Children, along with the elderly and pregnant women, are the most vulnerable populations in disasters. In developing countries, children also make up a disproportionate percentage of the population, as exemplified by Haiti, where over 40% of the population is under 18. Physiologically and psychologically, children are less fit to survive the acute, subacute, and chronic stresses imposed by a disaster than adults are. For example, children under the age of 5 in the Ethiopian famine of 2000 had a mortality rate double that of the general population during the crisis. Children depend on their parents or guardians for food, clothing, shelter, hygiene, sanitation, water, medical care, and general personal safety. Regardless of the type of disaster, inevitably, a certain percentage of surviving children will be separated from one or both of their parents or guardians. Without the appropriate stewardship of adults, the hazards imposed on children by the disaster situation are multiplied. Children are more likely than others are to suffer from malnutrition in the predisaster period and therefore are more sensitive to decreased food availability after the disaster. Children are also more likely to suffer multisystem organ injury during a disaster than adults are, as they are less likely to protect themselves, and their bodies have less protection of vital organs. In addition, they are more vulnerable to the risks of both dehydration and respiratory insufficiency from acute infection in the wake of the vast structural destruction. Disruption of the social fabric of their lives can lead to long-term depression, posttraumatic stress disorder (PTSD), interruption of normal growth and development, and lifelong disability. Sadly, orphaned children are also potential victims of unscrupulous adults who may seek to exploit them as slave workers, sex workers, or combatants in civil war and rebellion. Clearly, an entire text could be written about the proper medical and psychological care of children in disasters. This chapter will serve as an introduction and overview. References and additional readings are included at the end of the chapter for the interested reader.
Disaster response planners must consider the unique characteristics and needs of children, when designing, preparing, implementing, and assessing any disaster relief intervention. This chapter provides a historical perspective and focuses on current practices and pitfalls. It is important to be aware that many natural or human-made disasters will destroy the homes and social structures of the families of children. The children and their parents then become displaced persons or refugees, which presents them with a set of significant risks and challenges. This chapter considers a continuum of medical and psychological challenges for such children. Acute medical care must be provided in the immediate wake of the disaster, and then subacute and chronic care must be provided, locally or distantly, for displaced or refugee populations of children forced out of their domestic environment because of the disaster.
In the past, the international community’s response to disaster was disorganized, poorly monitored, and inefficient, with a focus on capital investment, structural replacement, and trans-shipment of large amounts of materials, such as medical supplies and equipment, clothing, canned food, and tents. Much of this material was outdated, culturally unacceptable, untranslated, misunderstood, and not specific to the pediatric population. Moreover, there were unintended negative outcomes resulting from improper use of pharmaceutical agents and equipment by untrained personnel. These historical problems associated with disaster relief were magnified when children were considered.
It was not until the 1980s that the emergency medical service(s) (EMS) systems in the United States began to treat children differently than adults in the prehospital setting. This change came about because most of the equipment, medications, and training were not pediatric specific and therefore children were not receiving treatment based on an adequate, medically appropriate, evidence-based approach to prehospital medical care. In the same vein, the disorganized and rarely assessed response to disaster relief that existed before the mid-1980s did not fully consider the separate and important medical and psychological needs of children affected by disasters. This is especially tragic because in many developing countries, about 40% of the population is younger than 15 years, and the most medically devastating natural and human-made disasters typically occur in the developing world. The level of human devastation is a direct result of inadequate intrinsic infrastructure, populations that are severely compromised and vulnerable before the disaster, and inadequate local and nationwide resources for acute and long-term responses to the disaster.
Even though many health care practitioners were eager to “do something” before there was a change in focus on children affected by disaster, few had experience, and even fewer were trained specifically in pediatric disaster medicine. Preliminary need assessments were not performed, planning was haphazard, and outcomes research was nonexistent. In the 1980s, primary health care, which was just beginning to be applied to health care development projects in developing countries, began to be applied to refugee and disaster medicine. Concepts of immunization, nutrition, oral rehydration therapy (ORT), cooperation and collaboration with the affected populations and between local and international nongovernment organizations, involvement of the local ministry of health, outcome evaluations, and appropriate information gathering, including needs assessment, were becoming more commonplace. This structured approach to disaster and refugee medical relief has been more effective.
Children routinely make up the highest mortality rates in disaster situations, and those rates are highest for children younger than 5 years. Unfortunately, there are many examples of the disproportionate mortality rates among children in the disaster literature. Among Ethiopians displaced to Sudan in the mid-1980s, children younger than 5 years old were twice as likely to die as the rest of the population were. In the mid-1990s, among Nicaraguan and Honduran children displaced to refugee camps because of the Contra war, infants represented 42% of all deaths, and children younger than 5 years represented 54% of all deaths. During the famine of 1992 in Somalia, a horrifying 74% of children died in the town of Baidoa. During the civil unrest in Rwanda in 1996, displaced Tutsi children represented 54% of all deaths among refugees in camps in Goma, Zaire, with the accrued mortality 15 to 18 times greater than their baseline. More recently, in Sudanese refugee camps in 2012, pediatric deaths were 58% of the total. It is clear from the examples that children are an especially vulnerable population. These mortality rates reflect tremendous suffering and waste of human capital.
Why are children dying? The common reported causes of death of children caught up in natural and human-made disasters involving civil unrest or war and transmigration to refugee camps include acute respiratory infection, measles, malaria, severe malnutrition, diarrheal disease, injury (e.g., gunshots, mines, shrapnel, and contusions), and burns. Countries experiencing armed conflict account for over 36% of the total child deaths, stillbirths, and maternal death worldwide, and even in this violent setting most of these deaths are due to indirect causes such as diarrheal diseases and malnutrition.
Appropriate disaster intervention aimed at decreasing the morbidity and mortality of children requires proper predisaster preparation, training, and equipment; prompt and appropriate assessment of the disaster situation; rapid intervention appropriate to the specific disaster and tailored to children’s specific needs; and long-term interventions that address chronic, predictable problems associated with different forms of complex emergencies.
During the last few decades, there have been significant advances in disaster medical relief activities, and groups such as the Sphere Project have sought to rigorously analyze and standardize guidelines. This has allowed planners to prepare more appropriately for and respond to complex emergencies that arise around the world. In this process, a growing emphasis has been placed on pediatric care, reflecting its central role in disaster response. This chapter will focus on the four elements of disaster response outlined by Sphere, as each relates to the care of children: water supply; sanitation and hygiene promotion; food security and nutrition; shelter, settlement, and nonfood items; and finally health action. We also provide a separate section dealing with psychological support.
Water, Sanitation, and Hygiene
Many human-made or natural disasters interrupt the clean water supply to a population. Earthquakes may destroy wells, urban water lines, and water treatment systems. Hurricanes and tsunamis introduce fecal material, toxic chemicals, and salt water to standing water sources and wells. Combatants in war and civil unrest often destroy water sources as strategic acts of war. Despite these threats to the water supply, the minimum personal water requirement is 15 L per day, and there is no evidence that children require less. Table 9-1 gives an outline of how water should be distributed across usages according to Sphere.
|Survival needs: water intake (drinking and food)||2.5-3 liters per day||Depends on the climate and individual physiology|
|Basic hygiene practices||2-6 liters per day||Depends on social and cultural norms|
|Basic cooking needs||3-6 liters per day||Depends on food type and social and cultural norms|
|Total basic water needs||7.5-15 liters per day|
Even more clean water is recommended in certain situations such as collective feeding centers for children, where 30 L is recommended; hospitals, in which the recommended amount is 40 to 60 L; and cholera treatment, where 60 L per person per day is recommended. It is also important to pay attention to details such as the need for families to have containers for transport and storage of water. In most cultures, mothers or older female children are responsible for collecting and managing water. These same individuals are usually responsible for child care, and a remote water source is a significant drain on limited resources, which is why individuals should have access to a water source within 500 m.
Sanitation is very important during and after disasters and complex emergencies. Sewage lines and sewage treatment may be disrupted by natural and human-made disasters. Many countries do not have adequate toilets, underground sewage, or sewage treatment in rural districts. Children are particularly vulnerable to fecal-oral pathogens. The so-called dirty-hands diseases, which include dysentery, cholera, typhoid, hepatitis A, polio, and helminthiasis, are transmitted because of poor hygiene and a lack of adequate clean water and soap. Providing soap and educating the population about appropriate hand washing as part of hygiene education can have a profound effect. This was demonstrated by Chinese schoolchildren, where rates of helminthic infection were decreased by 50%, after a brief education program with the provision of soap. Soap distributed to refugees from Mozambique similarly decreased the incidence of diarrhea in children by almost 30%.
The disaster response team should have training and experience in the assessment of the water supply and water treatment, as well as simple interventions directed at keeping the water supply safe. Short-term, rapid interventions may involve chlorination, filtration, boiling, or the provision of a mobile water supply. Long-term interventions include the drilling of deep or artesian wells that are protected from contamination by fenced wellheads. Basic hygiene items, including water containers, bathing and laundry soaps, and menstrual hygiene products, should be part of every intervention.
Responders should have an ability to assess the sanitation needs of the disaster-struck population and the cultural and sociological parameters of defecation in the affected population. In many developing countries, it is uncommon for toddlers to wear diapers or other coverings, and, even among adults, use of proper facilities may be unavailable or not used. When defecation takes place randomly throughout populated areas, it facilitates the spread of fecal pathogens. Fenced-off defecation fields, trenches, and pit latrines should be established at least 30 m from the nearest groundwater source and 1.5 m above the water table. Responders must consider traditional methods and habits of defecation, as well as religious, cultural, and social mores concerning defecation and the joint use of facilities across gender and age. Decisions must be made in conjunction with appropriate local authorities and solutions implemented rapidly because large populations separated from free access to toilets will find other means and sites of relief that are fraught with the potential for spreading epidemics.
Diarrheal disease is the single most common immediately precipitating cause of death in children under the age of 5 in disaster situations, and it is intimately related to the water supply. Epidemics, specifically in refugee camps, can accelerate rapidly, as was unfortunately exemplified in a Rwandan refugee camp in 1994. In a population of about 650,000 refugees in North Kivu, Democratic Republic of the Congo, an outbreak of Shigella and cholera caused 85% of the 50,000 deaths that were recorded in the first month. Children are disproportionally affected, and it has been shown that mortality as a result of cholera is greatest in children younger than 4 years, with a 4.5-fold relative risk of death when compared with older children and adults.
The mainstay of treatment for diarrheal disease in children is ORT. The UNICEF guidelines state that, per stool, children younger than 2 years should be provided ¼ to ½ of a large cup (250 mL) of ORT solution, and children 2 years or older, between ½ to 1 large cup. In 2006, the World Health Organization (WHO) released a new formula for ready-to-use ORT that is available in easy-to-use packets. If these ORT packets are unavailable, a solution of 1 L of clean water with ½ tablespoon (2.5 g) of salt with 6 level teaspoons (30 g) of sugar, stirred until completely dissolved, can be used instead. Vomiting is frequent, even with moderate dehydration, and oral therapy should be attempted, because vomiting will improve as the dehydration resolves. Intravenous therapy should be reserved for cases of severe dehydration (≥ 10%) or when children have failed oral therapy. Isotonic solutions, such as normal saline or Ringer’s lactate, should be used, whereas hypotonic solutions, such as D5, should be avoided. In children with severe malnutrition, ORT and intravenous hydration should be carried out carefully to avoid congestive heart failure (CHF).
Zinc supplementation is important adjunct therapy for diarrheal illness. It has been shown to reduce the duration of a diarrheal episode by about 25% and the stool volume by 30%. , All children under 5 with dysentery should receive daily treatment with elemental zinc (under 6 months, 10 mg; between 6 months and 5 years, 20 mg daily) for 2 weeks of treatment.
The treatment of diarrheal illness in disasters differs from standard treatment in the United States, where antibiotics are usually avoided, partially out of concern for precipitating hemolytic uremic syndrome. WHO guidelines state that all cases of dysentery should be treated with antibiotics, and cholera patients have been shown to benefit from the treatment. If possible, laboratory testing for Vibrio cholerae and Shigella should be carried out, with antibiotics tailored to the pathogen; however, presumptive treatment should begin before or even without laboratory confirmation. For treating bloody diarrhea in children, ciprofloxacin (totaling 15 mg/kg dosage [daily total] given for 3 days) is the current treatment of choice, despite the known risk of arthropathy. In addition, ciprofloxacin is also effective in cholera treatment; however, a single dose of azithromycin has also demonstrated effectiveness, and it is easier to implement. Surveillance is very important in managing an outbreak of diarrhea in a population of children after a disaster or a complex emergency. Surveillance should include case definitions, number and severity of cases, type of diarrhea by pathogen, age-specific and diarrhea-specific mortality, and demographics of the affected population.
Food Security and Nutrition
A disaster assessment team arriving on-site should be prepared to evaluate the pediatric population’s nutritional status, using simple anthropometric measurements. Measuring the child’s weight in relation to his or her height (weight-for-height [WFH]) and mid–upper-arm circumference (MUAC), and evaluating for edema are the most useful tools. A child with a WFH greater than 2 standard deviations (SDs) below the median for age by month is said to be wasted. Weight is more sensitive than height to sudden changes in food availability, which is why WFH is used instead of height-for-age (HFA) when evaluating acute malnutrition. HFA measurements reflect chronic nutritional deficiency and HFA greater than 2 SDs below the median is referred to as stunting. When performing these measurements, children less than 86 cm should be measured in the recumbent position, and fully extended by the provider. For weights, it is helpful to have a hanging scale that can be zeroed. Both WFH and HFA measurements are compared with WHO standardized growth charts, by sex and age, by month. The results are reported as Z scores, which are the number of SDs the patient falls above or below the median when compared with a breast-fed and well-nourished population. Frequently, the child’s exact age is not known, and this information can be estimated by using a local events calendar, where the family member is asked about surrounding dates, such as harvests, large storms, elections, or other memorable local events. A further advantage of WFH over HFA is that it does not suffer because of this estimation.
There are about 7 million annual deaths in children under the age of 5, and undernutrition is a primary cause in 45% of cases. Severe acute malnutrition (SAM) is the most serious form of undernutrition, and it is defined by a WFH 3 SDs less than the median or by the presence of bilateral edema. SAM is one of the most serious challenges children face during disasters, and children with this condition have an 11.6-fold (hazard ratio) increase in all causes of death compared with nonmalnourished children. This group requires refeeding and close medical attention because of their increased susceptibility to infectious diseases. One common and proven strategy is to provide 175 kcal per day per kg of ready-to-use therapeutic food (RUTF), such as Plumpy Nut, and to provide empiric antibiotic therapy. In the past, these children were often hospitalized or kept at a refeeding center, but more recently nontoxic appearing children with SAM are being discharged home with RUTF (see Table 9-2 ). This helps to keep the family unit together and to relieve the burden on an already stressed medical system. An important addition to this is that if a family has multiple children, supplementary food should be provided for all children in the household, even those without SAM, to assure that the RUTF is not split among the siblings.