FeaturePerspective

AAP: Pediatricians should be ready to respond to chemical and biological attacks

Children are susceptible to and may be disproportionately affected by chemical and biological acts of terrorism, and pediatricians need to be prepared to provide care in the event of such attacks, according to an updated policy statement and technical report published by the AAP.

In the technical report, the authors said public health initiatives developed following the terrorist attacks of Sept. 11, 2011, have not ensured the protection of children. Preparedness has evolved to an “all-hazards approach, in which response plans for terrorism are blended with those for unintentional disasters or outbreaks, [for example] natural events such as earthquakes or pandemic influenza” they wrote. But in the policy statement, the authors said stagnant or decreased funding for preparedness and response at the state and local levels “potentially [leaves] communities vulnerable].”

As the roles of pediatricians and public health agencies grow, only a coordinated readiness and response effort will ensure the safety of medical and mental health for all children, the authors said.

“We need to follow an all-hazards approach at the local, state, and federal level, so that our preparedness, response, and recovery can be as flexible as possible,” authors Sarita Chung, MD, FAAP, a physician at Boston Children’s Hospital and assistant professor of pediatrics and emergency medicine at Harvard Medical School, and Carl R. Baum, MD, FACMT, FAAP, a professor of pediatrics and emergency medicine at the Yale School of Medicine, told Healio.

‘Pivotal’ role

According to the authors, pediatricians play a “pivotal” role in providing care in the event of a chemical or biological incident and it is “critical” that they continue to educate themselves on the consequences such an attack would have on pediatric patients. In recent years, children have been victims in chemical attacks in Syria, they noted. But they also said that some “medical countermeasures for particular chemical and biological agents have not been adequately studied or approved in children.”

In the event of chemical or biological terrorism, pediatricians and their staff will need to be prepared to publicize information on readiness approaches; advise on pediatric decontamination strategies; provide appropriate medical care; offer anticipatory guidance to families; report appearances of unusual disease clusters; and help guide families after an event occurs, the authors wrote.

“We are living in an era of nearly instant communication,” Chung and Baum said. “Syndromic surveillance may be able to alert us when exposures or outbreaks first occur, but we need to be able to harness existing systems of communications, including social media, to protect our pediatric populations and their families.”

The documents replaced a 2006 AAP policy statement.
we went on to create a new technical report and to revise the original policy statement,” Baum said. “Outbreaks of biological agents, such as a novel coronavirus, can inform in real time our preparedness, response and recovery.”

Kids more susceptible

According to the authors, children are at a greater risk for both exposure and harm following an act of chemical or biological terrorism because they take in more of the sources of exposure — air, water and food. For example, children inhale more air on a per-weight basis than adults (400 vs. 140 mL/kg per minute), the authors reported.

When exposed to a chemical or biological agent, there are numerous physiological vulnerabilities to which children are prone, including underdeveloped self-preservation skills, an immature immune system, a greater risk for severe dehydration and a greater risk for anxiety and post-traumatic stress disorders.

“It is incumbent on providers to, at the very least, have an understanding of the overall structure of the problem, and to have a set of mechanisms and infrastructure that are in place for preparedness, response and recovery,” Chung and Baum said. by Ken Downey Jr. and Eamon Dreisbach

References:

Chung S, et al. Pediatrics. 2020;doi:10.1542/peds.2019-3749.

Chung S, et al. Pediatrics. 2020;doi:10.1542/peds.2019-3750.

Disclosures: Chung reports being the codirector of the Disaster Domain of the Emergency Medical Services for Children Innovation and Improvement Center. Baum reports being the medical director for a grant from the Agency for Toxic Substances and Disease Registry and American College of Medical Toxicology; an advisory board member for the National Biodefense Science Board, American Board of Pediatrics and Medical Toxicology Subboard, Elsevier and Wolters Kluwer; a shareholder at Biogen Inc; an author at UpToDate; and an expert witness for medical testimony on lead with attorney Michael Foley.

Children are susceptible to and may be disproportionately affected by chemical and biological acts of terrorism, and pediatricians need to be prepared to provide care in the event of such attacks, according to an updated policy statement and technical report published by the AAP.

In the technical report, the authors said public health initiatives developed following the terrorist attacks of Sept. 11, 2011, have not ensured the protection of children. Preparedness has evolved to an “all-hazards approach, in which response plans for terrorism are blended with those for unintentional disasters or outbreaks, [for example] natural events such as earthquakes or pandemic influenza” they wrote. But in the policy statement, the authors said stagnant or decreased funding for preparedness and response at the state and local levels “potentially [leaves] communities vulnerable].”

As the roles of pediatricians and public health agencies grow, only a coordinated readiness and response effort will ensure the safety of medical and mental health for all children, the authors said.

“We need to follow an all-hazards approach at the local, state, and federal level, so that our preparedness, response, and recovery can be as flexible as possible,” authors Sarita Chung, MD, FAAP, a physician at Boston Children’s Hospital and assistant professor of pediatrics and emergency medicine at Harvard Medical School, and Carl R. Baum, MD, FACMT, FAAP, a professor of pediatrics and emergency medicine at the Yale School of Medicine, told Healio.

‘Pivotal’ role

According to the authors, pediatricians play a “pivotal” role in providing care in the event of a chemical or biological incident and it is “critical” that they continue to educate themselves on the consequences such an attack would have on pediatric patients. In recent years, children have been victims in chemical attacks in Syria, they noted. But they also said that some “medical countermeasures for particular chemical and biological agents have not been adequately studied or approved in children.”

In the event of chemical or biological terrorism, pediatricians and their staff will need to be prepared to publicize information on readiness approaches; advise on pediatric decontamination strategies; provide appropriate medical care; offer anticipatory guidance to families; report appearances of unusual disease clusters; and help guide families after an event occurs, the authors wrote.

“We are living in an era of nearly instant communication,” Chung and Baum said. “Syndromic surveillance may be able to alert us when exposures or outbreaks first occur, but we need to be able to harness existing systems of communications, including social media, to protect our pediatric populations and their families.”

The documents replaced a 2006 AAP policy statement.
we went on to create a new technical report and to revise the original policy statement,” Baum said. “Outbreaks of biological agents, such as a novel coronavirus, can inform in real time our preparedness, response and recovery.”

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Kids more susceptible

According to the authors, children are at a greater risk for both exposure and harm following an act of chemical or biological terrorism because they take in more of the sources of exposure — air, water and food. For example, children inhale more air on a per-weight basis than adults (400 vs. 140 mL/kg per minute), the authors reported.

When exposed to a chemical or biological agent, there are numerous physiological vulnerabilities to which children are prone, including underdeveloped self-preservation skills, an immature immune system, a greater risk for severe dehydration and a greater risk for anxiety and post-traumatic stress disorders.

“It is incumbent on providers to, at the very least, have an understanding of the overall structure of the problem, and to have a set of mechanisms and infrastructure that are in place for preparedness, response and recovery,” Chung and Baum said. by Ken Downey Jr. and Eamon Dreisbach

References:

Chung S, et al. Pediatrics. 2020;doi:10.1542/peds.2019-3749.

Chung S, et al. Pediatrics. 2020;doi:10.1542/peds.2019-3750.

Disclosures: Chung reports being the codirector of the Disaster Domain of the Emergency Medical Services for Children Innovation and Improvement Center. Baum reports being the medical director for a grant from the Agency for Toxic Substances and Disease Registry and American College of Medical Toxicology; an advisory board member for the National Biodefense Science Board, American Board of Pediatrics and Medical Toxicology Subboard, Elsevier and Wolters Kluwer; a shareholder at Biogen Inc; an author at UpToDate; and an expert witness for medical testimony on lead with attorney Michael Foley.

    Perspective
    Joelle Simpson

    Joelle Simpson

    We have learned a lot of lessons, particularly around the need to have pediatricians or people with expertise managing kids at the table and building collaboration and relationships across the country to better mitigate and plan for these events as they occur.

    The comments in the policy about the cost-effectiveness of preparedness and increasing resilience of our communities are extremely important. It is much more expensive to respond to a disaster event where relationships have not been forged ahead of time in the community. Those relationships can be built around trainings or simulation events.

    I am on the executive committee for the AAP Council on Disaster Preparedness and Recovery, where these authors are also members, and we have put a lot of work into being represented on federal advisory boards and with the CDC and other agencies that manage these issues, not just only for kids, but for the country as a whole.

    I personally believe that biological or chemical terrorism — while it's one of the easier topics to sort of put in the back of your mind in the face of things like active shooters and other threats (because they are often more prominently covered in public media) — has the potential to have a much, much greater impact on the population than an act of violence.

    So, that's a concern that pertains to kids, because kids are so much more vulnerable in many ways than adults. As we know, every year with influenza, kids are sort of the canary in the coal mine — the first ones to show us the severity of the epidemic or pandemic that may be ensuing, because of the vulnerability of their immune system, the exposure they have just being around each other in a day care setting and all of the other things that are discussed in that article.

    We've learned now to have a more proactive vs. reactive response in disaster planning. In terms of addressing disaster preparedness from an all hazards perspective, we all come together to plan, not just for active shooters, not just for chemical terrorism or bioterrorism, but in terms of building relationships and thinking of protocols as they pertain to multiple events, not just individual events.

    The science part of some of the discussion of nerve agents and the biological threats discussed in the policy paper is awesome. We have now been able to advocate significantly for the development of not just the medications and antidotes to some of these threats, but also the delivery mechanisms like the auto-injectors. Trying to figure out the most efficient way to dose load for children is extremely important and had been a hurdle that we were struggling with a decade ago.

    The actual truth of the matter is most children around the country are not seen in children's hospitals or areas where there is a density of pediatricians. They are seen more often in emergency settings by ER providers, or family medicine providers who may not have the extensive clinical experience with children to recognize things like unusual symptoms or signs that could indicate an outbreak or a threat in a community.

    I think it's really important that they discussed pediatric readiness as a concept, that is not just on pediatricians to be understanding of how to care for kids, but there should be a benchmark of what that should be across multiple disciplines, because we are all responsible for the children.

    • Joelle Simpson, MD
    • Member, executive committee
      AAP Council on Disaster Preparedness and Recovery
      Medical director, emergency preparedness
      Children’s National Hospital Washington, D.C.

    Disclosures: Simpson reports no relevant financial disclosures.