Nicole Lurie, M.D., M.S.P.H.
Assistant Secretary for Preparedness and Response
RADM, U.S. Public Health Service
U.S. Department of Health and Human Services (HHS)
Children and Disasters: The Role of HHS in Evacuation Planning and Mental Health Recovery
The Committee on Homeland Security and Governmental Affairs
Ad Hoc Subcommittee on Disaster Recovery
United States Senate
Tuesday August 4, 2009
Good morning Madam Chairwoman Landrieu, Ranking Member Graham, and other distinguished Members of the Ad Hoc Subcommittee on Disaster Recovery. It is a privilege to appear before you today on behalf of the Department of Health and Human Services (HHS). I am Dr. Nicole Lurie, the HHS Assistant Secretary for Preparedness and Response. My office is also known as ASPR.
I want to begin by expressing my appreciation for your interest in, and continued support of, emergency preparedness, response, and recovery efforts at HHS, specifically as they relate to children, and the efforts of the men and women who support that undertaking at every level of government, and within the private and volunteer sectors.
You are no doubt aware that emergency preparedness and response is a challenging and highly complex arena, encompassing Federal, State, tribal and local governments along with voluntary agencies and private sector partners. Although I will focus my remarks on HHS activities, I readily acknowledge that each of these partners plays a critical role in meeting the unique needs of children in disasters.
The Department of Health and Human Services is committed to the highest level of response for children before, during, and after emergency events, and continues to focus on integrating pediatric issues into the public health and medical response to natural and human-caused emergencies and disasters, including pandemic influenza.
As part of this commitment, HHS has initiated programs and policies on a number of fronts to ensure that children receive the highest level of response before, during and after an incident. HHS recognizes that the needs of children are different when planning for disasters. Children require different skills and resources to treat their injuries and illnesses because they are far more than just “small adults.” They can get sicker faster, but they can also heal quicker. Determining the most beneficial treatment for children during an emergency situation requires a different set of criteria than those used for adults.
The Department of Health and Human Services serves as the lead for Emergency Support Function 8, Public Health and Medical Services, under the National Response Framework. This provides the mechanism for coordinated Federal assistance to supplement State, tribal, and local resources in response to a public health and medical disaster, incidents requiring a coordinated Federal response, or during a developing health and medical emergency.
Under ESF 8, HHS serves as the lead Federal partner in ensuring that the nation is maintaining appropriate levels of medical surge capacity, which is a critical element of our national, State, and local resiliency. HHS manages the Strategic National Stockpile, the Medical Reserve Corps, the National Disaster Medical System, the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) program, and other critical medical and public health resources that can be activated during catastrophic events. I’d like to take a few moments to let you know about some of the initiatives addressing the needs of children that are happening at the Department.
The National Disaster Medical System, otherwise known as NDMS, is the primary Federal program that supports care and transfer during evacuation of patients. NDMS is a component of ASPR comprised of over 1500 volunteer hospitals and over 6,000 intermittent Federal employees assigned to approximately 90 general disaster and specialty teams geographically dispersed across the United States. The overall purpose of NDMS is to establish a single integrated national medical response capability for assisting State and local authorities with the medical impacts of major peacetime disasters and to provide support to the military. NDMS is working to enhance its pediatric capability in several ways.
Data on current NDMS clinical practitioners show that 68% have pediatric-specific training, 5.6% have specific subspecialty training in pediatrics, and 47% have formalized training specific to pregnant women. Although the approach of NDMS in fielding targeted personnel capabilities is to deploy activated NDMS clinicians who have broad-based training related to all age and at-risk groups, we still recognize that more specialized skill sets can be quite valuable. Since children and pregnant women can be a particularly vulnerable population, NDMS is developing pediatric modules within the Disaster Medical Assistance Team (DMAT) structure. Not only will these professionals be able to support Federal missions, but the intent is for them to enhance State and local support networks. To achieve this goal, we will be holding a call this week with pediatric physicians and obstetricians to seek input on what NDMS can develop within the DMAT structure. To complement this effort, NDMS has recently conducted a review and upgrade of medical material in the NDMS response supplies to ensure that appropriate pediatric equipment and supplies are available to our response teams when they deploy.
In addition to clinical care, patient transportation is a key NDMS activity. NDMS has completed Phase 1 of the development of critical care transport team capability. Phase 1 has provided on-the-ground critical care support capability for mass patient evacuation and is capable of deploying to support the Department of Defense, including its National Guard Bureau, efforts to evacuate critical care patients. Each of these teams has clinical expertise and formal training in pediatric and obstetrical emergency care. Phase 2 of this program, tentatively scheduled for completion in the Spring of 2010, includes the further development and fielding of existing air-evacuation qualified critical care transport teams that will provide direct patient care during transport of critical care patients on multiple platforms, including fixed-wing and rotary-wing air, rail, and ground transport. Pediatric-specific critical care transport teams are planned as well as fielding air-evacuation qualified teams that have formal pediatric-specific training.
In response to the challenges faced by pediatric specialty facilities and their transport services, the Pediatric Disaster Coalition was formed by advocates in HHS Federal Planning Region VI. This region includes the States of Texas, Arkansas, Louisiana, Oklahoma and New Mexico. This planning group consists of subject matter experts from free-standing children’s hospitals, facilities with dedicated pediatric/neonatal units, pediatric specialty transport organizations, local and State public health, and Federal partners. The Coalition’s goals include incorporating the use of civilian air and ground medical resources in State contracts and Mutual Aid Agreement to ensure prompt and coordinated evacuation of specialty patients. Other goals include identifying appropriate receiving facilities to assume care of the evacuated patients, disseminating information to stakeholders responsible for pediatric and neonatal evacuation planning, and integrating recommendations into hospital, local, and State emergency operations plans.
The Coalition has met to address lessons learned from hurricanes Katrina and Rita, where several pediatric transport teams participated. Based on its research, actual incidents, and exercises, they concluded that the requirements for transportation resources exceed the local availability to evacuate pediatric facilities to similar facilities. Because of the small percentage of usage of hospital facilities by children versus adults, a more regionalized approach must be considered for children to significantly increase pediatric capacity during a disaster.
Transportation of pediatric and neonatal patients is a labor, training, and equipment intensive process and many challenges remain. The Department recognizes that there is a need for development of planning guidance for healthcare facilities as well as for local, State, regional, and Federal jurisdictions. While the National Response Framework mandates that States are responsible for determining patient evacuation requirements, Federal support can be requested when State capacity cannot support the evacuation requirements. Federal assets include ambulances from the DHS-funded FEMA National Ambulance Contract, administered by HHS. This contract provides for a neonatal specific typed rotary wing helicopter, and a neonatal specific typed fixed wing aircraft, both of these aircraft for neonatal transport were deployed during the 2008 hurricane season.
The Department continues to press forward on issues related to children on a number of other fronts. We are working hard to ensure that there are no gaps as we enter a season of hurricanes and H1N1. Let me highlight a few of these activities:
On June 17, ASPR and the National Biodefense Science Board hosted an all-day meeting of national experts and stakeholders to discuss pediatric issues in emergency response to inform planning for an ASPR sponsored Conference on Pediatric Preparedness and Response in Public Health Emergencies and Disasters to be held later this month. Participants provided information regarding concerns and approaches for medical response and medical countermeasures and other products for use in pediatric populations related to public health threats such as H1N1 influenza.
Also, this month the CDC is hosting a stakeholder meeting for Primary Care Providers, including obstetricians, to identify ways to reduce surge on hospitals and integrate providers into community planning.
In September, the CDC is leading a stakeholder meeting to address pediatric surge capabilities during disaster responses, such as H1N1 influenza. Expected outcomes are to reduce surge on hospitals through H1N1 Pandemic Influenza planning templates for various sizes of Pediatric Primary Care Offices and to identify operational best practices for concerns such as infection control, and optimizing resources. Other expected outcomes are integrating non pediatricians into pediatric care and identifying and developing education materials aimed at increasing coordination and communication between pediatric healthcare providers and public health.
In addition, CDC collaborated with HRSA to develop a National Newborn Screening Contingency Plan. As a result of the Newborn Screening Saves Lives Act of 2008, CDC, HRSA, and State departments of health (DOH) developed a national newborn screening contingency plan for use by a State, region, or consortia of States in the event of a public health emergency. The plan specifically addresses contingency planning, preparedness, and response activities around specimen collection, shipment, and processing, results reporting, confirmation, treatment and management resources, and education.
The Department’s Hospital Preparedness Program has funded three partnership projects focused primarily on ensuring medical surge and appropriate care for pediatric populations, including surge emphasis on neonates and pregnant women. A project at Children's Hospital Los Angeles organized an issue identification and consensus conference on pediatric evacuation and reunification. The conferences covered topics including transportation, Pediatric Psychosocial Support, Clinical Issues, Non-Medical Issues, Technology and Tracking, and Communications/Information and Regulatory Issues. A report will be published in the August Journal of Trauma (Supplement).
Today’s hearing is focused primarily on public health and medical services, including mental health. However, I would be remiss not to mention that HHS is also a support agency of Emergency Support Function 6, which encompasses mass care, emergency assistance, housing, and human services. During disasters, the Administration for Children and Families (ACF) gathers information about child care centers and Head Start centers which serve infant and toddler aged children. ACF maintains contact with state human services and emergency management agencies to determine if there are any other issues that affect children. ACF has conducted shelter assessments revealing unmet human services needs for children, particularly a lack of and/or inappropriate child care in some shelters. ACF also has developed a disaster case management model with FEMA. Finally, ACF provides operational support to the National Commission on Children and Disasters. I believe you will be hearing more about the important work of the Commission on the second panel.
Although there are many other examples of Departmental activities focused on children, let me spend my remaining time on the issue of children’s mental health and disaster recovery. The Department is focused on promoting the emotional recovery of children and their families affected by disasters and emergency events. Federal response entities such as the National Disaster Medical System and the Public Health Service have mental health professionals on their response teams, including professionals with expertise in working with children. Supplemental grant programs and on-going HHS disaster response and recovery efforts place an emphasis on meeting the needs of children, one of our most vulnerable populations in times of crisis and emergency.
An example of such efforts is the Crisis Counseling Assistance and Training Program, or CCP. This program is funded by the Federal Emergency Management Agency and is administered through an interagency agreement by HHS’s Substance Abuse and Mental Health Services Administration (otherwise known as SAMHSA). Crisis counseling programs employ an outreach model and a strengths-based approach to help disaster survivors access personal coping mechanisms and identify community resources. The CCP targets at-risk groups, including children and their caregivers, for services. Crisis counselors routinely work in schools, libraries, community centers, health fair events, and other places children congregate, such as boys' and girls' clubs, to facilitate the psychological resilience of children following an emergency event and encourage the recovery process.
Other HHS programs focus on the mental health needs of children who have experienced a traumatic event such as a disaster. The most direct example is The National Child Traumatic Stress Initiative, funded by a Congressional appropriation through SAMHSA. This initiative funds a network of grantees called the National Child Traumatic Stress Network. This Network develops mental health resources and interventions for traumatized children, their families, and their communities in the wake of natural and man-made disasters. Network members across the country collaborate to develop best-practice approaches supported by empirical evidence, so that clinicians and emergency responders can be confident in the efficacy of methods employed to assist children. Members also work directly with caregivers, teachers and professionals involved with children. In this way they enhance the ability of caregivers and community members to anticipate and address concerns of young people in their own communities who have experienced an emergency event.
To enhance acute disaster response, the Network maintains a Rapid Response Program that provides two trained Disaster Liaisons at each of the 51 funded Network Centers across the country. The Rapid Response Program can be mobilized nationally, regionally, and locally after a Presidential disaster declaration or catastrophic event. Rapid responders work closely with the Crisis Counseling Program, Federal partners, State disaster coordinators, and voluntary disaster response organizations.
Through Network funded grantees, and in partnership with the Veteran Administration’s National Center for Post Traumatic Stress Disorder and the National Center for Child Traumatic Stress, the Department launched the Psychological First Aid Field Operations Guide immediately after Hurricane Katrina in 2005. This manual serves as a training guide for professionals and paraprofessionals to provide emotional support to those impacted by disasters. Psychological First Aid adaptations have been developed for schools, volunteers, and faith-based disaster responders. As of 2009, there have been over 50,000 downloads of the guide, and an additional 10,000 hard copies have been distributed. Network staff have provided over 200 Psychological First Aid trainings around the country, training well over 5,000 disaster responders.
A number of current Network centers serve children in hurricane affected areas of the Gulf Coast. Grantees include Louisiana State University and Mercy Family Center, both in New Orleans. The Network’s Houston grantee, DePelchin Children's Center, has also been actively involved since Hurricane Katrina in providing direct services and disaster-related training. Over 20 Network grantees from across the country have deployed clinical staff to the Gulf Coast, provided operational support to centers that were impacted by the hurricanes, and supported children evacuated to receiving centers in their States since Hurricane Katrina and subsequent storms impacted the region. We know we have a great deal to learn from the Gulf Coast States. In order to further examine and improve our response and recovery efforts, the Network’s Terrorism and Disaster Center has developed and is now pilot testing a new approach for assessing and strengthening community resilience in the Gulf region.
Other Network resources related to children’s mental health include training for school-based cognitive behavioral interventions and an on-line speaker series focusing on the impact of terrorism and disasters on children. Speaker presentations are archived and may be accessed for free through the Network’s online learning center.
The CDC Public Health Emergency Preparedness (PHEP) cooperative agreement is another HHS program that has sponsored a number of preparedness and mental health activities for children. This program has funded projects such as: a six-hour training curriculum for school crisis teams, an Education/Mental Health Disaster Readiness Committee that addresses issues of mental health preparedness and response in schools, and a disaster communications guidebook for community use that addresses mental health messaging. Another example of efforts supported by the PHEP program is the development of innovative brochures on “emotional first aid” for children. These pocket-size pamphlets addressed mental health needs of children by developmental level and provided quick tips for assisting them after a disaster.
In addition to these activities, the Department’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) has funded several research grants, largely at Tulane University, to look at the effects of a massive natural disaster, such as Hurricane Katrina, on displaced New Orleans residents. Pilot work has been done that would allow a longer-term study to be conducted on the continuing social and economic effects of this population over the coming years. Questions address concerns about disaster experiences where complete recovery may not happen, as well as identifying individuals for whom the disaster may have been a life-altering experience for the better.
The Department is working in an ongoing manner to analyze and improve disaster behavioral health preparedness and response for children. To support these efforts the National Biodefense Science Board, based on input from its Disaster Mental Health Subcommittee, completed a set of recommendations pertaining to disaster behavioral health. These recommendations include a focus on ensuring that children’s needs are appropriately addressed following a disaster through developmentally and culturally-informed intervention, research, education, and training. Every relevant Federal department has provided an analysis of how the recommendations are currently being addressed and what must be done to further their implementation.
As part of these efforts, HHS has established the Office for At-Risk Individuals, Behavioral Health, and Human Services Coordination within ASPR to ensure that ASPR, along with the rest of the Department, is developing policies and capabilities for emergency planning, response, and recovery activities that are fully inclusive of the needs of children, including mental health needs, and also to ensure that efforts across the department remain coordinated.
In summary, I would like to thank you again for providing the opportunity for me to talk with you today about the Department’s many efforts to address the needs of children in disasters and public health emergencies. We have made significant strides in addressing the needs of our youngest citizens and we anticipate continuing this momentum in the future.
Thank you, Madam Chairwoman. We look forward to working with the Subcommittee as we continue to improve our preparedness and recovery for our Nation’s children.
I would be happy to answer any questions.
Last revised: April 19, 2011