Annual EMSC Grantee Meeting

Model Pediatric Component for State Disaster Plans:

A Completed Target Issue Grant Summary

June 20 – 22, 2006

DAVID MARKENSON: Thanks, Dan, and for those of you who know me, I probably should leave this slide up the longest because it seems to be the running joke of where I’m working this week. Because as many of you’ve known, in the last four years, I think I’ve had four different academic appointments. Despite the rumor, my goal is not to have an academic appointment in every medical school in the tri-state area. I’m close. I am only two away but that was not a goal. But this is my new home and it’s New York Medical College, which is different than NYU for those of you who aren’t New Yorkers.

But I want to talk to you a little bit about this project that I’ve been working on for the last three years and most of you have heard of that. And I think we’ve had a lot of goals and a lot of achievements in products during those three years but the product, what I would say is coming to closure, sort. Because as we all know, to prepare this world is a moving target so you can never say that we produce today will still be valid tomorrow, a year from now, from two years from now. So as the grant is coming to close, I’m glad to have additional products and resources for you and the EMSC community to use but it’s clear that this project will continue under the new home in New York Medical College, we’ll be housing these products and continually updating them so that they stay current with the newest information.

I really need to acknowledge some of the people that had a substantial impact on this project and probably the largest of those is the Center for Pediatric Emergency Medicine, which really was sort of my birth into this field; with all the wonderful people that I worked with there who really helped me in the EMSC world get to know mostly, is to get to know the process and understand the importance of this work. And throughout this project, and all of the off-shoots I’ve done in the last few years, have been everything from a sounding board to a great source of expert information. And I really couldn’t have done it without them.

Also, the Columbia University National Center for Disaster Preparedness, which was my home during the past year and a half of this grant. The expert consultants who worked on the many projects and I think a lot of you are in this room who provided input for this to some of the other products we’ve developed. And then, my new home and the new staff because I arrived in August of this year and said, “By the way, I’ve got a couple of grants to finish. I’ve got a couple of projects to finish and you now need to do it with me in the next couple of months.” And obviously, all the project staff from the EMSC program and on and the EMSC community in general who’s been very supportive of this work.

Some of the key principles that I think just sort of explains where we’ve been and where we’re going with this project. One of the key principles that we decided from the beginning, and I still believe this was a right move, but it’s been also a source of major consternation and problems, to base our plan or the product that we were going to develop on the national response plan formerly known as the federal response plan or the concept of operations plan. And the reason for this was we decided that if we came out with a separate pediatric document that was not linked to the federal, and now national response plan, it would not be easily used by states. We were afraid that we’d have to go in and advocate as we always do for pediatrics and it will be outside the routine planning. So, whether this was a pipe dream or reality, the plan was to make it the same format as the now the national response plan, which is copied by the states, which is how the state plans are written and to fully integrate it into the existing emergency support functions. So, if someone opened it up, they would see a traditional national response plan the same as if they download it from the DHS website but they would find new additions for pediatrics. And that way when the states got into their planning, they could follow suit. And just as they normally go through the planning steps to dividing each of the ESFs, the agencies that are responsible allow them to incorporate pediatrics as part of planning.

And that was a couple of goals. The problem with that goal is that what happened is that this federal response plan which is the cornerstone of what we were going to base our document on, instead of a stagnant object which hadn’t been updated in probably 15 years over the last four years, has become a moving target.

The federal response plan became the national response plan. Released in ’04, then it was revised again, by the way, if you aren’t familiar; this spring, was revised again. And so, the goal was to keep it consistent with that but that became an issue. And I still believe it’s the right decision and the product that we’ve put out is consistent with the revised spring ’06 national response plan, national incident management system, and consistent with the presidential security directives.

As such, it now has 15 emergency support functions, which are far more than the original plans had, and that reflects the changes that had gone on. Most of the ones that many in this room are still familiar with such as ESF eight: public health and medical services, and six: mass care, are relatively unchanged but there are some new additions and splits. And there’s actually some new discussion of who’s responsible for what under six and eight, and we had to accommodate those.

There are new annexes: biologic, catastrophic, cyber, nuclear, oil, terrorism, law enforcement. And we did include pediatrics in some of these. I will tell you that some of them we didn’t, because there wasn’t a specific pediatric focus. Things such as oil and hazardous materials, which really deals with spill clean-up and doesn’t deal with surveillance, really didn’t have any need concepts, so those we chose not to address.

We did not, in this iteration, address the support annexes. I will say that that’s one of the ongoing projects but it was outside the scope of the current project. But what we also found is that there were specific elements of the national response plan that didn’t really have the depth that you would need when addressing pediatrics.

And here you have a list of them: EMS was a single line in ESF eight, if at all included; mental health was almost mentioned zero; schools didn’t exist; DMATs were mentioned, but not in the specificity that we think one needs for pediatrics; and hospitals, because they’re far down the food chain, so to speak, in terms of planning, were not included but we realized at the local level many people wanted specific information for hospitals. So these were specific items we added to give guidance on pediatric goals.

And I would say the schools one is probably one of the bigger ones, because the absence of schools in federal response in disaster planning is mostly an afterthought or a mistake, not an intentional action. At the federal level, the Department of Education is not an operational entity. It is a grant-making entity. As a result, it’s not included under the original iterations of the national response plans.

Now since most state and local are just copies of those adapted for state and even the local need, guess what happens? Schools aren’t in the national plan, schools don’t show up in the state plan, schools don’t show up in the local plan. And while there are many states that have specific regulations for school planning usually related to fire and student safety, they aren’t coordinated with emergency planning. And so, what we tried to do is actually create an emergency support function around schools that may not make it at a national level but hopefully it’ll stay at the local level as we become part of comprehensive emergency planning. So the format that we chose, there’s going to be two versions and I think the two versions depends on what your function is. The first version is complete. Now, in that document, which will probably be -- and I just delivered -- we submitted it -- was almost, I think, 250 or 300 pages -- as Dan shakes his head and looked at this telephone book that I delivered -- was again the fully integrated model where it goes to the state and other than the pediatric additions, it’s the same thing they look at everyday and they can handle the same way. And that’s important for that audience to say, “Here’s a document that’s no different than your current planning documents except that it has a few pediatric considerations. Divvy it up amongst all your local or state agencies, treat it the same way you will.”

The second version is pulling out all those pediatric add-ons. Not to create a separate document that would sit on the shelf, because, to be honest, I think a lot of emergency managers would set that second document on the shelf, but to give it to people in the EMSC community, pediatric community at large to say, “Now, you need to go advocate for the state to pay attention to those pediatric elements in the integrated document so you need to know what they are.” And I would say, the pediatric pullout is more of the advocacy documents, so you know what to shoot for and the integrated is more for the functional emergency management individuals to use.

Additional resources which came out of this grant, some you’ve seen and some you will be seeing, are specific in guideline recommendations from the consensus conference, some templates for school planning, and detailed benchmarks which I’ll talk about in a minute.

So, as some of you who’ve heard my presentation before, this is one of my favorite slides. This is a civil defense era slide. I think it was ‘49 or ‘50 it was taken. And what astounds me is that at that time, and I won’t get into whether civil defense era planning have any value -- no duck and cover will protect you from any nuclear explosion, but putting that aside, what I find astounding is the detail that was given to the types of things we’d be advocating for today.

If you look at this family-centered approach, right? Families’ president planning. We have a pediatric specific device equivalent to an adult. Adult has gas mask, child has gas mask. Child has size for the child, it’s child-friendly, it’s child appropriate. Now, what I find humorous is this was in -- I just hit the wrong button, I think. Yeah, this was an 1940’s era attempt at preparedness planning.

Now, if I took a picture of a planning effort today, would I find family-centered, child equivalent for adult equivalent, child-friendly and child-appropriate? No. So, I keep this in my mind as this is not such an unattainable goal and that’s what we’re trying to achieve. We’re trying to integrate pediatrics into a family approach to planning.

Let’s see what happened to this slide. Somehow, this slide ended up backwards. I’m just going to go that way.

Part of the effort also is not to create this document standing alone but to coordinate with other federal efforts that are important to pediatrics. I think it was ‘03, maybe ‘03--'04, there was a national advisory committee on children and terrorism. It was a requirement for the bio-terrorism legislation. It was a committee that submitted a report to the Secretary of Health and Human Services. And, while I’m sure some might not be happy to hear me say this, it is basically been collecting dust.

But, I think, if any of you haven’t seen it, it’s worth looking at because it’s an excellent blueprint for pediatric preparedness. It’s directed towards public health, it was directed towards the secretary at the federal level, but by all means, it is equivalent to what you would direct to a state level, city or county level health department. And if you haven’t seen this document, it’s on the CDC’s website. That’s one place you could find it. It is worth having. It addresses a multitude of planning areas and it really talks about pediatric specific focus.

But obviously, even though that document has collected a lot of dust, because it was out there, we obviously wanted to make sure that whatever we created was equivalent to that. There’ve been changes to the strategic national stockpile to address pediatrics and again, that’s something we wanted to include changes at FDA policy. And then, the CDC and HRSA cooperative agreements that are responsible for state planning. We needed to make sure that our guidelines were integrated in them. And what I would say is that HRSA guidelines have gotten a lot better about pediatrics. The CDC ones are still fairly far behind and the only pediatric mentioned in the CDC Cooperative Agreements for Preparedness are those that are combined or cross-cutting benchmarks with the HRSA one.

Now, I hope we have a new avenue in our current administration, that the new CDC director of that coordinated offices is a pediatrician. It remains to be seen whether that will be an opening or not for advocacy on this issue. But again, whatever we do in preparedness at a state level has to match what our public health departments are told are their benchmarks.

Some additional resources that have been part of this grant, which you may have seen and will be seeing, I just want to make you aware of, is many of you are aware of the consensus conference that was held probably in ’03, so that’s now three years ago, which developed the national guidelines for pediatric preparedness. One of the problems we had when we started down creating the state document for disaster plans is what goes into it. And so, we did an extensive search to see what were the benchmarks for pediatric preparedness. Does anyone know what you need to include? I’ll be glad to include it but does anyone know what you should include? And the answer was that there was no document out that provided guidance. So, an offshoot of this project, again with some funding from EMSC, and again, this is a lot of the vision of, I think, Dan and the other people in the office, I went back to them and said there are no benchmarks, can you help us do this. And he in combination with EAHRQ provided funding literally on the idea and really help make this happen. And I would have to say that this document, which many of you may have seen already. Okay. There you go. A little problem with the advancing slides, I guess.

Many of you have seen is probably been one of the most widely disseminated documents that I’ve ever had the privilege to work on. And this was national guidelines for pediatric preparedness. And what I will tell you right now, is I would say in our last survey, 47 of 50 states have used the tables in here for their bioterrorism chemical and other agent guidelines. And the reason is that it was developed through a consensus process based on evidence of all the stakeholders both on the implementation side and on the design side, content experts, many of you in this room and other organizations.

This document was the basis for the pediatric state disaster plan we created. And if you want to look, have a good guideline as to what were the pediatric elements that were added to the disaster plan; you can read this because these are the pediatric benchmarks for preparedness. And so, step one was created in this document, which is the pediatric benchmarks and then integrated them in the state disaster plans. For those of you who haven’t read it, the areas that were addressed are: preparedness and treatments for biologic, chemical, and radiologic, then the national pharmaceutical stock piled decontamination, natural disasters hospital preparedness, mental health, primary care displaces children, natural disaster medical service system training, drills and simulations. And as you can see, those are all the elements that you would want in a state disaster plan. The integrated process that had to occur is now taking all those datas and breaking them up so they fit into each of the emergency support function that exists within a state disaster or federal disaster plan.

But that was the first consensus conference. I’m also happy to say that through some funding from, again, the different support agencies, we were able to have a second one. And the second one is, again, was to update the pediatrics. Again, those were in 2003. The hope was that by 2005, 2006, we would have brand new data, lots of research, lots of information. So, the goal was to update previous guidelines and expand the focus unto those areas that we don’t have a lot of time to cover: schools, community healthcare assets, decontamination, for example. The conferences are originally supposed to occur in the fall of this year, but many of the people who would be at such a conference as one could imagine were otherwise deployed to the gulf coast. So, it occurred in the winter of this year and those guidelines are currently going through revision and updating. Examples are, within the chemical guidelines and the biologic, there are new drugs that are available and immunizations that were not available when the first conference was held. So, there’s a lot of question about what are the dosages, what should be included, should stock piles change. The concept of reunification of children, we didn’t get into the depth we would like to, school planning, search capacity and all those issues. And those will be held in these guidelines.

In addition, so this occurred during the winter, again, the timeline was a little bit shifted because of the fact that Katrina happened and Rita. The draft guidelines are currently under development. The final version will be available in summer 2006. And just so all of you know, the model of pediatric document that we’ve put out that is available now, you should start using it because I think it’s a very good advocacy point of view but we will be updating it this summer to include any changes that came out in the second consensus conference. We wanted to make sure that you had the first document out so you have something to work with, but we do know and we’ve already received some of these guidance back on the second, that there have been changes in dosages, approaches to search, approaches to healthcare, approaches to reunification, which will require an updating. So, we knew when we released this first document called Draft One that there’ll be need for Draft Two sooner after there will be.

But there’s also a new focus on the second conference, which many of few may have interest in and that our approach to one vulnerable population being children, can be applied to other vulnerable populations. And as such we actually took on the task of persons with disability. And so those were two tracks in this conference, one handling just pediatric national guidelines and update and expansion. And then the first pass because there are no national guidelines for persons with disabilities and we actually addressed that. That conference is both adult and pediatric, so the guidelines have both adult and pediatric in them. It was multi-disciplinary as was the first conference, and we took a look at it from two different perspectives and the guidelines would come out, and we said there are two ways to look at a person with disability in terms of emergency planning.

You can look at them from a disability perspective such as what is the need of a person who has a hearing impairment, what’s the need of a person with a visual impairment and what are the guidelines for them. You can also take a look at it from the emergency management perspective, what are the issues for evacuation of persons with disability, what are the issues for sheltering. And in order to make sure we didn’t miss anything, we took it from both perspectives. So, we did both and we spent the first day on the disability perspective and the second day on emergency management function and the guidelines will be a blend in both of them. That document will also be available at the end of the summer. Then many of you are aware of the other offshoot, which was the process we setup to continually update these pediatric guidelines in the space between consensus conferences.

Consensus conferences are a highly big effort, funding effort; major undertaking but there may be issues that come up in between. And so, the group of people who are involve with consensus conference through electronic means have the ability to provide on going rapid information. Some of that’s been published already, some is not. I’ll give you an example of one of the ones that’s been published and I’ll tell you some issues that have been addressed and are being published.

I don’t know how many of you saw this but this was the first one we issued on AtroPen. It was looking at AtroPen using children and what happened after the first guidelines were created is a new devise came on the market. A pediatric AtroPen and in the first set of guidelines we said everyone should use Mark One for children. It’s safe. It’s effective. And so people then asked, does that guideline still apply now that there’s a pediatric AtroPen out there? And the information, if you haven’t heard this already is the AtroPen is only half of the Mark One kit. It doesn’t include paraladoxim. Paraladoxim should be added for appropriate therapy and to be honest the Mark One probably isn’t enough because it doesn’t have an anti-convulsive, which is important for children. As a result the recommendation is the whole explanation of the science and discussion behind it, should remain, as the antidote of choice for children and the pediatric AtroPen really doesn’t have a role.

The other ones that are now going to be published, there’s one on search capacity, there is one on decontamination and the one that’s really getting a lot of back and forth debate now, and this actually happened after the London bombings was when we started the discussion, was post-exposure prophylaxis and immunization from a terrorist blast. And I know CDC is handling this but they’re focusing on adults. After a blast injury, for example, if people have body fragments and I know this is a little bit graphic blown into them, do you need to give hepatitis B vaccination? Do you need to give HIV exposure prophylaxis? Do you need to get antibiotics for wound infection? The data from London and Israel is actually fairly clear; wound infection is high and in Israel they’ve actually reported cases of -- from suicide bombers of a hepatitis B transmission.

I will say that CDC is addressing this but they’re focusing only on Hep B and HIV, not bacterial infection and they’re not focusing on pediatrics at all. So, we have a group looking at that and that would be one of those post-exposure prophylaxis from a blast event.

In addition, the other area we’re looking at is CDC is looking at blast injury and blast lung injury and clinical premerisphora blast injury, again adult only focused, and so we felt it was important to provide the pediatric equivalent focus because they’re getting into treatment therapies, different modes of care and not fully addressing pediatrics. And so those are the kind of info-briefs that you’ll see coming out. Again all those were based on those EMSC grant and really have been spurred and supported by that funding.

In addition, with the school’s focus, we wanted to do both; provide guidelines based on consensus and what evidence was out there, but also provide a case study. And we had a very good case study in the New York City school system, and for those who haven’t seen it, a document we put out was actually a review by operational function of how the schools in New York City responded to 9/11, what they did well, what didn’t go so well, and what they learned from it. And the chapters are divided by very functional areas: finance, student safety, food, curriculum, and it talks about what went on in those schools, and at the end of each chapter, it has the lessons learned, that any other school can pick up and learn how to do.

Additional school resources that are around is a handbook for schools on preparedness, including some preparedness checklists. Again, for those of you who know emergency management this would seem if you read it beyond simplistic. But I hate to say when we evaluate the schools they weren’t at that simplistic level of, do you have an incident command? Do you have student records in a portable file? Do you have plans for evacuation? And so it’s that level but it’s a nice -- it’s a book that says this is the issues we’re planning for schools and here’s the checklists, start with looking at this, have you done this? Have you done this? And takes them through emergency planning at barely a 101 level. But if we can get the majority of schools that at least take on that 101 level, I think we’ll have a huge improvement.

The next steps again, was some of these documents, are these info briefs are they continually come out, as issues come up, that need to be addressed from this multi-disciplinary expert and evidence based approach. In addition the just released model pediatric component, we’ll be updated in the summer and into early fall of 2006. I would say the current document is very good. I just want to make sure as we’ve always put things out as all of us do that it’s the latest, and it would have included the current pediatric guidelines from our second consensus conference. Unfortunately, the timelines, which were so perfectly aligned, got messed up in the recent fall events. The original consensus conference was supposed to occur in early fall, guidelines would be done by December, including the document we put out for you guys at this point. Unfortunately, because that conference was put off to December, the groups that are working on those guidelines, despite me threatening, bribing, pleading, begging with, did not complete those guidelines ahead of schedule and will be on schedule at the end of the summer, and thus we’ll have to update the pediatric component.

All these information will be available from the New York Medical College and through the website there, through the website that many of you are familiar that we put up pediatricpreparedness.org. And so again, the documents that we already out is the (inaudible) states, a school resource book and the info briefs you’ve seen, the two coming will be the second consensus conference with the updated guidelines for children, and the new ones on person’s with disability, and updated model pediatric components to include those new guidelines and the info briefs on those new topics I’ve talked about. In addition, if there’s an info brief topic that were not addressing that you feel from your involvement emergency management that needs to be addressed, please feel free to email it to me because the group is always open to ideas that we haven’t thought of. And this work is going to be continuing over the next couple of years. I’ll stop here and answer any question that anyone has. Okay.

Model Pediatric Component for State Disaster Plans:

A Completed Targeted Issue Grant Summary