remain largely unmet.

Natural disasters in the last few years have also demonstrated the consequences of inadequate emergency planning for children. Due to the rapid pace of evacuation for Hurricanes Katrina and Rita of 2005, over 5,000 children were displaced from their families. A nongovernmental agency, the National Center for Missing and Exploited Children, was asked to step in and help reunite families, a process that lasted for 18 months.

Many recent events have demonstrated not only the vulnerability of children in school but, more disturbingly, that children in school may become specific targets of terrorism. Such events include the school hostage disaster in Beslan, Russia, that resulted in more than 300 casualties, and numerous school shootings. Collectively, these acts of terrorism make clear the need to create mechanisms that assure the safety of children when disasters occur. School safety is among the most important of response mechanisms.

Unique Issues Facing Children

In its policy statement, Chemical-Biological Terrorism and Its Impact on Children (2000), the American Academy of Pediatrics (AAP) outlined the many ways in which children would be disproportionately affected after an act of terrorism. Another statement, Radiation Disasters and Children, added the dimension of radiologic events and their impact on children (AAP Committee on Environmental Health, 2003). Both statements, as well as the subsequent monographs created by the AAP and other organizations over the last 6 years, have emphasized specific factors that place children disproportionately at risk for exposure and disproportionately at risk for life-threatening consequences after terrorism or other public health emergencies (AAP Committee on Psychosocial Aspects of Child and Family Health, 1999; AAP Committee on Infectious Diseases, 2002; Henretig, et al., 2002; Fairbrother, et al., 2004; Laraque, et al., 2004; Committee on Psychosocial Aspects of Child and Family Health, et al., 2005). Aspects of pediatric pathology that lead to greater impact compared with adults include: 

• A relatively faster respiratory rate.
• Less keratinized, more sensitive skin.
• A relatively larger body surface area.
• An immature immune system.
• Poorly developed self-preservation skills.
• Comparatively less fluid reserve.
• Greater risk of hyper- and hypothermia when exposed to the elements.
• A greater risk of long-term mental health consequences including post-traumatic stress disorder (PTSD).

Unique Issues Facing Schools

Among so-called child congregate facilities (schools, daycare centers, camps, athletic programs), schools constitute the largest group. More than 50 million children attend the Nation's 115,000 schools daily, spending more than 70-80 percent of their waking hours at school. Consequently, schools serve as surrogate parents, having primary responsibility for providing all of the needs of children, including their meals, education, treatment of illness, and protection from harm. 

Despite the integral nature of school in the life, health, and protection of children, there has been remarkably little attention devoted to emergency preparedness in schools. While certain aspects of school-based emergency response (e.g., fire drills and evacuation) are universal, other equally important aspects of emergency response, including sheltering-in and lockdown protocols, exist in few schools and school districts across the Nation. Based on our review, no comprehensive national guidelines have been created with flexibility needed for any school—regardless of size—to adopt.

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