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Hospitals Prepare to Treat Children for WMD Exposure By Chris Schneidmiller WASHINGTON — Health and government officials from around the national capital region gathered Tuesday to dedicate an expensive new facility they hope never to use (see GSN, Jan. 17). The $6.5 million decontamination unit at Children’s National Medical Center would be used to cleanse young victims of a terrorist attack involving a biological, chemical or radiological agent. It is the first of its kind in the area. “It’s not something that is pleasant to think about, but 9/11 taught us we need to think about these kind of issues,” said Ned Zechman, hospital president and chief executive officer. This week’s dedication event allowed visitors to examine two of the three decontamination rooms and to watch hospital staffers in full protective gear shower off baby-sized dolls. Following an actual incident, victims would be brought into a triage area for an initial examination. They would be decontaminated and then moved into another examination room. From there, they could be taken to the emergency room or a nonemergency patient care room. Patients too stricken to be decontaminated would be taken directly to a hospital quarantine area that is to be ready in 2007. The decontamination area can hold up to 48 people at any time. While all patients brought to the hospital would receive care, regardless of age, the area is designed particularly for the treatment of children and families. “Shopping cart” carriers would be used to hold infants during decontamination and inhalers would be available for asthmatic children. The rooms are painted in “child-friendly” light pastels. About 100 hospital staffers have been trained to work in the decontamination rooms, and up to 50 more are expected to receive the necessary instruction, officials said. “We hope that it’s a model that not only serves the children of the Washington metropolitan area but is a model for how this could and should be done in pediatric hospitals around the country,” said Dick Snowdon, chairman of the hospital board. The facility is one component of a continuing, but still incomplete, nationwide effort to safeguard children against the effects of an unconventional weapon. The threat in recent years has spurred hospitals to provide their staffs with training and materials to treat young patients following an incident. Plans are being prepared at all levels of government, and pediatricians in private practice are educating themselves on the signs that a patient has been sickened by a deadly agent. Gaps in preparedness, meanwhile, include the 1.7-million-dose order of a child-friendly antiradiation drug that has yet to make its way into the national stockpile. It is too early to say the medical community is fully ready to treat children following a WMD attack, said Dr. Michael Shannon, director of the Children’s Hospital Boston Center for Biopreparedness. “I wouldn’t say that. I would say they’re better prepared.” DangersTheir physical immaturity and youth mean children could suffer greater effects from exposure to a chemical, biological or radiological weapon, while potentially lacking the capacity to make good decisions to protect themselves in the aftermath of an attack. “They’re more likely to be exposed, they’re more likely to sustain an effect from this, and because they’re smaller it obviously doesn’t take as much chemical or poison or agent … to harm them than it would an adult,” said Dr. Michael Quinn, medical director for disaster preparedness at Children’s National in Washington. A March 2000 report by the American Academy of Pediatrics detailed the particular vulnerability of children to a chemical or biological agent. Young people — up to age 22 — breathe more rapidly than their elders, meaning they would inhale a larger amount of an agent such as sarin or anthrax in aerosol form. Gases such as sarin or chlorine tend to settle to earth, bringing them into a child’s breathing zone. Infants and children have a larger skin surface area relative to their weight than adults, more space for agents to be absorbed into the body. Youth also have less of the protein keratin in their skin, leaving them more vulnerable to corrosive agents, Shannon said. No children are immunized against smallpox, as vaccinations stopped after the disease was eradicated in its natural form in 1980. However, research samples remain in Russia and the United States and there are fears that the disease could be directed against civilians (see GSN, May 22). “Finally, children have significant developmental vulnerabilities,” the AAP report states. “Infants, toddlers and young children do not have the motor skills to escape from the site of a chemical-biological incident. Even if they are able to walk, they may not have the cognitive ability to decide in which direction to flee.” A 2003 academy policy statement on radiation disasters — either accidental or initiated by terrorists — states that breathing rate and size would again increase the risk to children exposed to a radioactive material from a nuclear power plant. That danger is compounded by the potential for breast or cow milk crucial to a child’s nutrition to become contaminated by radioactive material. Children are more susceptible to radiation-induced cancer, said Shannon, who served on the committee that prepared both papers. First, they can be expected to live longer than an adult, allowing the cancer more time to develop. Second, their cells are proliferating as they grow. “Anytime you have a situation of rapidly proliferating cells, it only takes one mutant, one aberration, to create a rapidly growing abnormal cell, which is what we call cancer,” he said. There were 577 cases of thyroid cancer reported between 1991 and 1997 among children and adolescents who lived in the fallout area of the 1986 Chernobyl nuclear power plant disaster, the AAP paper states. Only 59 cases were reported in the five years prior to the accident. Radiation can be similarly disastrous to unborn children, as shown by studies of babies born to women who survived the atomic strikes on Hiroshima and Nagasaki while pregnant. Even radiation doses that are too low to affect the mother can endanger a fetus, according to a Centers for Disease Control and Prevention fact sheet. “What we know from radiation disasters such as Hiroshima is that the most common adverse effect to the developing fetus is being smaller overall, having a smaller head size, which means less brain development, which means the risk of mental retardation and learning disabilities,” Shannon said. The AAP chemical-biological and radiation papers — among several recommendations — urge pediatricians to become well informed about the medical responses to a WMD incident, and to participate in community preparation and training for an event. Government agencies, in turn, should involve pediatricians and children’s health facilities in their response planning. Shannon said he believes pediatricians and public health departments have been receptive to the academy’s recommendations. Pediatricians are learning to identify the characteristics and dangers of WMD agents, and offering their expertise to governmental disaster planning, he said. Biopreparedness Center staff members travel the country offering information on managing mass-casualty events to children’s and general hospitals, pediatricians and emergency department personnel, Shannon said. “They want to do the right thing and do exactly what we recommended,” he said. A full picture of child-protection initiatives could not be produced for this article. The U.S. Health and Human Services Department and Centers for Disease Control and Prevention did not respond to repeated requests for comment on their efforts. A number of state and local health agencies also did not return calls for information, along with several Washington-area pediatric offices. Interviews with other hospital and health professionals, however, indicated that the danger is being taken seriously around the country. The Centers for Disease Control, in the wake of the Sept. 11 attacks, prepared teams of pediatricians and equipment to supply medical and psychological responses to a major disaster, said Dr. Dana Best, an attending pediatrician at Children’s National Medical Center in Washington. These teams have already been mobilized following Hurricane Katrina, the major earthquake in Pakistan last year and the 2004 Indian Ocean tsunami, she said. The federal health agency in 2004 also developed specific recommendations for use of potassium iodide by children, young adults and women who are pregnant or breast-feeding in the event of a release of radiation from a nuclear power plant. “Before it was very unclear,” Best said, “which was a problem” if it became necessary to prepare doses. Doctors expressed less satisfaction with the federal government’s efforts to meet the AAP recommendation to prepare medical countermeasures that are effective and dose-appropriate for children exposed to a WMD agent. Pediatric antibiotic solutions have been removed from Strategic National Stockpile “push packages” of medical supplies that could be delivered to any location within 12 hours of a disaster, said Dr. John Talarico, medical director for the Los Angeles County Health Services Department bioterrorism preparedness program. That could cause a delay in arrival of those needed antibiotics, he said. “Now if we had to deal with a mass exposure to anthrax … we would have to sit down with pharmacists and take down solutions and prepare doses on the fly,” Talarico said. The AAP environmental health committee in the 2003 statement called for the federal government to press for production of a liquid form of potassium iodide. “Little babies don’t take tablets,” Shannon said. Health and Human Services ordered a total of 4.8 million units of the black-raspberry-flavored treatment. The initial order of 1.7 million doses is being finished, after which it would be distributed to 31 states with commercial nuclear power reactors, said George Love, legal and regulatory affairs director for manufacturer Fleming & Co. The schedule for distribution was not immediately available. “In our mind it was something that needed to be done yesterday, and here it is three years later and there’s still no product,” Shannon said. “But the FDA and agencies say, ‘We’re attentive to this, we’re waiting for the right proposal and all the safety testing and then it’s going to happen.’ So it’s not like anyone is turning a deaf ear, it’s just that the wheels of change and progress are sometimes slow.” The Food and Drug Administration has approved a number of drugs that would be appropriate for pediatric use, the agency said by e-mail. These include the liquid potassium iodide and lower-dosage forms of atropine autoinjectors to counteract nerve agents. Awareness of children’s needs in such an incident should encompass preparation of stocks of nonmedical items such as bottles and formula, said Dr. Sally Reynolds, medical director for the emergency department at Children’s Memorial Hospital in Chicago. “You can’t feed a 3-month-old peanut butter,” she said. “I think we’re still urging the federal government to be responsive to children, to think about the needs of children, which might be different than adults,” Reynolds said. Hospital officials also noted, though, that federal funds have been crucial to their preparedness projects. For example, all but $1 million of the money for the Children’s National Medical Center decontamination unit came from Washington. Some pediatric hospitals around the nation are waiting for federal funds that would pay for preparedness efforts, Shannon said. These facilities would be on the front line for caring for children following an incident, and he argued that the hospitals should make improvements now rather than wait for the money. “The federal government has said, ‘Start your work, we’ll pay you back,” he said. Children’s Hospital Boston has spent millions on preparedness, he said. “We’re not going to wait for the check to come in the mail, we’re going to make the financial investment and get to work.” Children’s Memorial in Chicago two years ago bought a decontamination tent with money from the U.S. Health Resources and Services Administration. The tent could be erected within 15 minutes outside the hospital to cleanse patients of lethal particles before they enter the emergency room for further treatment. The emergency room itself has two hospital-funded negative pressure rooms in which infected patients can be placed to prevent contaminated air from flowing around the hospital, Reynolds said. Medical staffers at her hospital already deal frequently with children infected with natural illnesses, giving them useful experience in containing contagions. To complement that, they attend courses on recognizing biohazards, undergo training with mannequins that “exhibit” symptoms of an unnatural infection, and conduct live-patient drills The hospital’s pharmacy has been stocked with additional doses of drugs that could be used following a chemical, biological or radiation incident, and all hospital staff prepare generally for managing a disaster. Preparation extends past the hospital walls. Reynolds is the co-chairwoman of the Chicago Public Health Department’s pediatric preparedness subcommittee. The panel meets monthly to help the city prepare for a disaster, offering guidance to hospitals that treat few children on dealing with a surge of young patients following a natural event or intentional act. Support ranges from developing lists of supplies hospitals would need for children — from medication to diapers — to identifying pediatricians in private practice or experienced nurses who could help lead efforts. Quinn at the Washington children’s hospital said he hopes to pursue that sort of community planning for the capital area. “Where I think we need to go and what has not been strongly established is helping the local pediatrician and other community groups, the school system and local transportation systems as to what to do,” he said. “I suppose if there was a community-wide deficiency, that would be the place where we would want to focus a lot of our attention.” The hospital’s focus to date has been on preparing its own personnel and ensuring it can work with local emergency agencies during a crisis, Quinn said. Doctors and nurses in the emergency department have receiving training on recognizing and treating various forms of WMD-related injuries. The hospital also conducts internal disaster drills and participates in joint exercises with three nearby medical facilities and in citywide events. Health officials at other hospitals and health agencies said that they have undertaken similar efforts: — Georgetown University Hospital in Washington, the city’s second-largest pediatric provider, offers online training on treating children exposed to an unconventional weapon. The hospital also conducts a disaster course for medical personnel in the region and beyond. — Three New York City pediatric hospitals receiving federal funds through the city Bioterrorism Hospital Preparedness Program. The city’s Health and Mental Hygiene Department has funded formation of an advisory group to offer practical information to hospitals for the special needs of children during a disaster, and has sponsored tabletop exercises involving such issues. — Los Angeles County health officials have prepared triage procedures that addressing children’s needs, Talarico said. Medical personnel would work to keep families together and mental health professionals with experience working with children are prepared to respond. The county has also stockpiled child-friendly antibiotics and drug doses safe for children following a WMD incident. None of this promises a perfect response, officials conceded. Beyond the obvious life-saving measures following a disaster, there are numerous details that might seem small but must be considered when treating young patients, physicians said. Children must be kept warm following decontamination to ensure they do not become hypothermic. They are unlikely to carry identification and might not be able to speak, so hospitals must develop procedures for tracking the children and reuniting them with their parents. Emergency responders would have to balance protecting themselves from exposure while comforting their charges. “The decontaminators are dressed in these protective suits. Have you ever seen one of those suits? They make you look like a space alien. Think about a child who’s already totally terrified being faced with someone in one of these space alien suits,” Best said. The need to prepare for a WMD event must also compete with the daily business of caring for sick children, which often already leaves pediatric hospitals at or near capacity, and of preparing for other disasters, officials said. “Frankly, this is not No. 1 on the list of emergencies. This is a pretty unusual event, and thankfully it’s unusual,” Best said.
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