The Pediatric Perspective
Symposium on Pandemic Influenza - October 2007
By Jane D. Siegel, MD
The need to devote substantial time and human and fiscal resources to disaster preparedness planning has become increasingly more compelling since Sept. 11, 2001. These events demonstrate the need for preparedness planning and focus on the unique qualities of children:
- Terrorist attacks on the World Trade Center and the Pentagon on Sept. 11, 2001, inspired development of a Pediatric Disaster Advisory Group, which created detailed guidelines for pediatric disaster preparedness 1 to fill identified gaps.
- Letters containing anthrax were discovered. Eleven cases of inhalational anthrax and 12 cases of cutaneous anthrax, one of which was in an 8-month-old infant, were reported. 2 Special postexposure chemoprophylaxis regimens for children had to be developed. 3
- Concern for the threat of attacks using weaponized smallpox led to a widespread smallpox vaccine program in the military and to a limited degree in civilian health care personnel and public health responders in January 2003. 4 Although the civilian program was curtailed later that year, smallpox vaccination in the military continues, with reports of contact vaccinia in contacts of vaccinated individuals in that population, one of which was a recent case of eczema vaccinatum in a child. 5
- Outbreaks of severe acute respiratory syndrome (SARS) in 2003 required quarantine for control. The preparedness and response plans developed for SARS are a template for infectious disease disaster planning. 6 The adverse psychosocial effects of the strict isolation procedures imposed on hospitalized SARS patients were particularly serious for children. 7
- Increasing numbers of human cases of disease associated with avian strains of influenza H5N1 have been reported, with a 60.4 percent fatality rate (194 of 321) as of Aug. 16, 2007. Many cases have occurred in children, perhaps because of the greater frequency with which children play among infected poultry. 8
- During a severe seasonal influenza outbreak of H3N2 in the United States in the 2003-04 flu season, 153 children died. Forty-seven percent of those children had been previously healthy and did not meet the criteria for influenza vaccine defined in that season. 9 Many influenza-related deaths were associated with bacterial superinfection with methicillin-resistant Staphylococcus aureus (MRSA). 10,11 This reflects the ongoing epidemic of community-associated MRSA infections first recognized in children. 12,13
The May 2006 supplement to Pediatrics summarizes pertinent pediatric issues associated with Hurricane Katrina rescue and includes meeting emotional, emergency, and chronic medical needs; providing medications to those with chronic diseases, including children with transplants; and reuniting fractured families. 14
During the peak of the widespread outbreak of norovirus gastroenteritis among hurricane evacuees in a large Houston shelter, more than 40 percent of clinic visits by children were for gastroenteritis, compared with more than 21 percent by adults during the two peak days. 15
Furthermore, physicians' ability to link Houston pediatric clinics to the Louisiana state immunization registry just 10 days after the hurricane's landfall demonstrated a new and important use for registries that applies to pandemic influenza planning. 16
Unique Qualities and Needs of Children
The unique aspects of children must be considered in disaster planning, and pediatricians and other professionals experienced in children's health issues should assess children's needs (Table 1). Although children represent 27 percent of all emergency department (ED) visits, only 6 percent of EDs have the essential supplies for managing pediatric emergencies; only 50 percent of hospitals have at least 85 percent of those supplies. 17
A 2006 Institute of Medicine report on emergency care for children identified three broad areas that need addressing - coordination, regionalization, and accountability. The report recommended that hospital and emergency medical systems implement evidence-based approaches to reduce errors in emergency and trauma care for children. 17
Two specific recommendations for enhancing disaster preparedness for children include strengthening the pediatric workforce and improving the level of pediatric expertise on disaster medical assistance teams. The American Academy of Pediatrics (AAP) published a technical report, policy statements, and a statement for the Agency for Healthcare Research and Quality to educate and guide policymakers and pediatric health care providers involved in preparedness planning for children. 18-23 Descriptions of creating and implementing a mobile pediatric emergency response team in Houston and the lessons learned also can be used in planning. 24,25
Additionally, an evaluation of pediatric disaster preparedness was prepared for the Children's Hospital Association of Texas (CHAT) under the Lloyd Bentsen Child Health Policy Research Project and posted on the CHAT Web site in June 2007. 1 Specific differences between children and adults include:
- Anatomy and physiology,
- Special health care needs that often require technological support and medication for survival,
- Developmental limitations and psychological responses to stress,
- Vulnerability to caretakers' mental health status, and
- Dependence on adult family members for physical and emotional well-being. 1,18,22
Anatomy, Physiology, and Medical Conditions
A wide range of sizes are seen in children, from the smallest prematurely born infants to teens. Therefore, health care professionals and rescue workers must be familiar with normal values for vital signs by age and methods of calculating medication doses by weight or body surface area. Varied sizes of lifesaving equipment appropriate for all sizes of children and appropriate formulations of key medications must be available in EDs, makeshift rescue clinics, and transport vehicles. Children (especially children younger than 6 months) are more likely to absorb larger doses of infectious, chemical, or radioactive agents than are adults because of their more rapid respiratory rates and their larger surface area relative to body mass. Infants develop respiratory distress in response to agents that adversely affect the airways because of their small airways.
Children, especially young infants, have minimal reserve and become dehydrated more easily and are at relatively greater risk than are adults for developing hypovolemic shock when exposed to agents that cause vomiting and diarrhea. At the same time, otherwise healthy children may have a greater capacity to respond to resuscitation than adults with complex underlying conditions. Infants and young children may have clinical manifestations of certain infections, (e.g., SARS 26 ) that make it more difficult for those unfamiliar with pediatrics to recognize the disease processes. Because children are relatively closer to the ground, they will be exposed to larger doses of any agent that settles to the ground (e.g., nuclear fallout).
Infants and young children have immature immune systems and are more susceptible to developing infection after exposure to an infectious agent. Those who have not been fully immunized must continue to receive the indicated vaccines for full protection and to prevent outbreaks of preventable diseases under crowded conditions in rescue shelters. Many children have special health care needs (e.g., developmental delay; difficult airways due to congenital anomalies; and dependence on oxygen, mechanical ventilation, total parenteral nutrition, dialysis, 27 and medications to sustain life) and must receive special consideration during preparedness planning (Table 2).
Role of Children in Transmitting Seasonal Influenza
Children are highly effective transmitters of influenza virus because they shed a larger amount of virus for a prolonged period compared with adults. They also congregate in large groups under crowded conditions at schools and other social gatherings. Several studies have demonstrated that children are the center of community outbreaks of seasonal influenza and that respiratory illness and pneumonia related to influenza in all age groups are reduced significantly by influenza vaccination of school-age children. 28-36
If a novel strain of influenza virus emerged and its transmission characteristics were similar to those observed for seasonal influenza, then the role of children in the transmission is likely to be significant. Therefore, planning efforts should be directed toward lessening the spread of disease in this population.
Infants and young children are dependent on adult caregivers, most often parents, for physical and emotional care; they are especially vulnerable to their caregivers' mental health state. Thus, keeping families together, reuniting them after separation during rescue, and appointing a designated advocate for those children orphaned because of the disaster must always be priorities during and following rescue.
Children are very social and benefit from play with other children under circumstances of group gatherings. Additionally, play is therapeutic for children in stressful situations. However, with school closures and the suspension of mass gatherings, children most likely will remain in their homes; this relative isolation may increase their psychosocial stress. Further, if shelters are required during a pandemic, a shelter play area may facilitate transmission of infectious agents, especially those that cause respiratory and gastrointestinal tract disease. Therefore, organizers of shelters must implement proper infection-control precautions if play areas are to be implemented. 37,38
Developmental limitations of communication skills further impair the ability to express needs, feelings, and identifying information. Guidance for managing the psychosocial implications of disaster or terrorism on children provided by AAP is applicable for pandemic influenza planning. 22
Preparedness Planning for Children
Pediatricians should assume a central role in pandemic influenza and other disaster preparedness planning with children and their families. They can provide planning information to the families and answer questions that will arise during and after such an event. Their participation in disease surveillance and reporting to local health departments is critical, as influenza epidemics within a community generally begin with children, and the physicians who care for them recognize them first. 36 Pediatricians may also give families the local health department's rationale and support for closure of the school or child care center, as well as recommendations for quarantine measures.
Pediatricians and children's hospitals must be child advocates for both individual patients and the local and regional community at large. This includes obtaining funding from the legislature to support pandemic influenza planning and care for children, as children do not have other groups lobbying for their needs. While regional centers of expertise in pediatric care can be identified, local conditions must be improved to respond to the needs of children who cannot be moved long distances. Pediatricians must contribute their expertise and lead their colleagues and families in implementing pediatric-focused plans. Table 3 summarizes key components that pediatricians should address.
Seasonal Influenza Prevention
Pandemic influenza preparedness begins with seasonal influenza prevention education and interventions. Because children are the focus for seasonal influenza epidemics, 28-36 the Advisory Committee on Immunization Practices recommends annual influenza vaccination 39 of preschool and school-age children and the contacts of high-risk children. It also recommends the closing of schools and child care centers at the onset of pandemic influenza.
Furthermore, those who provide health care for children have an opportunity to educate families and children on the importance of hand hygiene, respiratory hygiene, and social distancing during both a seasonal community outbreak and a pandemic.
Networking of Pediatricians
Locally, pediatricians may network through local medical societies, children's hospitals, and county health departments, using communication modes such as blast fax and e-mail. Infrastructure for these activities must be established and tested if not already in existence.
Statewide, pediatricians will benefit from interaction with the Texas Pediatric Society (TPS) and the Texas Department of State Health Services (DSHS). Pediatricians may also provide important guidance for educating schoolchildren in methods of reducing transmission of infectious agents before a seasonal epidemic or pandemic occurs. The Federal Pandemic Preparedness Plan has specific guidance and preparedness checklists for child care centers and schools. 8
The TPS Committees on Infectious Diseases and Immunizations and Emergency Medicine include pediatric disaster preparedness in their agendas, and TPS works collaboratively with CHAT. Similar activities and information are available from AAP.
A structure for emergency response should be established within each community and should take advantage of the strengths and expertise of individuals available and should include pediatric representation in the county Incident Command Center.
Aids to help families prepare for a pandemic or other disasters that will affect children have been cited earlier. Pediatric subspecialists must identify the subspecialty-specific needs of children with chronic conditions and have that information readily available to primary care providers and families. The End Stage Renal Disease Network of Texas has distributed an emergency preparedness guide for adult dialysis and transplant patients, but it does not contain specific pediatric information. 40 Routine childhood, adolescent, and adult immunizations are an important part of pandemic influenza planning. Pandemic influenza planning also must include the identification of alternative means of child care, based on gathering no more than four to six children, so that adults who are critical to the workforce will be able to continue to work. Some child-specific information is in the most recent draft of the DSHS Pandemic Influenza Preparedness Plan. 41
Rescue Teams and Facilities
Adult multiple casualty incident triage systems do not consider a child's unique features and should not be used to triage pediatric victims. The JumpSTART Pediatric MCI triage tool 42 contains algorithms that take into consideration the specific vulnerabilities of children and prevent under- and over-treatment of children. Several states use this tool.
Physicians, nurses, respiratory therapists, and other ancillary personnel experienced in caring for infants and children should plan and staff temporary fever hotlines and fever clinics for children. Fever clinics removed from the site of the main pediatric ED will prevent crowding of the ED and facilitate more efficient care of those who truly require ED-level care. Such off-site clinics were useful during the SARS outbreak in Toronto.
A community-wide approach to surge capacity planning for appropriate types of beds, size of medical equipment, dosage formulations of medications, and staffing will provide the best care for the most children.
Ethical Decision Making
During recent seasonal influenza community outbreaks, health care professionals have been faced with the difficult decisions of prioritizing groups to receive influenza vaccine and antiviral agents when delivery of these products was delayed or the supply did not match the demand.
Recommendations have been made for vaccine prioritization for health care workers 43 and for patients with underlying conditions. 44 However, recommendations for tiered use of vaccine during a pandemic must be modified to prioritize those needed to provide health care for the increased number of sick individuals, those needed to produce vaccine and antiviral agents, and the first responders needed to keep the infrastructure of the community intact. 8,45
The Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America support the World Health Organization position against personal and family stockpiling of antiviral agents because that would limit the availability of these agents for priority groups. The ethical and legal considerations for pandemic influenza planning are summarized in a report of the proceedings of an Institute of Medicine workshop released in June 2007 45 and in other publications. 46,47 The considerations focus on transparency, utilitarianism versus social justice, personal liberty versus public welfare, and involvement of all stakeholders, including the public.
Because effective vaccines may not be available for at least the first six months of a pandemic, the emphasis is on transparency and ethical principles to guide decision making concerning the use of scarce supplies (e.g., ventilators and intensive care unit resources), recommending voluntary quarantine and isolation, and mandating closures of schools and child care centers. The Minnesota Department of Health has published criteria for offering or withdrawing ventilatory support based on probability of survival of adults. 48 To achieve the optimal outcomes for children, establishing similar criteria based on probability of survival in children is critical.
In Texas, we are fortunate to have a robust resource of talented individuals in child health in both our tertiary care children's hospitals and in our communities. If the private and public sectors can join in planning for children's needs during an influenza pandemic, we will succeed in mitigating the impact of a pandemic. The critical issues from Hurricane Katrina that need solutions 49 and areas requiring improvement in our state 1 have been summarized and provide us with a starting place.
Dr. Siegel is professor of pediatrics at The University of Texas Southwestern Medical Center in Dallas and attending physician and medical director of infection control at Children's Medical Center Dallas.
Gajdeczka AA. A makeshift shelter from the storm: an evaluation of pediatric disaster preparedness in Texas. Prepared for the Children's Hospital Association of Texas (CHAT). www.childhealthtx.org
. Accessed Aug. 20, 2007.
Roche KJ, Chang MW, Lazarus H. Images in clinical medicine: cutaneous anthrax infection. N Engl J Med . 2001;345(22):1611.
- CDC. Update: Interim recommendations for antimicrobial prophylaxis for children and breastfeeding mothers and treatment of children with anthrax. MMWR Morb Mortal Wkly Rep . 2001;50(45):1014-1016.
- CDC. Smallpox vaccination and adverse reactions. Guidance for clinicians. MMWR Recomm Rep . 2003;52(RR-4):1-28.
CDC. Household transmission of vaccinia virus from contact with a military smallpox vaccinee - Illinois and Indiana, 2007. MMWR Morb Mortal Wkly Rep . 2007;56(19):478-481.
- Srinivasan A, McDonald LC, Jernigan D, et al; SARS Healthcare Preparedness and Response Plan Team. Foundations of the severe acute respiratory syndrome preparedness and response plan for healthcare facilities. Infect Control Hosp Epidemiol . 2004;25(12):1020-1025.
Koller DF, Nicholas DB, Goldie RS, Gearing R, Selkirk EK. Bowlby and Robertson revisited: the impact of isolation on hospitalized children during SARS . J Dev Behav Pediatr . 2006;27(2):134-140.
Bhat N, Wright JG, Broder KR, et al; Influenza Special Investigations Team. Influenza-associated deaths among children in the United States, 2003-2004. N Engl J Med. 2005;353(24):2559-2567.
Hageman JC, Uyeki TM, Francis JS, et al. Severe community-acquired pneumonia due to Staphylococcus aureus , 2003-04 influenza season. Emerg Infect Dis. 2006;12(6):894-899.
CDC. Severe methicillin-resistant Staphylococcus aureus community-acquired pneumonia associated with influenza - Louisiana and Georgia, December 2006-January 2007. MMWR Morb Mortal Wkly Rep . 2007;56(14):325-329.
Herold BC, Immergluck LC, Maranan MC, et al. Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk . JAMA . 1998;279(8):593-598.
Zetola N, Francis JS, Nuermberger EL, Bishai WR. Community-acquired meticillin-resistant Staphylococcus aureus : an emerging threat. Lancet Infect Dis . 2005;5(5):275-286.
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Yee EL, Palacio H, Atmar RL, et al. Widespread outbreak of norovirus gastroenteritis among evacuees of Hurricane Katrina residing in a large "megashelter" in Houston, Texas: lessons learned for prevention. Clin Infect Dis . 2007;44(8):1032-1039.
Boom JA, Dragsbaek AC, Nelson CS. The success of an immunization information system in the wake of Hurricane Katrina. Pediatrics . 2007;119(6):1213-1217.
Markenson D, Reynolds S; American Academy of Pediatrics Committee on Pediatric Emergency Medicine; Task Force on Terrorism. The pediatrician and disaster preparedness. Pediatrics. 2006;117(2):e340-e362.
AAP. The pediatrician and disaster preparedness. Pediatrics. 2006;117(2):560-565.
American Academy of Pediatrics, Committee on Pediatric Emergency Medicine and American College of Emergency Physicians, and Pediatric Committee. Care of children in the emergency department: guidelines for preparedness. Pediatrics . 2001;107(4):777-781.
Emergency preparedness for children with special health care needs. Committee on Pediatric Emergency Medicine. American Academy of Pediatrics . Pediatrics . 1999;104(4):e53.
Hagan JF Jr; American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health; Task Force on Terrorism. Psychosocial implications of disaster of terrorism on children: a guide for the Pediatrician. Pediatrics . 2005;116(3):787-795.
Foltin GL, Schonfeld DJ, Shannon MW, eds. Pediatric terrorism and disaster preparedness: a resource for pediatricians. Rockville, Md.: Agency for Healthcare Research and Quality; October 2006. AHRQ publication no. 06(07)-056. http://www.ahrq.gov/research/pedprep/pedresource.pdf
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Sirbaugh PE, Gurwitch KD, Macias CG, Ligon BL, Gavagan T, Feigin RD. Creation and implementation of a mobile pediatric emergency response team: Regionalized caring for displaced children after a disaster. Pediatrics . 2006;17(5):S428-S438.
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Table 1. Unique characteristics of infants and young children.
- Anatomy and physiology
- Unique normal values for vital signs according to age and size
- Medication dosages based on weight or body surface area
- Less reserve, lower threshold for clinical deterioration
- Atypical clinical manifestations
- Ability to absorb larger doses of toxic or infectious agents
- Ongoing need for immunizations
- Special health care needs that often require technological support and medication for survival
- Developmental limitations and psychological responses to stress
- Dependence on adults for physical and emotional well-being
- Vulnerability to the mental health of the caretaker
- First group to be identified during seasonal influenza and more efficient transmitters of influenza viruses
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Table 2. Guidance for families of children with special health care needs.
- Notification of utility companies to provide emergency support during a disaster
- Maintenance of medications and equipment if supply is disrupted during a disaster
- Knowledge of mechanism to obtain medications and equipment during a disaster
- Training for family members to assume the role of in-home health care providers if such individuals are unavailable during a disaster
- Maintenance of an up-to-date emergency information form to provide health care workers with the patient's medical information, including medication regimen, if the regular provider is unavailable
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Table 3. Role of pediatricians in pandemic influenza planning and management during and after pandemic influenza.
Teach and implement all recommendations for prevention of seasonal influenza in families (e.g., hand hygiene, respiratory hygiene, social distancing, and vaccine administration according to recommendations of the Advisory Committee on Immunization Practices and the American Academy of Pediatrics) as a drill for pandemic flu
Advocate for inclusion of children's needs in all federal, state, and local planning efforts
Provide guidance for rationing of scarce supplies based on survival probability of children
Become knowledgeable in pediatric health needs and the use of antiviral agents and vaccines that may be unique to pandemic influenza
Participate in community and hospital planning, drills, and providing care outside the usual setting when needed
Provide guidance to families for planning, including plans for children with special health care needs and/or dependency on technology for survival
Provide guidance and educational information to schools and child care centers regarding:
Methods of preventing transmission of influenza, e.g., hand hygiene, respiratory hygiene, school or day care center closure
Explanation of the rationale for and support for the implementation of school and child care center closures, social distancing, and quarantine measures
- Deliver antivirals and vaccine when available according to recommendations of the U.S. Centers for Disease Control and Prevention and the American Academy of Pediatrics
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