Some infectious agents have the potential to be used in acts of bioterrorism. Because the threat of biological terrorism continues and children are likely to be affected disproportionately by such acts, pediatricians should be knowledgeable about agents of concern and the surveillance, management, and response systems needed to minimize physical and mental trauma to children. The Centers for Disease Control and Prevention (CDC) provides a complete list of biological agents and other bioterrorism resources. The CDC Hotline at 800/232-4636 offers assistance and advice. Additional details for health professionals can be found in the article Preparation for Terrorist Threats: Biologic and Chemical Agents.
Children and Bioterrorism
Children are particularly vulnerable to biological agents, because they have a more rapid respiratory rate, increased skin permeability, higher ratio of skin surface area to mass, and less fluid reserve compared with adults. Fever, malaise, headache, vomiting, and diarrhea are common early manifestations of illness caused by many bioterrorist agents and other infectious diseases. It can be challenging for clinicians to discriminate between an act of terrorism and a naturally occurring outbreak. Accurate and rapid diagnosis is more difficult in children because of their inability to describe symptoms. Symptoms may appear days after exposure or the adults on whom children depend for their health and safety may become ill or require quarantine during a bioterrorist event.
Agents of bioterrorism are generally not transmitted from person to person. The release of an agent is most likely from a point source. Smallpox, viral hemorrhagic fevers, and pneumonic plague may be highly transmissible from person to person via respiratory droplet and, in some cases, by aerosol spread. Rapidly detecting and isolating patients with an infectious illness related to a biological agent is essential to preventing transmission. However, optimal decontamination strategies for children have been the focus of considerable discussion, and recommendations continue to evolve (see Principles of Pediatric Decontamination). Consideration could be given to decontaminating family members together.
The CDC categorizes biological agents as Category A, Category B, or Category C.
- The highest-priority agents are designated as Category A because they have the potential for major public health effects, could cause panic or social disruption and require special action to promote preparedness. Category A agents are transmitted from person-to-person easily and cause high morbidity and mortality rates. Organisms in this category cause anthrax, botulism, plague, smallpox, tularemia, and viral hemorrhagic fevers (including Arenaviruses, Ebola, Marburg, Lassa, and other related viruses).
- Category B agents are moderately easy to disseminate, cause moderate morbidity and low mortality rates, and require enhanced diagnostic capacity and disease surveillance. Examples include: Alphaviruses or Arboviral Encephalitides; Brucella species (brucellosis); Chlamydophila psittaci (psittacosis); Coxiella burnetii (Q fever); Burkholderia mallei (glanders); Burkholderia pseudomallei (melioidosis); Rickettsia prowazekii (typhus); and toxins/toxic syndrome such as ricin toxin from Ricinus communis [castor beans], epsilon toxin of Clostridium perfringens, and Staphylococcus enterotoxin B. Other category B agents that are foodborne or waterborne safety threats, such as botulism, Escherichia coli O157:H7, salmonellosis, Shigella dysenteriae type 1, typhi (typhoid fever), Vibrio parahaemolyticus, and Vibrio vulnificus.
- Category C agents include emerging pathogens that could be engineered for mass dissemination because of availability, ease of production and dissemination, and potential for high morbidity and mortality rates and major health effects. Examples include Nipah virus, hantavirus, tickborne hemorrhagic fever viruses, tickborne encephalitis viruses, yellow fever virus, and multidrug-resistant Mycobacterium tuberculosis.
The Role of the Pediatrician
As part of the network of health responders, pediatricians need to be able to answer questions, recognize signs of possible exposure to a biological agent, understand first-line response to such attacks, and participate in disaster planning to ensure that the needs of children are addressed. Involvement of pediatricians in these activities increases the likelihood that the needs and vulnerabilities of children will be considered. Pediatricians who wish to increase their involvement should consider the following:
- Participate in local activities related to biological terrorism preparedness. The pediatrician can be a valuable resource to public health authorities in issues such as first-responder training and hospital preparedness.
- Work with local child care programs, school systems, and camps to develop plans for rapid evacuation, relocation, triage, and initial care of children who are in these facilities when an act of biological terrorism occurs.
- Assist families in developing disaster plans and deciding how to talk to children about terrorism and related topics.
- Ensure proper treatment for children exposed to circumstances beyond the scope of normal human experience to mitigate mental health consequences. Promoting adjustment and helping children cope is especially important after biological terrorism, as symptoms can develop days to months after the event.
Strategies for the Office Practice
Because victims of biological terrorism may present to a pediatrician's office, there should be consideration of plans and protocols for management of such children on site. Preparation may include the establishment of out-of-building decontamination protocols and isolation of potentially infectious patients from others. During a bioterrorist event, local pediatricians and their staff should maximize their ability to keep the office running smoothly and to provide care.
Every office needs an written emergency or disaster preparedness plan. When a biological or other type of terrorism event is suspected, the office staff should have a plan for how they will handle the potentially large number of clients who may call or arrive at the office without an appointment. The plan needs to address how to triage and sort those who are worried/anxious from those who need care. The plan should also address how office staff will isolate and evaluate children suspected of having an illness related to bioterrorism. For more information and a template office document, refer to the Pediatric Practice page.
Staff should also be educated about Infection Prevention and Control in Pediatric Ambulatory Settings and pediatricians should contact the appropriate state and local health department officials in advance of an event to ensure they understand what might be required in the early evaluation or transportation of a patient.
Collaborative Efforts for the Future
Many preventive and therapeutic agents recommended for adults exposed or potentially exposed to agents of bioterrorism have not been studied in infants and children, and pediatric doses have not been established or approved by the US Food and Drug Administration for use in children. Children also may be at risk of unique adverse effects from preventive and therapeutic agents that are recommended for treating exposure to agents of bioterrorism. Further, availability of appropriate pediatric formulations of medical countermeasures may be limited. The AAP Disaster Preparedness Advisory Council is working with federal agencies to develop a list of pediatric countermeasures where further action is needed.