Mommy, My gas mask doesn’t fit!

Pediatric Issues In Unconventional and Asymmetric Warfare

James M. Howson, CEM, CHEC, NRP UMBC PACE Medic Recertification February, 2021

Disclaimers:

 This presentation was prepared by James Howson in his personal capacity.  The opinions expressed in this presentation are the author's own and do not reflect the views of the National Institutes of Health, the Department of Health and Human Services, or the United States Government.  No classified sources were used in putting together this presentation. All information presented in this talk was gleaned from “Open Source” materials.

1 Disclaimers Continued

 This presentation contains some images from actual terrorist and criminal events that my be disturbing to some viewers.

“In the event of a terrorist attack, children would be one of the most vulnerable populations” US Department of Health and Human Services

2 “The use of chemical or biological weapons against a civilian population would disproportionately affect children”

American Academy Of Pediatrics

Unconventional Warfare

 Also called Asymmetric Warfare  Unconventional strategies and tactics adopted by a force when the military capabilities of belligerent powers are not simply unequal but are so significantly different that they cannot make the same sorts of attacks on each other.  Challenging the United States in conventional combat is an problematic, but use of unconventional weapons and tactics, such as those associated with guerrilla warfare and terrorist attacks can provide significant advantages.

3 Unconventional Warfare Continued

 Children are being specifically targeted.  Kankara town, Nigeria (2020-12)  Kidnaping of 333 boys from a school  Similar to the kidnapping of 276 girls in Chibok, Nigeria by Boko Haram in 2014  In the 2014 attack girls were targeted and the boys were simply killed (57 boys)  Peshawar, Pakistan (2014)  Chemical Attack on School - 132 dead  57 boys were killed in the incident  Beslan, Russia (2004)  Attack on a school - 777 children held hostage, 331 killed  Starogladovskaya, Chechnya (2005)  Nerve agent attack on a middle school - over 100 dead  Utoye Island, Norway (2011)  Shooting attack on a youth camp, 69 dead, 33 were under the age of 18

Unconventional Warfare Continued

Terrorist attacks against children have dramatically increased over the past 10 years. They have symbolic value There is significant media coverage Children and schools are considered “Soft Targets”, it is easy to inflict horrific damage on what are lightly defended targets.

4 Pediatric Issues In Asymmetric Warfare Areas of Concern

 Physiologic and Developmental Concerns  Personal Protective Equipment  Effective Medication Delivery Devices  Medications and Antidotes  Decontamination Issues  Psychological Issues

Physiologic Concerns

 Children are more vulnerable to agents that produce vomiting or diarrhea.  Because of their larger body surface area they are more susceptible to hypothermia after having been decontaminated.  Since Children’s lungs are generally not fully matured until 8 years of age, exposure to a chemical agent at an early age may cause developmental problems.

5 Physiologic Concerns

 Many chemical warfare agents are carcinogenic and mutagenic and may pose long term problems for children who are exposed in an attack.  Because children’s bones are more flexible there are fewer fractures that can be used as trauma markers, therefore, internal injuries may be over looked.

Developmental Concerns

 Young children do not have the cognitive ability to determine when or how to escape from danger.  Young children, toddlers and infants do not have the motor skills to escape from the site of a WMD Incident.  Nerve agents are known to cause neurophychiatric effects, what is unknown is how long these effects will last in children.

6 Psychological Issues

 Children are at risk for post traumatic stress disorder after experiencing a WMD event.  In a WMD Event they may witness the deaths of their siblings, peers or even their parents.  Even children not directly involved in the event may be affected by the repeated showings of the event by the media. “The CNN Effect”  Nerve agents are known to have degenerative cognitive effects on patients, but it is unknown how permanent these effects will be in the pediatric population.

Personal Protective Equipment

 Most gas masks and protective equipment are designed for use by adults and are not suitable for use by children.

7 Personal Protective Equipment Continued

 Attempts have been made over the years to develop protective masks for children.

This is an example of a gas mask designed by Walt Disney in the early 1940’s for use by children.

Examples of Pediatric Protective Equipment

8 Examples of Pediatric Protective Equipment Continued

Personal Protective Equipment Continued

 Although numerous attempts have been made to develop safe and effective pediatric protective equipment, no truly successful devices have been produced as yet.  In Israel during the first Gulf War 8 people, including 6 children, died due to improper use of protective masks.

9 Nerve Agent Issues

 Children can be disproportionately affected by exposure to chemical agents.  Generally, because they are inhaled, the can poise a greater threat to children due to their more rapid respiratory rates.

Lethal dose of SARIN

Nerve Agent Antidote Kits

 The current NAAK is the: Antidote Treatment Nerve Agent, Auto-Injector (ATNAA) (Replaces the Mark 1 Kit)  The ATNAA consists of one Auto injector that delivers  Atropine 2 mg in 0.7 ml  Pralidoxime Chloride 600 mg in 2 ml  Convulsant Antidote for Nerve Agents (CANA).  Diazepam 10 mg in 2 ml

10 Autoinjector Effectiveness Continued

 Rapid absorption of the antidote following automatic injection is enhanced by the degree of tissue dispersion achieved by the autoinjector.  Autoinjector medications are more efficiently diffused into surrounding muscle tissue due to the force with which it is expelled from the injector.

Pediatric Auto Injectors

1.0 mg Dose 2.0 mg Dose 0.5 mg Dose

11 Walter Reed Pediatric Nerve Agent Treatment Guide

Symptoms Triage Level Atropine Pralidoxime Diazepam Asymptomatic Delayed None None None

Miosis, Mild Delayed None None None Rhinnorhea Miosis Immediate: 0.05 mg/kg IV 25-50 mg/kg For any Neurologic effect 30 days to 5 years Repeat as needed Repeat q 1 hr and any other Moderate 0.05 to 0.3 mg/kg IV q 5-10 min until Watch for: symptom Admit To a max 5 mg/dose respiratory status Muscle Rigidity improves 5 years and older Laryngospasm 0.05 to 0.3 mg/kg IV Tachycardia To a max 10 mg/dose Apnea, Immediate: 0.05-0.1 mg/kg 25-50 mg/kg May repeat q 15-30 min Convulsions, Severe No Maximum IV or IM as Above Cardiac Arrest Admit ICU Repeat q 5-10 min As above

Source: Walter Reed Army Medical Center

Atropine Continued

 If only standard MARK 1 kits are available, a 2.0 mg atropine autoinjector may be used.  Note that infants and small children are at risk of being injured by the autoinjector needle.  The most significant adverse side effect of high dose atropine in the younger patient is the inhibition of sweating.

Source: USAMRICD

12 The “Nord-Ost” Incident

 In October 2002, Chechen separatists seized a Moscow theater, taking over 800 hostages.  Russian special forces assaulted the theater using a gas based on Fentanyl in an attempt to “Knock-Out” everyone in the theater.  At least 120 hostages died from the effects of the gas, 14 were children.  Although hard information remains difficult to obtain, it appears that the pediatric hostages died at over twice the rate of the adult hostages.

The “Nord-Ost” Incident Continued

13 Biological Agent Issues

 Children can be disproportionately affected by exposure to biological agents.  Children are more vulnerable to agents that produce vomiting or diarrhea.  Because children breathe at a faster rate than adults they would be subject to relatively larger doses of an agent during the same period of exposure as an adult.

Anthrax

 Anthrax is a bacterial disease caused by B anthracis and considered a potent biological weapon of mass destruction.  Attempts to weaponize B anthracis were made as early as 1916, by Germany.  They were attempting to contaminate raindeer herds in Norway and disrupt the movement of supplies from the allies to Russia.

14 Anthrax Continued

 The anthrax vaccine currently available in the US is not recommended for children by its manufacturer because it was only tested on age groups between 18 and 65 years.  No pediatric study of its effectiveness has apparently ever been done.  Some authorities have stated that the risk of vaccinating children with the current preparation would have to be weighed against the risk of not using every possible defense to protect children who have actually, or potentially been exposed to anthrax.

Antibiotics Pediatric Dosing for Anthrax Exposure

 The drugs of choice for prophylaxis are Ciprofloxin, penicillin or amoxicillin. (20 to 40 mg/kg/day div TID to QID)  NOTE - A genetically engineered BW agent might be resistant to penicillin or amoxicillin.  The strain of anthrax used in the 2001 Bio-Terror Letter Attacks was sensitive to penicillin.  In penicillin resistant cases, the drug of choice is doxycycline. (2 to 4 mg/kg/day div BID)  The discoloration of teeth often associated with doxycycline is typically not seen until after taking six courses of the antibiotic.

Source: USAMRIID

15 Anthrax Continued

 Doxycycline is normally not used in pediatric treatment because of side effects.  However, in this situation it is possible that benefits will outweigh the possible disadvantages, and one course of doxycycline is not likely to cause staining of the teeth.

Smallpox

 It first appeared in China and the Far East at least 2000 years ago.  Used by the British during the French Indian War and later against the American Colonists during their attack on Quebec.  There is some evidence that it may have been used by the Confederates against the Union forces during the American Civil War.

16 Smallpox Continued

 Smallpox can be fatal in 30% of untreated cases and disfiguring in all cases.  There have been no regular civilian vaccinations for Smallpox in the US since 1972.  Most people who have been vaccinated against Smallpox have lost their immunity.  There have been some studies that suggest that there may be some slight protection up to 50 years post vaccination.

Smallpox Continued

 There are approximately 98 million doses of Smallpox Vaccine available in the US at this time.  An RFP has been put out to make 300 million doses of new vaccine.  The CDC is vaccinating it’s response teams.  The last naturally occurring case was in Somalia in 1977.  Smallpox was declared to be eradicated in 1980.

17 Smallpox Continued

 Although officially eradicated, variola stocks remain at the CDC in the US and at the Research Institute for Viral Preparations in Russia.  It is suspected that there may be illicit strains in other locations.  The Russians were able to weaponize Smallpox in the 1960’s and placed it on ICBM warheads in the mid to late 1970’s.

 The current Smallpox vaccine is not recommended for use with children, although this restriction would most likely be lifted during an actual disease outbreak.

18 The Sverdlovsk Incident

 In 1979 there was an accident at the Biopreparat plant in the city of Sverdlovsk in the former Soviet Union that released anthrax into the air.  After the accident several hundred people became ill with anthrax.  Over 75 people died, but none of the fatalities were under 24 years old.  It is known that the anthrax plume passed over at least one school and teachers from that school did become ill.  One (1) child did get the cutaneous form of anthrax from this incident. Cutaneous anthrax lesion

Radiological Agent Issues

 Children were disproportionately affected by exposure to radiation during incidents in Brazil and Russia.  Radiation induced cancers occur more often in children than in adults exposed to the same dose.  Children exposed to radiation in utero are very prone to birth defects and DNA changes.

19 Potassium Iodide - KI

 Potassium iodide (KI) floods the thyroid with non-radioactive iodine and prevents the uptake of the radioactive molecules, which are subsequently excreted in the urine.  KI works only to prevent the thyroid from up-taking radioactive iodine.  KI is not a general radio-protective agent.  KI provides protection for approximately 24 hours, it should be dosed daily until the risk no longer exists.

FDA Threshold Thyroid Radiation Exposure And Recommended Doses Of KI

Expected thyroid KI dose (mg) Patient Population Exposure (rad) Adults over 40 > 500 cGy 130 mg Adults > 18 to 40 years > 10 cGy 130 mg Pregnant or Lactating women > 5 cGy 130 mg Adolescents > 12 to 18 years > 5 cGy 65 mg Children > 3 to 12 years > 5 cGy 65 mg Children > 1 month to 3 years > 5 cGy 32 mg Birth to 1 month > 5 cGy 16 mg Source: FDA

20 The Chernobyl Incident

 On April 26, 1986 the No. 4 Reactor at the Chernobyl Nuclear Power plant exploded and released thirty to forty times the radioactivity released by the atomic bombs dropped on Hiroshima and Nagasaki.  Prior to 1986, the Ukrainian thyroid cancer rate was 5 per million, it is now 45 per million.

The Chernobyl Incident Continued

 Children between the ages of 1 and 4 at the time of the accident appear to the most severely affected portion of the population.  A WHO study found "an unexpectedly high increase" in mutations among Ukrainian children born after the 1986 Chernobyl disaster.

21 Goiânia Incident

 On September 13, 1987, in Goiânia, Brazil a radiotherapy source was stolen from an abandoned hospital site in the city.  The source was broken open, exposing cesium chloride, and subsequently handled by many people, resulting in four deaths.  About 112,000 people were examined for radioactive contamination and 249 of them were found to have been contaminated.

Goiânia Incident

 Significate contamination was found in the city, including:  The regional health center  Several junk yards  3 buses  42 houses  14 cars  5 pigs Cesium Chloride  50,000 rolls of toilet paper  Post cleanup, a significant amount of radioactive material still remains unaccounted for.

22 Goiânia Incident Continued

 One of the thieves scraped some dust out of the source and spread on the concrete floor of his house.  His six-year-old daughter, was fascinated by the blue glow of the powder, applying it to her body and showing it off to her mother while eating a sandwich.  She eventually absorbed a total dose of 6.0 Gy (600 rad)  She was buried in a lead lined coffin to prevent the spread of radiation.  More than 2,000 people rioted to prevent her burial, all fearing that her corpse would poison the surrounding land.

Asymmetric Warfare

 Children are being specifically targeted.  Beslan, Russia (9/04)

 Attack on a school  Siem Reap, Cambodia (6/05)

 Attack on a school  Baghdad, Iraq (7/05)

 Car bomb attack on a group of children  Starogladovskaya, Chechnya (12/05)

 Nerve agent attack on a middle school

23 Asymmetric Warfare Continued

 Current triage criteria are ineffective for asymmetric warfare  They overlook children and effects of nails and booby traps  Blast tolerances for children are currently ill-defined  The current LD50s for blast injuries are based on a circa 1958 male weighing 70 KG  Children’s bones are more flexible  Because there are fewer fractures that can be used as trauma markers, internal injuries may be over looked

The Beslan School Attack

 On September 1st, 2004 Chechen separatists seized a school in southern Russia, taking over 1300 hostages.  The Chechens originally considered attacking an orphanage, but decided that there would be greater impact if they attacked a school because the children would have parents and relatives.  The siege lasted three days

24 The Beslan School Attack Continued

 186 children were killed  248 children were hospitalized  Most of the deaths occurred from explosions of mines and booby traps.  Many children who tried to escape were shot in the back

Decontamination Issues

 How do we decontaminate large numbers of pediatric patients?  Do we separate them from their parents?  Do we Decon parents and children of different sexes together?

25 Decontamination Issues Continued

 Once we take their clothing away, what are they going to wear?  Post Decon clothing kits designed for adults don’t generally fit children well.  Because children have a grater susceptibility to hypothermia, heat lamps and warming equipment must be made available when decontaminating children.

Pediatric Issues When Unconventional Weapons Are Involved

 Take away points:  Children are being specifically targeted by Terrorists  Children are particularly vulnerable to aerosolized CBRNE agents  Current triage criteria may be ineffective for unconventional events involving children  We don’t have good PPE for kids  Decontamination of children is difficult  There is significant risk of psychological effects

26 Questions?

James M. Howson, CEM, NRP 301-827-3195 [email protected]

27 Select Resources

 Medical Countermeasures for Children in Public Health Emergencies, Disasters, or Terrorism https://pediatrics.aappublications.org/content/137/2/e20154273  American Academy of Pediatrics Children & Disasters https://www.aap.org/en-us/advocacy-and-policy/aap-health- initiatives/Children-and-Disasters/Pages/default.aspx  Assistant Secretary or Preparedness and Response https://www.phe.gov/preparedness/pages/default.aspx  FEMA Children in disasters https://www.fema.gov/children-and-disasters  Disasters | The National Child Traumatic Stress Network https://www.nctsn.org/what-is-child-trauma/trauma-types/disasters

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