TECHNICAL REPORT Organizational Principles to Guide and Define the Child Health
Care System and/or Improve the Health of all Children
Chemical-Biological Terrorism and Its
Impact on Children
Sarita Chung, MD, FAAP,a Carl R. Baum, MD, FACMT, FAAP,b Ann-Christine Nyquist, MD, MSPH, FAAP,c DISASTER PREPAREDNESS
ADVISORY COUNCIL, COUNCIL ON ENVIRONMENTAL HEALTH, COMMITTEE ON INFECTIOUS DISEASES
Children are potential victims of chemical or biological terrorism. In recent
years, children have been victims of terrorist acts such as the chemical
attacks (2017–2018) in Syria. Consequently, it is necessary to prepare for and
respond to the needs of children after a chemical or biological attack. A broad
range of public health initiatives have occurred since the terrorist attacks of
September 11, 2001. However, in many cases, these initiatives have not
ensured the protection of children. Since 2001, public health preparedness has
broadened to an all-hazards approach, in which response plans for terrorism
are blended with those for unintentional disasters or outbreaks (eg, natural
events such as earthquakes or pandemic influenza or man-made catastrophes
such as a hazardous-materials spill). In response to new principles and
programs that have evolved over the last decade, this technical report
supports the accompanying update of the American Academy of Pediatrics
2006 policy statement “Chemical-Biological Terrorism and its Impact on
Children.” The roles of the pediatrician and public health agencies continue to
evolve, and only their coordinated readiness and response efforts will ensure
that the medical and mental health needs of children will be met successfully.
In this document, we will address chemical and biological incidents. Radiation
disasters are addressed separately.
BACKGROUND INFORMATION
In 2000, the American Academy of Pediatrics (AAP) published the policy
statement “Chemical-Biological Terrorism and its Impact on Children.”
Preceding events such as the 1995 sarin attack in Tokyo, Japan, illustrate
the reality that acts of domestic chemical terrorism can occur, with
significant impact on the health of children. The subsequent 2006 policy
statement highlighted the need for increased awareness and preparedness
in response to additional acts of chemical and biological terrorism,
including the release of anthrax spores through the US postal system,
intentional toxic chemical contamination of food in Michigan and
California, and the identification of ricin-laden letters in a post office in
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abstract
a
Division of Emergency Medicine, Boston Children’s Hospital and
Harvard Medical School, Harvard University, Boston, Massachusetts;
b
Section of Pediatric Emergency Medicine, Departments of Pediatrics
and Emergency Medicine, School of Medicine, Yale University, New
Haven, Connecticut; and cSection of Pediatric Infectious Diseases and
Epidemiology, Department of Pediatrics, Children’s Hospital Colorado
and School of Medicine, University of Colorado, Aurora, Colorado
Technical reports from the American Academy of Pediatrics benefit
from expertise and resources of liaisons and internal (AAP) and
external reviewers. However, technical reports from the American
Academy of Pediatrics may not reflect the views of the liaisons or the
organizations or government agencies that they represent.
Dr Chung provided substantial contributions to the conception and
design of the work, contributed to drafting and revising it critically for
important intellectual content, gives final approval of the version to be
published, and agrees to be accountable for all aspects of the work in
ensuring that questions related to the accuracy or integrity of any
part of the work are appropriately investigated and resolved; Drs
Baum and Nyquist provided substantial contributions to the
conception and design of the work and contributed to drafting and
revising it critically for important intellectual content; and all authors
approved the final manuscript as submitted.
The guidance in this report does not indicate an exclusive course of
treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
All technical reports from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.
To cite: Chung S, Baum CR, Nyquist A-C, AAP DISASTER
PREPAREDNESS ADVISORY COUNCIL, COUNCIL ON ENVIRONMENTAL
HEALTH, COMMITTEE ON INFECTIOUS DISEASES. Chemical-Biological
Terrorism and Its Impact on Children. Pediatrics. 2020;145(2):
e20193750
FROM THE AMERICAN ACADEMY OF PEDIATRICS
 South Carolina. Unfortunately, since
the publication of the 2006 policy
statement, there have been additional
chemical attacks affecting children,
such as the 2017 sarin1 and 2018
chlorine attacks2 in Syria. These
attacks have led to significant
pediatric morbidity and mortality.
Emerging biological threats, such as
Ebola and Zika viruses, have provided
opportunities to test the systems of
pediatric disaster preparedness
nationally and internationally. In the
same time frame, there continues to
be substantial progress as new
chemical and biological medical
countermeasures (MCMs) are
approved by the US Food and Drug
Administration (FDA), additional
methods for surveillance are in place,
and advances in pediatric disaster
preparedness and education are
available to assist emergency
responders with evidence-based best
practices.
Since the September 11, 2001,
terrorist attacks and subsequent
anthrax releases in the United States,
the AAP has recognized the need to
strategically address the impact of
terrorism (ie, an act designed to
frighten, hurt, or kill people) on
children at the national, state, and
local level. This has led to the
appointment of the AAP Disaster
Preparedness Advisory Council,
which collaborates with federal
partners (including the Department
of Health and Human Services
[DHHS] Office of the Assistant
Secretary for Preparedness and
Response [ASPR], Centers for Disease
Control and Prevention [CDC],
Department of Homeland Security
[DHS], FDA, Federal Emergency
Management Agency, and the
National Institute of Child Health and
Human Development) as well as more
than 70 AAP member disaster
preparedness contacts in all AAP
chapters who work with their local
and state partners to address the
needs of children throughout the
disaster cycle. The federal
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government also created the National
Commission on Children and
Disasters, the National Advisory
Committee on Children and Disasters,
and the National Biodefense Science
Board, all of which included pediatric
subject matter experts. The AAP hosts
a comprehensive Web site for
pediatric health care providers with
a page devoted to information on
terrorism and its impact on children
(www.aap.org/disasters/terrorism).
Additional AAP activities to promote
pediatric disaster awareness include
publication of disaster policy
statements such as “Ensuring the
Health of Children in Disasters” and
“Providing Psychosocial Support to
Children and Families in the
Aftermath of Disasters and Crises”
along with education on specific
chemical and biological threats in the
AAP manual Pediatric Environmental
Health (the “Green Book”) and the
AAP manual Red Book: 2018 Report of
the Committee on Infectious
Diseases.3–6 The AAP has also
promoted pediatric preparedness
through implementation of a 2016
regional pediatric and public health
tabletop exercise and a 2017 virtual
tabletop exercise (www.aap.org/
disasters/tabletop).7
The unfortunate continuing
occurrence of chemical and biological
terrorism demonstrates the ongoing
need to improve public health and
health care system preparedness in
all respects, including the detection of
covert events, establishment of
comprehensive response protocols
for children, and implementation of
plans for rapid resource mobilization
to care for children. At the
governmental level, the passage of
key federal legislation (Table 1) has
facilitated these efforts. However,
there remains a need for pediatric
health care providers to be
knowledgeable about the chemical
and biological weapons that could be
used against a population that
includes children and to be able to
provide care during the recovery
period. Moreover, principles of the
care of children after chemical and
biological terrorism are evolving, and
these approaches will continue to
inform future work.
STATEMENT OF THE PROBLEM
Pediatricians play a pivotal role in
providing care in the medical home
and supporting the community
before, during, and after a chemical or
biological event. It is critical for
pediatricians and others who care for
children in all care settings to
continue to educate themselves
regarding the pediatric consequences
of a chemical or biological attack.
Readiness resources and approaches
will vary depending on practice
setting, such as community hospitals,
pediatric hospitals, emergency
departments, and office practices. The
role of the pediatrician and others
who care for children in ensuring the
health of children in disasters has
been described.3,8 Specific to
chemical and biological terrorism,
pediatricians and their staff will need
to be prepared to promote and share
information on readiness approaches,
advise on pediatric decontamination
strategies, provide appropriate
medical care, offer anticipatory
guidance to families, report
appearances of unusual disease
clusters, and help guide families after
events. This technical report
summarizes relevant information
and evidence. Although the
focus of this document is geared
toward the US health care system,
principles of this technical report can
be applied to international health
care settings.
NEW INFORMATION
This technical report and its
accompanying policy statement9
replace the 2006 policy statement,
with an added focus on identifying
and resolving system issues that are
paramount to minimizing morbidity
and mortality in children after their
 TABLE 1 Federal Legislation Enacted Since 2001 To Improve Public Health Response to Bioterrorism and Other Public Health Emergencies
Date Bill Legislation
September 2001 Public Law 107-38 2001 Emergency Supplemental Appropriations Act for Recovery From and Response to Terrorist Attacks on the
United States
August 2002 Public Law 107-206 2002 Supplemental Appropriations Act for Further Recovery From and Response to Terrorist Attacks on the United
States
June 2002 Public Law 107-188 Public Health Security and Bioterrorism Preparedness and Response Act of 2002
November 2002 Public Law 107-296 Homeland Security Act of 2002
April 2003 Public Law 108-20 Smallpox Emergency Personnel Protection Act of 2003
December 2003 Public Law 108-169 United States Fire Administration Reauthorization Act of 2003
July 2004 Public Law 108-276 Project BioShield Act of 2004
October 2004 Public Law 108-324 Military Construction Appropriations and Emergency Hurricane Supplemental Appropriations Act, 2005
December 2004 Public Law 108-494 ENHANCE 911 Act of 2004
May 2005 Public Law 109-13 Emergency Supplemental Appropriations Act for Defense, the Global War on Terror, and Tsunami Relief, 2005
September 2005 Public Law 109-72 Flexibility for Displaced Workers Act
September 2005 Public Law 109-62 Second Emergency Supplemental Appropriations Act to Meet Immediate Needs Arising From the Consequences of
Hurricane Katrina, 2005
October 2005 Public Law 109-88 Community Disaster Loan Act of 2005
December 2005 Public Law 109-148 Department of Defense, Emergency Supplemental Appropriations to Address Hurricanes in the Gulf of Mexico, and
Pandemic Influenza Act, 2006
April 2006 Public Law 109-218 Local Community Recovery Act of 2006
September 2006 Public Law 109-288 Child and Family Services Improvement Act of 2006
June 2006 Public Law 109-234 Emergency Supplemental Appropriations Act for Defense, the Global War on Terror, and Hurricane Recovery, 2006
December 2006 Public Law 109-417 Pandemic and All-Hazards Preparedness Act
May 2007 Public Law 110-28 US Troop Readiness, Veterans’ Care, Katrina Recovery, and Iraq Accountability Appropriations Act, 2007
September 2008 Public Law 110-329 Consolidated Security, Disaster Assistance, and Continuing Appropriations Act, 2009
October 2008 Public Law 110-376 United States Fire Administration Reauthorization Act of 2008
October 2008 Public Law 110-377 Poison Center Support, Enhancement, and Awareness Act of 2008
October 2008 Public Law 110-392 Comprehensive Tuberculosis Elimination Act of 2008
April 2009 Public Law 111-13 Serve America Act
January 2011 Public Law 111-351 Predisaster Hazard Mitigation Act of 2010
March 2013 Public Law 113-5 Pandemic and All-Hazards Preparedness Reauthorization Act of 2013
November 2015 Public Law 114-80 DHS Social Media Improvement Act of 2015
December 2015 Public Law 114-111 Emergency Information Improvement Act of 2015
April 2016 Public Law 114-143 Integrated Public Alert and Warning System Modernization Act of 2015
September 2016 Public Law 114-223 Continuing Appropriations and Military Construction, Veterans Affairs, and Related Agencies Appropriations Act,
2017, and Zika Response and Preparedness Act
December 2016 Public Law 114-268 First Responder Anthrax Preparedness Act
December 2016 Public Law 114-255 21st Century Cures Act
December 2016 Public Law 114-326 National Urban Search and Rescue Response System Act of 2016

exposure to a chemical or biological
weapon.
REVIEW OF EVIDENCE
Exposure Sources for Chemical and
Biological Weapons
Exposure to chemical and biological
weapons can occur through several
potential sources. Airborne releases
of agents have remained the primary
concern because large populations
can be exposed by this route.
Potential mechanisms of exposure
include crop-dusting airplanes,
tainted letters, and release of agents
into confined spaces (eg, subway
tunnels, office buildings, theaters).
Contamination of the water supply is
also a potential source for exposure,
although dilution of chemical and
biological agents in water is
mitigating, and few chemical or
biological agents are both water
stable and resistant to water-
purification techniques that decrease
the risk. Finally, the contamination of
food that is either unprocessed (eg,
uncultivated grain) or processed (eg,
a consumer product) is considered
a potential means of exposure to
chemical or biological weapons.
Specific Vulnerabilities in Children
After events of chemical or biological
terrorism, children have a greater risk
of both exposure and harm, the result
of key developmental, anatomic, and
physiologic vulnerabilities. Children
have greater life expectancy than
adults and, therefore, have more time
in which to develop sequelae such as
cancer from a variety of sources of
exposure (air, water, or food) to
chemical or biological weapons. For
each source of exposure, children
possess a significantly greater
likelihood of exposure because of
their intake patterns. Children inhale
considerably more air on a per-
weight basis than adults (400 vs
140 mL/kg per minute, respectively).
Consequently, for any concentration
of an airborne toxicant, a child will
inhale more of the substance on
a per-kilogram basis than an adult.
Also, substances that are heavier than

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 air have their highest concentration
near the ground, closer to the
breathing zone of the child. Because
of a proportionately greater body-
surface area, children have both
greater exposure and an increased
likelihood of systemic toxicity to
agents that contact their skin.
Children have fluid and food intakes
that differ significantly from adults.
For example, children ingest
approximately 100 mL/kg of water
per day, whereas adults ingest 40 to
60 mL/kg per day. Children drink
more milk than adults, placing them
at risk for exposure to agents that can
enter the milk supply through
contamination of the grass on which
cows feed. In the Chernobyl radiation
disaster, cows grazed in contaminated
pastures, leading to excess
radioactivity in their milk. Children
drinking this milk sustained significant
exposure to radioisotopes, including
iodine and strontium.10 Finally, children
not only eat more food on a per-
kilogram basis but also have diets that
are distinctly different from adults (eg,
greater consumption of fruits). Once
exposed to a chemical or biological
agent, children have numerous
physiologic vulnerabilities that could
lead to a greater risk of harm. These
vulnerabilities include undeveloped self-
preservation skills that make them less
able to flee danger; an immature
immune system that makes them less
able to contain infection (eg, plague);
less fluid reserve, which can result in
a greater risk of severe dehydration
after exposure to agents that produce
excess gastrointestinal fluid loss (eg,
Ebola virus disease); and a greater risk
of anxiety reactions and posttraumatic
stress disorder after witnessing or being
victim to a terrorist act.4 Additionally,
with the advent of technology, there is
increased availability of social media to
children and adolescents, allowing for
access to online terrorist information or
suggestive material on how to terrorize.
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Public Health Preparedness
The All-Hazards Approach
In past years, resources have been
provided to public health authorities,
including the network of state and
regional poison control centers, and
first responders (fire officials, police
officers, and emergency medical
services personnel) to create systems
capable of responding to a possible
chemical attack. Similarly, emerging
and reemerging infections as well as
highly contagious organisms such as
Ebola have led to a massive public
health effort to improve response
capability to future acts of biological
terrorism. The initiation of these
response campaigns revealed large-
scale weaknesses in state and local
public health infrastructure. Moreover,
it became evident that intense effort
was being directed toward events
that might never occur rather than
toward public health threats of much
greater likelihood (eg, an unintentional
hazardous chemical release). Finally,
it became clear that a fragmented
and reactive public health response
plan is more expensive and inefficient
than a single, comprehensive plan.
As a result, disaster response agencies
and public health authorities have
increasingly embraced the concept of
the “all-hazards approach.”
Representing a dramatic paradigm
shift in the preparation for chemical
and biological terrorism, the all-hazards
approach is designed to augment the
public health infrastructure, using an
integrated model of disaster response.
The creation of all-hazards response
systems has led to improvements in
public health response capabilities.
For example, an effective public
health response protocol for a sarin
release would be equally effective
for a hazardous-materials (hazmat)
release in the community, such as the
2017 chemical fires in Texas that
followed massive flooding and power
losses in the wake of Hurricane
Harvey.11 Similarly, the same protocol
created to respond to the appearance
of smallpox can be modified easily to
contain an outbreak of severe acute
respiratory syndrome. However, as
threats increase and local and state
budgets fluctuate, there will continue
to be challenges to achieve adequate
responses.
Pediatric Disaster Preparedness and
Education
Several investigators have studied
disaster preparedness and education
specific to the needs of children. In
2008, Schobitz et al12 conducted a study
of pediatric and emergency medicine
residents at a single institution to
assess their baseline knowledge of
management of pediatric victims of
chemical and biological terrorism. Using
an expert-developed, validated test, the
investigators determined that the
residents of this era were unprepared to
manage these victims. The 2010
Pediatric Emergency Mass Critical Care
Task Force concluded that mass events
place unusual stresses on health care
providers, many of whom must provide
care outside of their scope of practice,
and that education and educational
resources can mitigate anxiety and
chaos in these contexts.13 Subsequent
research in pediatric disaster triage
has demonstrated that a multiple-
simulation curriculum can improve
prehospital care providers’ assessment
skills.14 In addition, studies have
revealed an increase in clinical staff’s
knowledge and confidence with
pediatric disaster skills with short,
topic-focused educational
interventions.15,16 There are also review
articles of pediatric disaster courses to
educate health care professionals.15,17,18
Agents of Concern
Chemicals
Three traditional assumptions
specific to chemical terrorism have
proven simplistic. These include the
narrow concepts that (1) such
weapons were intentionally and
specifically manufactured as
instruments of mass destruction; (2)
chemical terrorism was dramatic and
recognized immediately (eg, the sarin
 incident in Tokyo); and (3) only well-
organized, well-funded terrorist
groups were capable of releasing
chemical weapons after extensive
planning. These concepts have been
expanded to include the possibilities
that (1) readily available, legitimate
chemicals, such as chlorine, can
be misused (ie, “weapons of
opportunity”); (2) these acts can be
covert, with delayed recognition;
and (3) a motivated, “lone-wolf”
individual with few resources can
perpetrate significant releases.
Acts of chemical terrorism involving
children illustrate these expanded
concepts. In 1999, patrons of
a restaurant in Fresno, California,
developed severe gastroenteritis. An
investigation by public health
authorities discovered that the
carbamate insecticide methomyl had
been added maliciously to the salt.
More than 100 adults and children
became ill with nausea, vomiting, and
diarrhea; a perpetrator was never
identified.19 In 2003, in Grand Rapids,
Michigan, a disgruntled grocery store
worker placed a nicotine-containing
insecticide into ground beef, making it
available for purchase by unsuspecting
customers. It was not until widespread
illness (nausea, mouth burning,
vomiting) was reported and there was
a recall and analysis of the meat,
revealing the presence of nicotine, that
this was recognized as an act of
terrorism. Ultimately, more than 100
people became ill, including more than
40 children, in what is now considered
the largest act of chemical terrorism in
US history.20
Research in the past decade specific
to chemical exposures has been
focused on antidotes and resultant
injury after exposure. For nerve-agent
exposure, 3 classes of medication are
used in the treatment of nerve-agent
exposure: (1) anticholinergics,
usually first-line atropine, to block
excess acetylcholine at peripheral
muscarinic receptors; (2) oximes,
such as pralidoxime, to reactivate
inhibited acetylcholinesterase; and
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(3) anticonvulsants21 (please refer to
the Nerve Agents section for further
discussion of clinical effects). Some
studies have explored the problem of
antidote dosing in children,
particularly with respect to
prepackaged autoinjectors. Baker22
noted that adult doses of atropine are
well tolerated, even in young children,
and recommended the use of the
atropine (0.5 or 2 mg) autoinjector for
children younger than 1 year after
nerve-agent exposures when weight
dosing is impractical or not possible to
control excessive bronchorrhea and to
prevent respiratory failure.22 In a 2009
review of research on atropine dosing,
Sandilands et al23 considered
pharmacokinetic data to balance
sufficient and timely dosing of atropine
versus the risk of overdose; the authors
recommended relatively large initial
doses of atropine in children, who are
relatively resistant to its adverse
effects. Droste et al21 used
a pharmacokinetic model to analyze
current CDC and US Army treatment
protocols and found that in general,
oxime therapy alone was ineffective in
alleviating symptoms.19 The atropine
and pralidoxime combination
autoinjector can, in theory, be used in
children older than 1 year; as of 2018,
however, the combination autoinjector
was not FDA approved for pediatric
patients weighing less than 41 kg.
However, authors of an extensive
review of antidotes for a variety of
chemical agents concluded that the
strength of evidence supporting the use
of these antidotes is generally weak
and that more research is needed.24
Other investigators have studied
injury related to chemical exposures.
Custer et al25 used an in vitro test
lung to simulate pediatric lung injury;
the goal was to assess the efficacy of
transport and/or emergency
ventilators in the setting of mass-
casualty respiratory failure. These
investigators found that few of the
ventilators, chosen from a range of
manufacturers, were capable of the
minimum alarm and tidal volume
function necessary to support the
ventilation of pediatric victims.
Additional efforts have focused on
improving access to information after
chemical exposures. The ASPR, in
cooperation with the National Library
of Medicine, has developed a Web site
that is intended to enable health care
professionals to respond to mass-
casualty events involving chemicals
(https://chemm.nlm.nih.gov/). The
resource can be downloaded to
a computer or mobile device in
advance of an event that might limit
or interrupt Internet access.26
The analysis of a mass-casualty event
may identify 1 or more specific
chemicals. The World Health
Organization considers the following 6
categories of chemicals to be the most
likely threats: nerve agents, blistering
agents (vesicants), irritants
(corrosives), choking agents,
asphyxiants (cyanogens and carbon
monoxide), and disabling
(incapacitating) agents, including
lacrimators (Table 2).27
Nerve Agents
Nerve agents are well absorbed
through intact skin and even through
examination gloves used in clinical
settings. All nerve agents act as
acetylcholinesterase inhibitors,
producing the same symptoms and
signs associated with organophosphate
poisoning. Manifestations can range
from mild (miosis, nausea, diarrhea)
to severe (muscle weakness,
fasciculations, respiratory failure, coma,
and seizures).
In the 1995 sarin episode in Tokyo,
the most unanticipated sequela was
the degree of injury to health care
professionals.28 Several hundred
physicians, nurses, and other health
care professionals became ill as
a result of 2 factors: handling of sarin-
contaminated victims without
wearing personal protective
equipment (PPE) and entry of
contaminated victims into health care
facilities, allowing sarin vapor to
5
 enter the ventilation system.27,29 This
event firmly demonstrated the
importance of using PPE to protect
health care professionals,
decontaminating victims before
building entry to maintain office or
hospital safety, and using
environmental controls such as
airborne infection isolation rooms
(negative-pressure rooms).
Management of nerve-agent exposure
includes supportive care and, when
indicated, prompt administration of
the antidotes atropine and
pralidoxime (see the introduction to
the previous section, Chemicals, for
recent research regarding atropine,
pralidoxime, and autoinjectors).30
Autoinjectors are particularly
important in mass-casualty incidents
when there is a need to treat large
numbers of victims as quickly and
efficiently as possible. Until recently,
the absence of pediatric autoinjectors
complicated the rapid administration
of atropine and pralidoxime to
children; only the devices approved
for adults, containing 2 mg of
atropine and 600 mg of pralidoxime,
TABLE 2 Chemical Weapons of Concern
Agent Classification
Nerve agents
Blistering agents (vesicants)
Irritants (corrosives)
Choking agents
Asphyxiants
Disabling agents (incapacitators)
AC, hydrogen cyanide; BZ, 3-quinuclidinyl benzilate; CG, phosgene; CN, chloroacetophenone; CS, chlorobenzylidene; GA, tabun; GB, sarin; GD, soman; HD, mustard gas; L, lewisite; NATO, North
Atlantic Treaty Organization; NOx, nitrogen oxide; —, not applicable. Adapted from World Health Organization. Chemical weapons of concern. Available at: www.who.int/csr/delibepidemics/
annex1.pdf. Accessed June 15, 2018. Adapted from Tuorinksy SD, ed. Medical Aspects of Chemical Warfare. Washington, DC: Office of the Surgeon General at TMM Publications; 2008:
292–293.
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were available. In 2003, the FDA
approved new dosage forms of
atropine sulfate, approved since 1973
for adults, for use in children and
adolescents after nerve-agent
exposure.31 However, the continued
absence of a combination pediatric
autoinjector in the United States,
which is critical to the successful
treatment of central nervous system
and muscular toxicity from nerve
agents, leaves the use of standard,
multidose vials as the only
therapeutic option. To address this
issue, consensus guidelines now
recommend that children
weighing 13 kg or more (2–3 years of
age or older) receive a 600-mg
dose of pralidoxime from an
autoinjector because this
pralidoxime dose falls within the
range of safety for the drug.32
Children weighing less than 13 kg can
receive the customary weight-based
(20–50 mg/kg) dose, administered
from a multidose vial; if the multidose
vial is unavailable, an autoinjector
could be used. Repeat dosing of
atropine may be necessary to mitigate
secretions.
Built Weapon NATO Codes
Tabun GA
Sarin GB
Soman GD
VX gas VX
Lewisite L —
Mustard gas HD
Nitrogen mustard — —
— —
— —
— —
Phosgene CG
Nitrogen oxides NOx
Hydrogen cyanide AC
— —
— —
3-quinuclidinyl benzilate BZ
Cannabinoids — —
Barbiturates — —
Fentanyl derivatives — —
Lacrimators: Chloroacetophenone CN
Chlorobenzylidene CS
Other aspects of care to children who
have been exposed to nerve agents
are found in recent reviews.29,33
Blistering Agents (Vesicants)
Vesicants include sulfur mustard and
lewisite, an arsenic-based blistering
agent first used in World War I.
British antilewisite (dimercaprol) was
developed in subsequent years and
mitigated the risk to allied soldiers in
World War II; it remains useful today
as an antidote in some cases of heavy-
metal poisoning.34 The vesicants,
released as aerosols, produce
erythema, burning, vesiculation, and
then desquamation of the skin.
Victims of blistering-agent exposure
typically develop skin tingling, then
burning; within 24 hours, skin
sloughing begins to occur, with
wounds having the appearance of
partial-thickness burns. These
agents -are also immunosuppressive,
further increasing the risk of severe -
infection. Treatment is largely
supportive. Important principles of
management include topical
decontamination and PPE use to
protect health care professionals.35
Weapon of Opportunity
Pesticides
Nicotine
Organophosphates
Carbamates
—
Ammonia
Bromine
Chlorine
Perfluoroisobutylene (Teflon) and other chemical polymers
Smoke, products of combustion
Industrial cyanide
Sodium azide
Carbon monoxide
Anticholinergics
Lacrimators
Capsaicin
 Irritants (Corrosives)
The irritants and corrosives include
common chemicals such as ammonia,
bromine, and chlorine, which can
affect the skin, eyes, mucous
membranes, gastrointestinal tract,
and predominantly, the upper
and lower respiratory tracts.
Decontamination includes copious
water irrigation of the skin and eyes;
management is mainly supportive,
but the risk of delayed pulmonary
injury remains for 24 hours.36 The
Assad regime in Syria has used
chlorine gas against civilians, causing
at least 1 pediatric death.2,37
Choking Agents
Choking agents are created to
produce, usually in delayed fashion,
pulmonary injury: bronchospasm,
pulmonary edema, and respiratory
failure. Immediate symptoms
include eye burning, tearing, and
blepharospasm. The major agent of
this group is phosgene; however,
common industrial chemicals,
including polytef (Teflon) and other
chemical polymers, act as choking
agents depending on their ambient
concentration. Most choking agents
are heavier than air, which could
produce higher concentrations at the
breathing level of the child.
Treatment is supportive.
Asphyxiants (Cyanogens and Carbon
Monoxide)
The asphyxiants include the
cyanogens and carbon monoxide,
often generated in fires. Victims of
asphyxiant exposure must be
recognized promptly to remove them
from the source and to administer
life-saving antidotes.
The cyanogens (cyanide salts and
sodium azide) interrupt cellular use
of oxygen, producing respiratory
distress, coma, metabolic acidosis,
and lactic acidosis. In the United
States, the traditional cyanide
antidote “kit” was amyl nitrite
inhalation or sodium nitrite injection—
which generates methemoglobin—
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followed by sodium thiosulfate, which
reacts with methemoglobin and
converts the potentially lethal
cyanide ion to the stable thiocyanate
ion. Hydroxocobalamin is a newer
option that acts more rapidly than
thiosulfate and avoids the additional
hazard of the methemoglobin
intermediate.38
Carbon monoxide, a potential weapon
of opportunity, binds avidly to
hemoglobin and other hemoproteins,
interfering with oxygen transport and
tissue delivery, and may lead to
nonspecific symptoms that mimic
viral infections. After immediate
removal from carbon monoxide
exposure, victims will benefit from
receiving 100% oxygen administered
via a nonrebreather mask. The degree
of illness rather than specific
carboxyhemoglobin levels can guide
treatment; some experts recommend
consultation with a hyperbaric
oxygen facility for more severe
cases.39
Disabling (Incapacitating) Agents
Disabling or incapacitating agents
include several different chemical
classes (eg, anticholinergic agents,
hallucinogens, cannabinoids, and
fentanyl derivatives). In the 2002
Russian theater hostage incident,
a fentanyl-based disabling agent
may have been released during the
rescue effort. The agent, although
successful in overwhelming the
hostage-takers, also killed 127
hostages.40
Many disabling agents are weapons
of opportunity, easily acquired
pharmaceutical agents, or
substances of abuse that are added
surreptitiously to common sources of
food or drink.
Included among disabling agents are
lacrimators. Often referred to
collectively as Mace or “tear gas,”
lacrimators include the chemicals
chloroacetophenone and
chlorobenzylidene as well as
capsaicin (“pepper spray”).
Lacrimators are designed to produce
incapacitation from irritation of the
eye and other mucous membranes.
Exposure to lacrimators leads to eye
burning, tearing, and blepharospasm;
victims may become temporarily
blind. Inhalation produces mouth
pain, shortness of breath, and, in
rare cases, laryngospasm. Because
capsaicin is widely sold as a nonlethal
weapon, episodes of capsaicin release
into the ventilation system of schools
and buildings are a relatively
common prank, although such
incidents meet the definition of
terrorism.41
Biological Agents
Most of the biological agents that
could be used as weapons are now
discussed in the AAP Red Book,6
although some agents (eg, ricin) are
not discussed in detail. Ricin is
discussed in a subsequent section of
this report.
The biological agents of concern are
listed in Table 3. These agents have
been placed by the CDC into
categories A, B, or C. Thirty-nine
agents are included in these 3
categories.
Category A agents are considered
the greatest public health threat
because of their potential ease of
dissemination, resulting high
morbidity and mortality, and
potential to cause public panic and
need for special actions for public
health preparedness. Currently, there
are 6 agents in this group, including
the pathogens that cause anthrax,
botulism, plague, smallpox, tularemia,
and the viral hemorrhagic fevers,
specifically filoviruses (Ebola and
Marburg viruses) and arenaviruses
(Lassa and Machupo viruses).
Detailed descriptions of these agents
have been published in the AAP Red
Book and elsewhere.6,42 The second
highest-priority agents (category B)
are moderately easy to disseminate,
with moderate morbidity and low
mortality. Category B agents also
require additional enhancements of
7
 CDC diagnostic and surveillance
capabilities (Table 3). Category C
agents are of concern because of their
future potential to be engineered for
mass dissemination, with attendant
major health impact with high
morbidity and mortality. Mycotoxins
are toxins produced by fungi. Agents
of primary concern, trichothecenes
and aflatoxins, have properties of
both chemical weapons and biological
weapons and could be used in
chemical warfare (Tables 1 and
2).43,44
Smallpox (Variola)
Until the Ebola virus epidemic in
2013–2016, the most widely
discussed category A agent was
Variola major, the agent that causes
smallpox. Initial CDC smallpox
immunization efforts initiated in
2002 included a “ring immunization”
(surveillance and containment)
strategy in the United States.45,46
Subsequently, the CDC recommended
a 3-phase plan for smallpox
immunization of health care
professionals and other individuals,
although the program met with only
limited success in the first phase of
vaccination of health care
professionals in acute-care facilities.42
A high rate of vaccine refusal by
health care professionals, concerns
about the safety of the vaccine,
extensive contraindications to the
vaccine, and the appearance of
unrecognized adverse effects from
the vaccine (eg, fatal cardiac
disease)47,48 hampered the
program.49,50 In 2015, the CDC and
AAP published updated clinical
guidance for use of the 3 smallpox
vaccines in the US Strategic National
Stockpile (SNS) for people at risk for
smallpox infection after an intentional
or accidental release of the virus.43
Ricin
Although it is a category B agent, ricin
has become a major biological
weapon of concern because it is 1 of
the most toxic biological agents
known. A plant-derived, heat-stable
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toxin, ricin is an extract of the castor a congressional post office in January
bean (Ricinus communis). Ricin acts 2004. In June 2006, the CDC
by inhibition of protein synthesis of developed a comprehensive guideline
cells, ultimately resulting in cell for public health and medical officials
death. Rapidly dividing tissues, in response to a ricin incident.52 As
particularly the gastrointestinal recently as 2013, the Federal Bureau
epithelium, are most susceptible to of Investigation responded to reports
ricin actions. With these effects, ricin of suspicious letters received at mail
produces severe morbidity and facilities that contained ricin.53
mortality.
Ricin is a versatile agent that can be Syndromic Surveillance
administered by ingestion, inhalation,
Overt acts of chemical and biological
or injection. When ingested, it can
terrorism such as the sarin release in
produce a syndrome of severe
Tokyo present the challenge of
gastrointestinal upset, vomiting,
rapidly identifying the agent and
hemorrhagic gastroenteritis, shock,
mobilizing the proper interventions.
and cardiovascular collapse. After
However, acts of chemical and
inhalation, respiratory distress with
biological terrorism may also be
a necrotizing pneumonitis may occur.
covert. Examples include the cyanide
Injection produces rapid shock and
contamination of Tylenol (1982),54
cardiovascular collapse. Treatment is
the release of anthrax (2001), and the
supportive. A vaccine against ricin is
nicotine contamination of ground
currently under development.
beef (2003).18 Covert incidents pose
Ricin has been associated with a significantly greater public health
terrorist activity in the United States challenge and are more likely to
on multiple occasions, particularly as induce widespread fear than overt
an agent sent through the mail. In events. Mechanisms for early
October 2003, 2 ricin-containing recognition of a covert chemical or
letters were found in the US postal biological event, therefore, are
system.51 In a third incident, ricin necessary to contain the incident and
was found in the mail sorter of minimize its impact.
TABLE 3 Biological Weapons of Concern
Weapon Category
Category A
Anthrax (Bacillus anthracis)
Botulinum (Clostridium botulinum toxin)
Plague (Yersinia pestis)
Smallpox (Variola major)
Tularemia (Francisella tularensis)
Viral hemorrhagic fevers (filoviruses [eg, Ebola, Marburg] and arenaviruses [eg, Lassa, Machupo])
Category B
Brucellosis (Brucella species)
Epsilon toxin of Clostridium perfringens
Food-safety threats (eg, Salmonella species, Escherichia coli O157:H7)
Glanders (Burkholderia mallei)
Melioidosis (Burkholderia pseudomallei)
Psittacosis (Chlamydia psittaci)
Q fever (Coxiella burnetii)
Ricin toxin from Ricinus communis (castor beans)
Staphylococcal enterotoxin B
Typhus (Rickettsia prowazekii)
Viral encephalitis (alphaviruses [VEE, EEE, WEE])
Water safety threats (eg, Vibrio cholerae, Cryptosporidium parvum)
Category C
Emerging threat agents (eg, Nipah virus, hantavirus)
EEE, eastern equine encephalomyelitis; VEE, Venezuelan equine encephalomyelitis; WEE, western equine encephalomyelitis.
 Syndromic surveillance, a specialized
type of outbreak detection, is a term
used to describe mechanisms for
monitoring health indices or events
that reflect the early stages of
a chemical release or of an infection
or disease of public health
importance to minimize
consequences.55,56 Syndromic
surveillance is considered an
important means of identifying public
health emergencies in their initial
stages. Syndromic surveillance
techniques, summarized below, can
be clinician based or automated.
Many syndromic surveillance systems
are based in hospital emergency
departments.
Astute Clinician
The traditional mechanism of
detection of an unusual occurrence
has been the clinician who recognizes
atypical patterns of symptoms, signs,
or disease and reports them to public
health authorities. The “astute
clinician” principle places all health
care professionals (including
physicians, advanced practice
providers, nurses, paramedics,
emergency medical technicians,
infection preventionists,
laboratorians, pharmacists,
epidemiologists, and health
educators) in the role of sentinels for
the appearance of disease clusters or
other clinical abnormalities. It is
important to identify and work with
those who may already have
a defined role in syndromic
surveillance. For example, school
nurses have an established or
particular role in this area, and there
are other professionals with these
capabilities. The pivotal role of
physicians and other health care
professionals in surveillance,
particularly for acts of terrorism, has
led the CDC and other agencies to
educate clinicians about chemical and
biological weapons release and the
diseases they produce. Clinical cues,
case definitions, and syndromes for
chemical weapons exposure have
been published (Table 4) along with
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numerous resources to expand
clinicians’ ability to recognize covert
terrorist incidents.25,50,57
To facilitate uniform reporting among
local, state, and federal authorities
after unintentional or intentional
releases of chemical agents, the CDC
has developed case definitions for
illness.51
Automated Systems
Recently, there has been a rapid
increase in the development of real-
time, automated syndromic
surveillance tools. Such automated
decision support uses software to
identify sentinel events such as an
unusual amount of work or school
absenteeism, changes in consumer
purchase of over-the-counter
products (eg, antipyretics or cough
syrups), and changes in the chief-
complaint profile among those who
visit primary care physicians or
hospital emergency
departments.58–60
The CDC BioSense Platform (www.
cdc.gov/nssp/biosense/index.html) is
an integrated, national surveillance
system that gathers data from
diagnosis codes included in electronic
medical records to enhance
situational awareness for an all-
hazards approach. The DHS BioWatch
Program (www.dhs.gov/biowatch-
program) provides early warning of
a bioterrorist attack in more than 30
major metropolitan areas across the
country.
A number of surveillance studies have
attempted to use the massive volume
of data on the Internet to inform
rapid epidemic detection. Various
surveillance tools, such as the
Program for Monitoring Emerging
Diseases–Mail (available at www.
promedmail.org; International Society
for Infectious Diseases) and
HealthMap (available at www.
healthmap.org; Boston Children’s
Hospital), which aggregates content
from the Program for Monitoring
Emerging Diseases–Mail and other
sources, are capable of providing
alleged outbreak signals ranging from
days to months before official
reports.61,62
Crowdsourcing
An unconventional and unplanned
type of syndromic surveillance has
arisen in recent years with the advent
of mobile devices and social media
applications. For example, in the 2013
intentional release of sarin gas near
Damascus, Syria, many individuals
recorded videos of the atrocity that
killed 1400 civilians; Rosman et al63
searched the YouTube Web site for
videos that had been uploaded in the
weeks after the release. Many of these
videos documented significant
clinical signs—including dyspnea,
diaphoresis, and syncope—and also
revealed problems with the use of
PPE, decontamination strategies,
and antidote administration.
Nonclinicians contributed
“crowdsourced” data, in effect, to
syndromic surveillance. Although
there were no chemical or biological
releases at the 2013 Boston Marathon
bombings, investigators were able to
identify specific keywords that were
posted within minutes of the
explosions on the social media site
Twitter before any reports were
issued from public safety officials or
traditional news media outlets.64
Governmental Roles in Emergency
Preparedness
Although emergency preparedness
legislation existed before 2001, the
passage of additional rules has
resulted in efforts by the federal
government to improve public health
readiness across the nation (Table 1)
despite federal budgets remaining flat
for more than a decade and state and
local budgets declining for public
health and emergency response. In
contrast, there has been an escalating
need to ensure the safety of all US
citizens. Established in 2002, the DHS
is the main federal agency that leads
efforts to protect the US population
against chemical, biological, and
9
 TABLE 4 Clinical Syndromes Associated With Chemical and Biological Agents
Category
Cellular hypoxia
Cholinergic crisis
Gastrointestinal illness
Lacrimation
Mucosal irritation
Muscle rigidity
Muscle weakness
Peripheral neuropathy
Respiratory distress,
acute onset
Respiratory distress,
delayed
Clinical Syndrome Potential Etiologies
Altered mental status, dyspnea, seizures, and/or metabolic acidosis Cyanide, carbon monoxide, hydrogen sulfide,
and/or sodium azide
Salivation, diarrhea, lacrimation, bronchorrhea, diaphoresis, miosis, fasciculation, Nicotine, nerve agents, and/or
weakness, bradycardia, altered mental status, and/or seizures organophosphates
Abdominal pain, vomiting, profuse diarrhea, hypotension, and/or cardiovascular Ricin, staphylococcal enterotoxin E, arsenic,
collapse and/or Ebola
Tearing, blepharospasm, and/or incapacitation Lacrimators (Mace), ammonia, and/or
halogens (chlorine, bromine)
Tearing, nose and mouth burning, and/or sore throat Ammonia and/or halogens
Generalized muscle contractions, painful neck and/or limb spasm, and/or seizurelike Strychnine
activity
Generalized muscle weakness, ptosis, and/or respiratory embarrassment Botulism
Muscle weakness or atrophy, “stocking-glove” sensory loss, and/or depressed or Arsenic and/or thallium
absent deep tendon reflexes
Cough, wheeze, shortness of breath, and/or generalized mucosal irritation Ammonia and/or halogens
Cough, respiratory distress, wheeze, hypoxia, and/or pulmonary edema Phosgene and/or sulfur mustard

radiation threats. Specifically, the DHS
strives to secure the nation from
many threats (eg, aviation, border
security, cyber security, and
emergency response). Mission areas
include preventing terrorism and
enhancing security, managing the US
borders, administering immigration
laws, securing cyberspace, and
ensuring disaster resilience. Within
the DHHS, the ASPR was established
in 2006 to minimize the adverse
health consequences from disasters.
The ASPR has led the development of
the National Health Security Strategy
and oversees implementation of the
National Biodefense Strategy.65,66 The
ASPR continuously identifies and
addresses gaps in coordinating
patient care and transportation in
disasters, especially for coalitions and
states. The ASPR also offers support
in this area through the federally
funded Hospital Preparedness
Program, which is now focused on
health care coalition preparedness
efforts. The potential benefits of
regional disaster health response
systems are also being explored. The
ASPR also leads the disaster medical
assistance teams (DMATs), which
provide medical assistance to regions
after a large-scale disaster.67
Although there are individuals on
DMATs who have pediatric expertise,
personnel on DMATs are trained to
provide initial care for both adults
and children. The Medical Reserve
Corps, another federal effort designed
to create community “medical strike
teams,” has no clearly established
pediatric capability or standards
(https://mrc.hhs.gov/HomePage).
Other DHHS agencies have undergone
change; these include the CDC, FDA,
and National Institutes of Health, all
of which have reorganized practice,
regulatory, and research priorities to
include chemical and biological
terrorism, along with other public
health threats. In 2002, the CDC
established the Coordinating Office
for Terrorism Preparedness and
Emergency Response (later referred
to as the Office of Public Health
Preparedness and Response and now
renamed the Center for Preparedness
and Response), and in 2012, the CDC
launched the Children’s Preparedness
Unit to address children’s needs in
the context of infectious disease
outbreaks and other public health
emergencies. The CDC also integrated
a children’s health team into its
Emergency Operations Center
structure, beginning in 2009 with the
H1N1 influenza pandemic and
continuing through the responses
to the Ebola virus epidemic
(2013–2016); the Zika virus outbreak
in 2016–2018; the Flint, Michigan,
water contamination in 2016;
Hurricanes Harvey, Irma, and Maria in
2017; and Hurricane Michael in 2018.
At state and local levels, planning for
chemical and biological terrorism is
now coordinated by multiple
agencies, including departments of
health, emergency management
agencies, poison control centers, and
law enforcement authorities.68
Because there is variability across
states, pediatricians can inquire as to
which agencies are in charge of
planning for and responding to
chemical and biological attacks in
their local communities.
Poison Control Centers
The network of regional and state
poison control centers, funded by
federal, state, and local sources,
may be the first point of contact
for health care providers and
members of the public concerned
about possible terrorist attacks.
Callers can reach poison centers
24 hours a day via a national toll-free
number (800-222-1222), and call
data are uploaded automatically in
nearly real time (currently a median
of 9.5 minutes to upload data from all
centers) to the National Poison Data
System, maintained at the American
Association of Poison Control
Centers.69

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 SNS and Pediatric MCMs
The SNS has become 1 of the most
important initiatives in mass-casualty
disaster response.31 Designed to
respond to disasters that overwhelm
state and local resources, the SNS
includes such capabilities as the
delivery of medications and medical
supplies to areas of need within
a clinically relevant time frame. The
SNS supplies include pediatric dosage
forms and pediatric sizes of medical
supplies as well as instructions for
compounding certain tablets and
capsules into liquid formulations
for some but not all MCMs.70
Unfortunately, not all MCMs are
licensed for use in children, and not
all MCMs are available in ideal
formulations that are appropriate for
younger children. According to the
2013 US Government Accountability
Office, 40% of the MCMs in the SNS
have not been approved for pediatric
use. Of the 60% of MCMs that are
approved for children, there are many
instances when use is limited to
people of specific ages. Currently,
unapproved MCMs may be
distributed under FDA emergency use
authorization or investigational new
drug application. If an MCM is
considered under the investigational
new drug application, additional
consent would be needed, which
would be challenging to explain to
frightened parents and would likely
prolong MCM mass distribution
efforts during a public health
emergency. Ongoing efforts continue
within the ASPR to address the MCM
needs of pediatric populations in
relation to the current medications
within the SNS and make prioritized
recommendations for formulary
additions or changes. The AAP has
identified several concerns and
recommendations in its policy,
“Medical Countermeasures for
Children in Public Health
Emergencies, Disasters, or
Terrorism.”71 Even with an increased
awareness of the need, significant
barriers remain to developing,
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testing, procuring, and distributing
medications in doses and
formulations appropriate for
children.62,72 In addition, state and
local plans for medication
distribution need to be developed in
collaboration with pediatric experts
and consider children’s needs for
maximum effectiveness and
efficiency.
The Primary Care Provider and
Community Response
Pediatricians play a pivotal role in
providing care in the medical home
and supporting the community
before, during, and after a chemical or
biological attack.4 Most families will
seek medical advice from a trusted
source such as their pediatrician.
Pediatricians can emphasize the need
for family disaster preparedness
planning before an event and provide
resources such as the AAP Family
Readiness Kit.73 After an attack or
outbreak, pediatricians and their staff
will need to be knowledgeable about
the medical course for the agent of
concern and provide anticipatory
guidance to the families. Although
victims of a chemical or biological
attack may be treated initially in
hospital emergency department
settings, victims may also seek care
from the medical home. Thus,
pediatricians will need to be prepared
for a surge in communications with
patients and families, have the
appropriate PPE (and related training
on how to use the equipment), and
have developed isolation procedures.
Pediatricians will also need to be
prepared to help families care for the
long-term physical and emotional
sequelae. Additional information on
the role of the pediatrician in disaster
preparedness and response is
available.3,8
Prehospital and Hospital
Preparedness
Hospital protocols for pediatric
victims of chemical or biological
terrorism must be established in all
hospitals. These disaster protocols
require an integrated response from
the emergency department, ICU,
operating rooms, and other key
clinical areas within the hospital.
Response needs include having an
adequate number of pediatric
supplies and staff members trained in
the care of ill children, including
pediatric medication weight-based
dosing (milligrams of medication per
kilogram of body weight) to minimize
morbidity and mortality.3,31,74,75 The
needs of children with chronic health
conditions as well as physical and
intellectual disabilities need to be
considered in the disaster plan. All
hospitals should have disaster
protocols for pediatric patients,
including mobilization of child-life
specialists, volunteers, and others
such as behavioral health
professionals who can provide
comfort to and minimize the stress of
children, particularly if those children
are separated from their parents. For
hospitals that do not treat large
numbers of children, telehealth and
telementoring technologies offer
access to information and to pediatric
subspecialists to facilitate the care of
children.76 In addition, hospitals
participating in a regional coalition
may be asked to provide care for
victims far away from the
affected site.
To be fully prepared for chemical or
biological terrorism, pediatric and
general hospitals must also have an
evacuation plan for times when the
hospital environment becomes
uninhabitable. Although protocols for
“vertical evacuation” (ie, the removal
of patients to other areas or floors
within the same building) are well
established in hospital-based disaster
response, comprehensive plans for
complete building evacuation are less
well developed. Pediatric hospitals
requiring full evacuation may have
the additional challenge of
transporting pediatric patients to
health care facilities with relatively
few pediatric resources. Nonetheless,
memoranda of agreement with
11
 nearby or affiliated institutions and
regional alliances are a key part of
a comprehensive pediatric hospital
disaster plan.
Decontamination
Several investigators have focused on
the logistics of prehospital and
hospital preparedness. In a study of 2
mass decontamination field exercises,
investigators in the United Kingdom
used radio-frequency identification
tags and detection mats to examine
bottlenecks in the process. Computer
analysis revealed that bottlenecks
occurred at specific phases of the
process (eg, the redressing or
“rerobing” that followed
decontamination showers), and
subsequent simulations revealed that
shortening the duration of showers
and adding capacity in the rerobing
area could improve throughput of
casualties.77
After exposure to a chemical or
biological weapon, children may
become covered by toxic material that
can produce skin injury or be
absorbed, producing systemic
toxicity. In the case of infectious
material, the contamination of skin
could be sufficient to represent
a threat to health care professionals
as well as the victim. When children
are covered with unknown but
potentially dangerous chemical or
infectious material, immediate
decontamination is required.78 To
minimize exposure to health care
professionals and patients within the
health care facility, the child should
be disrobed outdoors—as per
Occupational Safety and Health
Administration regulations—before
entering the ambulance or building,
with attention to prevention of
hypothermia, as noted below. Plans
should address the collection of
contaminated water. Disrobing alone
accounts for more than 85% of
topical decontamination and is an
extremely effective means of ending
exposure. In the Tokyo sarin
experience, it was determined that
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removal of clothing can eliminate
pockets of trapped gas.79 When
possible, the victim should disrobe
himself or herself to minimize
exposure to others. Health care
professionals should not assist in
disrobing unless they are wearing
appropriate PPE.68
There is some debate about the
merits of dry decontamination
(removal of clothing, scraping,
absorbent or adsorbent materials,
vacuuming, pressurized air, provision
of replacement clothing) alone versus
wet decontamination, which adds
showering to topical
decontamination. The decision to use
dry versus wet decontamination may
depend, for example, on the presence
of clearly visible contamination or
evidence of a blistering agent.66
Showering further removes
chemicals, microbes, and debris. As
with disrobing, showering usually
happens outdoors. However, some
institutions may have specially
designed indoor hazmat
decontamination facilities. Protocols
should include strategies for using
warm water and low-pressure
showers (to avoid trauma to the skin),
etc, to prevent hypothermia in
children, as well as methods for the
collection of contaminated water.
Principles of showering include the
establishment of 3 management
zones in the decontamination staging
area (hot [maximum contamination],
warm [less contamination]), and cold
[no contamination] zones), use of
water that has been warmed to
a temperature of 100°F, a water
pressure of 60 lb psi, and
containment of the wastewater. If the
toxic material is oily or firmly
adherent to the child’s skin, a mild
soap or shampoo should be used;
solutions such as mild bleach should
not be used on children because of
the risk of skin injury.31 If an outdoor
shower is not available, the child can
be simply disrobed before being
brought into the health care facility
for further care. Decontamination can
be a frightening procedure for
children, exacerbated by the identity-
concealing PPE that clinicians are
wearing. Efforts can be made to keep
parents nearby and families intact;
when possible, parents should remain
with their child to offer psychological
support and assist with their child’s
decontamination.80
A number of studies have explored
various materials—including water—
for decontamination. One preliminary
study of water-only decontamination
of an oil-based, mock chemical-
biological agent suggested that 100%
of subjects could be decontaminated
within 90 seconds.81 Although
proprietary agents are available for
specific types of exposures, a review
of corrosive dermal exposures found
that water is efficacious, widely
available, and inexpensive.82 In
specific, known exposures, other
decontamination agents may be more
effective: a study of the molecular
tracer 4-cyanophenol found that
decontamination efficiency from
porcine skin was 54% with water, up
to 70% with dry fuller’s earth, and
around 90% with a suspension of
fuller’s earth.83 In terms of wet
versus dry decontamination, another
study of absorbent materials in an
ex vivo model indicated that dry
decontamination was superior to wet
methods for removing liquid
contaminants but was not effective
against particulate matter.84
The consensus among investigators,
however, is that time is the single
most important factor in successful
decontamination.85 In most cases,
decontamination is most successful if
performed within minutes of
exposure, which has the added
benefit of mitigating the demand on
health care facilities. This has
introduced the concept of self-care
decontamination and the mnemonic
MADE: move and assist, disrobe and
decontaminate, evaluate and
evacuate.86
FROM THE AMERICAN ACADEMY OF PEDIATRICS
 All health care professionals who
assist in decontamination must
protect themselves by wearing
appropriate PPE.87 Currently, there
are 4 levels of PPE, ranging from level
A, which is the highest level of
protection, to level D, which consists
of a simple gown, gloves, and surgical
mask. Many exposed subjects self-
present to health care facilities.
For hospital personnel, level C PPE
(a chemical-resistant suit and
gloves, with an air-purifying
respirator) is considered adequate
for hospital-based management
of most contaminated victims.
Health care facilities can develop
plans for rapid access to PPE
equipment and train staff on its
use. Other recently published
principles of decontamination
and PPE are outlined in
Table 5.88,89
Isolation and Containment
In the current era, hospitals and
health clinics need to develop
protocols to be vigilant in screening,
isolating, and starting treatment of
patients with highly contagious
emerging infectious diseases. Ideally,
integrated communication systems
will be in place to help clinicians
identify pediatric patients with
concerning travel history and
possible exposures to an emerging
infectious disease. Clinicians can
become better prepared by knowing
how to contact local and state public
health officials if there is concern of
a highly contagious pathogen, an
emerging infection, or a cluster of
illness. Preparation for the
2013–2016 Ebola virus outbreak has
led to federally identified
biocontainment treatment centers in
each US region, including, in some
cases, tertiary care pediatric
hospitals. Institutions caring for
a child with a high-consequence
pathogen require policies that include
and recognize the developmental and
psychological needs of children as
well as policies that address parental
presence and the use of age-
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appropriate equipment and triage, ideally outside of the hospital;
supplies.90,91 (5) identification of care sites for
those whose injuries are minor; (6)
Surge Capacity mechanisms for labeling and tracking
An effective response to large-scale patients, particularly children who
chemical or biological terrorism (ie, arrive without personal identification
an incident with more casualties than and may not be able to identify their
routine operations can accommodate) parents; and (7) plans for
requires the creation of surge maintaining hospital security by
capacity protocols. Federal, state, and preventing the entry of contaminated
local public health authorities are victims and other unauthorized
essential in assisting health facilities individuals.94,95 For nonpediatric
during crises of large magnitude. hospitals, surge capacity plans for
Crisis standards of care have been a mass-casualty chemical or biological
reviewed and established at all incident involving children can
levels.92 Definitive care of pediatric include mechanisms for mobilizing
patients is increasingly dependent on health care professionals with
interhospital transfers and referral pediatric expertise, including
centers.93 Lack of disaster planning telemedicine. Surge capacity
for children in local health care principles are summarized in Table 6.
facilities will impede and complicate
the care of children. Because disasters Pediatric Mental Health
happen locally, all health care systems Given that the primary intent of
must consult with pediatric experts terrorist attacks is to cause
and plan for the needs of children psychological distress among victims,
during a disaster. Plans for such an witnesses, and the general
event might include (1) the creation population, it is to be expected that
of additional bed spaces through adjustment reactions will be a major
cohorting; (2) mechanisms for the challenge—if not the primary
rapid discharge of inpatients to challenge—after chemical and
increase capacity; (3) an inventory of biological terrorism, for both children
all sites in the hospital where critical and adults. Children are among those
care can be provided; (4) most at risk for psychological trauma
establishment of a site for patient and behavioral difficulties after
TABLE 5 Principles of Decontamination
Principles
All decontamination should occur outside of the health care facility.
All health care professionals should wear appropriate PPE, as determined by their safety officer and
occupational health specialist.
All levels of health care professionals should be trained to quickly access and use PPE, including
physicians, nurses, clinical assistants, security, and environmental services.
Remove clothing from the victims as quickly as possible. Victims should disrobe themselves when
possible.
Discarded clothing should be placed in a labeled plastic bag and stored for possible use by law
enforcement.
Consider dry (removal of clothing, scraping, absorbent or adsorbent materials, vacuuming, pressurized
air, and/or provision of replacement clothing) versus wet decontamination (addition of showers).
If showering is used, ensure the following:
The water should have a temperature of approximately 100°F and a pressure of 60 psi.
Water alone is used routinely. If the material is oily, a mild soap or shampoo should be added.
Victims should shower for 5 min unless specific alternative recommendations are given.
When possible, water effluent should be contained rather than placing it in the local wastewater
stream.
Use heat lamps, blankets, and other mechanisms to prevent hypothermia.
Cover hands, feet, and other exposed areas of the victim if there is evidence of gross contamination.
If there are multiple victims, anticipate the need to perform out-of-hospital triage.
13
 a disaster and will also be influenced
by their parents’ reactions and by
coverage in social and public media.
Children may experience short- and
long-term effects on their
psychological functioning, emotional
adjustment, and developmental
trajectory. Adjustment reactions may
include anxiety, worries, or fears;
sadness or depression; difficulties
with concentration and learning;
developmental or social regression;
sleep or eating problems; substance
abuse or other risk-taking behavior;
posttraumatic reactions and
disorders; bereavement when deaths
have occurred; and somatization.
These reactions may be seen even
among children in the community
who have had no direct or indirect
exposure to the chemical or biological
agents. These reactions may
persist long after an event, which
should be a consideration for those
children who have escaped countries
where such terrorist attacks are
known or believed to have occurred
in the past.
Emotional distress may interfere with
accurate reporting of symptoms or
instead mimic physical responses to
the chemical or biological agents.
Primary and subspecialty care
pediatricians will often be the first to
see children experiencing
psychological distress in this setting,
whether it presents as physical
complaints, an adjustment reaction to
the terrorist attack, or a combination.
Given that virtually all children in
a community affected by a terrorist
attack are likely to experience some
degree of emotional distress and
anxiety, it is critical that pediatricians
become comfortable in the
assessment and acute management of
adjustment reactions and mental
health problems that may be seen.
Pediatricians should be prepared to
provide psychosocial support,
psychological first aid, and
psychoeducation in addition to
evaluation and referral to mental
14
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TABLE 6 Surge Capacity Principles for Hospitals
Principles
Preparation
Obtain PPE, showers, and other emergency-response equipment
Stockpile pediatric supplies
Stockpile or plan for additional pediatric pharmaceuticals
Perform drills; consider tabletop exercises using pediatric victims
Familiarize with wt-based dosing (eg, milligrams of medication per kilogram of body wt) for pediatric
emergency medicines
Response
Anticipate a 1:5:7 ratio of critically ill/urgently ill (“walking wounded”)/well (“worried well”)
casualties96,97
Anticipate the “second-wave” phenomenon98
Reserve the emergency department for critically ill patients
Perform triage and decontamination outside of the hospital
Put protocols in place to prevent campus security from unauthorized intrusion
Identify and use alternate sites of care; identify transportation options
health specialists when indicated and there continue to be gaps in
resources allow.5 incorporating children into disaster
planning, especially with respect to
Pediatricians who live in communities the use of pediatric MCMs. Pediatric
affected by terrorist attacks are likely health care providers will need to
to be worried about the health of be knowledgeable of possible agents
family, friends, and themselves. They and sequelae to provide optimal
may find the delivery of care medical and mental health
exhausting and emotionally draining management for children exposed
given the surge in health care needs to chemical or biological terrorism.
(in most cases predominantly Pediatric health care providers
because of the large number of will need to be trained on pediatric
individuals with psychological decontamination strategies as
distress), the uncertainty of providing well as the use of PPE. Pediatric
care during an evolving crisis for health providers can also help
which the pediatrician has limited their communities with chemical
information and experience, and the and biological preparedness and
distress that results from delivering response activities.
compassionate care and witnessing
the suffering of children and their
families, pediatric colleagues, and LEAD AUTHORS
the pediatrician’s own family and Sarita Chung, MD, FAAP
friends. Attention to self-care Carl R. Baum, MD, FACMT, FAAP
Ann-Christine Nyquist, MD, MSPH, FAAP
and support of professional
colleagues is an important component
of the response to the crisis DISASTER PREPAREDNESS ADVISORY
throughout the long-term recovery COUNCIL, 2018–2019
period.5 Steven E. Krug, MD, FAAP, Chairperson
Sarita Chung, MD, FAAP
Daniel B. Fagbuyi, MD, FAAP
Margaret C. Fisher, MD, FAAP
CONCLUSIONS
Scott Needle, MD, FAAP
The threat of a chemical or biological David J. Schonfeld, MD, FAAP
attack remains high. Children can be
the intended target or part of the LIAISONS
targeted group. Although advances
John J. Alexander, MD, FAAP – US Food and
have been made in surveillance, Drug Administration
pediatric disaster education, Kevin M. Chatham-Stephens, MD, FAAP –
decontamination, and awareness, Centers for Disease Control and Prevention
FROM THE AMERICAN ACADEMY OF PEDIATRICS
 Daniel Dodgen, PhD – Office of the Assistant
Secretary for Preparedness and Response
Sangeeta Kaushik, MD, MPH – US Department
of Homeland Security
Shana Godfred-Cato, DO, FAAP – Centers for
Disease Control and Prevention
Georgina Peacock, MD, MPH, FAAP – Centers
for Disease Control and Prevention
Erica Radden, MD, FAAFP – US Food and
Drug Administration
Robert F. Tamburro, Jr, MD, FAAP – Eunice
Kennedy Shriver National Institute of Child
Health and Human Development
Mary H. Ward, PhD – National Cancer Natasha B. Halasa, MD, MPH, FAAP –
Institute Pediatric Infectious Diseases Society
Nicole Le Saux, MD, FRCP(C) – Canadian
Paediatric Society
STAFF Scot Moore, MD, FAAP – Committee on
Practice Ambulatory Medicine
Paul Spire Neil S. Silverman, MD – American College of
Obstetricians and Gynecologists
Jeffrey R. Starke, MD, FAAP – American
COMMITTEE ON INFECTIOUS DISEASES, Thoracic Society
2018–2019 James J. Stevermer, MD, MSPH, FAAFP –
American Academy of Family Physicians
Yvonne A. Maldonado, MD, FAAP,
Kay M. Tomashek, MD, MPH, DTM – National
Chairperson
Theoklis E. Zaoutis, MD, MSCE, FAAP, Vice Institutes of Health

STAFF Chairperson
Ritu Banerjee, MD, PhD, FAAP STAFF
Laura Aird, MS Elizabeth D. Barnett, MD, FAAP
Sean Diederich James D. Campbell, MD, MS, FAAP Jennifer M. Frantz, MPH
Tamar Magarik Haro Jeffrey S. Gerber, MD, PhD, FAAP
Athena P. Kourtis, MD, PhD, MPH, FAAP
Ruth Lynfield, MD, FAAP
COUNCIL ON ENVIRONMENTAL HEALTH Flor M. Munoz, MD, MSc, FAAP
EXECUTIVE COMMITTEE, 2018–2019 Dawn Nolt, MD, MPH, FAAP
ABBREVIATIONS
Jennifer Ann Lowry, MD, FAAP, Chairperson Ann-Christine Nyquist, MD, MSPH, FAAP
Samantha Ahdoot, MD, FAAP Sean T. O’Leary, MD, MPH, FAAP AAP: American Academy of
Carl R. Baum, MD, FACMT, FAAP Mark H. Sawyer, MD, FAAP Pediatrics
Aaron S. Bernstein, MD, FAAP William J. Steinbach, MD, FAAP
Aparna Bole, MD, FAAP Tina Q. Tan, MD, FAAP ASPR: Office of the Assistant
Lori G. Byron, MD, FAAP Secretary for Preparedness
Philip J. Landrigan, MD, MSc, FAAP and Response
Steven M. Marcus, MD, FAAP EX OFFICIO CDC: Centers for Disease Control
Susan E. Pacheco, MD, FAAP
David W. Kimberlin, MD, FAAP – Red Book and Prevention
Adam J. Spanier, MD, PhD, MPH, FAAP
Editor DHHS: Department of Health and
Alan D. Woolf, MD, MPH, FAAP, FAACT,
Henry H. Bernstein, DO, MHCM, FAAP – Red Human Services
FACMT
Book Online Associate Editor
H. Cody Meissner, MD, FAAP – Visual Red
DHS: Department of Homeland
Book Associate Editor Security
LIAISONS
DMAT: disaster medical
John M. Balbus, MD, MPH – National Institute
assistance team
of Environmental Health Sciences
Nathaniel G. DeNicola, MD, MSc – American
LIAISONS FDA: Food and Drug
College of Obstetricians and Gynecologists Amanda C. Cohn, MD, FAAP – Centers for Administration
Ruth A. Etzel, MD, PhD, FAAP – US Disease Control and Prevention MCM: medical countermeasure
Environmental Protection Agency Jamie Deseda-Tous, MD – Sociedad PPE: personal protective
Natalie Villafranco, MD, FAAP – Section on Latinoamericana de Infectologia Pediatrica
equipment
Pediatric Trainees Karen M. Farizo, MD – US Food and Drug
Mary Ellen Mortensen, MD, MS – Centers for Administration SNS: Strategic National
Disease Control and Prevention and National Marc Fischer, MD, FAAP – Centers for Disease Stockpile
Center for Environmental Health Control and Prevention

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements
with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
DOI: https://doi.org/10.1542/peds.2019-3750
Address correspondence to Sarita Chung, MD, FAAP. E-mail: sarita.chung@childrens.harvard.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2020 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: Dr Chung is the codirector for the Disaster Domain of the Emergency Medical Services for Children Innovation and Improvement Center.
Dr Baum is the medical director for a grant from the Agency for Toxic Substances and Disease Registry and American College of Medical Toxicology; advisory board

PEDIATRICS Volume 145, number 2, February 2020 15

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 member for the National Biodefense Science Board, American Board of Pediatrics and Medical Toxicology Subboard, Elsevier, and Wolters Kluwer; a shareholder at
Biogen Inc; an author at UpToDate; and an expert witness for medical testimony on lead with attorney Michael Foley.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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