TECHNICAL REPORT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

Chemical-Biological Terrorism and Its Impact on Children Sarita Chung, MD, FAAP,a Carl R. Baum, MD, FACMT, FAAP,b Ann-Christine Nyquist, MD, MSPH, FAAP,c DISASTER PREPAREDNESS ADVISORY COUNCIL, COUNCIL ON ENVIRONMENTAL HEALTH, COMMITTEE ON INFECTIOUS DISEASES

Children are potential victims of chemical or biological terrorism. In recent abstract years, children have been victims of terrorist acts such as the chemical attacks (2017–2018) in Syria. Consequently, it is necessary to prepare for and respond to the needs of children after a chemical or biological attack. A broad range of public health initiatives have occurred since the terrorist attacks of September 11, 2001. However, in many cases, these initiatives have not ensured the protection of children. Since 2001, public health preparedness has aDivision of Emergency Medicine, Boston Children’s Hospital and broadened to an all-hazards approach, in which response plans for terrorism Harvard Medical School, Harvard University, Boston, Massachusetts; bSection of Pediatric Emergency Medicine, Departments of Pediatrics are blended with those for unintentional disasters or outbreaks (eg, natural and Emergency Medicine, School of Medicine, Yale University, New events such as earthquakes or pandemic influenza or man-made catastrophes Haven, Connecticut; and cSection of Pediatric Infectious Diseases and Epidemiology, Department of Pediatrics, Children’s Hospital Colorado such as a hazardous-materials spill). In response to new principles and and School of Medicine, University of Colorado, Aurora, Colorado programs that have evolved over the last decade, this technical report Technical reports from the American Academy of Pediatrics benefit supports the accompanying update of the American Academy of Pediatrics from expertise and resources of liaisons and internal (AAP) and “ external reviewers. However, technical reports from the American 2006 policy statement Chemical-Biological Terrorism and its Impact on Academy of Pediatrics may not reflect the views of the liaisons or the Children.” The roles of the pediatrician and public health agencies continue to organizations or government agencies that they represent. evolve, and only their coordinated readiness and response efforts will ensure Dr Chung provided substantial contributions to the conception and design of the work, contributed to drafting and revising it critically for that the medical and mental health needs of children will be met successfully. important intellectual content, gives final approval of the version to be In this document, we will address chemical and biological incidents. Radiation published, and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any disasters are addressed separately. part of the work are appropriately investigated and resolved; Drs Baum and Nyquist provided substantial contributions to the conception and design of the work and contributed to drafting and revising it critically for important intellectual content; and all authors approved the final manuscript as submitted.

BACKGROUND INFORMATION The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking In 2000, the American Academy of Pediatrics (AAP) published the policy into account individual circumstances, may be appropriate. statement “Chemical-Biological Terrorism and its Impact on Children.” All technical reports from the American Academy of Pediatrics Preceding events such as the 1995 sarin attack in Tokyo, Japan, illustrate automatically expire 5 years after publication unless reaffirmed, the reality that acts of domestic chemical terrorism can occur, with revised, or retired at or before that time. significant impact on the health of children. The subsequent 2006 policy statement highlighted the need for increased awareness and preparedness To cite: Chung S, Baum CR, Nyquist A-C, AAP DISASTER in response to additional acts of chemical and biological terrorism, PREPAREDNESS ADVISORY COUNCIL, COUNCIL ON ENVIRONMENTAL including the release of anthrax spores through the US postal system, HEALTH, COMMITTEE ON INFECTIOUS DISEASES. Chemical-Biological intentional toxic chemical contamination of food in Michigan and Terrorism and Its Impact on Children. Pediatrics. 2020;145(2): e20193750 California, and the identification of ricin-laden letters in a post office in

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 145, number 2, February 2020:e20193750 FROM THE AMERICAN ACADEMY OF PEDIATRICS South Carolina. Unfortunately, since government also created the National period. Moreover, principles of the the publication of the 2006 policy Commission on Children and care of children after chemical and statement, there have been additional Disasters, the National Advisory biological terrorism are evolving, and chemical attacks affecting children, Committee on Children and Disasters, these approaches will continue to such as the 2017 sarin1 and 2018 and the National Biodefense Science inform future work. chlorine attacks2 in Syria. These Board, all of which included pediatric attacks have led to significant subject matter experts. The AAP hosts pediatric morbidity and mortality. a comprehensive Web site for STATEMENT OF THE PROBLEM Emerging biological threats, such as pediatric health care providers with Pediatricians play a pivotal role in Ebola and Zika viruses, have provided a page devoted to information on providing care in the medical home opportunities to test the systems of terrorism and its impact on children and supporting the community pediatric disaster preparedness (www.aap.org/disasters/terrorism). before, during, and after a chemical or nationally and internationally. In the Additional AAP activities to promote biological event. It is critical for same time frame, there continues to pediatric disaster awareness include pediatricians and others who care for be substantial progress as new publication of disaster policy children in all care settings to chemical and biological medical statements such as “Ensuring the continue to educate themselves countermeasures (MCMs) are Health of Children in Disasters” and regarding the pediatric consequences approved by the US Food and Drug “Providing Psychosocial Support to of a chemical or biological attack. Administration (FDA), additional Children and Families in the Readiness resources and approaches methods for surveillance are in place, Aftermath of Disasters and Crises” will vary depending on practice and advances in pediatric disaster along with education on specific setting, such as community hospitals, preparedness and education are chemical and biological threats in the pediatric hospitals, emergency available to assist emergency AAP manual Pediatric Environmental departments, and office practices. The responders with evidence-based best Health (the “Green Book”) and the role of the pediatrician and others practices. AAP manual Red Book: 2018 Report of who care for children in ensuring the the Committee on Infectious health of children in disasters has Since the September 11, 2001, Diseases.3–6 The AAP has also been described.3,8 Specificto terrorist attacks and subsequent promoted pediatric preparedness chemical and biological terrorism, anthrax releases in the United States, through implementation of a 2016 pediatricians and their staff will need the AAP has recognized the need to regional pediatric and public health to be prepared to promote and share strategically address the impact of tabletop exercise and a 2017 virtual information on readiness approaches, terrorism (ie, an act designed to tabletop exercise (www.aap.org/ advise on pediatric decontamination frighten, hurt, or kill people) on disasters/tabletop).7 strategies, provide appropriate children at the national, state, and medical care, offer anticipatory local level. This has led to the The unfortunate continuing guidance to families, report appointment of the AAP Disaster occurrence of chemical and biological appearances of unusual disease Preparedness Advisory Council, terrorism demonstrates the ongoing clusters, and help guide families after which collaborates with federal need to improve public health and events. This technical report partners (including the Department health care system preparedness in summarizes relevant information of Health and Human Services all respects, including the detection of and evidence. Although the [DHHS] Office of the Assistant covert events, establishment of focus of this document is geared Secretary for Preparedness and comprehensive response protocols toward the US health care system, Response [ASPR], Centers for Disease for children, and implementation of principles of this technical report can Control and Prevention [CDC], plans for rapid resource mobilization be applied to international health Department of Homeland Security to care for children. At the care settings. [DHS], FDA, Federal Emergency governmental level, the passage of Management Agency, and the key federal legislation (Table 1) has National Institute of Child Health and facilitated these efforts. However, NEW INFORMATION Human Development) as well as more there remains a need for pediatric This technical report and its than 70 AAP member disaster health care providers to be accompanying policy statement9 preparedness contacts in all AAP knowledgeable about the chemical replace the 2006 policy statement, chapters who work with their local and biological weapons that could be with an added focus on identifying and state partners to address the used against a population that and resolving system issues that are needs of children throughout the includes children and to be able to paramount to minimizing morbidity disaster cycle. The federal provide care during the recovery and mortality in children after their

Downloaded from www.aappublications.org/news by guest on September 25, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 1 Federal Legislation Enacted Since 2001 To Improve Public Health Response to Bioterrorism and Other Public Health Emergencies Date Bill Legislation September 2001 Public Law 107-38 2001 Emergency Supplemental Appropriations Act for Recovery From and Response to Terrorist Attacks on the United States August 2002 Public Law 107-206 2002 Supplemental Appropriations Act for Further Recovery From and Response to Terrorist Attacks on the United States June 2002 Public Law 107-188 Public Health Security and Bioterrorism Preparedness and Response Act of 2002 November 2002 Public Law 107-296 Homeland Security Act of 2002 April 2003 Public Law 108-20 Smallpox Emergency Personnel Protection Act of 2003 December 2003 Public Law 108-169 United States Fire Administration Reauthorization Act of 2003 July 2004 Public Law 108-276 Project BioShield Act of 2004 October 2004 Public Law 108-324 Military Construction Appropriations and Emergency Hurricane Supplemental Appropriations Act, 2005 December 2004 Public Law 108-494 ENHANCE 911 Act of 2004 May 2005 Public Law 109-13 Emergency Supplemental Appropriations Act for Defense, the Global War on Terror, and Tsunami Relief, 2005 September 2005 Public Law 109-72 Flexibility for Displaced Workers Act September 2005 Public Law 109-62 Second Emergency Supplemental Appropriations Act to Meet Immediate Needs Arising From the Consequences of Hurricane Katrina, 2005 October 2005 Public Law 109-88 Community Disaster Loan Act of 2005 December 2005 Public Law 109-148 Department of Defense, Emergency Supplemental Appropriations to Address Hurricanes in the Gulf of Mexico, and Pandemic Influenza Act, 2006 April 2006 Public Law 109-218 Local Community Recovery Act of 2006 September 2006 Public Law 109-288 Child and Family Services Improvement Act of 2006 June 2006 Public Law 109-234 Emergency Supplemental Appropriations Act for Defense, the Global War on Terror, and Hurricane Recovery, 2006 December 2006 Public Law 109-417 Pandemic and All-Hazards Preparedness Act May 2007 Public Law 110-28 US Troop Readiness, Veterans’ Care, Katrina Recovery, and Iraq Accountability Appropriations Act, 2007 September 2008 Public Law 110-329 Consolidated Security, Disaster Assistance, and Continuing Appropriations Act, 2009 October 2008 Public Law 110-376 United States Fire Administration Reauthorization Act of 2008 October 2008 Public Law 110-377 Poison Center Support, Enhancement, and Awareness Act of 2008 October 2008 Public Law 110-392 Comprehensive Tuberculosis Elimination Act of 2008 April 2009 Public Law 111-13 Serve America Act January 2011 Public Law 111-351 Predisaster Hazard Mitigation Act of 2010 March 2013 Public Law 113-5 Pandemic and All-Hazards Preparedness Reauthorization Act of 2013 November 2015 Public Law 114-80 DHS Social Media Improvement Act of 2015 December 2015 Public Law 114-111 Emergency Information Improvement Act of 2015 April 2016 Public Law 114-143 Integrated Public Alert and Warning System Modernization Act of 2015 September 2016 Public Law 114-223 Continuing Appropriations and Military Construction, Veterans Affairs, and Related Agencies Appropriations Act, 2017, and Zika Response and Preparedness Act December 2016 Public Law 114-268 First Responder Anthrax Preparedness Act December 2016 Public Law 114-255 21st Century Cures Act December 2016 Public Law 114-326 National Urban Search and Rescue Response System Act of 2016 exposure to a chemical or biological also a potential source for exposure, physiologic vulnerabilities. Children weapon. although dilution of chemical and have greater life expectancy than biological agents in water is adults and, therefore, have more time mitigating, and few chemical or in which to develop sequelae such as REVIEW OF EVIDENCE biological agents are both water cancer from a variety of sources of Exposure Sources for Chemical and stable and resistant to water- exposure (air, water, or food) to Biological Weapons purification techniques that decrease chemical or biological weapons. For the risk. Finally, the contamination of each source of exposure, children Exposure to chemical and biological food that is either unprocessed (eg, fi weapons can occur through several possess a signi cantly greater uncultivated grain) or processed (eg, potential sources. Airborne releases likelihood of exposure because of a consumer product) is considered of agents have remained the primary their intake patterns. Children inhale a potential means of exposure to concern because large populations considerably more air on a per- chemical or biological weapons. can be exposed by this route. weight basis than adults (400 vs Potential mechanisms of exposure 140 mL/kg per minute, respectively). fi include crop-dusting airplanes, Speci c Vulnerabilities in Children Consequently, for any concentration tainted letters, and release of agents After events of chemical or biological of an airborne toxicant, a child will into confined spaces (eg, subway terrorism, children have a greater risk inhale more of the substance on tunnels, office buildings, theaters). of both exposure and harm, the result a per-kilogram basis than an adult. Contamination of the water supply is of key developmental, anatomic, and Also, substances that are heavier than

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 145, number 2, February 2020 3 air have their highest concentration Public Health Preparedness contain an outbreak of severe acute near the ground, closer to the The All-Hazards Approach respiratory syndrome. However, as breathing zone of the child. Because threats increase and local and state In past years, resources have been budgets fluctuate, there will continue of a proportionately greater body- provided to public health authorities, surface area, children have both to be challenges to achieve adequate including the network of state and responses. greater exposure and an increased regional poison control centers, and likelihood of systemic toxicity to fi fi fi rst responders ( re of cials, police Pediatric Disaster Preparedness and fi agents that contact their skin. of cers, and emergency medical Education Children have fluid and food intakes services personnel) to create systems that differ significantly from adults. capable of responding to a possible Several investigators have studied disaster preparedness and education For example, children ingest chemical attack. Similarly, emerging specific to the needs of children. In approximately 100 mL/kg of water and reemerging infections as well as 12 highly contagious organisms such as 2008, Schobitz et al conducted a study per day, whereas adults ingest 40 to of pediatric and emergency medicine 60 mL/kg per day. Children drink Ebolahaveledtoamassivepublic health effort to improve response residents at a single institution to more milk than adults, placing them capability to future acts of biological assess their baseline knowledge of at risk for exposure to agents that can terrorism. The initiation of these management of pediatric victims of enter the milk supply through response campaigns revealed large- chemical and biological terrorism. Using contamination of the grass on which scale weaknesses in state and local an expert-developed, validated test, the investigators determined that the cows feed. In the Chernobyl radiation public health infrastructure. Moreover, residents of this era were unprepared to disaster, cows grazed in contaminated it became evident that intense effort manage these victims. The 2010 pastures, leading to excess was being directed toward events Pediatric Emergency Mass Critical Care radioactivity in their milk. Children that might never occur rather than Task Force concluded that mass events drinking this milk sustained significant toward public health threats of much place unusual stresses on health care exposure to radioisotopes, including greater likelihood (eg, an unintentional providers, many of whom must provide iodine and strontium.10 Finally, children hazardous chemical release). Finally, care outside of their scope of practice, it became clear that a fragmented not only eat more food on a per- and that education and educational and reactive public health response kilogram basis but also have diets that resources can mitigate anxiety and plan is more expensive and inefficient are distinctly different from adults (eg, chaos in these contexts.13 Subsequent than a single, comprehensive plan. greater consumption of fruits). Once research in pediatric disaster triage As a result, disaster response agencies exposed to a chemical or biological has demonstrated that a multiple- and public health authorities have agent, children have numerous simulation curriculum can improve increasingly embraced the concept of prehospital care providers’ assessment physiologic vulnerabilities that could the “all-hazards approach.” skills.14 In addition, studies have lead to a greater risk of harm. These Representing a dramatic paradigm revealed an increase in clinical staff’s vulnerabilities include undeveloped self- shift in the preparation for chemical knowledge and confidence with preservation skills that make them less and biological terrorism, the all-hazards pediatric disaster skills with short, able to flee danger; an immature approach is designed to augment the topic-focused educational immune system that makes them less public health infrastructure, using an interventions.15,16 There are also review integrated model of disaster response. able to contain infection (eg, plague); articles of pediatric disaster courses to fl The creation of all-hazards response less uid reserve, which can result in educate health care professionals.15,17,18 a greater risk of severe dehydration systems has led to improvements in public health response capabilities. after exposure to agents that produce Agents of Concern excess gastrointestinal fluid loss (eg, For example, an effective public health response protocol for a sarin Chemicals Ebola virus disease); and a greater risk release would be equally effective Three traditional assumptions of anxiety reactions and posttraumatic for a hazardous-materials (hazmat) specific to chemical terrorism have stress disorder after witnessing or being release in the community, such as the proven simplistic. These include the victim to a terrorist act.4 Additionally, 2017 chemical fires in Texas that narrow concepts that (1) such with the advent of technology, there is followed massive flooding and power weapons were intentionally and increased availability of social media to losses in the wake of Hurricane specifically manufactured as children and adolescents, allowing for Harvey.11 Similarly,thesameprotocol instruments of mass destruction; (2) access to online terrorist information or created to respond to the appearance chemical terrorism was dramatic and suggestive material on how to terrorize. of smallpox can be modified easily to recognized immediately (eg, the sarin

Downloaded from www.aappublications.org/news by guest on September 25, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS incident in Tokyo); and (3) only well- (3) anticonvulsants21 (please refer to function necessary to support the organized, well-funded terrorist the Nerve Agents section for further ventilation of pediatric victims. groups were capable of releasing discussion of clinical effects). Some Additional efforts have focused on chemical weapons after extensive studies have explored the problem of improving access to information after planning. These concepts have been antidote dosing in children, chemical exposures. The ASPR, in expanded to include the possibilities particularly with respect to cooperation with the National Library that (1) readily available, legitimate prepackaged autoinjectors. Baker22 of Medicine, has developed a Web site chemicals, such as chlorine, can noted that adult doses of atropine are that is intended to enable health care be misused (ie, “weapons of well tolerated, even in young children, professionals to respond to mass- opportunity”); (2) these acts can be and recommended the use of the casualty events involving chemicals covert, with delayed recognition; atropine (0.5 or 2 mg) autoinjector for (https://chemm.nlm.nih.gov/). The and (3) a motivated, “lone-wolf” children younger than 1 year after resource can be downloaded to individual with few resources can nerve-agent exposures when weight a computer or mobile device in perpetrate significant releases. dosing is impractical or not possible to advance of an event that might limit control excessive bronchorrhea and to Acts of chemical terrorism involving or interrupt Internet access.26 prevent respiratory failure.22 In a 2009 children illustrate these expanded review of research on atropine dosing, concepts. In 1999, patrons of The analysis of a mass-casualty event Sandilands et al23 considered fi a restaurant in Fresno, California, may identify 1 or more speci c pharmacokinetic data to balance developed severe gastroenteritis. An chemicals. The World Health sufficient and timely dosing of atropine investigation by public health Organization considers the following 6 versus the risk of overdose; the authors authorities discovered that the categories of chemicals to be the most recommended relatively large initial carbamate insecticide methomyl had likely threats: nerve agents, blistering doses of atropine in children, who are agents (vesicants), irritants been added maliciously to the salt. relatively resistant to its adverse (corrosives), choking agents, More than 100 adults and children effects. Droste et al21 used became ill with nausea, vomiting, and asphyxiants (cyanogens and carbon a pharmacokinetic model to analyze diarrhea; a perpetrator was never monoxide), and disabling current CDC and US Army treatment identified.19 In 2003, in Grand Rapids, (incapacitating) agents, including protocols and found that in general, 27 Michigan, a disgruntled grocery store lacrimators (Table 2). oximetherapyalonewasineffectivein worker placed a nicotine-containing alleviating symptoms.19 The atropine Nerve Agents insecticide into ground beef, making it and pralidoxime combination available for purchase by unsuspecting Nerve agents are well absorbed autoinjector can, in theory, be used in customers. It was not until widespread through intact skin and even through children older than 1 year; as of 2018, illness (nausea, mouth burning, examination gloves used in clinical however, the combination autoinjector vomiting) was reported and there was settings. All nerve agents act as was not FDA approved for pediatric a recall and analysis of the meat, acetylcholinesterase inhibitors, patients weighing less than 41 kg. revealing the presence of nicotine, that producing the same symptoms and However, authors of an extensive thiswasrecognizedasanactof signs associated with organophosphate review of antidotes for a variety of terrorism. Ultimately, more than 100 poisoning. Manifestations can range chemical agents concluded that the people became ill, including more than from mild (miosis, nausea, diarrhea) strength of evidence supporting the use 40 children, in what is now considered to severe (muscle weakness, of these antidotes is generally weak the largest act of chemical terrorism in 24 fasciculations, respiratory failure, coma, US history.20 and that more research is needed. and seizures). Research in the past decade specific Other investigators have studied In the 1995 sarin episode in Tokyo, to chemical exposures has been injury related to chemical exposures. the most unanticipated sequela was focused on antidotes and resultant Custer et al25 used an in vitro test the degree of injury to health care injury after exposure. For nerve-agent lung to simulate pediatric lung injury; professionals.28 Several hundred exposure, 3 classes of medication are the goal was to assess the efficacy of physicians, nurses, and other health used in the treatment of nerve-agent transport and/or emergency care professionals became ill as exposure: (1) anticholinergics, ventilators in the setting of mass- a result of 2 factors: handling of sarin- usually first-line atropine, to block casualty respiratory failure. These contaminated victims without excess acetylcholine at peripheral investigators found that few of the wearing personal protective muscarinic receptors; (2) oximes, ventilators, chosen from a range of equipment (PPE) and entry of such as pralidoxime, to reactivate manufacturers, were capable of the contaminated victims into health care inhibited acetylcholinesterase; and minimum alarm and tidal volume facilities, allowing sarin vapor to

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 145, number 2, February 2020 5 enter the ventilation system.27,29 This were available. In 2003, the FDA Other aspects of care to children who event firmly demonstrated the approved new dosage forms of have been exposed to nerve agents importance of using PPE to protect atropine sulfate, approved since 1973 are found in recent reviews.29,33 health care professionals, for adults, for use in children and decontaminating victims before adolescents after nerve-agent Blistering Agents (Vesicants) building entry to maintain office or exposure.31 However, the continued Vesicants include sulfur mustard and hospital safety, and using absence of a combination pediatric lewisite, an arsenic-based blistering environmental controls such as autoinjector in the United States, agent first used in World War I. airborne infection isolation rooms which is critical to the successful British antilewisite (dimercaprol) was (negative-pressure rooms). treatment of central nervous system developed in subsequent years and and muscular toxicity from nerve mitigated the risk to allied soldiers in Management of nerve-agent exposure agents, leaves the use of standard, World War II; it remains useful today includes supportive care and, when multidose vials as the only as an antidote in some cases of heavy- indicated, prompt administration of therapeutic option. To address this metal poisoning.34 The vesicants, the antidotes atropine and issue, consensus guidelines now released as aerosols, produce pralidoxime (see the introduction to recommend that children erythema, burning, vesiculation, and the previous section, Chemicals, for weighing 13 kg or more (2–3 years of then desquamation of the skin. recent research regarding atropine, age or older) receive a 600-mg Victims of blistering-agent exposure pralidoxime, and autoinjectors).30 dose of pralidoxime from an typically develop skin tingling, then Autoinjectors are particularly autoinjector because this burning; within 24 hours, skin important in mass-casualty incidents pralidoxime dose falls within the sloughing begins to occur, with when there is a need to treat large range of safety for the drug.32 wounds having the appearance of numbers of victims as quickly and Children weighing less than 13 kg can partial-thickness burns. These efficiently as possible. Until recently, receive the customary weight-based agents -are also immunosuppressive, the absence of pediatric autoinjectors (20–50 mg/kg) dose, administered further increasing the risk of severe - complicated the rapid administration from a multidose vial; if the multidose infection. Treatment is largely of atropine and pralidoxime to vial is unavailable, an autoinjector supportive. Important principles of children; only the devices approved could be used. Repeat dosing of management include topical for adults, containing 2 mg of atropine may be necessary to mitigate decontamination and PPE use to atropine and 600 mg of pralidoxime, secretions. protect health care professionals.35

TABLE 2 Chemical Weapons of Concern Agent Classification Built Weapon NATO Codes Weapon of Opportunity Nerve agents Tabun GA Pesticides Sarin GB Nicotine Soman GD Organophosphates VX gas VX Carbamates Blistering agents (vesicants) Lewisite L — Mustard gas HD — Nitrogen mustard —— Irritants (corrosives) ——Ammonia ——Bromine ——Chlorine Choking agents Phosgene CG Perfluoroisobutylene (Teflon) and other chemical polymers Nitrogen oxides NOx Smoke, products of combustion Asphyxiants Hydrogen cyanide AC Industrial cyanide ——Sodium azide ——Carbon monoxide Disabling agents (incapacitators) 3-quinuclidinyl benzilate BZ Anticholinergics Cannabinoids —— Barbiturates —— Fentanyl derivatives —— Lacrimators: Chloroacetophenone CN Lacrimators Chlorobenzylidene CS Capsaicin AC, hydrogen cyanide; BZ, 3-quinuclidinyl benzilate; CG, phosgene; CN, chloroacetophenone; CS, chlorobenzylidene; GA, tabun; GB, sarin; GD, soman; HD, mustard gas; L, lewisite; NATO, North Atlantic Treaty Organization; NOx, nitrogen oxide; —, not applicable. Adapted from World Health Organization. Chemical weapons of concern. Available at: www.who.int/csr/delibepidemics/ annex1.pdf. Accessed June 15, 2018. Adapted from Tuorinksy SD, ed. Medical Aspects of Chemical Warfare. Washington, DC: Office of the Surgeon General at TMM Publications; 2008: 292–293.

Downloaded from www.aappublications.org/news by guest on September 25, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS Irritants (Corrosives) followed by sodium thiosulfate, which Lacrimators are designed to produce The irritants and corrosives include reacts with methemoglobin and incapacitation from irritation of the common chemicals such as ammonia, converts the potentially lethal eye and other mucous membranes. bromine, and chlorine, which can cyanide ion to the stable thiocyanate Exposure to lacrimators leads to eye affect the skin, eyes, mucous ion. Hydroxocobalamin is a newer burning, tearing, and blepharospasm; membranes, gastrointestinal tract, option that acts more rapidly than victims may become temporarily and predominantly, the upper thiosulfate and avoids the additional blind. Inhalation produces mouth hazard of the methemoglobin pain, shortness of breath, and, in and lower respiratory tracts. 38 Decontamination includes copious intermediate. rare cases, laryngospasm. Because capsaicin is widely sold as a nonlethal water irrigation of the skin and eyes; Carbon monoxide, a potential weapon weapon, episodes of capsaicin release management is mainly supportive, of opportunity, binds avidly to into the ventilation system of schools but the risk of delayed pulmonary hemoglobin and other hemoproteins, 36 and buildings are a relatively injury remains for 24 hours. The interfering with oxygen transport and common prank, although such Assad regime in Syria has used tissue delivery, and may lead to incidents meet the definition of chlorine gas against civilians, causing nonspecific symptoms that mimic 41 2,37 terrorism. at least 1 pediatric death. viral infections. After immediate removal from carbon monoxide Biological Agents Choking Agents exposure, victims will benefitfrom Choking agents are created to receiving 100% oxygen administered Most of the biological agents that could be used as weapons are now produce, usually in delayed fashion, via a nonrebreather mask. The degree 6 pulmonary injury: bronchospasm, of illness rather than specific discussed in the AAP Red Book, pulmonary edema, and respiratory carboxyhemoglobin levels can guide although some agents (eg, ricin) are not discussed in detail. Ricin is failure. Immediate symptoms treatment; some experts recommend include eye burning, tearing, and consultation with a hyperbaric discussed in a subsequent section of blepharospasm. The major agent of oxygen facility for more severe this report. this group is phosgene; however, cases.39 The biological agents of concern are common industrial chemicals, listed in Table 3. These agents have including polytef (Teflon) and other Disabling (Incapacitating) Agents been placed by the CDC into chemical polymers, act as choking categories A, B, or C. Thirty-nine Disabling or incapacitating agents agents depending on their ambient agents are included in these 3 include several different chemical concentration. Most choking agents categories. classes (eg, anticholinergic agents, are heavier than air, which could hallucinogens, cannabinoids, and Category A agents are considered produce higher concentrations at the fentanyl derivatives). In the 2002 the greatest public health threat breathing level of the child. Russian theater hostage incident, because of their potential ease of Treatment is supportive. a fentanyl-based disabling agent dissemination, resulting high Asphyxiants (Cyanogens and Carbon may have been released during the morbidity and mortality, and Monoxide) rescue effort. The agent, although potential to cause public panic and successful in overwhelming the need for special actions for public The asphyxiants include the hostage-takers, also killed 127 health preparedness. Currently, there cyanogens and carbon monoxide, hostages.40 are 6 agents in this group, including often generated in fires. Victims of the pathogens that cause anthrax, asphyxiant exposure must be Many disabling agents are weapons botulism, plague, smallpox, tularemia, recognized promptly to remove them of opportunity, easily acquired and the viral hemorrhagic fevers, from the source and to administer pharmaceutical agents, or specifically filoviruses (Ebola and life-saving antidotes. substances of abuse that are added Marburg viruses) and arenaviruses surreptitiously to common sources of The cyanogens (cyanide salts and (Lassa and Machupo viruses). food or drink. sodium azide) interrupt cellular use Detailed descriptions of these agents of oxygen, producing respiratory Included among disabling agents are have been published in the AAP Red distress, coma, metabolic acidosis, lacrimators. Often referred to Book and elsewhere.6,42 The second and lactic acidosis. In the United collectively as Mace or “tear gas,” highest-priority agents (category B) States, the traditional cyanide lacrimators include the chemicals are moderately easy to disseminate, antidote “kit” was amyl nitrite chloroacetophenone and with moderate morbidity and low inhalation or sodium nitrite injection— chlorobenzylidene as well as mortality. Category B agents also which generates methemoglobin— capsaicin (“pepper spray”). require additional enhancements of

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 145, number 2, February 2020 7 CDC diagnostic and surveillance toxin, ricin is an extract of the castor a congressional post office in January capabilities (Table 3). Category C bean (Ricinus communis). Ricin acts 2004. In June 2006, the CDC agents are of concern because of their by inhibition of protein synthesis of developed a comprehensive guideline future potential to be engineered for cells, ultimately resulting in cell for public health and medical officials mass dissemination, with attendant death. Rapidly dividing tissues, in response to a ricin incident.52 As major health impact with high particularly the gastrointestinal recently as 2013, the Federal Bureau morbidity and mortality. Mycotoxins epithelium, are most susceptible to of Investigation responded to reports are toxins produced by fungi. Agents ricin actions. With these effects, ricin of suspicious letters received at mail of primary concern, trichothecenes produces severe morbidity and facilities that contained ricin.53 and aflatoxins, have properties of mortality. both chemical weapons and biological Ricin is a versatile agent that can be weapons and could be used in Syndromic Surveillance administered by ingestion, inhalation, chemical warfare (Tables 1 and Overt acts of chemical and biological or injection. When ingested, it can 2).43,44 terrorism such as the sarin release in produce a syndrome of severe Tokyo present the challenge of gastrointestinal upset, vomiting, Smallpox (Variola) rapidly identifying the agent and hemorrhagic gastroenteritis, shock, Until the Ebola virus epidemic in mobilizing the proper interventions. and cardiovascular collapse. After 2013–2016, the most widely However, acts of chemical and inhalation, respiratory distress with discussed category A agent was biological terrorism may also be a necrotizing pneumonitis may occur. Variola major, the agent that causes covert. Examples include the cyanide Injection produces rapid shock and smallpox. Initial CDC smallpox contamination of Tylenol (1982),54 cardiovascular collapse. Treatment is immunization efforts initiated in the release of anthrax (2001), and the supportive. A vaccine against ricin is 2002 included a “ring immunization” nicotine contamination of ground currently under development. (surveillance and containment) beef (2003).18 Covert incidents pose strategy in the United States.45,46 Ricin has been associated with a significantly greater public health Subsequently, the CDC recommended terrorist activity in the United States challenge and are more likely to a 3-phase plan for smallpox on multiple occasions, particularly as induce widespread fear than overt immunization of health care an agent sent through the mail. In events. Mechanisms for early professionals and other individuals, October 2003, 2 ricin-containing recognition of a covert chemical or although the program met with only letters were found in the US postal biological event, therefore, are limited success in the first phase of system.51 In a third incident, ricin necessary to contain the incident and vaccination of health care was found in the mail sorter of minimize its impact. professionals in acute-care facilities.42 A high rate of vaccine refusal by TABLE 3 Biological Weapons of Concern health care professionals, concerns Weapon Category about the safety of the vaccine, Category A extensive contraindications to the Anthrax (Bacillus anthracis) vaccine, and the appearance of Botulinum (Clostridium botulinum toxin) unrecognized adverse effects from Plague (Yersinia pestis) the vaccine (eg, fatal cardiac Smallpox (Variola major) 47,48 Tularemia (Francisella tularensis) disease) hampered the Viral hemorrhagic fevers (filoviruses [eg, Ebola, Marburg] and arenaviruses [eg, Lassa, Machupo]) 49,50 program. In 2015, the CDC and Category B AAP published updated clinical Brucellosis (Brucella species) guidance for use of the 3 smallpox Epsilon toxin of Clostridium perfringens vaccines in the US Strategic National Food-safety threats (eg, Salmonella species, Escherichia coli O157:H7) Glanders (Burkholderia mallei) Stockpile (SNS) for people at risk for Melioidosis (Burkholderia pseudomallei) smallpox infection after an intentional Psittacosis (Chlamydia psittaci) or accidental release of the virus.43 Q fever (Coxiella burnetii) Ricin toxin from Ricinus communis (castor beans) Ricin Staphylococcal enterotoxin B Typhus (Rickettsia prowazekii) Although it is a category B agent, ricin Viral encephalitis (alphaviruses [VEE, EEE, WEE]) has become a major biological Water safety threats (eg, Vibrio cholerae, Cryptosporidium parvum) weapon of concern because it is 1 of Category C the most toxic biological agents Emerging threat agents (eg, Nipah virus, hantavirus) known. A plant-derived, heat-stable EEE, eastern equine encephalomyelitis; VEE, Venezuelan equine encephalomyelitis; WEE, western equine encephalomyelitis.

Downloaded from www.aappublications.org/news by guest on September 25, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS Syndromic surveillance, a specialized numerous resources to expand sources, are capable of providing type of outbreak detection, is a term clinicians’ ability to recognize covert alleged outbreak signals ranging from used to describe mechanisms for terrorist incidents.25,50,57 days to months before official monitoring health indices or events reports.61,62 To facilitate uniform reporting among that reflect the early stages of local, state, and federal authorities a chemical release or of an infection Crowdsourcing after unintentional or intentional or disease of public health An unconventional and unplanned releases of chemical agents, the CDC importance to minimize type of syndromic surveillance has has developed case definitions for consequences.55,56 Syndromic arisen in recent years with the advent illness.51 surveillance is considered an of mobile devices and social media important means of identifying public applications. For example, in the 2013 Automated Systems health emergencies in their initial intentional release of sarin gas near stages. Syndromic surveillance Recently, there has been a rapid Damascus, Syria, many individuals techniques, summarized below, can increase in the development of real- recorded videos of the atrocity that be clinician based or automated. time, automated syndromic killed 1400 civilians; Rosman et al63 Many syndromic surveillance systems surveillance tools. Such automated searched the YouTube Web site for are based in hospital emergency decision support uses software to videos that had been uploaded in the departments. identify sentinel events such as an weeks after the release. Many of these unusual amount of work or school videos documented significant Astute Clinician absenteeism, changes in consumer clinical signs—including dyspnea, The traditional mechanism of purchase of over-the-counter diaphoresis, and syncope—and also detection of an unusual occurrence products (eg, antipyretics or cough revealed problems with the use of has been the clinician who recognizes syrups), and changes in the chief- PPE, decontamination strategies, atypical patterns of symptoms, signs, complaint profile among those who and antidote administration. or disease and reports them to public visit primary care physicians or Nonclinicians contributed health authorities. The “astute hospital emergency “crowdsourced” data, in effect, to 58–60 clinician” principle places all health departments. syndromic surveillance. Although care professionals (including there were no chemical or biological The CDC BioSense Platform (www. physicians, advanced practice releases at the 2013 Boston Marathon cdc.gov/nssp/biosense/index.html) is providers, nurses, paramedics, bombings, investigators were able to an integrated, national surveillance emergency medical technicians, identify specific keywords that were system that gathers data from infection preventionists, posted within minutes of the diagnosis codes included in electronic laboratorians, pharmacists, explosions on the social media site medical records to enhance epidemiologists, and health Twitter before any reports were situational awareness for an all- educators) in the role of sentinels for issued from public safety officials or hazards approach. The DHS BioWatch the appearance of disease clusters or traditional news media outlets.64 Program (www.dhs.gov/biowatch- other clinical abnormalities. It is program) provides early warning of important to identify and work with Governmental Roles in Emergency a bioterrorist attack in more than 30 those who may already have Preparedness major metropolitan areas across the adefined role in syndromic Although emergency preparedness country. surveillance. For example, school legislation existed before 2001, the nurses have an established or A number of surveillance studies have passage of additional rules has particular role in this area, and there attempted to use the massive volume resulted in efforts by the federal are other professionals with these of data on the Internet to inform government to improve public health capabilities. The pivotal role of rapid epidemic detection. Various readiness across the nation (Table 1) physicians and other health care surveillance tools, such as the despite federal budgets remaining flat professionals in surveillance, Program for Monitoring Emerging for more than a decade and state and particularly for acts of terrorism, has Diseases–Mail (available at www. local budgets declining for public led the CDC and other agencies to promedmail.org; International Society health and emergency response. In educate clinicians about chemical and for Infectious Diseases) and contrast, there has been an escalating biological weapons release and the HealthMap (available at www. need to ensure the safety of all US diseases they produce. Clinical cues, healthmap.org; Boston Children’s citizens. Established in 2002, the DHS case definitions, and syndromes for Hospital), which aggregates content is the main federal agency that leads chemical weapons exposure have from the Program for Monitoring efforts to protect the US population been published (Table 4) along with Emerging Diseases–Mail and other against chemical, biological, and

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 145, number 2, February 2020 9 TABLE 4 Clinical Syndromes Associated With Chemical and Biological Agents Category Clinical Syndrome Potential Etiologies Cellular hypoxia Altered mental status, dyspnea, seizures, and/or metabolic acidosis Cyanide, carbon monoxide, hydrogen sulfide, and/or sodium azide Cholinergic crisis Salivation, diarrhea, lacrimation, bronchorrhea, diaphoresis, miosis, fasciculation, Nicotine, nerve agents, and/or weakness, bradycardia, altered mental status, and/or seizures organophosphates Gastrointestinal illness Abdominal pain, vomiting, profuse diarrhea, hypotension, and/or cardiovascular Ricin, staphylococcal enterotoxin E, arsenic, collapse and/or Ebola Lacrimation Tearing, blepharospasm, and/or incapacitation Lacrimators (Mace), ammonia, and/or halogens (chlorine, bromine) Mucosal irritation Tearing, nose and mouth burning, and/or sore throat Ammonia and/or halogens Muscle rigidity Generalized muscle contractions, painful neck and/or limb spasm, and/or seizurelike Strychnine activity Muscle weakness Generalized muscle weakness, ptosis, and/or respiratory embarrassment Botulism Peripheral neuropathy Muscle weakness or atrophy, “stocking-glove” sensory loss, and/or depressed or Arsenic and/or thallium absent deep tendon reflexes Respiratory distress, Cough, wheeze, shortness of breath, and/or generalized mucosal irritation Ammonia and/or halogens acute onset Respiratory distress, Cough, respiratory distress, wheeze, hypoxia, and/or pulmonary edema Phosgene and/or sulfur mustard delayed radiation threats. Specifically, the DHS provide initial care for both adults water contamination in 2016; strives to secure the nation from and children. The Medical Reserve Hurricanes Harvey, Irma, and Maria in many threats (eg, aviation, border Corps, another federal effort designed 2017; and Hurricane Michael in 2018. security, cyber security, and to create community “medical strike At state and local levels, planning for emergency response). Mission areas teams,” has no clearly established chemical and biological terrorism is include preventing terrorism and pediatric capability or standards now coordinated by multiple enhancing security, managing the US (https://mrc.hhs.gov/HomePage). agencies, including departments of borders, administering immigration health, emergency management laws, securing cyberspace, and Other DHHS agencies have undergone agencies, poison control centers, and ensuring disaster resilience. Within change; these include the CDC, FDA, law enforcement authorities.68 the DHHS, the ASPR was established and National Institutes of Health, all Because there is variability across in 2006 to minimize the adverse of which have reorganized practice, states, pediatricians can inquire as to health consequences from disasters. regulatory, and research priorities to which agencies are in charge of The ASPR has led the development of include chemical and biological planning for and responding to the National Health Security Strategy terrorism, along with other public chemical and biological attacks in and oversees implementation of the health threats. In 2002, the CDC their local communities. National Biodefense Strategy.65,66 The established the Coordinating Office ASPR continuously identifies and for Terrorism Preparedness and addresses gaps in coordinating Emergency Response (later referred Poison Control Centers patient care and transportation in to as the Office of Public Health The network of regional and state disasters, especially for coalitions and Preparedness and Response and now poison control centers, funded by states. The ASPR also offers support renamed the Center for Preparedness federal, state, and local sources, in this area through the federally and Response), and in 2012, the CDC may be the first point of contact funded Hospital Preparedness launched the Children’s Preparedness for health care providers and Program, which is now focused on Unit to address children’s needs in members of the public concerned health care coalition preparedness the context of infectious disease about possible terrorist attacks. efforts. The potential benefits of outbreaks and other public health Callers can reach poison centers regional disaster health response emergencies. The CDC also integrated 24 hours a day via a national toll-free systems are also being explored. The a children’s health team into its number (800-222-1222), and call ASPR also leads the disaster medical Emergency Operations Center data are uploaded automatically in assistance teams (DMATs), which structure, beginning in 2009 with the nearly real time (currently a median provide medical assistance to regions H1N1 influenza pandemic and of 9.5 minutes to upload data from all after a large-scale disaster.67 continuing through the responses centers) to the National Poison Data Although there are individuals on to the Ebola virus epidemic System, maintained at the American DMATs who have pediatric expertise, (2013–2016); the Zika virus outbreak Association of Poison Control personnel on DMATs are trained to in 2016–2018; the Flint, Michigan, Centers.69

Downloaded from www.aappublications.org/news by guest on September 25, 2021 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS SNS and Pediatric MCMs testing, procuring, and distributing require an integrated response from The SNS has become 1 of the most medications in doses and the emergency department, ICU, formulations appropriate for operating rooms, and other key important initiatives in mass-casualty 62,72 disaster response.31 Designed to children. In addition, state and clinical areas within the hospital. respond to disasters that overwhelm local plans for medication Response needs include having an state and local resources, the SNS distribution need to be developed in adequate number of pediatric collaboration with pediatric experts supplies and staff members trained in includes such capabilities as the and consider children’s needs for the care of ill children, including delivery of medications and medical maximum effectiveness and pediatric medication weight-based supplies to areas of need within efficiency. dosing (milligrams of medication per a clinically relevant time frame. The kilogram of body weight) to minimize SNS supplies include pediatric dosage The Primary Care Provider and morbidity and mortality.3,31,74,75 The forms and pediatric sizes of medical Community Response needs of children with chronic health supplies as well as instructions for Pediatricians play a pivotal role in conditions as well as physical and compounding certain tablets and providing care in the medical home intellectual disabilities need to be capsules into liquid formulations and supporting the community considered in the disaster plan. All for some but not all MCMs.70 before, during, and after a chemical or hospitals should have disaster Unfortunately, not all MCMs are biological attack.4 Most families will protocols for pediatric patients, licensed for use in children, and not seek medical advice from a trusted including mobilization of child-life all MCMs are available in ideal source such as their pediatrician. specialists, volunteers, and others formulations that are appropriate for Pediatricians can emphasize the need such as behavioral health younger children. According to the for family disaster preparedness professionals who can provide 2013 US Government Accountability planning before an event and provide comfort to and minimize the stress of fi Of ce, 40% of the MCMs in the SNS resources such as the AAP Family children, particularly if those children have not been approved for pediatric Readiness Kit.73 After an attack or are separated from their parents. For use. Of the 60% of MCMs that are outbreak, pediatricians and their staff hospitals that do not treat large approved for children, there are many will need to be knowledgeable about numbers of children, telehealth and instances when use is limited to the medical course for the agent of telementoring technologies offer fi people of speci c ages. Currently, concern and provide anticipatory access to information and to pediatric unapproved MCMs may be guidance to the families. Although subspecialists to facilitate the care of distributed under FDA emergency use victims of a chemical or biological children.76 In addition, hospitals authorization or investigational new attack may be treated initially in participating in a regional coalition drug application. If an MCM is hospital emergency department may be asked to provide care for considered under the investigational settings, victims may also seek care victims far away from the new drug application, additional from the medical home. Thus, affected site. consent would be needed, which pediatricians will need to be prepared would be challenging to explain to for a surge in communications with To be fully prepared for chemical or frightened parents and would likely patients and families, have the biological terrorism, pediatric and prolong MCM mass distribution appropriate PPE (and related training general hospitals must also have an efforts during a public health on how to use the equipment), and evacuation plan for times when the emergency. Ongoing efforts continue have developed isolation procedures. hospital environment becomes within the ASPR to address the MCM Pediatricians will also need to be uninhabitable. Although protocols for needs of pediatric populations in prepared to help families care for the “vertical evacuation” (ie, the removal relation to the current medications long-term physical and emotional of patients to other areas or floors within the SNS and make prioritized sequelae. Additional information on within the same building) are well recommendations for formulary the role of the pediatrician in disaster established in hospital-based disaster additions or changes. The AAP has preparedness and response is response, comprehensive plans for identified several concerns and available.3,8 complete building evacuation are less recommendations in its policy, well developed. Pediatric hospitals “Medical Countermeasures for Prehospital and Hospital requiring full evacuation may have Children in Public Health Preparedness the additional challenge of Emergencies, Disasters, or Hospital protocols for pediatric transporting pediatric patients to Terrorism.”71 Even with an increased victims of chemical or biological health care facilities with relatively awareness of the need, significant terrorism must be established in all few pediatric resources. Nonetheless, barriers remain to developing, hospitals. These disaster protocols memoranda of agreement with

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 145, number 2, February 2020 11 nearby or affiliated institutions and removal of clothing can eliminate be a frightening procedure for regional alliances are a key part of pockets of trapped gas.79 When children, exacerbated by the identity- a comprehensive pediatric hospital possible, the victim should disrobe concealing PPE that clinicians are disaster plan. himself or herself to minimize wearing. Efforts can be made to keep exposure to others. Health care parents nearby and families intact; Decontamination professionals should not assist in when possible, parents should remain disrobing unless they are wearing with their child to offer psychological Several investigators have focused on appropriate PPE.68 support and assist with their child’s the logistics of prehospital and decontamination.80 hospital preparedness. In a study of 2 There is some debate about the mass decontamination field exercises, merits of dry decontamination investigators in the United Kingdom (removal of clothing, scraping, A number of studies have explored used radio-frequency identification absorbent or adsorbent materials, various materials—including water— tags and detection mats to examine vacuuming, pressurized air, provision for decontamination. One preliminary bottlenecks in the process. Computer of replacement clothing) alone versus study of water-only decontamination analysis revealed that bottlenecks wet decontamination, which adds of an oil-based, mock chemical- occurred at specific phases of the showering to topical biological agent suggested that 100% process (eg, the redressing or decontamination. The decision to use of subjects could be decontaminated “rerobing” that followed dry versus wet decontamination may within 90 seconds.81 Although decontamination showers), and depend, for example, on the presence proprietary agents are available for subsequent simulations revealed that of clearly visible contamination or specific types of exposures, a review shortening the duration of showers evidence of a blistering agent.66 of corrosive dermal exposures found and adding capacity in the rerobing that water is efficacious, widely Showering further removes area could improve throughput of available, and inexpensive.82 In chemicals, microbes, and debris. As casualties.77 specific, known exposures, other with disrobing, showering usually decontamination agents may be more After exposure to a chemical or happens outdoors. However, some effective: a study of the molecular biological weapon, children may institutions may have specially tracer 4-cyanophenol found that become covered by toxic material that designed indoor hazmat decontamination efficiency from can produce skin injury or be decontamination facilities. Protocols porcine skin was 54% with water, up absorbed, producing systemic should include strategies for using to 70% with dry fuller’s earth, and toxicity. In the case of infectious warm water and low-pressure around 90% with a suspension of material, the contamination of skin showers (to avoid trauma to the skin), fuller’s earth.83 In terms of wet could be sufficient to represent etc, to prevent hypothermia in versus dry decontamination, another a threat to health care professionals children, as well as methods for the study of absorbent materials in an as well as the victim. When children collection of contaminated water. ex vivo model indicated that dry are covered with unknown but Principles of showering include the decontamination was superior to wet potentially dangerous chemical or establishment of 3 management methods for removing liquid infectious material, immediate zones in the decontamination staging contaminants but was not effective decontamination is required.78 To area (hot [maximum contamination], against particulate matter.84 minimize exposure to health care warm [less contamination]), and cold professionals and patients within the [no contamination] zones), use of health care facility, the child should water that has been warmed to The consensus among investigators, be disrobed outdoors—as per a temperature of 100°F, a water however, is that time is the single Occupational Safety and Health pressure of 60 lb psi, and most important factor in successful Administration regulations—before containment of the wastewater. If the decontamination.85 In most cases, entering the ambulance or building, toxic material is oily or firmly decontamination is most successful if with attention to prevention of adherent to the child’s skin, a mild performed within minutes of hypothermia, as noted below. Plans soap or shampoo should be used; exposure, which has the added should address the collection of solutions such as mild bleach should benefit of mitigating the demand on contaminated water. Disrobing alone not be used on children because of health care facilities. This has accounts for more than 85% of the risk of skin injury.31 If an outdoor introduced the concept of self-care topical decontamination and is an shower is not available, the child can decontamination and the mnemonic extremely effective means of ending be simply disrobed before being MADE: move and assist, disrobe and exposure. In the Tokyo sarin brought into the health care facility decontaminate, evaluate and experience, it was determined that for further care. Decontamination can evacuate.86

Downloaded from www.aappublications.org/news by guest on September 25, 2021 12 FROM THE AMERICAN ACADEMY OF PEDIATRICS All health care professionals who appropriate equipment and triage, ideally outside of the hospital; assist in decontamination must supplies.90,91 (5) identification of care sites for protect themselves by wearing those whose injuries are minor; (6) appropriate PPE.87 Currently, there Surge Capacity mechanisms for labeling and tracking are 4 levels of PPE, ranging from level An effective response to large-scale patients, particularly children who A, which is the highest level of chemical or biological terrorism (ie, arrive without personal identification protection, to level D, which consists an incident with more casualties than and may not be able to identify their of a simple gown, gloves, and surgical routine operations can accommodate) parents; and (7) plans for mask. Many exposed subjects self- requires the creation of surge maintaining hospital security by present to health care facilities. capacity protocols. Federal, state, and preventing the entry of contaminated For hospital personnel, level C PPE local public health authorities are victims and other unauthorized (a chemical-resistant suit and essential in assisting health facilities individuals.94,95 For nonpediatric gloves, with an air-purifying during crises of large magnitude. hospitals, surge capacity plans for respirator) is considered adequate Crisis standards of care have been a mass-casualty chemical or biological for hospital-based management reviewed and established at all incident involving children can of most contaminated victims. levels.92 Definitive care of pediatric include mechanisms for mobilizing Health care facilities can develop patients is increasingly dependent on health care professionals with plans for rapid access to PPE interhospital transfers and referral pediatric expertise, including equipment and train staff on its centers.93 Lack of disaster planning telemedicine. Surge capacity use. Other recently published for children in local health care principles are summarized in Table 6. principles of decontamination facilities will impede and complicate and PPE are outlined in the care of children. Because disasters Pediatric Mental Health Table 5.88,89 happen locally, all health care systems Given that the primary intent of must consult with pediatric experts terrorist attacks is to cause Isolation and Containment and plan for the needs of children psychological distress among victims, In the current era, hospitals and during a disaster. Plans for such an witnesses, and the general health clinics need to develop event might include (1) the creation population, it is to be expected that protocols to be vigilant in screening, of additional bed spaces through adjustment reactions will be a major isolating, and starting treatment of cohorting; (2) mechanisms for the challenge—if not the primary patients with highly contagious rapid discharge of inpatients to challenge—after chemical and emerging infectious diseases. Ideally, increase capacity; (3) an inventory of biological terrorism, for both children integrated communication systems all sites in the hospital where critical and adults. Children are among those will be in place to help clinicians care can be provided; (4) most at risk for psychological trauma identify pediatric patients with establishment of a site for patient and behavioral difficulties after concerning travel history and possible exposures to an emerging TABLE 5 Principles of Decontamination infectious disease. Clinicians can become better prepared by knowing Principles how to contact local and state public All decontamination should occur outside of the health care facility. fi health officials if there is concern of All health care professionals should wear appropriate PPE, as determined by their safety of cer and occupational health specialist. a highly contagious pathogen, an All levels of health care professionals should be trained to quickly access and use PPE, including emerging infection, or a cluster of physicians, nurses, clinical assistants, security, and environmental services. illness. Preparation for the Remove clothing from the victims as quickly as possible. Victims should disrobe themselves when 2013–2016 Ebola virus outbreak has possible. led to federally identified Discarded clothing should be placed in a labeled plastic bag and stored for possible use by law enforcement. biocontainment treatment centers in Consider dry (removal of clothing, scraping, absorbent or adsorbent materials, vacuuming, pressurized each US region, including, in some air, and/or provision of replacement clothing) versus wet decontamination (addition of showers). cases, tertiary care pediatric If showering is used, ensure the following: hospitals. Institutions caring for The water should have a temperature of approximately 100°F and a pressure of 60 psi. a child with a high-consequence Water alone is used routinely. If the material is oily, a mild soap or shampoo should be added. Victims should shower for 5 min unless specific alternative recommendations are given. pathogen require policies that include When possible, water effluent should be contained rather than placing it in the local wastewater and recognize the developmental and stream. psychological needs of children as Use heat lamps, blankets, and other mechanisms to prevent hypothermia. well as policies that address parental Cover hands, feet, and other exposed areas of the victim if there is evidence of gross contamination. presence and the use of age- If there are multiple victims, anticipate the need to perform out-of-hospital triage.

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 145, number 2, February 2020 13 a disaster and will also be influenced TABLE 6 Surge Capacity Principles for Hospitals by their parents’ reactions and by Principles coverage in social and public media. Preparation Children may experience short- and Obtain PPE, showers, and other emergency-response equipment long-term effects on their Stockpile pediatric supplies psychological functioning, emotional Stockpile or plan for additional pediatric pharmaceuticals Perform drills; consider tabletop exercises using pediatric victims adjustment, and developmental Familiarize with wt-based dosing (eg, milligrams of medication per kilogram of body wt) for pediatric trajectory. Adjustment reactions may emergency medicines include anxiety, worries, or fears; Response sadness or depression; difficulties Anticipate a 1:5:7 ratio of critically ill/urgently ill (“walking wounded”)/well (“worried well”) casualties96,97 with concentration and learning; Anticipate the “second-wave” phenomenon98 developmental or social regression; Reserve the emergency department for critically ill patients sleep or eating problems; substance Perform triage and decontamination outside of the hospital abuse or other risk-taking behavior; Put protocols in place to prevent campus security from unauthorized intrusion Identify and use alternate sites of care; identify transportation options posttraumatic reactions and disorders; bereavement when deaths have occurred; and somatization. health specialists when indicated and there continue to be gaps in These reactions may be seen even resources allow.5 incorporating children into disaster among children in the community planning, especially with respect to who have had no direct or indirect Pediatricians who live in communities the use of pediatric MCMs. Pediatric exposure to the chemical or biological affected by terrorist attacks are likely health care providers will need to agents. These reactions may to be worried about the health of be knowledgeable of possible agents persist long after an event, which family, friends, and themselves. They and sequelae to provide optimal fi should be a consideration for those may nd the delivery of care medical and mental health children who have escaped countries exhausting and emotionally draining management for children exposed where such terrorist attacks are given the surge in health care needs to chemical or biological terrorism. known or believed to have occurred (in most cases predominantly Pediatric health care providers in the past. because of the large number of will need to be trained on pediatric individuals with psychological decontamination strategies as Emotional distress may interfere with distress), the uncertainty of providing well as the use of PPE. Pediatric accurate reporting of symptoms or care during an evolving crisis for health providers can also help instead mimic physical responses to which the pediatrician has limited their communities with chemical the chemical or biological agents. information and experience, and the and biological preparedness and Primary and subspecialty care distress that results from delivering response activities. pediatricians will often be the first to compassionate care and witnessing see children experiencing the suffering of children and their LEAD AUTHORS psychological distress in this setting, families, pediatric colleagues, and ’ whether it presents as physical the pediatrician s own family and Sarita Chung, MD, FAAP friends. Attention to self-care Carl R. Baum, MD, FACMT, FAAP complaints, an adjustment reaction to Ann-Christine Nyquist, MD, MSPH, FAAP the terrorist attack, or a combination. and support of professional Given that virtually all children in colleagues is an important component a community affected by a terrorist of the response to the crisis DISASTER PREPAREDNESS ADVISORY COUNCIL, 2018–2019 attack are likely to experience some throughout the long-term recovery 5 degree of emotional distress and period. Steven E. Krug, MD, FAAP, Chairperson anxiety, it is critical that pediatricians Sarita Chung, MD, FAAP Daniel B. Fagbuyi, MD, FAAP become comfortable in the CONCLUSIONS Margaret C. Fisher, MD, FAAP assessment and acute management of Scott Needle, MD, FAAP adjustment reactions and mental The threat of a chemical or biological David J. Schonfeld, MD, FAAP health problems that may be seen. attack remains high. Children can be Pediatricians should be prepared to the intended target or part of the LIAISONS provide psychosocial support, targeted group. Although advances – fi John J. Alexander, MD, FAAP US Food and psychological rst aid, and have been made in surveillance, Drug Administration psychoeducation in addition to pediatric disaster education, Kevin M. Chatham-Stephens, MD, FAAP – evaluation and referral to mental decontamination, and awareness, Centers for Disease Control and Prevention

Downloaded from www.aappublications.org/news by guest on September 25, 2021 14 FROM THE AMERICAN ACADEMY OF PEDIATRICS Daniel Dodgen, PhD – Office of the Assistant Mary H. Ward, PhD – National Cancer Natasha B. Halasa, MD, MPH, FAAP – Secretary for Preparedness and Response Institute Pediatric Infectious Diseases Society Sangeeta Kaushik, MD, MPH – US Department Nicole Le Saux, MD, FRCP(C) – Canadian of Homeland Security Paediatric Society Shana Godfred-Cato, DO, FAAP – Centers for STAFF Scot Moore, MD, FAAP – Committee on Disease Control and Prevention Practice Ambulatory Medicine Georgina Peacock, MD, MPH, FAAP – Centers Paul Spire Neil S. Silverman, MD – American College of for Disease Control and Prevention Obstetricians and Gynecologists Erica Radden, MD, FAAFP – US Food and Jeffrey R. Starke, MD, FAAP – American Drug Administration COMMITTEE ON INFECTIOUS DISEASES, Thoracic Society Robert F. Tamburro, Jr, MD, FAAP – Eunice 2018–2019 James J. Stevermer, MD, MSPH, FAAFP – Kennedy Shriver National Institute of Child American Academy of Family Physicians Yvonne A. Maldonado, MD, FAAP, Health and Human Development Kay M. Tomashek, MD, MPH, DTM – National Chairperson Theoklis E. Zaoutis, MD, MSCE, FAAP, Vice Institutes of Health STAFF Chairperson Ritu Banerjee, MD, PhD, FAAP STAFF Laura Aird, MS Elizabeth D. Barnett, MD, FAAP Sean Diederich James D. Campbell, MD, MS, FAAP Jennifer M. Frantz, MPH Tamar Magarik Haro Jeffrey S. Gerber, MD, PhD, FAAP Athena P. Kourtis, MD, PhD, MPH, FAAP Ruth Lynfield, MD, FAAP COUNCIL ON ENVIRONMENTAL HEALTH Flor M. Munoz, MD, MSc, FAAP EXECUTIVE COMMITTEE, 2018–2019 Dawn Nolt, MD, MPH, FAAP ABBREVIATIONS Jennifer Ann Lowry, MD, FAAP, Chairperson Ann-Christine Nyquist, MD, MSPH, FAAP Samantha Ahdoot, MD, FAAP Sean T. O’Leary, MD, MPH, FAAP AAP: American Academy of Carl R. Baum, MD, FACMT, FAAP Mark H. Sawyer, MD, FAAP Pediatrics William J. Steinbach, MD, FAAP Aaron S. Bernstein, MD, FAAP fi Aparna Bole, MD, FAAP Tina Q. Tan, MD, FAAP ASPR: Of ce of the Assistant Lori G. Byron, MD, FAAP Secretary for Preparedness Philip J. Landrigan, MD, MSc, FAAP and Response Steven M. Marcus, MD, FAAP EX OFFICIO CDC: Centers for Disease Control Susan E. Pacheco, MD, FAAP David W. Kimberlin, MD, FAAP – Red Book and Prevention Adam J. Spanier, MD, PhD, MPH, FAAP Editor Alan D. Woolf, MD, MPH, FAAP, FAACT, DHHS: Department of Health and Henry H. Bernstein, DO, MHCM, FAAP – Red FACMT Human Services Book Online Associate Editor DHS: Department of Homeland H. Cody Meissner, MD, FAAP – Visual Red LIAISONS Book Associate Editor Security DMAT: disaster medical – John M. Balbus, MD, MPH National Institute assistance team of Environmental Health Sciences LIAISONS Nathaniel G. DeNicola, MD, MSc – American FDA: Food and Drug College of Obstetricians and Gynecologists Amanda C. Cohn, MD, FAAP – Centers for Administration Ruth A. Etzel, MD, PhD, FAAP – US Disease Control and Prevention MCM: medical countermeasure Environmental Protection Agency Jamie Deseda-Tous, MD – Sociedad PPE: personal protective – Natalie Villafranco, MD, FAAP Section on Latinoamericana de Infectologia Pediatrica equipment Pediatric Trainees Karen M. Farizo, MD – US Food and Drug Mary Ellen Mortensen, MD, MS – Centers for Administration SNS: Strategic National Disease Control and Prevention and National Marc Fischer, MD, FAAP – Centers for Disease Stockpile Center for Environmental Health Control and Prevention

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. DOI: https://doi.org/10.1542/peds.2019-3750 Address correspondence to Sarita Chung, MD, FAAP. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2020 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: Dr Chung is the codirector for the Disaster Domain of the Emergency Medical Services for Children Innovation and Improvement Center. Dr Baum is the medical director for a grant from the Agency for Toxic Substances and Disease Registry and American College of Medical Toxicology; advisory board

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 145, number 2, February 2020 15 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. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on September 25, 2021 Chemical-Biological Terrorism and Its Impact on Children Sarita Chung, Carl R. Baum, Ann-Christine Nyquist and DISASTER PREPAREDNESS ADVISORY COUNCIL, COUNCIL ON ENVIRONMENTAL HEALTH, COMMITTEE ON INFECTIOUS DISEASES Pediatrics 2020;145; DOI: 10.1542/peds.2019-3750 originally published online January 27, 2020;

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2020 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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