Abstract:This article is part of a collaborativeeffort by experts in the field ofemergency preparedness to com-plete an overview begun by the lateMichael Shannon, MD, MPH, on thecurrent challenges and future direc-tions in pediatric disaster readiness.This particular article, "Preparing forNatural Disasters," will addresspertinent clinical and disaster man-agement issues relating to caring forchildren and families impacted bynatural disasters.

Division of Emergency Medicine, Children’s

Hospital Boston, Harvard Medical School,

Boston, MA.

Reprint requests and correspondence:

Mark Waltzman, MD, Division of Emer-

gency Medicine, Children’s Hospital

Boston, Harvard Medical School,

Boston, MA 02115.

1522-8401/$ - see front matter

© 2009 Elsevier Inc. All rights reserved.

144 VOL. 10, NO. 3 • PREPARING FOR NATURAL DIS

Preparing forNatural Disasters

ASTERS / WALTZMAN AND FLEEG

Mark Waltzman, MD,Eric Fleegler, MD, MPH

“disaster” denotes a low-probability but high-impactevent that causes a large number of individuals to

Abecome ill or injured. The International Federation ofRed Cross and Red Crescent Societies defines a disaster

as an event that causes more than 10 deaths, affects more than100 people, or leads to an appeal for assistance by those affected.1

A “natural disaster” is one in which a large number of individualsbecome ill or injured secondary to events that are not directlycaused by humankind. These types of disasters range frommeteorological events such as hurricanes and tsunamis toinfectious disease epidemics of influenza or outbreaks offoodborne illness. The response to these events will be varied,but all have the same downstream impact of overburdening thehealth care system, potentially impacting care. Challenges persistto prepare for these events especially the physical and psychologiceffects on children.

METEOROLOGIC EVENTSLarge-scale natural disasters, such as hurricanes and earth-

quakes, will often require cooperation of multiple agencies andservices at the local, state, and federal level. These systems maywork together, in parallel, or most often in a mixed model thatevolves over time as both the consequences and medical needs ofthe disaster become evident and as the agencies themselves havethe opportunity to entrench and organize. Within the context ofpreparing to meet the needs of an unknown number of patientswith an as yet unclear severity of trauma and illness, it is essentialto recognize that pediatric patients may encompass a significantpercentage of the patients seen and that personnel trained inpediatric care should be fully integrated into the disastermanagement and emergency care system.

Preparation for large-scale natural disasters must includeconsideration of a broad range of needs. These include injuriesor problems directly attributable to the disaster, such as injuriesresulting from a lack of services (electricity, heat, shelter, or

LER

PREPARING FOR NATURAL DISASTERS / WALTZMAN AND FLEEGLER • VOL. 10, NO. 3 145

access to adequate food and water). In addition,patients with preexisting medical conditions add tothe stress and burden of a system that has beenoverloaded and may be structurally damaged. Therewill be a growing population of displaced personswho lack adequate housing, have limited access tofood and water, have decreased mobility due to lossof private and public transportation, will lackcommunication capability, and will potentially beseparated from their family. All of these problemsare multiplied in the pediatric population in respectto their inability to primarily care for themselves.

DOMESTIC AND INTERNATIONALPERSPECTIVES

There is significant divergence in the capabilitiesfor natural disaster preparedness between the devel-oped world and the developing world. The UnitedStates, for example, has developed the infrastructurefor responding to disasters at the federal, state, andlocal levels. The National Disaster Medical Systemhas critical functioning in the assessment of healthand medical needs as well as deployment of medicalcare personnel, equipment, and supplies. It assistswith victim identification and mortuary services aswell as aiding in patient evacuation and in-hospitalcare of patients.

Developing countries are more reliant on theinternational community given their potential lim-itations of trained personnel, infrastructure, andfinancial considerations. This may result in delays inthe rescue and treatment of ill or injured persons. Tovarying degrees, international relief efforts respondto the immediate, life-threatening needs of anaffected country 2-4 and not to the preparation fordisasters. On December 26, 2003, an earthquakemeasuring 6.5 on the Richter scale caused cata-strophic damage to the city of Bam and neighboringvillages, with a collective population of approxi-mately 142 000. There were more than 40 000deaths and tens of thousands of injuries. Accordingto the United Nations Disaster Assessment and Co-ordination team mission report, this earthquakedestroyed 87% of the buildings in Bam and left 80000 persons homeless. A total of 18 000 buildings inBam and the surrounding villages were destroyedincluding 131 school buildings, 3 hospitals, 95health centers, and 14 rural health clinics.5 The2004 Indian Ocean Tsunami resulted in more than150 000 deaths and eventually required more than$7 billion in aid and assistance in Indonesia.6 The2005 earthquake in Pakistan, which occurred 1month after Hurricane Katrina, killed approxi-

mately 80 000 people and injured an additional200 000, of whom half were children.7 Even moredevastating was the 2008 earthquake strikingWenchuan County in China's Sichuan Province.This 7.9 magnitude earthquake directly resulted ininfrastructure collapse and damage but triggeredmore than 12 000 landslides and mudflows, causingflooding. More than 87 000 people were killed(more than 5300 children, most as a result of thecollapse of school buildings), 374 000 peoplewere injured, and 15 million people were lefthomeless. The economic impact has reached morethan $124 billion.8

In general, the primary assessments for thesetypes of disasters reveal that the main causes ofmorbidity are from direct injuries, including frac-tures from collapse of structures, and the maincauses of mortality are traumatic injury andsuffocation.9 The burden of caring for the injuredand traumatized patients fall on local heath systemsthat may be damaged themselves. Treatment foracute trauma, emergency surgical interventions,and acute medical life-support activities will likelyfully consume the capacity of regional health caresystems. These systems may have limited equip-ment, supplies, and expertise to manage theparticular needs of the injured or traumatized child.

INJURIES AND DISEASESInfants and young children are especially prone to

injuries and diseases after a disaster for a number ofreasons. Children are physically closer to theground and are naturally curious about thingsaround them. For this reason, they may interactwith dangerous items including building debris,fallen trees, downed power lines, and bodies ofwater. They are less able to protect themselves, andtheir organs are proportionally larger, closertogether, and less well protected.10 As a result,they are highly susceptible to wounds, head trauma,multisystem organ injury, fractures, burns, anddrowning. Adolescents may likewise be prone tomany of these problems due to their immaturityrelative to adults.

Likewise, children are highly susceptible to manydiseases including respiratory, gastrointestinal, andskin infections. Children have increased fluid needsproportional to their size and will not necessarilyadequately hydrate themselves without adult super-vision and encouragement. Access to age-appropri-ate foods and hydration (ie, infant formula) may bemore difficult to obtain after a disaster. Youngchildren are not only particularly prone to dehydra-tion and undernutrition, but theymay also be unable

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to communicate if they are in distress. Familymembers, in the setting of dealing with other urgentneeds,maynot recognize theneeds of young childrenuntil a crisis develops. In addition, children withchronic medical conditions who are separated fromfamily members may not be able to communicatetheir medical needs and may thus be undertreated.

Chronic conditions, especially asthma and dia-betes, will worsen during these disasters because ofmissing medications, worsening environmental con-ditions, and inadequate attention paid to routinemanagement of these diseases. Children with morecomplex illnesses, especially those hospitalized andrequiring ongoing treatment, will have to betransferred to appropriate facilities away from thedisaster that can manage pediatric patients.

Lack of adequate housing exposes disastervictims to weather extremes leaving childrenvulnerable to hyperthermia and/or hypothermia,often within the span of 24 hours. Once outside thefamily home, access to food and water may belimited. Providing food and water to these familiesis a cornerstone of preventing new and worseningmedical problems.

The treatment of these problems requires per-sonnel who can appropriately evaluate and managepediatric patients, including physicians, nurses,respiratory therapists, and pharmacists trained inpediatric care. They require pediatric-specificequipment, supplies, and pharmaceuticals.

DISPLACED FAMILIESFamilies with children pose multiple challenges

that can be anticipated in advance. Wheneverpossible, family units should stay together to providephysical, psychologic, and emotional support to oneanother. If a family member is injured or sick andrequires medical attention, special considerationmust be given to keeping the family together even ifspace is limited. If a child is ill, a parent can providethe 24-hour care and attention required that willotherwise not be afforded by the medical staff.

Children separated from their families pose anespecially challenging problem. Hurricane Katrinaclearly demonstrated the problem of young childrenunable to properly identify themselves or theirparents and families separated by hundreds ofmiles upon relocation during a massive storm.Systems that can capture physical-identifying dataabout children before disasters will play an impor-tant role in the future. Computer pattern identifica-tion tools also have the potential to reunite childrenand families.

INFECTIOUS DISEASE DISASTERSInfectious agents leading to natural disasters are

not limited to airborne or contact transmitteddiseases. Consider the fervor surrounding largeoutbreaks of foodborn disease. In early January2009, the US Food and Drug Administration, alongwith the US Centers for Disease Control andPrevention issued warnings to consumers of peanutproducts contaminated with Salmonella, originatingat a single processing plant. In 2006, clusters ofEscherichia coli 0157:H7 was traced to contaminatedspinach. These warnings led to massive productrecalls, media hysteria, and ensuing public appealfor evaluation, assistance, and governmental over-sight. Packaged food that has been contaminated(such as with the peanut products) pose a significantrisk to children because they are easy to distributein multiple venues (home, school, daycare settings,vending machines) and are perceived to be safebecause they are “factory sealed.” Despite theconcern, according to the Centers for DiseaseControl's Food-borne Active Surveillance Network(FoodNet), over the past decade, there has actuallybeen a substantial decrease in the incidence ofdifferent bacterial pathogens commonly transmittedthrough food.11 The reality of the problem is far lessthan the generated fear, leading to massive appealsfrom those concerned, thereby meeting the defini-tion of a “disaster.”

The international crisis caused by the H1N1pandemic exemplifies how a “natural disaster”may unfold with moderate federal and local govern-mental involvement and minimal intervention. OnApril 9, 2009, it became apparent to public healthofficials in Mexico City that an outbreak of influenzawas in progress late in the influenza season.12

Within a period of weeks, it had spread to theUnited States, Canada, as well as Europe and Asia.The World Health Organization eventually elevatedthe pandemic alert level to “Phase 6” (characterizedby human-to-human spread of the virus into at least2 countries in 1 World Health Organization region).Although this outbreak led to thousands of con-firmed cases, there have been less than 500 deathsas of August 2009 in the United States associatedwith this disease. Children are at increased risk ofcontracting these types of airborne illnesses becausethey are cohorted in schools and daycare settings.The impact of H1N1 that was placed on the localhealth care system was extraordinary. Despiterecommendations from federal and local healthofficials that patients with mild illness stay home,13

the media fervor caused by H1N1 and some incon-sistent responses from local public officials resulted

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in either a child with a suspected case or with aconfirmed case of H1N1 being kept out of school,or the other extreme, a single case leading to anentire school closing. This resulted in patientsinundating their primary care providers' office withrequests for evaluations and the primary careproviders referring patients to local emergencydepartments (EDs) for testing and/or treatment.This upsurge in patient volume in some EDstriggered hospital “surge protocols.” Emergencydepartments reported visitation rates up to 2- to3-fold higher than normal, and increased levelspersisted for more than a month after the outbreakbegan. Children's Memorial Hospital in Chicagosaw its ED volume double from a May 2008 averageof 170 patients per day, with peak daily volumesapproaching 400 visits in early May.14,15 Althoughthis incident was a useful test of many hospitals'crisis response plans (many instituted after theWorld Trade Center attacks in 2001, but neverformally tested), it demonstrated that there is stilla significant amount of work that needs to be donein the preparation for a similar but more lethalmass casualty event.

RECOMMENDATIONSIt is impossible to adequately plan for all types of

natural disasters. The scope of the problem faroutweighs the financial, physical, and personnelcapacities needed to anticipate all potential eventsand their consequences. What needs careful atten-tion is a generalizable approach to planning fornatural disasters and a coordinated effort in theresponse once these events do occur. These plansneed to take place at the local level, in the primarycare provider's office, in the schools, and incommunity hospitals. Local, state, and federalgovernments must develop the infrastructure neces-sary to coordinate response efforts. Efforts such asactive surveillance of disease can alert healthofficials of atypical illness patterns that may foretella coming pandemic.16-18 Plans for disseminatinginformation to members of the community thatinform but do not evoke panic must be developed.Stockpiling of equipment (such as ventilators) inappropriate sizes for all patients must be consid-ered. Using a hypothetical influenza outbreakmodel, assuming that 35% of the population wouldbe affected, the New York State Department ofHealth estimated that there could be 93 753 totalinfluenza-related hospital admission with more than14 000 total influenza patients requiring care in anintensive care unit. It is estimated that more than7000 cumulative influenza patients would require

ventilatory support during the duration of theoutbreak, with more than 2171 patients needingthem simultaneously during the peak weeks, whichfar exceeds the current ventilator capacity of thestate.19 The needs of children who are at higher riskfor severe disease, will readily outstrip pediatricintensive care capacity.

In addition to information technology systemsand durable medical equipment, consideration mustbe given to developing a cache of medications. Therecent H1N1 outbreak demonstrated that localpharmacies can become overrun early in thepandemic, depleting their supply of antiviral med-ications such as Oseltamivir. The federal govern-ment provided states with hundreds of thousands ofcourses of the medication from the NationalStrategic Stockpile; however, these were distributedonly to hospitals and health centers. Thus, the“walking well,” who were not ill enough to requirehospitalization but needed/wanted treatment, couldnot obtain the medications in their local pharmacy.This resulted in patients adding to the pressures oflocal EDs and hospitals to provide medication thatwas being reserved for the critically ill. The need forliquid formulations of medications must also beaddressed to fully anticipate the needs of the veryyoung and very old.

In the post 9/11 days, local, state, and the federalgovernments have made significant strides in theplanning for man-made disasters. These prepara-tions have resulted in systems that are useful in theface of natural disasters. The creation of disasterresponse teams with specific training in pediatricshas been a crucial step. Additional thought iswarranted toward active surveillance of diseasesin children; increasing the supply of durablemedical equipment that are required in theneonatal and pediatric intensive care units andthe creation and maintenance of a cache ofmedications with pediatric formulations should befactored in to the strategic planning for futuredisaster planning.

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