At-Risk / Special Needs Populations
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Managing At-Risk / Special Needs Populations - General
- At-risk / special needs populations require special attention during a radiation incident.
- Health care providers must identify and respect their needs and respond appropriately to them, considering the resources available.
- Selected issues particularly relevant to radiation incidents are discussed below
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- Bone marrow reserve diminishes with age
- Predisposition to anemia
- Predisposition to infection
- Predisposition to bleeding
- May have increased risk of bleeding due to medications, poor diet, or other factors
- Increasing number of co-existing diseases and conditions may be associated with
- Inability to tolerate certain drugs
- Lesser ability to tolerate aggressive salvage treatments, such as stem cell transplant for treatment of Acute Radiation Syndrome
- Cognitive issues may need to be addressed
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- Whole body radiation exposure will exacerbate pre-existing diminished immune functions.
- Countermeasures (e.g., myeloid cytokines) used to enhance blood cell production may be less effective.
- Affected individuals are more susceptible to infection.
- These individuals usually require leuko-reduced, irradiated blood.
- May not be able to tolerate radiation-induced prolonged pancytopenia or stem cell transplant due to underlying condition (e.g., cancer, congenital or acquired immune deficiency).
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Infants and Young Children
- Statement on Tissue Reactions / Early and Late Effects of Radiation in Normal Tissues and Organs - Threshold Doses for Tissue Reactions in a Radiation Protection Context, ICRP Publication 118, Ann. ICRP 41(1/2), 2012
- Pediatric Preparedness Resource Kit (PDF - 8.3 MB) (American Academy of Pediatrics, 2013)
- This excellent document provides organizational, policy, and practical recommendations for a variety of issues related to childhood and maternal health during disasters.
- Preparedness, Response, and Recovery Considerations for Children and Families - Workshop Summary (Institute of Medicine of the National Academies, December 17, 2013)
- IOM Forum on Medical and Public Health Preparedness for Catastrophic Events: Medical and Public Health Preparedness, Response and Recovery Considerations for Chiildren and Familiies. (Institute of Medicine of the National Academies, June 10, 2013)
- 2011 Update on Children and Disasters: Summary of Recommendations and Implementation Efforts (PDF - 98 KB) (HHS, April, 2012)
- National Commission on Children and Disasters: 2010 Report to the President and Congress, (October 2010)
- National Advisory Committee on Children and Terrorism (NACCT) (HHS/CDC, April 2003)
- Pediatric Disaster and Terrorism Preparedness: A National Consensus Conference and The Pediatric Expert Advisory Panel (PDF - 1.19 MB) (David Markenson, MD, Columbia University)
- Pediatric Counter-Terrorism Measures (FDA, February 2010). See information on KI.
Radiation Incidents and Children
- Scientific finding on effects of radiation exposure of children UNSCEAR 2013 Report to the General Assembly, Volume II, Scientific Annex B.
- Preconception and Prenatal Radiation Exposure: Health Effects and Protective Guidance, (NCRP Report No. 174), Bethesda, MD, 2013.
- Guidance on the application of dose coefficients for the embryo, fetus and breastfed infant in dose assessments for members of the public (RCE-5) (Public Health England [PHE], formerly Health Protection Agency [HPA], 2008)
- ICRP Publication 95: Doses to Infants from Ingestion of Radionuclides in Mother's Milk, 95 (International Commission of Radiological Protection, ICRP Publication 95, 2004)
- American Academy of Pediatrics Committee on Environmental Health. Radiation disasters and children. Pediatrics. 2003 Jun;111(6 Pt 1):1455-66. [PubMed Citation]
- Meeting Proceedings
- AHRQ Resources:
- Planning and Preparedness for Children's Needs in Public Health Emergencies (HHS/AHRQ, May 2009)
- Pediatric Hospital Surge Capacity in Public Health Emergencies (HHS/AHRQ, January 2009)
- School-based Emergency Preparedness: A National Analysis and Recommended Protocol (HHS/AHRQ, January 2009)
- Decontamination of Children - Preparedness and Response for Hospital Emergency Departments (HHS/AHRQ, October 2008)
- Terrorism and Disaster Preparedness Resource for Pediatricians
(AHRQ Publication No. 06-0048, October 28, 2006)
- Strategies and Tools for Meeting the Needs of Children: Public Health Emergencies
(HHS/AHRQ, a free Web conference, 4 Web lectures, broadcast January 11, 2006)
- Public Health Emergency Preparedness — Surge Capacity (HHS/AHRQ)
- Other HHS agencies
- Other government agencies
- American Academy of Pediatrics
- Useful Guidance
- Schreiber, M. (2011). National Children's Disaster Mental Health Concept of Operations. (PDF - 1.21 MB) (Terrorism and Disaster Center at the University of Oklahoma Health Sciences Center)
- Listen, Protect, Connect Program
- Research results
- Ramirez M, Harland K, Frederick M, Shepherd R, Wong M, Cavanaugh JE. Listen protect connect for traumatized schoolchildren: a pilot study of psychological first aid. BMC Psychology 2013;1:26.
- Chandra A, Kim J, Pieters HC, Tang J, McCreary M, Schreiber M, Wells K. Implementing psychological first-aid training for medical reserve corps volunteers. Disaster Med Public Health Prep. 2014 Feb;8(1):95-100. [PubMed Citation]
- Program descriptions
- Psychological First Aid (PDF - 2.9 MB) (National Child Traumatic Stress Network, National Center for PTSD, 2006)
- Mace SE, Sharieff G, Bern A, Benjamin L, Burbulys D, Johnson R, Schreiber M. Pediatric issues in disaster management, Part 1: the emergency medical system and surge capacity. Am J Disaster Med. 2010 Mar-Apr;5(2):83-93. [PubMed Citation]
- Mace SE, Sharieff G, Bern A, Benjamin L, Burbulys D, Johnson R, Schreiber M. Pediatric issues in disaster management, Part 2: evacuation centers and family separation/reunification. Am J Disaster Med. 2010 May-Jun;5(3):149-61. [PubMed Citation]
- Mace SE, Sharieff G, Bern A, Benjamin L, Burbulys D, Johnson R, Schreiber M. Pediatric issues in disaster management, Part 3: special healthcare needs patients and mental health issues. Am J Disaster Med. 2010 Sep-Oct;5(5):261-74. [PubMed Citation]
- Responding to Terrorism and War: Information for Parents (PDF - 93.6 KB) (National Youth Violence Prevention Resource Center)
- Disaster Preparedness Resource Guide for Child Welfare Agencies (Annie E. Casey Foundation)
- Pediatric Disaster and Terrorism Preparedness, by David Markenson, M.D., Columbia University, July 13, 2004 (PowerPoint® - 1135 KB) (Text version))
- Gurwitch RH, Kees M, Becker SM, Schreiber M, Pfefferbaum B, Diamond D. When disaster strikes: responding to the needs of children. Prehospital Disaster Med. 2004 Jan-Mar;19(1):21-8. [PubMed Citation]
- What You Should Know about the Emotional Impact of Radiological Terrorism with an RDD ("Dirty Bomb") (National Child Traumatic Stress Network)
- Pediatric Disaster Preparedness Guidelines (PDF - 249 KB) (Illinois Department of Public Health, Loyola University Medical Center)
- Psychological First Aid: Field Operations Guide (PDF - 3.37 MB) (National Child Traumatic Stress Network, National Center for PTSD, 2nd edition, July 2006)
- Children in Disasters: Hospital Guidelines for Pediatric Preparedness (PDF - 1.81 MB) (New York City Department of Health and Mental Hygiene, August 2008)
Video: Decontamination of Infants and Children (HHS/AHRQ, Children's Hospital Boston)
(Watch video )
- Decontamination of Children (HHS/AHRQ) provides a step-by-step decontamination demonstration in real time, and trains clinicians about the nuances of treating infants and children, who require special attention during decontamination.
- For example, children may be frightened not only by the emergency situation itself, but also by the decontamination process as well.
- Decontamination of children also takes longer than decontamination of adults.
- Video focuses on chemical decontamination, but radiation decontamination is similar.
- Some of the differences between chemical and radiation decontamination include:
- Video, available for free, is produced by Children's Hospital of Boston with funding from HHS/AHRQ.
Mass Casualty Triage in Children
General Principles of Radiation Safety Are the Same as in Adults
- Minimize time child is exposed to radiation source
- Maximize child's distance from the radiation source
- Maximize the shielding between the source and the child
Special Vulnerabilities of Children
PowerPoint® files can be viewed with Microsoft® PowerPoint® or with a free PowerPoint® Viewer.
- Unique anatomy and physiology of children (adapted from Pediatric Disaster and Terrorism Preparedness, by David Markenson, M.D. (PowerPoint® - 1135 KB) (Text version))
- Increased surface area/volume ratio
- More absorptive surface
- More susceptible to volume loss
- Increased breathing rate
- Shorter stature: lower breathing zone, closer to ground contamination
- Enhanced transdermal absorption: thinner, underkeritinized epidermis
- Immature blood brain barrier
- Greater propensity to dehydration and shock
- Psychological immaturity, dependent, more difficulty following complex directions
- May have pre-existing conditions that confer extra vulnerability
- Special vulnerability to late carcinogenic effects, especially thyroid
- Special needs of children during decontamination procedures (Adapted from Considerations in Emergency Preparedness: A Two-track Conference, by David Markenson, M.D. (PowerPoint® - 95 KB) (Text Version))
- Decontamination must be done with high-volume, low-pressure, heated water systems
- Infants and young children may need to be held by adult during decontamination, but all surfaces must be reached
- Hypothermia issues must be addressed; replacement clothing or covering must be available immediately in cold environments
- Obtain Decontamination of Children video (AHRQ, October 2005)
- Drug doses appropriate for children must be available (e.g., agents for decorporation and treatment of Acute Radiation Syndrome)
- Treatment protocols for children are different from those for adults
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Management of Febrile Neutropenia in Children
- Lehrnbecher T, Phillips R, Alexander S, Alvaro F, Carlesse F, Fisher B, Hakim H, Santolaya M, Castagnola E, Davis BL, Dupuis LL, Gibson F, Groll AH, Gaur A, Gupta A, Kebudi R, Petrilli S, Steinbach WJ, Villarroel M, Zaoutis T, Sung L. Guideline for the management of fever and neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplantation. J Clin Oncol. 2012 Dec 10;30(35):4427-38. [PubMed Citation]
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Pregnant Woman and Fetus
- National Council on Radiation Protection and Measurement (NCRP)
- International Committee on Radiation Protection (ICRP)
- Biological effects after prenatal irradiation (embryo and fetus), ICRP Publication 90, Ann. ICRP 33(1-2), 2003.
- Doses to infants from radionuclides ingested in mothers' milk, ICRP Publication 95, Ann. ICRP 34(3-4), 2004. Errata published (PDF - 62 KB)
- Doses to the embryo and fetus from intakes of radionuclides by the mother, ICRP Publication 88, Ann. ICRP 31(1-3), 2001.
- Pregnancy and medical radiation, ICRP Publication 84, Ann. ICRP 30(1), 2000.
- ICRP 84, Pregnancy and medical radiation; Free, downloadable, educational material for teachers, doctors, those in radiological protection. (English and Spanish versions)
- Health Physcis Society (HPS)
- Government publications
- Public Health England (PHE) (formerly Health Protection Agency [HPA], United Kingdom)
- Other publications
- Mabuchi K, Fukiwara S, Preston DL, Shimizu Y, Nakamura N, Shore RE. Atomic-bomb survivors: Long-term health effects of radiation, Chapter 8, pp 89-113 in Human Radiation Injury, Shrieve DC, Loeffler JS, eds.: Wolters Kluwer | Lippincott Williams & Wilkins, Philadelphia, PA, 2011.
- Brent RL. The effects of embryonic and fetal exposure to x-rays and isotopes. in: Barron WM, Lindheimer MD, eds. Medical disorders during pregnancy. 3rd ed. St. Louis: Mosby Yearbook; 2000, pp. 586-610.
- Brent RL. Utilization of developmental basic science principles in the evaluation of reproductive risks from pre- and postconception environmental radiation exposures. Teratology. 1999 Apr;59(4):182-204. Review. [PubMed Citation]
- Brent RL. Counseling patients exposed to ionizing radiation during pregnancy. Rev Panam Salud Publica. 2006; 20(2/3): 198-204. [PubMed Citation]
- Boice JD, Miller RW. Childhood and adult cancer after intrauterine exposure to ionizing radiation. Teratology 1999;59:227-233. [PubMed Citation]
- Donnelly EH, Smith JM, Farfan EB, Ozcan I. Prenatal Radiation Exposure: Background Material for Counseling Pregnant Patients Following Exposure to Radiation. Disaster Med Public Health Prep. 2011 Mar;5(1):62-8. [PubMed Citation]
- Izumi S, Suyama, A, Koyama K. Radiation-related mortality among offspring of atomic bomb survivors: a half-century of follow-up. Int J Cancer. 2003 Nov 1;107(2):292-7. [PubMed Citation]
- Schull WJ, The children of atomic bomb survivors: a synopsis. J Radiol Prot. 2003 Dec;23(4):369-84. [PubMed Citation]
- Brent RL and Mettler FA, Pregnancy Policy. AJR Am J Roentgenol. 2004 Mar;182(3):819-22. [PubMed Citation]
- Prasad KN, Cole WC, Haase GM. Health risks of low dose ionizing radiation in humans: a review. Exp Biol Med (Maywood). 2004 May;229(5):378-82. Review. [PubMed Citation]
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Persons with Disabilities and Other Special Needs
- Patients with diminished mobility may not be able to
- Evacuate the radiation scene as directed
- Tolerate the austere environments required during the emergency
- Mobilize without assistance for transportation or decontamination
- Transportation issues may need to be arranged to accommodate special needs.
- Patients with diminished mental capacity may not be able to follow directions.
- Patients with limited language proficiency or non-English speakers may not be able to follow directions.
- Patients with medical disabilities may not be able to tolerate standard radiation rescue treatments and may be disconnected from chronic treatments such as dialysis, oxygen, insulin, and other chronic medications.
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