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INTRODUCTION

Disasters of one type or another are a common occurrence in the world today. Local and national media document the events from whatever part of the globe they are occurring. The result is increased sensitization and awareness of the general population to these threats and their devastating impact. Disasters can affect individuals, families, and sadly, children. Victims and witnesses to the devastation frequently struggle with disaster reactions and recovery. Health care providers who see and hear about disaster often try to imagine how they would handle similar disasters, and when children are involved, their empathy and compassion is part of their reaction. Those who have worked in disaster response can educate pharmacists about pediatric readiness with a critical piece of advice: Preparation promotes resiliency.

THE CHANGING FACE OF DISASTERS

When we think of disasters, most of us tend to think of weather-related and high-profile events such as tornadoes, plane crashes or fires. Disasters, however, come in a large variety of types. The International Federation of Red Cross and Red Crescent Societies (IFRC) define a disaster as "a sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material and economic or environmental losses that exceed the community's or society's ability to cope using its own resources."¹

Vulnerability

Unanticipated, threatening events of equally apparent magnitude that occur in different places can have vastly different consequences. The IFRC uses a mathematical equation to explain how an event that is inconvenient or temporarily stagnating in one place becomes a disaster in another¹:

                                         (vulnerability + hazard)/capacity = disaster

Vulnerability-the diminished capacity to anticipate, cope with, resist and recover from the impact of a natural or man-made hazard-changes with time and situation. Poverty is a primary contributor to vulnerability. An example of vulnerability is a common problem in many areas: poorly constructed or maintained housing in low-income areas will not withstand hurricane winds or floods as well as better (and more costly) housing. However, isolation, insecurity, and defenselessness also influence vulnerability. Thus, physical, economic, social, and political factors determine vulnerability.¹

Hazards are just what they seem: natural or manmade occurrences that create danger.¹

Capacity is preparedness: measures taken to prepare for and reduce any disaster's impact. The health care system is a critical component of capacity.¹

Children and Disaster

Who are your community's most vulnerable and has your health care system and community planned for them? People who are isolated, such as older patients, or those who are defenseless, such as the chronically ill or hospitalized, need extra help during disasters. Here we discuss a third group-children who are dependent on others, have little experience, and possess no resources of their own. This triad makes them insecure and exceedingly vulnerable, yet many disaster plans focus mainly on adults.

Importance of Anticipating Children's Injuries

United States (U.S.) census data from 2014 estimate that children under the age of 5 years account for 6.2% of our population. A full 23.1% of our population is less than 18 years of age.² Traditionally, disaster planners have considered children and to some extent, adolescents, as primarily secondary victims-patients who are exposed to the disaster but shielded by adults-and addressed children in proportion to their census representation.

Perpetrators of terrorism in recent situations have victimized children intentionally to create a greater psychological shock.^3,4,5,6 Terrorist attacks may harm greater numbers of children, and sometimes harm only children.³ Terrorists may plan concurrent multiple attacks simultaneously to increase fear and bottleneck the first police, firefighters and emergency medical technicians to arrive at the scene (first responders).^3,7 This possibility mandates careful planning in places where children dwell: home, schools and day care centers.⁴

Disasters' changing nature should prompt health care systems to revisit their ideal surge capacities (the ability to rapidly move from normal operation to a significantly higher capacity) and antidote/treatment needs. Increasingly, surge capacity needs to anticipate pediatric victims. Only 55% of all U.S. hospitals have children's beds, and only 5% of adult hospitals have sufficient resources to manage a broad range of pediatric needs. This raises unique concerns about resources.^3,7

Preparing in Advance

Local hospitals generally hold annual disaster training drills, tabletop exercises, or mock disasters (see Table 1). These drills, required by the Joint Commission and other accrediting and certifying organizations, are designed to promote teamwork skills in high-stress disaster environments. They focus on improving health care team members' communication and collaboration, and also teach team members to "suspend disbelief."

Table 1. Preparedness Exercises for Health Care Systems and Communities

Source: References 8 and 9

Samuel Taylor Coleridge coined the term "suspend belief" 200 years ago. Originally it meant appreciating literary or dramatic works that explore events or characters that would ordinarily be considered implausible. It's been adapted in disasters to mean put aside emotions and preconceived notions and temporarily accept the new reality. Those involved in triaging children at the scene or in the hospital may be unfamiliar with children in general or pediatric medicine specifically, or may be overly empathic in situations where the child may die from his or her exposure.¹⁰

Often, hospitals and health care systems either overlook or under-represent pediatric patients in disaster planning. They fail to acknowledge how children will affect surge capacity and may underestimate health care providers' emotional stress (and difficulty suspending disbelief) when an event harms children.⁶

DISASTER TEAMS/GOVERNMENT RESOURCES

The federal government establishes the disaster response structure that state and communities entities follow, and it influences every health care system's specific disaster response protocols. The U.S. Department of Homeland Security (DHS) is responsible for thwarting terrorist plans and ensuring preparedness for such attacks and appropriate response to those events.³

The Federal Emergency Management Agency (FEMA) was initially created in 1978 and is now part of DHS. Working out of 10 regions, FEMA staff members coordinate actions and respond to homeland disasters when local and state resources have been exhausted.³

Disaster Medical Assistance Teams (DMAT) are groups of health care providers and support personnel, including pharmacists. DMATs can be activated for a period of 2 weeks. DMAT teams provide rapid-response medical care to disaster areas. Once deployed, they bring supplies and equipment to sustain their mission for up to 72 hours. Their responsibilities include triaging and medically managing critically ill patients in inhospitable environments. DMATs currently have no pediatric requirements for team members, and the teams carry limited pharmaceuticals and equipment for children. In the U.S., 2 pediatric teams exist; however, they are self-certified. ^3,11,12

The Medical Reserve Corps (MRC) includes groups of public health and medical volunteers dedicated to their communities' health and safety. They prepare for natural disasters and other unanticipated emergencies that affect public health. They have no clear pediatric capabilities in disasters, nor is pediatric readiness an MRC requirement.³

Congress established the CDC's Strategic National Stockpile (SNS) in 1999. Its mission is to resupply essential medical supplies and equipment needs during emergency disasters. States and communities can tap into the SNS within 12 hours of exhausting local caches once the federal government approves the community for assistance. SNS provides U.S. Food and Drug Administration (FDA)-approved antibiotics, antidotes/antitoxins, airway management supplies (e.g., ventilators, inhalers) and other medical and surgical supplies free of charge. The CDC SNS staff members deploy a "push package" first that includes a wide range of pharmaceuticals, antidotes, and supplies intended to cover unknown disasters. The SNS stores these push packages regionally to permit deployment within 12 hours of federal approval. Once area health and safety personnel define an incident and supplies dwindle, contracted distribution centers ship vendor-managed inventory (VMI) within 24 to 36 hours with supplies and pharmaceuticals more specific to the exposure/event. The SNS's utility in caring for pediatric disaster victims is limited because many antidotes/antitoxins used in pediatric care are not FDA-approved.³

PEDIATRIC PATIENTS: NOT SMALL ADULTS

In addition to understanding the emergency response system, pharmacists need to understand some basics of pediatric care. Pediatric patients' vulnerability stems from their physiologic and psychological immaturity, which significantly increases mortality risk.

Developmental Considerations

Pediatric patients' development is immature, and their systems differ from those of adults in important ways (see Table 2). Most health care providers are aware of pediatric patients' predisposition to gastrointestinal distress. Children are highly susceptible to dehydration due to nausea, vomiting, and diarrhea. Clinicians may be unaware that vascular access is likely to be a problem with smaller children. They need to know about intraosseous infusion (injecting directly into bone marrow to provide a noncollapsible entry point into the systemic venous system). In addition, children can be quite thin or obese, and some health care providers are unfamiliar with autoinjector devices (i.e., atropine, epinephrine, pralidoxime chloride).^3,6,13

Heightened awareness of needle length, dose, and the actual injection process ensures successful use. The autoinjector's needle may be too long for thin children, and too short for obese children. Atropine and pralidoxime autoinjectors formulated for adults deliver doses too large for infants and children, although children often tolerate atropine overdose. Children symptomatic from nerve agent poisoning will likely need both supraphysiologic doses and frequent redosing of atropine. Human factors also interfere with drug efficacy. Unlike regular injections, some autoinjectors are not designed for jab and pull administration, and need to rest in place on the patients skin for several seconds.^14-16

Table 2. Children's Unique Characteristics

Source: References 3, 7, 13, and 17

In essence, "The smaller the child, the bigger the problem regarding any of these considerations such as hypothermia, airway management, separation of family, and ability to effectively decontaminate the child."¹³

Collateral Concerns

Acute injury is just one consideration when children are harmed in disasters. Exposure to toxins, carcinogens, and radiation can damage DNA and predispose children to cancer at later time points; good documentation in children's medical records is critical.^3,6,13 Other concerns include making every attempt possible to keep families together, and if not, reuniting pediatric patients with family members as soon as possible. This can be a challenge.

IDENTIFYING AND TRIAGING PATIENTS

The CDC developed the mnemonic, SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport) to channel patient triage in times of a mass casualty. It is useful in all populations. When triaging pediatric patients, health care providers must emphasize to airway assessment, as children are more likely to experience respiratory arrest than adults (who are more likely to have cardiac arrest). SALT's goal is appropriate transport and rapid treatment with the correct decontamination, antidotes, and supportive care measures.¹⁰

Clinicians need to be cognizant of pediatric patients' unique psychological needs. Their physical symptoms (abdominal pain, headache) may actually be manifestations of stress or anxiety. Disasters themselves cause stress and anxiety, but health care settings do, too. Children have limited to no understanding of the health care system. Clinicians can reduce children's stress by taking these steps¹⁸:

• Minimizing painful and/or invasive procedures
• Discussing procedures before starting so children will know what to expect
• Educating children in an age-appropriate way about their injuries or illnesses
• Asking parents to coach and soothe the patient
• Having activities (coloring books, toys, television) to redirect children's attention during waiting times

Stress may also worsen pre-existing disease, such as an increase in blood glucose for those with diabetes or worsening of asthma symptoms.¹⁹

Types of Threats

Some disasters are seasonal variants (e.g., tornados, hurricanes, floods). Though often caused by nature, disasters can and often do have human origins. Manmade disasters can include bridge failures, accidental industrial explosions, transportation disasters, and other unanticipated events. In recent years, thoroughly unpredictable terrorist attacks have challenged the disaster response system and created a need for health care providers to familiarize themselves with the weapons that terrorists use.³

Natural Disasters

The majority presidentially declared disasters (90%) are weather-related. Cornell University Cooperative Extension Service notes that weather-related and natural disasters seem to occur more frequently lately and result in greater devastation. Presidentially declared disasters cause an average of 500 deaths and $14 billion in damage annually.²⁰ Meteorologists can predict many weather-related events, while others such as earthquakes and tsunamis occur randomly. Regardless, the ensuing damage depends on many variables. Adequate public warning systems, heightened awareness and appropriate actions-that is, planning, preparation, and following through with appropriate and timely action-make huge differences in the aftermath.

Natural disasters come in many forms, and create concerns about injury and illness, food and water safety, environmental concerns including mold, and animal (rodents, snakes, and stray dogs) and insect (mosquitoes and ticks) hazards. Table 3 describes events that often lead to widespread disaster. Of note, when traumatic injury is possible, some researchers now recommend using personal protective devices including infant car seats and helmets inside the house to protect children.²¹

Table 3. Natural Disasters and Health Care Concerns

Source: References 21-28

Natural disasters can injure people who remain in the area or displace victims from their homes. Both often occur. This challenges health care systems, and especially emergency departments, in the disaster area and in communities that accept evacuees. Emergency departments often experience overcrowding as people harmed in the disaster seek emergency care and in areas that have extensive damage, need to replace the supply of medications for chronic diseases. Evacuees often forget or lose their medications as they flee the disaster. Faced with temporary relocation, they seek care for emergency and routine problems such as prescription refills in urgent care and emergency departments because they have no local primary care relationships. The jurisdictions' mobile units and county public health employees are sent to help.²⁹

A significant concern in the aftermath of natural disasters is carbon monoxide poisoning, which causes headache, dizziness, weakness, nausea, vomiting, sleepiness, confusion, and ultimately death. Gasoline-powered generators release carbon monoxide. People who use gasoline-powered generators for energy need to be reminded to install them correctly and away from their homes. They must not use generators, charcoal or gas grills, gas lanterns, or camping stoves in enclosed areas, nor should they use ovens as heat sources.²⁴

Biological Agents

• Biological agents have the potential to kill or maim large numbers of people very quickly, and are a leading concern among disaster response agencies. Methods that aerosolization or mass dispersion of bacterial agents create considerable concern. Children are likely to be most vulnerable to these biologics due to their unique physiology. Pathogenic biological agents affect the child through production of toxins and/or host cell invasion.

Exposure to many of these agents causes an initially mild prodrome. The pediatric patient typically presents with nondescript complaints of fever, chills, headache, nausea, vomiting, and/or diarrhea. Differential diagnosis (i.e., is the problem a typical pediatric viral illness or exposure to a toxin?) is difficult. Further, very young patients lack language skills to describe their symptoms effectively.

Biological agents are classified as Class A, B, or C (Table 4). Anthrax, botulinin toxin, plague, smallpox, tularemia, and viral hemorrhagic fevers are the greatest public health risks.³⁰

Table 4. Biological Agents by Class

Source: 30

The first step in responding to a known biological attack is addressing the health system/hospital's triage needs. Practitioners must be prepared not only for the exposed and sick children but for the worried well. Determining the need for isolation and quarantining exposed patients is necessary to protect nonexposed patients and health care staff. Decontamination methods must also be evaluated.³¹

The next step is addressing the specific agent. Many different antibacterial agents exist, but pediatric dosing, dosage formulations, and FDA approval may be lacking or challenging. Treatment dosing differs from prophylaxis dosing. Since 1969, the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) has prepared and updated a resource that addresses mass dispensing. Available online, it includes treatment doses, prophylaxis doses, and vaccination information along with monitoring perimeters for affected individuals.³¹

Chemical Agents

Chemical agents-called weapons of mass destruction (WMD) because they can kill hundreds of people quickly-have been used in many wars (see Table 5). They tend to be inexpensive, easy to obtain, and generate more fear than either biological and/or radiological terrorism. Small amounts dispersed as gases, liquids, or aerosolized agents can create mass causalities.³²

Table 5. Weapons of Mass Destruction32-34

When terrorists use chemical agents, patients develop signs and symptoms quickly but first responders and health care providers may not be able to determine the specific agent immediately; symptoms, onset, and latency overlap and vary considerably among agents.³⁴ Treatment is twofold: evacuating the affected area followed by rapid decontamination.

First responders and public health officials identify the event's "hot zone" (the area considered to be in greatest danger) to help with triage and treatment needs.³⁵Decontamination has 2 objectives: (1) to treat exposed individuals and (2) to minimize the risk of health care providers experiencing secondary exposure (exposure via residues on patients' clothing and belongings).³² As in many other areas of medicine, emergency responders increasingly rely on mobile medical applications and identification/diagnostic tools to identify the agent quickly, triage effectively, and access information quickly.³⁴

Physical decontamination includes elimination of chemicals. It starts with removal and sequestration of all clothing and accessories, followed by cleansing with soap and water, or using adsorption with adsorbent agents (e.g., activated charcoal, kaolin, resin, talc). In an emergent setting, responders could use available adsorbents (e.g., uncontaminated soil or flour) as scrubbing agents in the decontamination process. The wash water and adsorbent materials become contaminated and require their own specialized handling and disposal.³²

Another method of decontamination is to create a chemical reaction (nucleophilic or oxidation reactions) that render the chemical weapon useless. When used appropriately, this method is more effective than physical decontamination. Commercial decontamination kits are available and may contain ethanol, phenol, sodium hydroxide, ammonia, and water. Household bleach can be used as a skin decontaminant.³²

Radiological Agents

Humans are exposed to low levels of radiation-called background radiation-from sunlight, radon gas, and microwaves daily. In the United States, background radiation accounts for about half of all human radiation exposure. Medical radiographs account for the remaining usual dose, with a total average dose of 620 millirem (0.0062 Gy). Patients who undergo radiation for cancer have exposures that are considerably larger than the average American.³⁶ Radiation levels can be troublesome in some natural disasters. An example is the 2011 Fukuskima nuclear disaster, in which an earthquake and resulting tsunami destroyed a nuclear power plant.³⁷

Radiation is also employed by terrorists. Terrorists' dirty bombs spread low-grade radioactive materials, creating more panic and fear than physical injury and exposure after detonation. However, significant radiation exposure can occur, and the total radiation dose, measured using biodosimetry tools developed for field and bedside use, is the most reliable predicator of patient outcome.^34,38 Foreign bodies imbedded in skin and tissue also cause injuries.^33,39

Acute radiation syndrome progresses through 4 phases (Table 6). Radiation doses that exceed 2 Gy are most likely to cause acute radiation syndrome.^36,40

Table 6. Four Phases of Acute Radiation Syndrome

Source: References 33 and 39

Abbreviations used: CNS - central nervous system; G-CSF - granulocyte colony stimulating factor; GI - gastrointestinal; Gy -gray, unit to measure irradiation. 1 Gy = 100 rads; PRBC - packed red blood cells; rad - radiation absorbed dose.

Public health officials act when radiation disasters occur. Actions range from advising residents to remain indoors (sheltering in place) to evacuation, which minimize or prevent radiation exposure. During Fukuskima nuclear disaster, the public health response was swift. No radiation-related deaths occurred because of the rapid evacuation of the affected area.³⁷

Radioactive iodine-131, a fission product, is emitted in many nuclear disasters. Administration of potassium iodide (KI) is a possible prophylactic agent or treatment. Most effective when taken before exposure, KI blocks thyroid 100% of uptake of radioactive iodine . It exerts its effects for up to 24 hours, making it an ideal prophylactic agent for those near nuclear plants. After exposure, clinicians must give children KI within 24 hours as its efficacy decreases dramatically to less than 10% after that.³⁹ Experts recommend treating children more aggressively than adults, and administering KI at an exposure threshold of 5 rem; adults are treated at 10 rem. KI is an appropriate protective action only in radioactive iodine; it does not provide protection against other radioactive substances.^41,42

Pediatric patients, with their greater body surface area and poorly keratinized skin, are at great risk for thermal and radiation burns. Small children are usually uneducated about
the need to shield their eyes from radiation sources (or incapable of doing so); this increases risk of eye injuries as their lens is more sensitive to radiation damage from blast, radiation, or thermal exposures.³⁹

As with other agents, decontamination is an important first step in radiation containment. Removal of the child's clothing, shoes, and accessories followed by double bagging can contain up to 90% of the radiological agent. Cleaning and scrubbing with soap and water removes radiological dust. All bodily fluids (blood, emesis, stool, urine) must be considered contaminated and handled as toxic waste.³⁹

Clinicians should draw blood and order complete blood counts 3 times daily for the first 2 to 3 days, watching for changes in the patient's lymphocyte counts.³⁹ Several cytokines can be employed to correct radiation-related myelosuppression, and they can be used in children. The FDA has approved a filgrastim dose of 10 mcg/kg/day as a single dose in children, with daily dosing until the absolute neutrophil count exceeds 1,000/mm³. Pegylated filgrastim is also FDA-approved, and clinicians should refer to the approved product labeling for pediatric dosing. The need for cytokines may far exceed their availability, and because of this, U.S. Department of Health and Human Services Radiation and Emergency Medical Management division provides an online triage calculator to help health care providers determine which patients have the greatest need based on exposure type and resultant laboratory values.⁴¹

Low-level radiation's psychological effects can linger for many years. Damage from very-low-level radiation is undetectable; people who are exposed worry about long-term effects or possible reproductive issues (so they avoid having children). They have also been stigmatized by their communities.^43,44

PHARMACIST OPPORTUNITIES

Mass casualties consume pediatric resources, quickly overwhelming systems. Developing a pediatric-specific cache of medications and policies and procedures that address handling, storage, expiration considerations (with rotating soon-to-expire drugs back into hospital supplies), recipes for compounding oral solutions, compounding injectable medications from bulk powders (atropine), and dosing guides, will prepare pharmacists to be effective members of health care support disaster teams.^3,45,46

Most communities need health care professionals including pharmacists to become more involved in disaster planning. As drug experts, pharmacists who volunteer with hospital-based disaster teams and community planning can advocate for appropriate medications and ongoing training. They can mentor and educate new pharmacists and help experienced pharmacists maintain relevant skills. Training is the cornerstone of preparation, and scheduling disaster drills and tabletop exercises that include pharmacists and pharmacy technicians maintains essential skill sets.^3,45,46

Protocols and order sets that are both online and in hard copy are essential. Pharmacy involvement from design to implementation is important. Pharmacists can address pediatric patients' unique characteristics and dosage concerns, thereby reducing risks. Pharmacists need to be part of discussion on how to manage limited resources and be familiar with ethical considerations and criteria for release to use on pediatric patients. Understanding triage and decontamination needs will also help minimize pharmacist and/or pharmacy technician risk of secondary exposure.^3,45,46

During disasters, pharmacists in leadership roles and those with scheduling responsibilities need to anticipate workforce problems. Studies have demonstrated up to 17% reduction in overall workforce during mass casualties. Health care employees, like others in the area, have family and/or child care needs. That reality influences their willingness and ability to respond to a disaster. Their families' and their own safety will be another obstacle; employers who anticipate their needs will be best positioned to help.^3,45,46

SUMMARY

In times of disaster, pharmacists have unique roles, knowledge, and responsibilities. They can ensure that hospitals and communities plan adequately for pediatric needs. Pharmacists' advice about treatment plans, order sets, and procurement of necessary pharmaceuticals and supplies is invaluable. In addition, all health care providers must work with agencies outside their institutions to streamline those decision processes regarding pharmaceuticals and identify new roles that advance pharmacy's mission and vision.

References

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2. United States Census Bureau. QuickFacts United States 2014. Available at http://quickfacts.census.gov/qfd/states/00000.html. Accessed January 24, 2016.

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6. Dolan MA, Krug SE. Pediatric disaster preparedness in the wake of Katrina: lessons to be learned. Clin Ped Emerg Med. 2006;7:59-66.

7. Abraham H. Planning for Pediatrics in Disasters. 2014 http://www.jems.com/articles/print/volume-39/issue-9/patient-care/planning-pediatrics-disasters.html Accessed Jun 15 2015.

8. Chandra A, Williams MV, Lopez C, Tang et al. Developing a tabletop exercise to test community resilience: lessons from the Los Angeles County Community Disaster Resilience Project. Disaster Med Public Health Prep. 2015;9(5):484-488.

9. California Hospital Association. What is the difference between a tabletop exercise, a drill, a functional exercise, and a full-scale exercise? Available at http://www.calhospitalprepare.org/post/what-difference-between-tabletop-exercise-drill-functional-exercise-and-full-scale-exercise. Accessed February 4, 2016.

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11. Gnauck KA, Nufer KE, LaValley JM, et al. Do pediatric and adult disaster victims differ? A descriptive analysis of clinical encounters from four natural disaster DMAT deployments. Prehosp Disast Med. 2007;22(1):67-73.

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13. The Pediatric Disaster Preparedness Subcommittee (California). EMSC Pediatric Disaster Preparedness Guidelines: LEMSAS. http://www.emsa.ca.gov/media/default/pdf/emsa197.pdf. Accessed January 28, 2016.

14. Baker MD. Antidotes for nerve agent poisoning: should we differentiate children from adults? Curr Opin Pediatr. 2007;19(2):211-215.

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31. United States Army Medical research Institute of Infectious Disease. Medical management of biological casualties handbook. 7th edition. Available at http://www.usamriid.army.mil/education/bluebookpdf/USAMRIID%20BlueBook %207th%20Edition%20-%20Sep%202011.pdf. Accessed February 5, 2016.

32. Ganesan K, Raza SK, Vijayaraghavan R. Chemical warfarin agents. J Pharm Bioallied Sci. 2010; 2(3):166-179.

33. Chemical-biological terrorism and its impact of children. Pediatrics. 2006;118(3):1267-1278.

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35. Ramesh AC, Kumar S. Triage, monitoring, and treatment of mass casualty events involving chemical, biological, radiological, or nuclear agents. J Pharm Bioallied Sci. 2010;2(3):239-247.

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37. World Nuclear Association. Fukushima accident. January 2016. Available at http://www.world-nuclear.org/information-library/safety-and-security/safety-of-plants/fukushima-accident.aspx. Accessed February 5, 2016.

38. Marx J, Hockberger R, Walls R, Adams J, Rosen P. Rosen's Emergency Medicine - Concepts and Clinical Practice. 7th ed. Philadelphia, Pennsylvania: Mosby/Elsevier; 2010.

39. AAP Health Initiatives. Children and Disasters. Radiologic or nuclear terrorism and agents. Available at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/Radiologic-or-Nuclear-Terrorism-and-Agents.aspx. Accessed February 5, 2016.

40. US Department of Health and Human Services. White cell growth factors/cytokines-radiation emergency medical management. REMM Web site. Available at http://www.remm.nlm.gov/cytokines.htm. Accessed January 31, 2016.

41. Radiation and Emergency Medical Management. Triage category and cytokine (G-CSF) use after a nuclear detonation. Available at http://www.remm.nlm.gov/triagetool5.htm. Accessed February 5, 2016.

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43. Revkin AC. Nuclear risk and fear, from Hiroshima to Fukushima. New York Times. March 10, 2012. Available at http://dotearth.blogs.nytimes.com/2012/03/10/nuclear-risk-and-fear-from-hiroshima-to-fukushima/?_r=0. Accessed February 5, 2016.

44. Yamashita S, Takamura N. Post-crisis efforts towards recovery and resilience after the Fukushima Daiichi Nuclear Power Plant accident. Jpn J Clin Oncol. 2015;45(8):700-7.

45. American Society of Health-System Pharmacists. ASHP statement on the role of health-system pharmacists in emergency preparedness. Am J Health-Syst Pharm. 2003;60:1993-1995.

46. American Society of Health-System Pharmacists. ASHP statement on pharmacy services to the emergency department. Am J Health-Syst Pharm. 2008; 65: 2380-2383.

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