Kanter, Robert K. (2012) The 2011 Tuscaloosa Tornado: Integration of Pediatric Disaster Services into Regional Systems of Care
The Journal of Pediatrics, Division of Pediatric Critical Care Medicine, Department of Pediatrics, SUNY Upstate Medical University, Syracuse, NY; National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, New York, NY
Stehling-Ariza, T., Park, Y., Sury, J., & Abramson, D. (2012) Measuring the Impact of Hurricane Katrina on Access to a Personal Healthcare Provider: The Use of the National Survey of Children's Health for an External Comparison Group.
Maternal and Child Health Journal, 16(0), 170-177. doi: 10.1007/s10995-012-1006-y
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Regional variation in critical care evacuation needs for children after a mass casualty incident.
Disaster Med Public Health Prep. 2012 Jun;6(2):146-9.
Kanter RK., Department of Pediatrics, SUNY Upstate Medical University, Syracuse, and National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, New York, New York.
Objectives: To determine the ability of five New York statewide regions to accommodate 30 children needing critical care after a hypothetical mass casualty incident (MCI) and the duration to complete an evacuation to facilities in other regions if the surge exceeded local capacity. Methods: A quantitative model evaluated pediatric intensive care unit (PICU) vacancies for MCI patients, based on data on existing resources, historical average occupancy, and evidence on early discharges and transfers in a public health emergency. Evacuation of patients exceeding local capacity to the nearest PICU center with vacancies was modeled in discrete event chronological simulations for three scenarios in each region: pediatric critical care transport teams were considered to originate from other PICU hospitals statewide, using (1) ground ambulances or (2) helicopters, and (3) noncritical care teams were considered to originate from the local MCI region using ground ambulances. Chronology of key events was modeled. Results: Across five regions, the number of children needing evacuation would vary from 0 to 23. The New York City (NYC) metropolitan area could accommodate all patients. The region closest to NYC could evacuate all excess patients to PICU hospitals in NYC within 12 hours using statewide critical care teams traveling by ground ambulance. Helicopters and local noncritical care teams would not shorten the evacuation. For other statewide regions, evacuation of excess patients by statewide critical care teams traveling by ground ambulance would require up to nearly 26 hours. Helicopter transport would reduce evacuation time by 40%-44%, while local noncritical care teams traveling by ground would reduce evacuation time by 16%-34%. Conclusions: The present study provides a quantitative, evidence-based approach to estimate regional pediatric critical care evacuation needs after an MCI. Large metropolitan areas with many PICU beds would be better able to accommodate patients in a local MCI, and would serve as a crucial resource if an MCI occurred in a smaller community. Regions near a metropolitan area could be rapidly served by critical care transport teams traveling by ground ambulance. Regions distant from a metropolitan area might benefit from helicopter transport. Using local noncritical care transport teams would involve shorter delays and less expert care during evacuation.
Thyroid doses for evacuees from the Fukushima nuclear accident
Sci Rep. 2012;2:507. Epub 2012 Jul 12.
Tokonami S, Hosoda M, Akiba S, Sorimachi A, Kashiwakura I, Balonov M.
A primary health concern among residents and evacuees in affected areas immediately after a nuclear accident is the internal exposure of the thyroid to radioiodine, particularly I-131, and subsequent thyroid cancer risk. In Japan, the natural disasters of the earthquake and tsunami in March 2011 destroyed an important function of the Fukushima Daiichi Nuclear Power Plant (F1-NPP) and a large amount of radioactive material was released to the environment. Here we report for the first time extensive measurements of the exposure to I-131 revealing I-131 activity in the thyroid of 46 out of the 62 residents and evacuees measured. The median thyroid equivalent dose was estimated to be 4.2 mSv and 3.5 mSv for children and adults, respectively, much smaller than the mean thyroid dose in the Chernobyl accident (490 mSv in evacuees). Maximum thyroid doses for children and adults were 23 mSv and 33 mSv, respectively.
Pediatric Medical Countermeasures
Most of the interventions to treat children in a public health emergency will require adapting every-day resources to the particular circumstances of the crisis. However, the treatment of some pathogens and toxins requires disease specific and life saving medical countermeasures. In many cases, the evidence is lacking to evaluate risks and benefits of medical countermeasures. Even where evidence is available, regulatory and logistical obstacles limit access to rapid availability for large populations. These problems are especially challenging in trying to provide medical countermeasures for children.
-When compelling emergency circumstances warrant use of a potentially beneficial medication before its approval for routine use, a federal Food and Drug Administration “emergency use authorization” (EUA) can be issued. When a medication is administered under EUA, providers are required to report adverse events. The preliminary data for intravenous peramivir to treat severe H1N1 influenza A illustrates the difficulty in evaluating risks and benefits for medical countermeasures that have not been well studied.
The FDA received 344 reports of patients with adverse events (including 28 children) in patients receiving peramivir for H1N1 influenza that was unresponsive to other available antiviral agents. Most occurred in patients who were critically ill and had already received many other medications. Adverse events included death, respiratory failure, and renal failure. The adverse events were all expected complications of the infection or may have been adverse effects of other medications. The bad news: It was impossible to determine the impact of peramivir on outcomes or complications. It was not even possible to determine the number of patients treated with peramivir. The good news: Peramivir was available within 24 hours of the request for >1100 critically ill patients. Next steps: How to design better formats to learn from such experience (case control studies, methods to collect data during a crisis)? More info:
-The Disaster Preparedness Advisory Council of the American Academy of Pediatrics is developing an agenda for priority medical countermeasure research and policy efforts. See:
-The President’s Bioethics Commission meets on May 17, 2012 to consider ethical and regulatory issues in conducting research involving children. Questions were stimulated by the prospects of testing a pediatric anthrax vaccine. See:
Latest Environmental Health Hazards - Child Lead Poisoning
In the US, decades of dramatic improvements in public health practices have allowed many to forget the latent persisting hazards of lead poisoning that may be present every day, or may be unmasked by natural disasters.
In 2001 Eckel and colleagues reported that defunct smelting plants, no longer in existence, may have contaminated the soil in residential neighborhoods of communities across the US. Approximately 430 potential sites were identified from historical records that were unknown to federal authorities. Only 5 of 319 of these sites were known to state authorities among the top 8 states [Am J Public Health 2001;91:625-7].
An investigation of many of these sites reported in USA Today on April 19 and 20, 2012 reveals that current nearby residents are typically unaware of the local history of industrial sites or the potential for environmental toxicity. In some cases the former industrial sites occupy the present location of playgrounds, with toxic lead levels persisting in surface soil. Cleanup efforts have been sporadic and risks often ignored. See more:
USA Today article - 1
USA Today article - 2
In Joplin Missouri, waste from defunct lead mines was identified as a hazard to children in the 1970s and 1980s. Effective remediation involved removal of surface contamination in federally funded cleanup efforts during the 1990s. As a result, there were large declines in the number of children with elevated blood lead levels. However, the May 22, 2011 tornado that devastated a large portion of Joplin also deeply disrupted and dispersed contaminated soil throughout the community. In interviews with NCDP staff seven months after the storm, some physicians and public health officials have noted sporadic cases of children with mildly elevated blood lead levels in a range not often seen in recent years. Further surveillance is in progress to determine the prevalence and extent of health hazards in Joplin.
How many of the other known toxic sites are located in residential neighborhoods at high risk for dispersal by natural disasters?
For more details, see:
Care of Children After the 2011 Tuscaloosa Tornado
In a major disaster, children's needs may overwhelm pediatric hospitals. Disasters may occur at a remote location far from pediatric subspecialists. In order to provide immediate lifesaving care for children, pediatric disaster services must be integrated into local and regional systems of care.
On April 27, 2011, Tuscaloosa, Alabama was struck by an F4 tornado that damaged a major portion of the city and killed 46. A report by Bob Kanter, Senior Investigator and Affiliated Faculty member at the National Center for Disaster Preparedness, describes Tuscaloosa's response in a community with no pediatric emergency department or pediatric intensive care unit facing one of the largest emergency department disaster surges at a single hospital in US history.
The night of the storm, Tuscaloosa's DCH Regional Medical Center served 800 patients. More than 100 of these were children, including more than 20 with critical injuries. Many children were unaccompanied and unidentified on arrival. Resuscitation and stabilization were performed by nonpediatric prehospital and emergency department staff. More than 20 children were then secondarily transported to the nearest children's hospital in Birmingham, Alabama, an hour away under the care of nonpediatric local emergency medical services providers. No preventable adverse events were identified in the resuscitation and secondary transport phases of care. Stockpiled supplies and equipment strategically located near the hospitals in Tuscaloosa and Birmingham were adequate to serve all children's needs.
Essential aspects of preparation included pediatric-specific clinical skills, supplies and equipment, as well as operational disaster plans applied by experienced staff and leaders, in a community familiar with interagency practice embedded in everyday work. Opportunities for improvement included more timely public response to tornado warnings, improved practices for identifying unaccompanied children, and enhanced child safety in shelters. Tuscaloosa's response challenge all other regions. Could we match Alabama's performance caring for children?
For more details, see:
Preventable Epidemic - Pertussis (Whooping Cough)
On May 4 the US Centers for Disease Control reported that across the US cases of pertussis (whooping cough) are occurring at a rate that greatly exceeds historical trends (through April 28, 2012). Current rates exceed the same period in 2011 by a factor of 2 in New England, by 3-fold in the Mid Atlantic states, and by more than 10-fold in the state of Washington resulting in a declared epidemic. Because provisional reports may be incomplete, the actual rates may be even higher. The disease is particularly dangerous for infants, with 20 babies under the age of 1 year hospitalized so far this year in Washington. Whooping cough results in uncontrollable fits of coughing so violent that some infants cannot feed or catch their breath. For infants under the age of 3 months, pertussis remains an important and preventable cause of infant mortality. Washington’s Governor Gregoire has activated a public awareness campaign to encourage immunizations, to be paid for by emergency funds. Caregivers and households contacts of young infants are particular targets for improved immunization rates. Why this outbreak? Washington State leads the nation in the proportion of children whose families refuse immunizations. Once in progress, response to the outbreak has been impaired by cutbacks in state and local health department budgets.
For more details:
Robert K. Kanter, MD, (firstname.lastname@example.org) Division of Pediatric Critical Care Medicine, Department of Pediatrics, SUNY Upstate Medical University, Syracuse, NY & National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, New York, NY