National Preparedness Month: Children in Public Health Emergencies - Transcript

Moderator: Mabel Woghiren
Presenters: Jessica Franks, MPH, CHES; Robyn Cree, PhD; Cindy Hinton, PhD, MS, MPH
Date/Time: September 19, 2018, 1:00 – 2:00 pm ET

>> Good afternoon. I am Mabel Woghiren and [inaudible] fellow appointed to CDC’s office of [inaudible] preparedness and response. Division of emergency operations.
Thank you for joining us for today’s emergency partners information connection webinar tied to national preparedness month children in public health emergencies. Today we will hear from CDC’s Cindy
Hinton, Robyn Cree, and Jessica Franks. Who work in CDC’s national Center on birth defects and developmental disabilities. If you do not wish for your participation to be recorded at this time, please exit.
Before you begin– before we begin today’s presentation, we would like to inform you that we will be having a shelter in place drill on our campus at 2 PM. So that we request you have your
questions prepared for our presenters to answer during the Q&A session. Thank you so much. Today, we would just like to give a brief thanks to the Oak Reach Institute
for science education [inaudible] Jessica Franks and I are [inaudible] fellows appointed to CDC. The [inaudible] program has significantly helped CDC [inaudible] expand its emergency communication outreach efforts.
You can earn continuing education by completing this webinar. Please follow the instructions linked in the invitation you received. The course access code is E-P-I-C
0919 with all the letters capitalized. To repeat, the course access code is E-P-I-C 0919 all in caps. Today’s webinar is interactive. To make a comment, click the chat button
on your screen and enter your thoughts. To ask a question, please use the Q&A button and then the Q&A session will begin after presenters have finished. We are fortunate to have three presenters
today covering different aspects of this topic. First we have– first we will welcome Cindy Hinton. Cindy Hinton is a health scientist in the disability and health branch in the division
of human development and disability at the Centers for Disease Control and Prevention. Dr. Hinton has over 20 years’ experience with public health genetics and newborn screenings. She began her career with CDC
as an epidemiologist– sorry. As an epidemic intelligence service officer with the pediatrics genetics team. She worked on children’s health team during CDC’s Ebola response or she has worked
in the disability and health branch for three years where she continues her work in emergency preparedness. Promoting disability inclusion in
emergency preparedness at the CDC. She oversaw the development of CDC’s online emergency preparedness catalog for people with disabilities. She participated in CDC’s 2017
hurricane response as a lead for the at risk population task force and she is currently supporting the hurricane Florence response on the at risk population team.
Thanks for joining us, Cindy. Next, is Robyn Cree. Dr. Robyn Cree is an EIS officer assigned to the child development studies team and children’s preparedness
in CDC’s national Center on birth defects and development of disabilities. Her work focuses on studying risk and protective factors related
to childhood mental behavioral and developmental disorders. She has also sat on the at risk task force as part of CDC’s 2017 hurricane response. Helping to ensure that mental health needs
of children were identified and prioritized. Thanks, Robyn. And then finally, we have Jessica Franks Jessica Franks is and [inaudible] fellow working as a health communications specialist
for children’s preparedness unit in the national Center of birth defects and developmental disabilities. Her work advances children’s inclusion in emergency preparedness planning
and response efforts at a national state and local level. Jessica participated in CDC’s emergency response efforts for the Flint Michigan water
contamination the zika virus outbreak, and hurricanes Matthew, Harvey, Irma, and Maria. As a member of the at risk task force for child health. Thanks, Jessica.
Thank you all so much for joining us today. Please begin.

>> Thanks, Mabel. And thanks to everyone for joining the webinar today.
My name is Jessica Franks and I’m a health communications fellow for the children’s preparedness unit. In the national Center on birth defects and development disabilities.
I will be co-presenting with my colleagues Dr. Cindy Hinton and Dr. Robyn Cree both from the division of human development and disability. I’m glad we have the opportunity to speak to
you all today because as a parent, caregiver, educator, healthcare provider, or public health professional, we all have a role to play in helping children in public health emergencies.
Next slide. I’m going to start with some background on national preparedness month and why emergency preparedness for kids is so important.
I will discuss the biological and physiological differences in kids and how they are affected in the context of biological threats such as infectious disease outbreaks. Then Cindy will discuss the unique developmental
and social differences among children and in particular children with special health care needs. In the context of chemical nuclear and other threats.
To wrap it up, Robyn looks when the behavior and mental health differences in kids and focus on coping and mental health stress on kids as a result of natural disasters. Next slide.
Before we get started, I want to share some background about my team at the children’s preparedness unit. We sit in the division of human development and disability of the national Center
on birth defects and developmental disabilities. And we work closely with the office of Public health preparedness and response. Our mission is to champion the needs of children in emergency preparedness response
and we are the only team that CDC solely focused on the needs of children in emergencies. This is a key message we promote with our work. Children are 22.8% of our population and 100% of our future.
That’s more than one in five people at the US population. And it’s why emergency preparedness for kids is so important. Next slide.
National preparedness month happens every September. It provides an opportunity to remind us that we all must prepare ourselves and our families now and throughout the year.
Throughout September CDC and more than 3000 organizations national regional and local governments as well as private and public organizations are supporting emergency preparedness efforts
and encouraged Americans to take action. We have weekly themes with accompanying activities and resources to share. You can learn more about it from the link at the bottom of this page.
And for the purposes of this webinar, we will only be discussing preparedness response and recovery related to children. Next slide. Starting with what makes children different,
children are not just little adults. They have unique needs that make them more vulnerable in emergencies. As you know, public health emergencies can take many forms.
Infectious diseases and outbreaks, natural disasters, chemical disasters, nuclear emergencies, and man-made terrorist events. In any type of disaster, children
have physical biological developmental and behavioral differences that we must be aware of to keep them safe. These are just a few examples that we will break down for you starting
with developmental and social differences. Excuse me– starting with biological differences. And we want to acknowledge the importance of children of child development here as well.
Because symptoms and behaviors can manifest differently depending on the child’s age and development of stage. This means there may be different needs and responses depending
on that child’s age and developmental stage. Next slide. And now we will move on to biologic threats in the context of biological and physiological differences in children.
Next slide. A biologic threat is an infectious disease with the potential to spread and cause an emergency. Some of the more common threats you might have heard are listed here.
Infectious diseases are illnesses caused by germs such as bacteria and viruses. Some infectious diseases require close contact between two people like when people speak to each other such as flu or Ebola.
Other infectious diseases can only spread by germs carried in air, water, food, or soil. Or by animals or biting insects like we saw with the Zika virus outbreak. Biologic threats may spread naturally
as in a worldwide flu outbreak or be released intentionally in a bioterrorism attack. An example of this was the 2001– was in 2001 when anthrax was intentionally
released to cause harm. We will go over some real world examples of outbreaks and discuss why kids were disproportionately impacted by these infectious disease outbreaks.
Next slide. Here are a few examples we have seen in past years of how public health emergencies can further disproportionately affect pediatric populations.
The photo on the left is from the 2010 polio outbreak even children who seemed to fully recover can develop new muscle pain weakness or paralysis as adults 15 to 40 years later.
Zika virus outbreak was another example of the disproportionate impact of a public health emergency and children. In adults, Zika virus infection may cause mild symptoms or even no symptoms at all.
But if infection occurs prenatally, there’s a risk of the baby being born with congenital Zika syndrome. Microcephaly being the most apparent symptom of infection in utero.
Next slide. In October, 2010 and outbreak of cholera was confirmed in Haiti for the first time in more than a century. Following the catastrophic
earthquake that killed over 200,000 people and displaced over 1 million. CDC confirmed this as the worst cholera outbreak in recent history.
With over 665,000 cases and 8103 deaths. Cholera is a diarrheal infection caused by ingestion of contaminated food or water. Rapid loss of body fluids can lead to dehydration and shock.
Without treatment, death can occur within hours. We look at this in the context of children’s biological and physiological differences, we know that they have less fluid in their bodies.
This means that they have smaller reserves for the amount of fluid loss in color. Making them more prone to dehydration at a much quicker rate than adults. Next slide.
And in the case of biologic threat, children are more likely to get sick and have a more severe illness compared to healthy adults for several reasons. This is just one from the info
graphic you stop the beginning. Children absorb harmful materials from the air more readily because they breathe in more air for their size than adults. So if there is something toxic in the air
they’re going to breathe and more of it. Let’s go over a few more. Next slide. Here are a few anatomical and physiological differences that make kids more vulnerable
in the context of biologic threats. Please note that this list is not exhaustive. First children have a fast metabolism which can lead to hypo or hyperthermia faster than adults. This also increases their
susceptibility to inhale toxins. They have a higher respiratory rate so if there’s something toxic in the air they’re going to breathe in more of it.
Their more permeable skin makes them more sensitive to changes in the body temperature and losing too much body heat which can also lead to hypothermia. This also makes them more likely to take in
more harmful substances through the skin. Less fluid in their bodies makes them more prone to dehydration and other fluid loss like blood can have a bigger effect on kids. They have more active cell division
which creates a higher proportion of rapidly growing tissues and can lead to higher rates of exposure during a nuclear or radiation incident.
Which Cindy will discuss. Their immune systems are not fully developed which means they can more easily get an infection and may have a harder time
fighting off infection. This can make children especially susceptible to anything contagious. And as Cindy will cover more in the next section, germs can spread rapidly
because children typically have frequent close contact with other children or family members and they put their hands them out more often than adults do. Also they may not understand how to protect
themselves or understand the importance of safety measures like wearing a facemask or proper handwashing to prevent the spread of germs. Next slide.
Treatments for biologic threats vary depending on the germs that are causing the illness. However there are ways to protect your family in the event of an infectious disease emergency. Number one, prepare an emergency kit.
In the event of widespread illness it’s possible that services and facilities in the community like restaurants public transportation and banks will close temporarily. Similar to preparedness for
other types of emergencies, it’s important that you have essential supplies at home including at least a three day supply of food and water that spoil.
As well as any medicines that your family members need daily. Number two, stay informed. In an emergency seek out information early and often.
Public health authorities will communicate these things to you and what you can do to protect yourself and your family. The CDC will provide information through television, radio,
the Internet, or social media pages. And number three, know your family’s medical history. It may be necessary to take antibiotics receive vaccines
or take other medicines to treat infection. Healthcare professionals want to know about your family’s health and any medical problems you and your relatives have had in the past. You can help by keeping a written
medical history for your family that includes medical conditions, allergies, medicines that family members are taking and each child’s weight. Next slide.
I will share some more resources at the end of the presentation but here are a few related to some of the biologic threats we just discussed. On the left is a patron CDC’s caring
for children in a disaster website. We have a page dedicated to biological threats and children with a lot of– with a lot of helpful information. We also develop materials not
just about kids but for kids to help them take charge of their own preparedness. One example is the ready Wrigley preparedness series.
These are activity books for children to help them learn about different disasters and ways to prepare their families. We also work with the US Department of Education and the American Academy of pediatrics
to help disseminate these two teachers and healthcare providers. These are some examples of books related to biologic threats such as flu, Zika, and mold. You can access all of the books as well as
the caring for children in a disaster site through the links at the bottom of this page and at the end of this presentation. And now I will pass it over to my colleague Dr. Cindy Hinton to discuss the developmental
and social differences in children– I’m sorry – yes– with special healthcare needs in the context of chemical radiologic and nuclear threats.

>> All right.
Thank you, Jessica. And welcome, everyone. I’m delighted to be with you here today. Next slide. Next slide, please.
All right. Let’s revisit the info graphic that Jessica shared earlier and I want to highlight some issues that are particularly relevant to children, their development,
and vulnerability in a chemical or radiologic event. As she mentioned, children spend more time outside. Their lower to the ground.
Inc. of how a baby or toddler explores his world. A toddler touches its surroundings a baby puts its hand in its mouth. The child explores the world through play.
Chemical or radioactive dust from explosions will settle on the ground and objects where children are more likely to come into contact with it. Especially as they touch things
put objects in their hands in the mouth or rub their eyes and nose. Chemical gas is heavy. It sinks low to the ground. Child level.
Physically as Jessica mentioned, children will take in more substances and if they are exposed to gas, they will be taking in more of a gas and they will have more damage to their lungs after the same exposure as an adult.
Radiation effects rapidly dividing cells. Earlier Jessica mentioned that children have rapid metabolism and cell division. Because of their growing bodies, children are extremely vulnerable to radiation.
Depending on the exposure, children can experience damage to their cardiovascular system, their central nervous system such as developing brain their
guts, and the bone marrow. This can lead to childhood cancers or increased occurrence of cancers in adulthood. Socially, children are dependent on caregivers whether this be a parent or another adult,
and what I would like to add here is that children are dependent on adults because they may not have that same cell– that same sense of self-preservation as an adult. They won’t necessarily recognize risk.
Therefore a chemical attack might look like a white cloud and they do not recognize the danger. Next slide, please. What are chemical and radiologic threats
chemical and radiological threats result from industrial accidents, transportation accidents, sabotage, acts of terrorism or war. And I’ve listed a few examples here. That the first one 4-methylcoclohexanemethanol
is a mouthful especially when it ends up in your water supply. You might remember this industrial accident. In 2014 freedom industries located in West Virginia released about 7500 gallons
of this industrial detergent into the elk River. This was the third chemical spill in that River Valley in the five-year period leading up to this event.
MCHM causes headaches, eye and skin irritation and difficulty breathing for prolonged exposures at high concentration. Everyone is at risk from the exposure but remember
that children have thinner skin and smaller airways. They are more vulnerable to the harms from this industrial detergent. Chlorine is typically in solid or liquid form
and we are familiar with the because we use it to disinfect water and in sanitation. Transporting chlorine carries most risks with train or truck accidents resulting
in release into the community. But accidents can happen as close as your local swimming pool. Chlorine gas is also used as a weapon in war along with serin a nerve agent
and mustard gas a blistering agent. Nuclear power plants have released radioactivity into the environment due to infernal damage. Human error or equipment malfunction.
And a dirty bomb is a device that combines radioactive material with conventional explosives. The resulting explosion would cause physical blast damage
and throw chemical debris along with radiation into the air. The radioactive fallout would settle as dust on the ground and other surfaces where children are more likely
to be exposed to it. Next slide, please. How have children been affected? These are some examples and I mentioned chlorine gas and more.
Here we have children receiving treatments after a gas attack in Syria. This year. One doesn’t need to be in a war zone. I mentioned community pools.
Earlier this year 35 people including children received emergency treatment after chlorine exposure at the local pool. An accident in the pump room CASA worker to mix chlorine liquid
with the cleaning agent forming chlorine gas which was then breathed in by the people enjoying the pool. Next slide please. Again, how are children affected?
First here I have listed Chernobyl, 1986. Chernobyl began as a safety test that ran up against reactor design flaws. Resulting in a catastrophic explosion and release
of radioactive material into the atmosphere. The four most harmful radio nucleotides spread from Chernobyl were iodine 131 cesium 134 cesium 137 and strontium 90. Iodine is concentrated in the thyroid gland.
It also concentrates in the milk glands of lactating women. Another route of exposure for infants. This leads to increased incidence of thyroid cancers.
Cesium tends to accumulate in vital organs such as the heart while strontium accumulates in bones and is a particular risk to rapidly developing bone marrow and lymphocytes. Children in the Chernobyl area
are still born with a greater risk of immune system deficiencies and heart disorders and many have been born with developmental disabilities and physical disabilities.
I want to bring up another radiation incident that occurred in the town of Goiania, Brazil. This event illustrates how children’s psychological and social development impacts
their increased vulnerability. A cancer clinic had closed and moved to a new location but left their obsolete radiation equipment behind.
Scavengers broken for scrap metal and began disassembling the equipment. One of the pieces was a small metal canister and when the scrap dealer broken open, it was filled with a blue glowing powder.
His six-year-old daughter thought it was so pretty that she rubbed it all over her exposed skin. It was cesium 137. The daughter along with others
who had close contamination died. Over the course of this event, hundreds of people were potentially exposed and whole sections of the city had to be dug up and contained.
But I really want to come back to this little girl who saw only beauty and magic and proceeded to touch and play and pretend. More recently we have Fukushima. This event began as a natural emergency.
When an earthquake set off a tsunami. The event progressed as would be expected the earthquake set off sensors at the Fukushima Daiichi nuclear power plant then emergency systems kicked into place
and they shut the fission reactors down. But, this tsunami also disabled the backup generator that would’ve controlled the pumps that cooled reactors.
Therefore there were meltdowns and release of radioactivity into the environment. A 2012 study found that about one third of the children in the region had abnormal
growths in their fibroids. There has been an increase in thyroid cancer detected in children since then possibly related to the nuclear disaster.
Next slide. I’ve covered a number of different types of events and the type of events and the proximity to the event will dictate whether one’s family will shelter in place or need to evacuate.
It will be very important to listen for any public service announcements about evacuating or sheltering in place. But limiting exposure time for physical shielding decontaminating items of clothing
or personal equipment or by showering will be keys to protection. And there are resources at the end of this presentation that will lead you to more information about specific threats.
Next slide, please. A couple of points about children with special health care needs. National data show that an estimated 15% of the US children have been identified
as having a special health care needs. Children with special health care needs are defined as having a chronic physical developmental behavioral or emotional condition
and who require health and related services of a type or amount beyond that which would be required by children generally. This is a broad definition.
I have here some examples of special health care needs and this would include conditions such as autism and ADHD, heart defects, muscular dystrophy, blood disorders and asthma. Next slide please.
So, what my children with special health care needs required to be prepared for any type of event? Well, earlier, Jessica touched on having kits for evacuation or sheltering in place.
Families with children with special health care needs will want to add onto that kits. Some examples of things to keep in mind our medication list special medications, your specialty provider contacts personal
health records, you may want battery chargers as a backup to electronic devices. Plans for any special transportation needs that might impact the ability to evacuate. Strategies to maintain a daily routine as
best as possible under the circumstances. An event might happen during the school day. So parents or caregivers should have a discussion with special education or IEP teams to learn about the school’s emergency plan and
at what special items their child might have with them in the event of an emergency. Next slide. Disaster planning and preparation might sound daunting especially
for child with special health care needs. Here is one example of a free downloadable toolkit that will walk a family through the steps to be prepared. And the list is there on the screen.
Your estate might have something similar on its emergency management website. But if not, this is an excellent comprehensive resource. Next slide please.
Well, thank you for your attention and I would like to turn the presentation over to my colleague Dr. Robyn Cree.

>> Thank you, Cindy. During last year’s particularly
active hurricane season, millions of children were exposed to traumatizing events. And as Jessica mentioned, more than 22% of the US population is under the age of 18.
Considering this, children’s exposure to hurricane -related trauma was extensive. The hurricanes disrupted hospital operations, including children’s hospitals, schools, and childcare centers.
Next slide please. Thousands of families were displaced and stayed in shelters and the regions are still recovering from the aftermath.
And as you know, children are currently being affected by hurricane Florence and will continue to be affected by disasters in the future. Next slide. Children are among those most
at risk for psychological trauma and behavioral difficulties after a disaster. Children are not small adults. They may not have the verbal skills or understanding
to explain what hurts or is bothering them. Children may be scared that the event will happen again, that someone they love will die, or that they will be separated from their family.
Children can’t control their environments. And can’t take care of themselves. As Cindy mentioned earlier, they depend on adults to keep them safe both physically
and emotionally. It is also important to realize that children’s responses are often tied to how their parents cope and their environments.
Thus supporting parents is a key part of supporting children. Children need to feel safe. Being with a trusted adult can help them feel safe, calm,
connected, and give them a sense of hope. Finally, we know that early traumatic events such as being involved in a disaster has the potential to cause long-term effects even into adulthood
on psychological development and health. Next slide. Again, back to the info graphic that you saw the beginning of this presentation. Children are more vulnerable in
natural disasters such as hurricanes because they may not be able to communicate their symptoms or feelings during an emergency. When disaster strikes, a child’s view of the world as a safe
and unpredictable place is temporarily lost. Compared to adults, children understand less about the situation. They feel less able to control events and they have less experienced
coping with difficult situations. Just because a child doesn’t say they are scared doesn’t mean that they are not. Next slide. Symptoms of psychological
distress will vary depending on a child’s age and development of stage. For example, infants may become irritable. They may cry more than usual or want to be held and cuddled more.
Toddlers may also experience other behavioral and physiological impacts such as changes in sleep and eating habits or regression to earlier behaviors they have outgrown. Such as bedwetting, being
frightened about being separated from their parents or caregivers, or have tantrums. Older children may experience difficulty concentrating or may focus
on details of the disaster events. They may wish to speak about it often or not want to talk about it all. In kids, irritability can also be a sign of depression.
Children may also experience symptoms of anxiety depression posttraumatic stress or acting out. Anxiety may present as fear or worry about can also make children irritable and angry. Anxiety symptoms can also include trouble
sleeping, as well as physical symptoms like fatigue, headaches or stomachaches. Some anxious children keep their worries to themselves and thus the symptoms can be missed. Preteens and teenagers may act out including
reckless driving, alcohol, or drug use. They may also cut back on how much time they spend with friends or not want to leave home. They may also argue or fight more with siblings and caregivers or other adults.
It is important to note that the symptoms on this slide are broken out based on developmental stage where they are most likely to occur. However, these symptoms can be
seen across many different ages and symptoms may be displayed differently depending on the age of the child. For example, younger children who are anxious or depressed might seem irritable or be afraid
of being separated from their parents and caregivers. While older children might have trouble paying attention in school or not want to participate in activities they did before.
Next slide. But who is most vulnerable? Although all children are at risk for experiencing psychological distress, during and after an emergency, disasters
can be particularly hard on children who have experienced trauma in the past or already have a mental behavioral or developmental disorder before the event occurs.
Such as anxiety, depression, attention deficit hyperactivity disorder or autism spectrum disorder. Children with anxious or irritable temperaments may also be at greater risk.
Other circumstances that could increase risk include being separated from a parent, losing a home even temporarily, and getting out of the usual routine if school is closed for an
extended period of time. Next slide. Additionally, increased stress from disasters experienced during pregnancy is associated with a host of poor mental
and physical child outcomes. Such as increased risk for fetal distress, mental disorders, and poor communication and social skills. So what can we do to help children and
families cope during an emergency response? Next slide. Children’s mental health can be supported by parents schools healthcare providers faith-based organizations
and any other groups interacting with children during a response. Reuniting with children with their parents and or other primary caregivers is critical in supporting the child during a difficult time.
Especially for young children it is important to share age-appropriate information and to encourage children to ask questions. Letting them know that it is okay to be scared and it is not their fault.
That they are cared for and loved. It is important to understand what children already know so that we can address their questions without providing additional scary information
and to reduce worry and unnecessary stress. For older children, allowing them to talk through what happened can be very helpful. Limiting media exposure is important. If young children seek disturbing
images shown repeatedly, they may think that an event is happening over and over. Young children are also unlikely to understand the images they see.
Finally, returning to a routine as soon as possible even if it is a new routine helps make the child’s environment feel more predictable and safe and can decrease their stress and worry.
Next slide. Like in all aspects of a response, partnerships are key to promoting mental health following an emergency.
Some key partners include responders, who can support their own self-care be aware of how stress may impact the affected population and become familiar with psychological first aid.
Healthcare providers can also consider stress and anxiety and how a patient or their family may be affected even if not in the local area of the event. State and local governments can involve
stakeholders including community members in assessing resilience and identifying actions to improve resilience prior to an emergency. And giving actions– action items to empower community members
to take care of themselves and others. Schools can help support children and share resources with parents about how to support children. Individuals and families can seek ways to
comfort each other to support others affected in their communities and support responders through cooperation and voicing their appreciation. All leaders can help empower community
members based on their strengths and common messages across– and common messages across these partners will strengthen the likelihood that the message is heard. Next slide.
The important thing to remember is that disasters can have long-term effects on the mental and emotional health of children. Children who have serious emotional or behavioral problems are at particular risk
for stress after disaster or traumatic events. It is important that educators parents responders and healthcare providers understand how to help children cope after an emergency
to support their health and well-being. We have many free resources available on CDC’s website to help you do that. The graphic on the left is another ready Wrigley book that was created in response to a request
from Puerto Rico after hurricane Maria for materials for children about coping. We also developed a fact sheet for parents in Puerto Rico on children and coping in response to a request from FEMA.
The fact sheet was translated into Spanish and distributed in Puerto Rico. We also have a webpage on our caring for children in disaster site about helping children cope with emergencies
which you see pictured on the right. It discusses the factors that influence the emotional impact on children in emergencies what you can do to help children cope and common reactions
which vary by age and development of stage. Now I will hit it off to Jessica who will cover additional resources to help children and families. Thank you.

>> Thanks, Robyn. We can go to the next slide. So the next few slides include some resources we have available to help children prepare for
and cope with emergencies. Next slide. As I mentioned the CDC has a site dedicated to caring for children in a disaster. We have many tools and resources
available to you across the site. This page is organized by audience type and you can see the other sections of the site on the left navigation including how children are different helping children cope children
with special health care needs before during and after an emergency specific threats and real stories. Next slide. I mentioned the ready Wrigley children’s
activity books earlier in the presentation and I want to share a few more preparedness resources with you. So, the backpack card pictured on the left is for kids to learn the three steps
to protect them through the school day. It walks kids through questions to help them think about what they might need in an emergency and could be used as a classroom activity or at home with the family.
Another interactive tool we have helps families make an emergency kit. We have a general checklist for families and another checklist especially for families of children with special health care needs.
These can be used at home or in the classroom as well to teach kids about emergencies and preparedness. Next slide. Parents and caregivers educators
healthcare providers childcare providers and public health professionals who can recognize the physical developmental and emotional characteristics of children that make them more vulnerable it will be able
to help them stay safe in emergencies. To wrap up, I hope you have learned something new about how emergencies affect children and are able to view some of the materials and stories we share today.
Next slide. And before he finished, we want to leave you with a list of some of our key resources from this presentation. And on behalf of all of us would like to
thank everyone for their attention and thanks to the epic group for the opportunity to present some of the pediatric preparedness work we do at CDC. Our contact information is on the final
slide and we will open it up to questions.

>> Thank you, so much everyone, for presenting. That was a beautiful presentation. We will now transition to our Q&A session. We will be answering questions
about hurricane Florence on how hurricane Florence affects children as well. So, we’re going to go to the first question. You mentioned some of the effects in
children not becoming apparent until later. Like radiation from Fukushima power plant explosion causing thyroid cancer in children that were exposed and children who seem to recover from polio developing
symptoms that [inaudible] later. Are there other examples like these that have– that the effects don’t appear until later?

>> Sorry. So somebody feel free to jump in but so great question.
The Flint Michigan water contamination response is a good example. So the impact of lead exposure may be greater on children’s development but we also– we often don’t see those
results until years later. So obviously more vulnerable populations like infants and younger children and pregnant women are at greater risk for having high lead levels
and for experiencing potential adverse health effects.

>> I would also add what we know about Zika. They are still looking [inaudible] impact infants who have been impacted [inaudible] Zika.
So that’s another [ Inaudible ]

>> Thank you, very much. We have another question. Is the CDC able to help build child mental
health professional capacity post natural disaster in areas impacted?

>> Thank you. I’m not really able to speak I guess specifically to that.
We– and I can actually probably handed off to Jessica I guess a little more of what they’re doing with hurricane Florence right now. But I know in previous disasters I was
involved in the 2017 hurricane response and we worked a lot to develop messages related to coping and mental health and we put on as I mentioned a webinar for healthcare providers
to help them understand what they can do to support children and families during emergencies and to promote coping and helping them to understand what symptoms to watch out for among children and also another
very important piece of that was the idea of professional self-care and really promoting that among responders and healthcare providers. In order to effectively care for children, professionals need to also care
for their own mental health as they are also impacted by these disasters.

>> Yeah. And I will just add to that. So we are activated for the hurricane Florence response right now
in CDC’s emergency operations center and we are monitoring the mental health impact on children and all vulnerable populations right now because like Robyn said it was a major issue last year in the 2017 hurricane response.
So we are in close contact with [inaudible] and collaborating to work on sending out communications related to that like [inaudible] calls and other messaging.

>> Thank you very much, Jessica.
We have another question. Is there a crisis response team that I– I’m sorry. Are there any chemical guidance resources on amount or length
of exposure is specifically helpful to children? [ Inaudible ]

>> Thank you, very much. You have any recommendations on how to address the communication
with deaf populations in case of emergency?

>> I can speak a little bit to that. So, we are actually working right now with FEMA to develop or public service announcement videos in American sign language we made quite a
few last year related to risk communication for the hurricane so like generator safety, floodwater safety, food safety, things like that. So we are working closely with FEMA right now to
develop some more and so, the needs of the death and all adverse populations are taken into account. So–

>> Thank you, Jessica.
We have another question. They are asking what efforts are in place to assist schools in preparing for natural disasters?

>> I can speak a little bit to that.
So, that is on a state-by-state basis. So, we do look at data from– I’m going to forget the acronym– from [inaudible] data to look at the different preparedness and response capabilities
and efforts that are in place and we also work closely with Department of Education to get any kind of messaging out but again, it is a state-by-state basis and we don’t regulate all of that here.
>> So, thank you so much, Jessica. What are some other changes or difficulties children may face following a disaster?

>> In terms of mental health? I don’t know if Robyn– do
you want to add a few more?

>> Sure. Yeah. In terms of mental health, obsolete. There are many different symptoms of adjustment reactions that children can have
that physicians and parents should be aware of. And that I guess I mentioned it could include sleep problems caught regression to earlier behaviors, difficulty with concentration,
deterioration in academic performance, and then other behaviors can include things like separation anxiety, fears and worries, depression, or substance use and as I mentioned previously, and others
have mentioned, symptoms will vary depending on the age and the development of stage of the child. And children may have long lasting effects following disasters.
So it’s important to not just pay attention to these things immediately while the disasters taking place, but also in the months and years following as well.

>> Thank you Dr. Robyn. We have another question from Sandra, and she’s asking if you can only do one thing to improve local preparedness for children, what should we concentrate on doing?

>> Well that’s a great question. Was Cindy going to answer?

>> All right. This is life. Okay but one of the things that I think is
really important about preparing children has to do a lot with the preparation and getting involved at a local level or really connecting. I’m thinking about when Robyn was talking about healthcare providers schools local governments,
these are groups that are working on a regular basis to have emergency preparedness have plans in place and the more people can really take advantage of some of the drills or preparations that your local emergency managers are
putting out, I think would be really helpful. This is especially important for families who have children with special health care needs. There are groups perhaps you are connected with in your neighborhood
and I think being proactive going to your local governments, going to your schools, letting them know that you are concerned letting them know that you want to be involved will go a long way to help
overall with the care for children and children with special health care needs in the event of an emergency.

>> Thank you very much, Robyn. There’s another question.
Can you speak more about resiliency after a disaster and the importance of building that to be better prepared for an emergency.

>> Yeah. Of course. So resilience is a person’s
ability to bounce back from a difficult or life-changing event. Like the diagnosis of chronic disease or the impact of natural disaster. And people are more resilient and better able to
withstand or adapt to and recover from adversity when they make healthy choices including the decision to prepare for different types of emergencies. And communities are more resilient
when their citizens are prepared. So, yeah.

>> Thank you. We have just a question from Nicole. And she is asking what exactly
would be the definition for a hurricane related death or or associated death. What would be a good definition for this

>> I do not feel like I’m well-versed to
answer anything like– [inaudible] Oh, okay.

>> So we will go on to the next question. So this question is what are examples of good practices states can implement to support mental health of children
during or following natural disasters?

>> Well, there are many things that states can do to support mental health. And one of the best ways is to think about mental health before the disaster occurs.
And incorporate this into planning for emergencies. Such as ensuring parents community members schools and primary care physicians have the
resources and the information available so that they can recognize symptoms of distress and be able to support children during a disaster. Also, during the response of governments
can provide psychological first-aid at response sites. They can monitor mental health needs of communities and responders. They can provide access to
counselors and appropriate languages. Distribute educational information appropriate to the event. Use a triage system to connect victims and acute distress with professional services
and also provide coping resources for responders and their families.

>> And I would just add to that since the response last year to the hurricanes we do have
a lot of new mental health and coping resources available on our website. So I would encourage everyone to check those out or reach out to us and we can help you find them.

>> Thank you so much, everyone for you know that beautiful presentation. I and thank you all for joining us for today’s webinar. If you have additional questions
you may email them to epic@cdc.gov. That is E-P-I-C at CDC dot gov. As a reminder, today’s presentation has been recorded and you can earn continuing education
credits for your participation. Please follow the instructions linked in the invitation you received. The course access code is E-P-I-C-0919 with all letters capitalized.
I repeat,E-P-I-C 0919. Thank you so much for joining. Goodbye.