During the 2009 influenza A (H1N1) pandemic, many pregnant women experienced severe illness and some gave birth while ill with suspected or confirmed pandemic (H1N1) 2009 influenza. Because of concerns about possible transmission of this novel virus to immunologically naïve newborns, and the absence of definitive studies regarding this risk, the Centers for Disease Control and Prevention (CDC) reviewed relevant literature to understand the potential burden of disease and routes of transmission affecting newborns. This report describes the issues considered during the 2009 H1N1 pandemic as CDC developed guidance to protect newborns in hospital settings. Also presented is a framework of protection efforts to prevent novel influenza infection in fetuses/newborns before birth and in hospital settings. Although developed specifically for the pandemic, the framework may be useful during future novel influenza outbreaks.

(Disaster Med Public Health Preparedness. 2012;6:97-103)

Objective: This report provides an overview and assessment of the School Dismissal Monitoring System (SDMS) that was developed by the Centers for Disease Control and Prevention (CDC) and the US Department of Education (ED) to monitor influenza-like illness (ILI)-related school dismissals during the 2009-2010 school year in the United States.

Methods: SDMS was developed with considerable consultation with CDC's and ED's partners. Further, each state appointed a single school dismissal monitoring contact, even if that state also had its own school-dismissal monitoring system in place. The SDMS received data from three sources: (1) direct reports submitted through CDC's Web site, (2) state monitoring systems, and (3) media scans and online searches. All cases identified through any of the three data sources were verified.

Results: Between August 3, 2009, and December 18, 2009, a total of 812 dismissal events (ie, a single school dismissal or dismissal of all schools in a district) were reported in the United States. These dismissal events had an impact on 1947 schools, approximately 623 616 students, and 40 521 teachers.

Conclusions: The SDMS yielded real-time, national summary data that were used widely throughout the US government for situational awareness to assess the impact of CDC guidance and community mitigation efforts and to inform the development of guidance, resources, and tools for schools.

(Disaster Med Public Health Preparedness. 2012;6:104-112)

Objective: To describe initiatives undertaken by a network of community pediatricians to increase a city's surge capacity for patients presenting with influenza-like illnesses during the 2009 H1N1 influenza A pandemic.

Methods: This was a descriptive quality improvement project detailing the measures employed by a network of private practice community pediatricians in Houston, Texas, caring for both insured and uninsured children.

Results: Four categories of interventions were used: enhanced communication, increasing community pediatrician presence, vaccine distribution, and targeted viral diagnosis and antiviral utilization. Promoting communication between clinicians, families, and an affiliated local tertiary care children's hospital allowed for the efficient coordination of resources as well as a unified and consistent message. Increasing access of families to their primary medical home by employing additional clinicians, extending office hours, and locating additional space served to decrease the number of children with low-acuity illness seen in the local emergency centers. Vaccine distribution was enhanced by effective communication between clinicians and families. Finally, targeted antiviral testing and adherence to national recommendations on antiviral utilization enabled judicious utilization of a limited supply of antiviral medications.

Conclusions: Effective communication and improved access to health care enabled children within the network with influenza-like illnesses to continue to be cared for in their medical home. The measures used in response to novel influenza virus outbreaks can be adapted for other situations requiring increased community surge capacity.

(Disaster Med Public Health Preparedness 2012;6:113-116)

Objective: The objective is to describe by geographic proximity the extent to which the US pediatric population (aged 0-17 years) has access to pediatric and other specialized critical care facilities, and to highlight regional differences in population and critical resource distribution for preparedness planning and utilization during a mass public health disaster.

Methods: The analysis focused on pediatric hospitals and pediatric and general medical/surgical hospitals with specialized pediatric critical care capabilities, including pediatric intensive care units (PICU), pediatric cardiac ICUs (PCICU), level I and II trauma and pediatric trauma centers, and general and pediatric burn centers. The proximity analysis uses a geographic information system overlay function: spatial buffers or zones of a defined radius are superimposed on a dasymetric map of the pediatric population. By comparing the population living within the zones to the total population, the proportion of children with access to each type of specialized unit can be estimated. The project was conducted in three steps: preparation of the geospatial layer of the pediatric population using dasymetric mapping methods; preparation of the geospatial layer for each resource zone including the identification, verification, and location of hospital facilities with the target resources; and proximity analysis of the pediatric population within these zones.

Results: Nationally, 63.7% of the pediatric population lives within 50 miles of a pediatric hospital; 81.5% lives within 50 miles of a hospital with a PICU; 76.1% lives within 50 miles of a hospital with a PCICU; 80.2% lives within 50 miles of a level I or II trauma center; and 70.8% lives within 50 miles of a burn center. However, state-specific proportions vary from less than 10% to virtually 100%. Restricting the burn and trauma centers to pediatric units only decreases the national proportion to 26.3% for pediatric burn centers and 53.1% for pediatric trauma centers.

Conclusions: This geospatial analysis describes the current state of pediatric critical care hospital resources and provides a visual and analytic overview of existing gaps in local pediatric hospital coverage. It also highlights the use of dasymetric mapping as a tool for public health preparedness planning.

(Disaster Med Public Health Preparedness. 2012;6:117–125)

Objective: A pediatric triage tool is needed during times of resource scarcity to optimize critical care utilization. This study compares the modified sequential organ failure assessment score (M-SOFA), the Pediatric Early Warning System (PEWS) score, the Pediatric Risk of Admission Score II (PRISA-II), and physician judgment to predict the need for pediatric intensive care unit (PICU) interventions.

Methods: This retrospective cohort study evaluates three illness severity scores for all non-neonatal pediatric patients transported and admitted to a single center in 2006. The outcome of interest was receipt of a PICU intervention (mechanical ventilation, acute dialysis, depressed consciousness, or persistent hypotension). Predictive ability was assessed using receiver operating curves (ROCs).

Results: Of 752 patients admitted to the hospital, 287 received a PICU intervention. Median scores for all tools were significantly higher for children receiving an intervention than for those who did not. ROCs showed PEWS had the least discriminatory ability, followed by PRISA-II and pediatric M-SOFA. No value of the pediatric M-SOFA produced both positive and negative predictive values better than clinician judgment.

Conclusions: No score had a clinically acceptable discriminate ability to predict patients who required a PICU intervention from those who did not. Physician judgment outperformed all three triage scores.

(Disaster Med Public Health Preparedness. 2012;6:126–130)

Objective: The novel H1N1 influenza pandemic renewed the concern that during a severe pandemic illness, critical care and mechanical ventilation resources will be inadequate to meet the needs of patients. Several published protocols address the need to triage patients for access to ventilator resources. However, to our knowledge, none of these has addressed the pediatric populations.

Methods: We used a systematic review of the pediatric critical care literature to evaluate pediatric critical care prognosis and multisystem organ failure scoring systems. We used multiple search engines, including MEDLINE and EMBASE, using a search for terms and key words including including multiple organ failure, multiple organ dysfunction, PELOD, PRISM III, pediatric risk of mortality score, pediatric logistic organ dysfunction, pediatric index of mortality pediatric multiple organ dysfunction score, “child+multiple organ failure + scoring system. ” Searches were conducted in the period January 2010-February 2010.

Results: Of the 69 papers reviewed, 22 were used. Five independently derived scoring systems were evaluated for use in a respiratory pandemic ventilator triage protocol. The Pediatric Logistic Organ Dysfunction (PELOD) scoring system was the most appropriate for use in such a triage protocol.

Conclusions: We present a pediatric-specific ventilator triage protocol using the PELOD scoring system to complement the NY State adult triage protocol. Further evaluation of pediatric scoring systems is imperative to ensure appropriate triage of pediatric patients.

(Disaster Med Public Health Preparedness. 2012;6:131–137)

Objective: This project evaluated New York (NY) hospitals outside of New York City (upstate) for their awareness and utilization of the NY State Department of Health Pediatric and Obstetric Emergency Preparedness Toolkit (toolkit) and presence of pediatric emergency preparedness planning elements.

Methods: A survey assessing toolkit awareness and utilization was distributed to all 145 upstate NY hospitals. Quantitative survey data were analyzed using summary statistics, χ2 analysis, and odds ratios (OR) in aggregate, by hospital size, and by presence of pediatric medicine/surgery, pediatric intensive care unit (PICU), and/or neonatal ICU (NICU) beds (pediatric beds).

Results: Of the 145 hospitals, 116 (80%) completed the survey; 86% of these had reviewed the toolkit. Most had staff clinicians with pediatric expertise, but fewer had appointed pediatric clinical (physician or nurse) coordinators. Hospitals with at least one pediatric bed were more than 2.5 times more likely to have an emergency management plan (EMP) for pediatric patients (P =. 0223) and nearly 8 times more likely to have appointed a pediatric physician coordinator (P <. 0001) than were hospitals without pediatric beds. Appointment of a pediatric clinical coordinator was significantly associated (P <. 001) with presence of various pediatric emergency plan elements (OR range: 3.06-15.13), while staff pediatric clinical expertise or toolkit review were not.

Conclusions: Appointment of at least one pediatric clinical coordinator and the presence of one or more pediatric beds were significantly associated with having developed key EMP pediatric elements. Further research should examine barriers to pediatric clinical coordinator appointment and explore the awareness that pediatric patients may arrive at nonpediatric hospitals during a disaster with no option for transfer.

(Disaster Med Public Health Preparedness. 2012;6:138–145)

Objectives: To determine the ability of five New York statewide regions to accommodate 30 children needing critical care after a hypothetical mass casualty incident (MCI) and the duration to complete an evacuation to facilities in other regions if the surge exceeded local capacity.

Methods: A quantitative model evaluated pediatric intensive care unit (PICU) vacancies for MCI patients, based on data on existing resources, historical average occupancy, and evidence on early discharges and transfers in a public health emergency. Evacuation of patients exceeding local capacity to the nearest PICU center with vacancies was modeled in discrete event chronological simulations for three scenarios in each region: pediatric critical care transport teams were considered to originate from other PICU hospitals statewide, using (1) ground ambulances or (2) helicopters, and (3) noncritical care teams were considered to originate from the local MCI region using ground ambulances. Chronology of key events was modeled.

Results: Across five regions, the number of children needing evacuation would vary from 0 to 23. The New York City (NYC) metropolitan area could accommodate all patients. The region closest to NYC could evacuate all excess patients to PICU hospitals in NYC within 12 hours using statewide critical care teams traveling by ground ambulance. Helicopters and local noncritical care teams would not shorten the evacuation. For other statewide regions, evacuation of excess patients by statewide critical care teams traveling by ground ambulance would require up to nearly 26 hours. Helicopter transport would reduce evacuation time by 40%-44%, while local noncritical care teams traveling by ground would reduce evacuation time by 16%-34%.

Conclusions: The present study provides a quantitative, evidence-based approach to estimate regional pediatric critical care evacuation needs after an MCI. Large metropolitan areas with many PICU beds would be better able to accommodate patients in a local MCI, and would serve as a crucial resource if an MCI occurred in a smaller community. Regions near a metropolitan area could be rapidly served by critical care transport teams traveling by ground ambulance. Regions distant from a metropolitan area might benefit from helicopter transport. Using local noncritical care transport teams would involve shorter delays and less expert care during evacuation.

(Disaster Med Public Health Preparedness. 2012;6:146–149)

Objective: To assess the adequacy of the pediatric triage system in an acute care general hospital.

Methods: All children younger than 14 years of age who presented with a primary medical condition to the accident and emergency department (ED) during January to March 2009 were recruited. Suitability of the triage system was assessed according to the vital parameters taken and the priority code assigned. Triage workload was assessed from the number of children presenting to ED and the timing of presentation.

Results: Of 2269 children presenting to ED, 1617 (71.3%) were younger than 5 years, and 883 (38.9%) were younger than 2 years. Only 0.26% (6/2269) had four vital parameters crucial for priority assignment measured, and 19.3% (437/2269) had at least one parameter measured. A priority code was assigned to 10% (225/2269).

Conclusions: Our study revealed inadequacies in the pediatric triage system. A simple and objective triage system that is based on the measurement of crucial vital parameters and on prompt recognition of warning signs and symptoms to correctly identify high-risk groups has been introduced to ensure appropriate and effective triage of sick children.

(Disaster Med Public Health Preparedness. 2012;6:151–154)

Objective: A reunification tool that captures images of children at the time of the disaster would enable parents to locate their missing children, particularly if the children are unable to communicate their identity. This study assessed the ideal features and parameters of a photographic-based reunification tool.

Methods: A convenience sample of federal, state, and hospital-based emergency management professionals were surveyed to elicit their preferences regarding an image-based reunification algorithm, to assess the parents' level of difficulty in viewing images with facial trauma, and to determine the minimum percentage of successful reunifications needed to justify adoption of a reunification tool.

Results: Of 322 emergency management professionals surveyed, 129 (40%) responded. Only 18% favored a photographic-based tool that would display images in which only the categories of age, gender, and facial features (eye, hair, and skin color) would exactly match the parent's description of the child. However, 72% preferred a broader, less-rigid system in which the images displayed would match all or most features in the parents’ description of the missing child, allowing parents to view more of the image database. Most (85%) preferred a tool showing unedited images of living children, allowing parents to view facial trauma. However, more respondents reported that parents would find viewing unedited images with facial trauma somewhat or very difficult emotionally compared with edited images for both living (77% vs 20%, P <. 001) and deceased children (91% vs 70%, P <. 001.) In a disaster involving 1000 children, a tool that reunites a minimum of 10% of families would be adopted by over 50% of the participants. Participants were willing to accept a lower percentage of reunifications in a disaster involving 1000 children compared with disasters involving 10 (P <. 001) or 100 children. (P <. 001).

Conclusions: Emergency management professionals identified desirable characteristics of a photographic-based reunification tool, including an algorithm displaying unedited photographs of missing children that loosely matches the parents' description, acknowledging the parents' emotional difficulty in viewing photographs with facial trauma. Participants were also willing to accept a lower percentage of successful reunifications as the scale of the disaster size increased.

(Disaster Med Public Health Preparedness. 2012;6:156–162)

Geographic information systems (GIS) and geospatial technology (GT) can help hospitals improve plans for postdisaster surge by assessing numbers of potential patients in a catchment area and providing estimates of special needs populations, such as pediatrics. In this study, census-derived variables are computed for blockgroups within a 3-mile radius from Children's Hospital Los Angeles (CHLA) and from Los Angeles County–University of Southern California (LAC–USC) Medical Center. Landslide and liquefaction zones are overlaid on US Census Bureau blockgroups. Units that intersect with the hazard zones are selected for computation of pediatric surge potential in case of an earthquake. In addition, cartographic visualization and cluster analysis are performed on the entire 3-mile study area to identify hot spots of socially vulnerable populations. The results suggest the need for locally specified vulnerability models for pediatric populations. GIS and GT have untapped potential to contribute local specificity to planning for surge potential after a disaster. Although this case focuses on an earthquake hazard, the methodology is appropriate for an all-hazards approach. With the advent of Google Earth, GIS output can now be easily shared with medical personnel for broader application and improvement in planning.

(Disaster Med Public Health Preparedness. 2012;6:163–169)

US government programs and communications regarding citizen preparedness for disasters rest on several untested, and therefore unverified, assumptions. We explore the assumptions related to citizen preparedness promotion and argue that in spite of extensive messaging about the importance of citizen preparedness and countless household surveys purporting to track the preparedness activities of individuals and households, the role individual Americans are being asked to play is largely based on conventional wisdom. Recommendations for conceptualizing and measuring citizen preparedness are discussed.

(Disaster Med Public Health Preparedness. 2012;6:170–173)

Although increasing evidence suggests that children are at particular risk from disasters and evidence-based practices have been developed to triage and treat them effectively, no strategy or concept of operations linking best practices for disaster response is currently in place. To our knowledge, this report describes the first effort to address this critical gap and outlines a triage-driven children's disaster mental health incident response strategy for seamless preparedness, response, and recovery elements that can be used now. The national children's disaster mental health concept of operations (NCDMH CONOPS) details the essential elements needed for an interoperable, coordinated response for the mental health needs of children by local communities, counties, regions, and states to better meet the needs of children affected by disasters and terrorism incidents. This CONOPS for children proposes the use of an evidence-based, rapid triage system to provide a common data metric to incident response and recovery action and to rationally align limited resources to those at greater need in a population-based approach.

(Disaster Med Public Health Preparedness. 2012;6:174–181)

We examined the response of 11 Los Angeles County (LAC) hospitals designated as Disaster Resource Centers (DRCs) to a statewide, earthquake preparedness drill, LAC's most comprehensive earthquake disaster drill to date. Semistructured interviews were conducted with the coordinators of 11 of the 14 LAC DRCs within 3 weeks of the drill. Interviews were transcribed and thematic analysis was supported by analytical software (Atlas.ti). Except for one pediatric specialty DRC, most DRCs did little to fully test their institutions' capacity to manage pediatric patients. Few DRCs included children as mock victims. Little or no attention was focused on pediatric triage and other pediatric clinical, psychosocial, and resource issues. Respondents maintained that community readiness is hampered by compartmentalizing the preparedness planning, training, and drilling. Without a mandate to coordinate with other agencies, few DRCs reported coordination with other community entities. Those that did were in smaller submunicipalities within LAC. Community coordination is critical to effective response to disasters, yet disaster preparedness planning and drills are most often uncoordinated and compartmentalized. Drills and training need to be transdisciplinary and coordinated with other community entities likely to play a role in pediatric disaster management.

(Disaster Med Public Health Preparedness. 2012;6:182–186)