Peter D. Rumm, MD, MPH, FACPM Director, Center for Public Health Readiness and Communication

1. The National Advisory Committee on Children and Terrorism and Current U.S. Changes in How Preparedness is Evaluated Peter D. Rumm, MD, MPH, FACPM Director, Center for Public Health Readiness and Communication Drexel School of Public Health pdr26@drexel.edu or 215-762-1652

2. Most Famous Anthrax Disaster: Sverdlovsk • In late April of 1979, an outbreak of pulmonary anthrax occurred in Sverdlovsk (now Yekaterinburg) in the former Soviet Union. • While, originally, the outbreak was described as being due to ingestion of infected meat, it was later discovered that the cause was from an accidental release of anthrax in aerosol form from the Soviet Military Compound 19, a huge Soviet bioweapons facility. • Residents living downwind from this compound developed high fever and difficulty breathing, and a large number died. The final death toll was estimated at the time to be between 200 and 1,000.

3. Cutaneous Anthrax (day 5) www.dermatologyabout.com

4. Anthrax Inhalation Cases (10) and their Timeline CDC, EID Vol 7 No 6 Nov-Dec 2001

5. The “Challenge of Bioterrorism” • Biological weapons are a formidable challenge. The use of a bioagent as a weapon is a multidimensional problem because of the diversity of bioagents, the large number of vulnerable targets, and the varied routes of dissemination. • Terrorists using biological warfare can decimate a large population, inflict enormous psychological and economic hardship, and incite political unrest by merely attacking small populations in multiple sites over a long period of time.

6. US Postal Cases • In October 2001, anthrax spores were sent through the U.S. mail and caused 18 confirmed cases of anthrax (11 inhalation, 7 cutaneous). Five individuals with inhalation anthrax died; none of the cutaneous cases was fatal. • One of the cutaneous cases was a child that did well. • We learned a lot about the potential vulnerability of children, the aged and other populations.

7. Soviet Union and Russia Although the former Soviet Union was a signatory to the Biological Weapons Convention, their development of biological weapons only intensified after the accord and continued with full steam into the 1990s.

8. Overlooked Populations • Many groups of people are frequently overlooked in response plans, including those regarding mental health, and the needs of children, elderly, disabled, and ethnic minority groups that are vulnerable to backlash or hate crimes.

9. Some Resources • American Academy of PediatricsChildren, Terrorism and Disasters: Disaster Preparedness to Meet Children’s Needs • Columbia University Mailman School of Public HealthThe National Center for Disaster Preparedness, Program for Pediatric Preparedness • American Red CrossChildren and Disasters

10. Other Populations • Disabled: American Red CrossSpecial Needs & Concerns: Disaster Preparedness for People with Disabilities • Hate crimes: Council on American-Islamic RelationsMuslim Community Safety Kit • Seniors: International Longevity CenterEmergency Preparedness for Older People • Mental Health: American Psychological AssociationBriefing Sheet: The Psychological Impact of Terrorism on Vulnerable Populations

11. Children may be most vulnerable population, at home or in schools • A survey by the National Safety Resource Officers in Schools in 2003 stated that 68% of schools unprepared for a disaster or act of terrorism. • Children have special vulnerabilities both physiologically and mentally. • According to the WHO in 2002 most casualties of both man made and natural disasters were children.

12. Purpose of the NACCT • Created by joint legislation introduced first by Senator Hillary Clinton in 2001. • The objective of the National Advisory Committee on Children and Terrorism (NACCT) as specified in the legislation was to assess and provide recommendations for Health and Human Services Secretary Tommy Thompson

13. Public Health Security and Bioterrorism Preparedness and Response Act of 2002 • Established a National Advisory Committee on Children and Bioterrorism; assured that our national system of responding and countering bioterrorism. • Provided training to health professionals on the special needs of children; • Promoted 211 hotlines and other communications systems.

14. Background Information • There are more than 70 million children under the age of 18 in the United States today, and more than 22 million are ages five and younger. • In the event of a terrorist attack, these children would be among the most vulnerable populations in our society • As recently as 1997, data collected by FEMA showed that no state disaster plans had pediatric components.

15. Reports Consensus • Children are not simply small adults. Children breathe faster and have faster heart rates than adults, making them more vulnerable to aerosolized biological and chemical agents. • Children metabolize drugs differently, requiring different dosages of drugs and different antidotes to many agents, as well as specially sized equipment to administer many treatments.

16. Classic Presentation of a Severe Case about 1 Week, 10 Days

17. Committee Consensus • Ill and injured children react differently than adults to stress, and their psychological vulnerabilities in the aftermath of disasters and emergencies are still only imperfectly understood. • On every level, physical, medical, psychological, emotional and social, children have unique needs and vulnerabilities that must be taken into account.

18. Focus Areas • Primary Care Pediatricians, Office-Based Practice & Urgent Care Centers • Community Involvement • Children’s School and Childcare • Research and Data • Training • Mental Health Response Phase • Children with Special Health Care Needs • Mental Health Recovery and Mitigation Phase • Hospital Preparedness • Public Health Departments • Pre-Hospital and Critical Care

19. Methods • Each of 12 members began working with 3-4 CDC staff and consultants wrote a 30-50 page draft report on their focus area that they led. This involved a massive literature review and seeking out expert opinions. • Four meetings were held in two places (DC, Atlanta)

20. Methods Continued • Over a 3-4 month time we each spent hours working with the CDC and HHS senior staff and other staff to compose report. • Report is available on line at www.bt.cdc.gov and a supplement has also been published at: • J Sch Health. 2004 Feb;74(2):39-51.Schools and terrorism. A supplement to the report of the National Advisory Committee on Children and Terrorism.

21. Key Recommendation • 1.3 Conduct a national survey of Federal, state and local terrorism and disaster plans that includes a specific assessment of preparedness and training for the medical and psychological effects of terrorism on children.

22. Key Recommendation of This Committee • 1.2 Assure that the unique physical and mental health needs of children are recognized and resources provided for in all DHHS terrorism preparedness and response funding initiatives, strategic plans and priority setting activities.

23. History of Bioterrorism = Not New! • Before the era of modern microbiology brought the prospect of germ warfare to the world of the 21st century, ancient armies used filth, cadavers, animal carcasses and contagion as weapons against each other. • They knew that fear of infectious diseases could rapidly demoralize and dismantle enemy forces. • During the North American colonization, British forces purposely spread smallpox among the native Indian population by sending smallpox-infested blankets as "gifts"; to Indian tribes who resisted British authority.

24. Key Recommendation • 1.6 Expand the State Children's Health Insurance Program (SCHIP) to provide financial mechanisms for States to support post-disaster physical and mental healthcare to all children.

25. Key Recommendation – focus on mental health and resiliency • 3.1 Conduct research relating to identifying patterns of child trauma, resilience, coping and recovery in the aftermath of disasters and terrorism. • This research should include studying the topic of resiliency.

26. Key Recommendations on Risk Communication and “Translational Research” • 9.1-3 Implement risk communication strategies to positively affect the nation as a whole during times of elevated threat levels and actual terrorist events, in light of the special effects these threats and events have on children. • Develop clear, concise and situation-specific guidance for parents, caregivers and teachers concerning helping children to cope with terrorism and disasters, and ensure that consistent information is disseminated by all DHHS agencies.

27. Public Health Ramps Up for Terrorism • The CDC over the last four years has spent approximately 1.2 billion per year on terrorism preparedness. • They use about 150 million per year internally to improve internal terrorism preparedness and the syndrome biosurveillance initiative. • The rest of the money is distributed primarily to state agencies and US territories through annual appropriations (some goes directly to large cities) • The U.S. DHHS has also spent billions on hospital and medical training primarily through the Human Resources Services Administration. • www.cdc.gov/fmo.fmofybudget.htm

28. Future etc? • Former members of the NACCT believe that funding for children and special populations is increasing for this usage but is not enough per recent conference calls. • Will the Committee be reinstated?

29. Red Cross and Special Populations • During emergencies and disasters, it is especially important to provide assistance to those people with special needs. These include the elderly and disabled and people with limited English proficiency (LEP). • The Red Cross has developed materials to assist these individuals. • http://www.redcross.org/services/ disaster/beprepared/disability.html

30. FEMA (Federal Emergency Management Agency) • Promotes self-help networks = are arrangements of people who agree to assist an individual with a disability in an emergency. Discuss with the relative, friend or co-worker who has a disability what assistance he or she may need. (http://www.fema.gov/rrr/assistf.shtm)

31. A Renowned Local Effort • One of the best is in the San Francisco area that was spurred by the earthquake during the 1997 baseball World Series. • PrepareNow.org “provides the tools, expertise and access to resources to assist anyone engaged in disaster planning for individuals with special needs. • http://www.preparenow.org/purpose.html

32. Past Measures to Gauge Preparedness • Centered around U.S CHC and HRSA guidance that dealt with focus areas. • Centered on Capacity – several instruments done on volunteer basis • National BTAIP by ASTHO revealed a nation better but still under—prepared in workforce, information systems and surveillance.

33. Billions for What? • Sidell and Cohen others blast wasted spending since 9’11” and anthrax attacks. • Rumm and others challenge that spending has at least improved our public health system and especially our laboratories. • Trust for America Report continues to blast some state efforts and calls for common metrics. • Gursky calls for a Force Protection Agency.

34. Gaskin and Rumm Study • Over 50 assessments, few on children and special needs. • Continuing lack in some sectors in training, communications, surveillance systems and most importantly in workforce. • Has been substantial improvement in laboratory capacity and some improvement in hospital surge capacity.

35. Today Movement toward Metrics – away from capacity toward capability! • CPHRC leadership on the Lehigh Valley Study and the Federal Regional Preparedness Metrics. • Commonality of metrics coming under the leadership of the U.S. DHS Disaster Response Plan and Target Capabilities. • CDC and other Capability studies including those by RAND – is this a good thing?