Early Dialysis and Adverse Outcomes After Hurricane Sandy

Disaster preparedness for people with kidney disease and kidney healthcare providers

PURPOSE OF REVIEW

Man-made and natural disasters become more frequent and provoke significant morbidity and mortality, particularly among vulnerable people such as patients with underlying kidney diseases. This review summarizes strategies to minimize the risks associated with mass disasters among kidney healthcare providers and patients affected by kidney disease.

RECENT FINDINGS

Considering patients, in advance displacement or evacuation are the only options to avoid harmful consequences of predictable disasters such as hurricanes. Following unpredictable catastrophes, one can only rely upon educational initiatives for disaster risk mitigation. Preparatory initiatives before disasters such as training courses should target minimizing hazards in order to decrease morbidity and mortality by effective interventions during and early after disasters. Retrospective evaluation of previous interventions is essential to identify adverse consequences of disaster-related health risks and to assess the efficacy of the medical response. However, preparations and subsequent responses are always open for ameliorations, even in well developed countries that are aware of disaster risks, and even after predictable disasters.

SUMMARY

Adverse consequences of disasters in patients with kidney diseases and kidney healthcare providers can be mitigated by predisaster preparedness and by applying action plans and pragmatic interventions during and after disasters. Preparing clear, practical and concise recommendations and algorithms in various languages is mandatory.

Hurricanes and Mortality among Patients Receiving Dialysis

BACKGROUND

Hurricanes are severe weather events that can disrupt power, water, and transportation systems. These disruptions may be deadly for patients requiring maintenance dialysis. We hypothesized that the mortality risk among patients requiring maintenance dialysis would be increased in the 30 days after a hurricane.

METHODS

Patients registered as requiring maintenance dialysis in the United States Renal Data System who initiated treatment between January 1, 1997 and December 31, 2017 in one of 108 hurricane-afflicted counties were followed from dialysis initiation until transplantation, dialysis discontinuation, a move to a nonafflicted county, or death. Hurricane exposure was determined as a tropical cyclone event with peak local wind speeds ≥64 knots in the county of a patient's residence. The risk of death after the hurricane was estimated using time-varying Cox proportional hazards models.

RESULTS

The median age of the 187,388 patients was 65 years (IQR, 53-75) and 43.7% were female. There were 27 hurricanes and 105,398 deaths in 529,339 person-years of follow-up on dialysis. In total, 29,849 patients were exposed to at least one hurricane. Hurricane exposure was associated with a significantly higher mortality after adjusting for demographic and socioeconomic covariates (hazard ratio, 1.13; 95% confidence interval, 1.05 to 1.22). The association persisted when adjusting for seasonality.

CONCLUSIONS

Patients requiring maintenance dialysis have a higher mortality risk in the 30 days after a hurricane.

Assessing short-term and long-term mental health effects among older adults after Hurricane Sandy

BACKGROUND

Few studies have evaluated the long-term effects of disasters on older adults. We examined if older individuals experienced increased mental health (MH) effects immediately and long-term after Hurricane Sandy and if these effects varied by socioeconomic status (SES), disease subtypes, number of comorbidities, and length of stay.

METHODS

We identified older patients (≥64 years) with hospital admissions and Emergency Department (ED) visits (2001-2015) with primary diagnosis of MH diseases using the New York State discharged data. We quantified both short-term (immediately post-Sandy) and long-term effects (3-month, 1-year, 2-year, and 3-year) following Hurricane Sandy, and used the pre-Sandy period in the affected counties as the control period. Poisson regression was used to compare daily counts of MH cases overall and by multiple strata pre-/post Sandy.

FINDINGS

Older individuals had significantly increased risk of MH ED visits immediately (32%), and 3-months, 1, 2, and 3-years after Sandy (2%, 9%, 15%, and 10%, respectively). MH hospital admissions did not increase immediately, but significantly increased by 8% a year later. Males and those with low SES had delayed, but increased risks of MH 1-3 years after Sandy (RRs range: 1.14-1.71). The top MH subtypes after Sandy were psychosis, mood disorders, substance abuse, suicide, and anxiety (RRs range: 1.12-2.62). After Sandy, patients with ≥8 comorbidities increased from 15% to >25%, along with their length of hospital stay.

CONCLUSION

We found long-term adverse effects of MH after Sandy, especially among vulnerable populations, which may help plan future disaster preparedness and recovery efforts.

Where are People Dying in Disasters, and Where is it Being Studied? A Mapping Review of Scientific Articles on Tropical Cyclone Mortality in English and Chinese

Background:

Tropical cyclones are a recurrent, lethal hazard. Climate change, demographic, and development trends contribute to increasing hazards and vulnerability. This mapping review of articles on tropical cyclone mortality assesses geographic publication patterns, research gaps, and priorities for investigation to inform evidence-based risk reduction.

Methods:

A mapping review of published scientific articles on tropical cyclone-related mortality indexed in PubMed and EMBASE (English) and SINOMED and CNKI (Chinese), focusing on research approach, location, and storm information, was conducted. Results were compared with data on historical tropical cyclone disasters.

Findings:

A total of 150 articles were included, 116 in English and 34 in Chinese. Nine cyclones accounted for 61% of specific event analyses. The United States (US) reported 0.76% of fatalities but was studied in 51% of articles, 96% in English and four percent in Chinese. Asian nations reported 90.4% of fatalities but were studied in 39% of articles, 50% in English and 50% in Chinese. Within the US, New York, New Jersey, and Pennsylvania experienced 4.59% of US tropical cyclones but were studied in 24% of US articles. Of the 12 articles where data were collected beyond six months from impact, 11 focused on storms in the US. Climate change was mentioned in eight percent of article abstracts.

Interpretation:

Regions that have historically experienced high mortality from tropical cyclones have not been studied as extensively as some regions with lower mortality impacts. Long-term mortality and the implications of climate change have not been extensively studied nor discussed in most settings. Research in highly impacted settings should be prioritized.

Observations from the emergency management of dialysis patients evacuated from the US Virgin Islands to Puerto Rico following hurricane Irma

Two category 5 hurricanes, Irma and Maria, arrived in the Caribbean in September 2017 in rapid succession. On September 6, Irma devastated the islands of St. Thomas and St. John, in the Virgin Islands of the United States (USVI). Most medical infrastructure was damaged, including hemodialysis facilities, paralyzing dialysis operations. After Irma’s landfall, Puerto Rico served as a safehaven for thousands of displaced and repatriated persons from the impacted islands. These included a cohort of 129 hemodialysis patients evacuated from St. Thomas, USVI to San Juan, Puerto Rico from September 9−11, 2017. The hemodialysis patients arrived first at hotels in San Juan and were then transferred to a Special Needs Shelter, run by the Commonwealth of Puerto Rico and located in the Puerto Rico Convention Center. With the imminent arrival of Hurricane Maria, most patients were evacuated on September 19 to a special needs shelter on the campus of the Florida International University, in Miami, Florida. While in San Juan, hemodialysis treatments were provided by local nephrologists working with local hemodialysis centers. Here, we describe the challenges and the emergency management actions taken to ensure continuity of care, including providing dialysis, general medical care, shelter, food and transportation for USVI dialysis patients during their stay in San Juan, Puerto Rico. We describe here the experiences of federal and host state/territorial officials in the special needs shelter, in the context of the state/territorial and federal response to disasters, in order to provide ideas about challenges, solutions, and approaches to coordinating care for dialysis patients evacuated from a disaster.

Increased risk of multiple pregnancy complications following large-scale power outages during Hurricane Sandy in New York State

BACKGROUND

Large-scale power outages (PO) are increasing in the context of climate change. Although some research has been conducted into the adverse health impacts of POs, significant gaps remain regarding whether POs would affect the health of pregnant women. We investigated the association between ED visits due to pregnancy complications and the occurence, intensity, and duration of large-scale POs in eight Sandy-affected counties in New York State (NYS).

METHODS

In this cross-sectional study, daily ED visits for pregnancy complications and large-scale PO data in eight counties in NYS from October to December in 2005-2014 were collected. Using time-series analysis, we estimated the relative increase in ED visits for pregnancy complications during POs compared with non-PO periods at lag 0-7 days. Short-term health impacts of PO intensity and PO duration were investigated. Estimations were also stratified by sociodemographic characteristics and disease subtypes including threatened or spontaneous abortion, threatened or early labor, hypertension complications, infections of genitourinary tract, renal diseases, gestational diabetes mellitus, mental illnesses, and cardiovascular diseases during pregnancy.

RESULTS

From October to December in 2005-2014, there were 307,739 ED visits for pregnancy complications in the eight counties. We found significant increases in ED visits for overall pregnancy complications (16.6%, 95% confidence interval [CI]: 10.3%, 23.2%) during the Hurricane-PO period at lag 0-7 days. The ED visits increased by 8.8% per level increase in PO intensity and 1.4% per day increase in PO duration. Specifically, threatened/early delivery and gestational diabetes mellitus during the PO period increased by 26.7% (95% CI: 8.2%, 48.4%) and 111.8% (95% CI: 16.7%, 284.4%), respectively. Young adult, Black, Hispanic, and uninsured individuals were at higher risk of complications.

CONCLUSIONS

POs may adversely impact pregnancy, especially for certain pregnancy complications and among low sociodemographic women.

Kidney problems in disaster situations

Mass disasters, particularly earthquakes, cause many medical problems, including kidney problems, but an organized approach to cope with them was initiated only at the end of previous century, subsequent to the Armenian Spitak earthquake in 1988. Originally, interventions were focused on acute kidney injury (AKI) following crush injury and rhabdomyolysis in victims who had been trapped under the debris of collapsed buildings. However, similar problems were also registered in the context of other catastrophic events, especially man-made disasters like wars and torture. Other kidney-related problems, such as the preservation of treatment continuity in chronic kidney disease (CKD), especially in maintenance dialysis patients, deserved attention as well. Specific therapeutic principles apply to disaster-related kidney problems and these may differ from usual day-to-day clinical practice. Those approaches have been formulated in global and specific country-related guidelines and recommendations. It is clear that a well-conceived and organized management of kidney diseases in disasters benefits outcomes. Furthermore, it may be useful if the model and philosophy that were applied over the last three decades could be adapted by broadening the scope of disasters leading to intervention. Actions should be guided and coordinated by a panel of experts steering ad hoc interventions, rather than applying the "old" static model where a single coordinating center instructs and uses volunteers listed long before a potential event occurs.

Sepsis Among Medicare Beneficiaries: 1. The Burdens of Sepsis, 2012-2018

Supplemental Digital Content is available in the text.

To provide contemporary estimates of the burdens (costs and mortality) associated with acute inpatient Medicare beneficiary admissions for sepsis.

Health Outcomes After Disaster for Older Adults With Chronic Disease: A Systematic Review

BACKGROUND AND OBJECTIVES

This review synthesizes the current literature surrounding chronic disease outcomes after weather- and climate-related disasters among older adults. The associations between exposure of older adults to weather- and climate-related disasters and the primary outcomes of diabetes, end-stage renal disease (ESRD), congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD) were examined.

RESEARCH DESIGN AND METHODS

A systematic review of studies reporting on clinical outcomes of four chronic diseases after disaster exposure was performed. Under the direction of an informationist, the databases PubMed, Scopus, EMBASE, and Web of Science (Science and Social Science Citation Index) were searched from inception to July 2019.

RESULTS

Of 5,229 citations identified, 17 articles met the study criteria. Included articles were retrospective observational in nature and focused on earthquakes (24%, n = 4), hurricane (41%, n = 7), and wildfire (35%, n = 6) disasters. Outcome data by disease process included COPD (35%, n = 6), ESRD (41%, n = 7), CHF (24%, n = 4), and diabetes (29%, n = 5). Three main categories were identified: access to health care, postdisaster health care utilization, and study rigor. The age-stratified analyses reported in this review found multiple instances where disasters have limited or insignificant effects on older adults relative to younger populations.

DISCUSSION AND IMPLICATIONS

Disaster research faces unique methodological challenges, and there remains a need for data-driven conclusions on how best to care for older adults before, during, and after disasters. To encourage consistent dialogue among studies, we advocate for the use of rigorous and standardized scientific methodology to examine the health impacts of disasters on adults with chronic disease.

Access to Care for VA Dialysis Patients During Superstorm Sandy

Introduction: This study examines the use of dialysis services by end-stage renal disease (ESRD) patients following the Superstorm Sandy-related, months-long closure of the New York campus of the US Department of Veterans Affairs (VA) New York Harbor VA Healthcare System (NYHHS, Manhattan VAMC). Methods: Outpatient visits, dialysis care, emergency department visits, and hospitalizations at VA and non-VA facilities for 47 Manhattan VAMC ESRD patients were examined 12 months pre- and post-Sandy using VA administrative and clinical data. Results: The Brooklyn campus of NYHHS, which is within ten miles of Manhattan VAMC, experienced the largest increase in the number of dialysis encounters after the closure. Dialysis encounters for VA patients also increased at non-VA facilities, rising on average, to 106 per month. For the James J Peters Bronx VAMC, the number of total dialysis encounters for Manhattan VAMC patients fluctuated between 39 and 43 per month, dropping to less than 30 after the Manhattan VAMC dialysis unit reopened. Conclusion: Manhattan VAMC ESRD patients used nearby alternate VA sites and non-VA clinics for their care during the closure of the Manhattan VAMC dialysis unit. The VA electronic health records played an important role in ensuring continuity of care for patients who exclusively used VAMC facilities post-Sandy because patient information was immediately accessible at other VA facilities. The events related to Superstorm Sandy highlight the need for dialysis providers to have a comprehensive disaster plan, including nearby alternate care sites that can increase service capacity when a dialysis facility is closed because of a disaster.

Natural Disasters in the Americas, Dialysis Patients, and Implications for Emergency Planning: A Systematic Review

Introduction

Natural hazards are elements of the physical environment caused by forces extraneous to human intervention and may be harmful to human beings. Natural hazards, such as weather events, can lead to natural disasters, which are serious societal disruptions that can disrupt dialysis provision, a life-threatening event for dialysis-dependent people. The adverse outcomes associated with missed dialysis sessions are likely exacerbated in island settings, where health care resources and emergency procedures are limited. The effect of natural disasters on dialysis patients living in geographically vulnerable areas such as the Cayman Islands is largely understudied. To inform predisaster interventions, we systematically reviewed studies examining the effects of disasters on dialysis patients and discussed the implications for emergency preparedness in the Cayman Islands.

Methods

Two reviewers independently screened 434 titles and abstracts from PubMed, Scopus, CINAHL, and Cochrane Library. We included studies if they were original research articles published in English from 2009 to 2019 and conducted in the Americas.

Results

Our search yielded 15 relevant articles, which we included in the final analysis. Results showed that disasters have both direct and indirect effects on dialysis patients. Lack of electricity, clean water, and transportation, and closure of dialysis centers can disrupt dialysis care, lead to missed dialysis sessions, and increase the number of hospitalizations and use of the emergency department. Additionally, disasters can exacerbate depression and lead to posttraumatic stress disorder among dialysis patients.

Conclusion

To our knowledge, this systematic review is the first study that presents a synthesis of the scientific literature on the effects of disasters on dialysis populations. The indirect and direct effects of disasters on dialysis patients highlight the need for predisaster interventions at the patient and health care system levels. Particularly, educating patients about an emergency renal diet and offering early dialysis can help to mitigate the negative effects of disasters.

Bundled Payment Reform and Dialysis Facility Closures in ESKD

BACKGROUND

In 2011, inclusion of injectable medications into an expanded ESKD payment bundle prompted concerns that dialysis facilities facing higher costs might close, disrupting care delivery and access to care. Whether this policy change influenced dialysis facility closures is unknown.

METHODS

To examine whether facility closures increased after 2011 and whether factors influencing closures changed, we analyzed US Renal Data System registry data to identify all patients receiving in-center hemodialysis from 2006 through 2015 and to track dialysis facility closures. We used interrupted time series logistic regression models and estimated marginal effects to examine immediate and longer-term changes in the likelihood of being affected by facility closures following payment reform. We also examined whether associations between selected predictors of closures indicating populations at "high risk" of closure (patient characteristics, facility characteristics, and geography-related characteristics) and closures changed after payment reform.

RESULTS

Dialysis facility closures were uncommon over the study period. In adjusted models, the relative odds of experiencing a closure declined by 37% (odds ratio [OR], 0.63; 95% confidence interval [95% CI], 0.59 to 0.67) immediately after payment reform and declined by an additional 6% (OR, 0.94; 95% CI, 0.91 to 0.97) annually thereafter, corresponding to a 0.3% lower absolute probability of closure in 2015 in association with payment reform. Patients who were black and who dialyzed at small, hospital-based facilities experienced slight increases in closures following payment reform, whereas Hispanic and Medicare/Medicaid dual-eligible patients experienced slight decreases in closures.

CONCLUSIONS

Expansion of the ESKD payment bundle was not associated with increased closure of dialysis facilities, although the likelihood of closures changed slightly for some higher-risk populations.

Home Health Service Provision After Hurricane Harvey

OBJECTIVE

To determine the extent of service disruption among home health agencies impacted by Hurricane Harvey.

METHODS

Structured interviews with optional open-ended questions were conducted with home health agencies in and around Houston, Texas. A random sample of 277 agencies was selected and contacted via telephone during the study period, from February to May of 2018.

RESULTS

Only 45% of 122 participating agencies indicated that their offices were open during Hurricane Harvey, and three-fourths reported that home visits were disrupted. The length of disruption varied: 7% reported a disruption of 1 day or less and 46% indicated a disruption of 1 week or longer. Disruption occurred even though nearly all (99%) of the agencies had-and close to all (92%) of them activated-an emergency preparedness plan.

CONCLUSIONS

Although most of the participating home health agencies activated their emergency preparedness plan, significant disruption in home health services occurred. While agencies are required to have clear, detailed plans in place, gaps in effective implementation of emergency preparedness plans remain.

The immediate and lasting impact of Hurricane Sandy on pregnancy complications in eight affected counties of New York State

BACKGROUND

The frequency and intensity of hurricane have increased greatly. However, whether hurricane exposure is associated with an increased risk of pregnancy complications is less known.

OBJECTIVE

To assess the immediate impact and lasting impact of Hurricane Sandy (Sandy) on pregnancy complications.

METHODS

Using time-series study, we estimated the relative risks (RRs) of emergency department (ED) visits for pregnancy complications in eight affected counties in New York State, based on data of 2005-2014. The immediate impact was estimated by comparing the ED visits of pregnancy complications during the Sandy period to the non-Sandy periods. For the lasting impact of Sandy, we estimated the RRs by contrasting the ED visits in the following 12 months after Sandy with the same months of other years.

RESULTS

We found that ED visits for overall pregnancy complications increased 6.3% (95% confidence interval (CI): 2.2%, 10.5%) during the Sandy month. ED visits increased for threatened abortion (9.9%, 95% CI: 4.4%, 15.7%), threatened labor (10.1%, 95% CI: 1.9%, 18.9%), early onset of delivery (115.9%, 95% CI: 6.9%, 336.3%), renal disease (73.2%, 95% CI: 0.3%, 199.4%), and diabetes (42.3%, 95% CI: 15.0%, 76.0%). Gestational hypertension and renal disease were elevated 7-8 months after Sandy. The ED visits of mental illness increased gradually after Sandy and peaked eight months later with visits increasing 33.2%.

CONCLUSIONS

This study suggests that hurricanes may impact pregnancy health immediately and that some negative health may last for months thereafter.

Renal Failure Patients in Disasters

Disasters occur regularly, and frequently large numbers of patients treated with maintenance dialysis or with the recent onset of acute kidney injury are put at risk owing to the lack of access to dialysis care precipitating also a kidney failure disaster. The absence of necessary dialysis treatments can result in excessive emergency department visits, hospitalizations, morbidity, or an early death. Those with kidney failure are often evaluated in disaster medical locations or hospitals without nephrologists in attendance. Here we offer guidance for medical personnel evaluating such patients so that dialysis-dependent individuals can be properly assessed and managed with the need for urgent dialysis recognized. A disaster dialysis triage system is proposed. (Disaster Med Public Health Preparedness. 2019;13:782-790).

Lack of access to medical care during Hurricane Sandy and mental health symptoms

Destruction caused by natural disasters compromises medical providers' and hospitals' abilities to administer care. Hurricane Sandy was particularly devastating, resulting in massive disruptions of medical care in the region. This study aimed to determine whether a lack of access to medical care during Hurricane Sandy was associated with posttraumatic stress disorder (PTSD) symptoms and other mental health/substance abuse outcomes. A secondary aim was to examine whether having a chronic illness moderates those associations. Self-reported medical access and mental health symptomatology were obtained from New York City and Long Island residents (n = 1669) following Hurricane Sandy under the Leaders in Gathering Hope Together project (10/23/2013–2/25/2015) and Project Restoration (6/5/2014–8/9/2016). Multivariable logistic regressions were utilized to determine the relationship between lack of access to medical care and mental health outcomes. Of the 1669 participants, 994 (59.57%) were female, 866 (51.89%) were white, and the mean age was 46.22 (SD = 19.2) years old. Those without access to medical care had significantly higher odds of showing symptoms of PTSD (AOR = 2.71, CI = [1.77–4.16]), as well as depression (AOR = 1.94, CI = [1.29–2.92]) and anxiety (AOR = 1.61, CI = [1.08–2.39]) compared to those with access. Lack of access to care was associated with a 2.12 point increase in perceived stress scale score (SE = 0.63). The interaction between having a chronic illness and lack of access to medical care was not significantly associated with any outcomes. The findings emphasize the importance of making medical care more accessible to patients, both chronically and acutely ill, during natural disasters to benefit their physical as well as their mental health.

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Individuals without access to medical care had asignificantly higher odds of showing symptoms of mental health difficulties.

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Chronic illness did not moderate the relationship between a lack of access to care and mental health outcomes.

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Access to medical care during natural disasters may benefit the mental health of survivors with and without chronic illness.</span>

Perceptions of severe storms, climate change, ecological structures and resiliency three years post-hurricane Sandy in New Jersey

Global warming is leading to increased frequency and severity of storms that are associated with flooding, increasing the risk to urban, coastal populations. This study examined perceptions of the relationship between severe storms, sea level rise, climate change and ecological barriers by a vulnerable environmental justice population in New Jersey. Patients using New Jersey's Federally Qualified Health Centers were interviewed after Hurricane [Superstorm] Sandy because it is essential to understand the perceptions of uninsured, underinsured, and economically challenged people to better develop a resiliency strategy for the most vulnerable people. Patients (N = 355) using 6 centers were interviewed using a structured interview form. Patients were interviewed in the order they entered the reception area, in either English or Spanish. Respondents were asked to rate their agreement with environmental statements. Respondents 1) agreed with experts that "severe storms were due to climate change", "storms will come more often", and that "flooding was due to sea level rise", 2) did not agree as strongly that "climate change was due to human activity", 3) were neutral for statements that "Sandy damages were due to loss of dunes or salt marshes". 4) did not differ as a function of ethnic/racial categories, and 5) showed few gender differences. It is imperative that the public understand that climate change and sea level rise are occurring so that they support community programs (and funding) to prepare for increased frequency of storms and coastal flooding. The lack of high ratings for the role of dunes and marshes in preventing flooding indicates a lack of understanding that ecological structures protect coasts, and suggests a lack of support for management actions to restore dunes as part of a coastal preparedness strategy. Perceptions that do not support a public policy of coastal zone management to protect coastlines can lead to increased flooding, extensive property damages, and injuries or loss of life.

Geographic Distribution of Disaster-Specific Emergency Department Use After Hurricane Sandy in New York City

Objective

We aimed to characterize the geographic distribution of post-Hurricane Sandy emergency department use in administrative flood evacuation zones of New York City.

Methods

Using emergency claims data, we identified significant deviations in emergency department use after Hurricane Sandy. Using time-series analysis, we analyzed the frequency of visits for specific conditions and comorbidities to identify medically vulnerable populations who developed acute postdisaster medical needs.

Results

We found statistically significant decreases in overall post-Sandy emergency department use in New York City but increased utilization in the most vulnerable evacuation zone. In addition to dialysis- and ventilator-dependent patients, we identified that patients who were elderly or homeless or who had diabetes, dementia, cardiac conditions, limitations in mobility, or drug dependence were more likely to visit emergency departments after Hurricane Sandy. Furthermore, patients were more likely to develop drug-resistant infections, require isolation, and present for hypothermia, environmental exposures, or administrative reasons.

Conclusions

Our study identified high-risk populations who developed acute medical and social needs in specific geographic areas after Hurricane Sandy. Our findings can inform coherent and targeted responses to disasters. Early identification of medically vulnerable populations can help to map “hot spots” requiring additional medical and social attention and prioritize resources for areas most impacted by disasters. (Disaster Med Public Health Preparedness. 2016;10:351–361)

CDC Grand Rounds: Addressing Preparedness Challenges for Children in Public Health Emergencies

Recent public health emergencies including Hurricane Katrina (2005), the influenza H1N1 pandemic (2009), and the Ebola virus disease outbreak in West Africa (2014–2015) have demonstrated the importance of multiple-level emergency planning and response. An effective response requires integrating coordinated contributions from community-based health care providers, regional health care coalitions, state and local health departments, and federal agency initiatives. This is especially important when planning for the needs of children, who make up 23% of the U.S. population (1) and have unique needs that require unique planning strategies.