Introduction
The growing frequency of natural disasters and children’s unique vulnerabilities necessitate a focused examination of factors that promote resilience in this demographic. Existing literature has predominantly concentrated on adult populations, leaving a gap in understanding child resilience, particularly in the context of disasters.Reference Masten1 This review aims to synthesize current evidence on the factors that contribute to resilience in children during disasters, with specific attention to social support, mental health, family function, and the effects of the COVID-19 pandemic.
Resilience is broadly defined as the capacity to recover quickly from adversity and adapt successfully in the face of challenges and stressors.Reference Arshad, Mughal and Giallo2 The Federal Emergency Management Agency (FEMA) defines resilience as “the ability to prepare for threats and hazards, adapt to changing conditions, and withstand and recover rapidly from disruptions.”3 In the context of children, resilience refers to their ability to overcome traumatic experiences, such as natural disasters, and return to a state of emotional and psychological well-being.Reference Masten and Narayan4
Children are particularly vulnerable during disasters due to their physical, emotional, and cognitive developmental stages, which limit their ability to navigate crises independently.Reference Mao and Agyapong5 Resilience in children is critical for mitigating the long-term effects of disasters, such as anxiety and depression.Reference Thibodeau-Nielsen, Palermo and White6 Resilience enables children to adapt to rapidly changing environments, maintain mental stability, and recover from emotional trauma. Therefore, fostering resilience in children is essential for their immediate well-being and long-term developmental outcomes.Reference Wang, Ge and Wan7
Natural disasters are becoming more frequent and severe due to climate change, with 353 million children and adolescents globally affected by traumatic events in 2016 alone.Reference Wang, Ge and Wan7 Communities worldwide recognize that crises cannot always be prevented, leading to the establishment of more efficient programs to enhance resilience and mitigate the impact of these events. The heightened occurrence of disasters underscores the urgency for targeted interventions aimed at children, who are disproportionately affected due to their developmental vulnerabilities.Reference Masten and Narayan4
The concept of resilience has garnered significant global interest, particularly in the context of community and individual recovery from disasters. Several resilience frameworks exist, such as the “PEOPLES Resilience Framework,”Reference Renschler, Frazier and Arendt8 Twigg’s “Characteristics of Disaster-Resilient Communities,” and the “USAID Measurement for Community Resilience.”Reference McDonald-Harker, Drolet and Sehgal9 While these frameworks primarily focus on adult populations and community structures, they often overlook the unique needs of children and the family unit.Reference Masten1 The family context is especially important, as children’s resilience is deeply influenced by their immediate environment, including their relationships with caregivers and peers.Reference Masten and Narayan4
Given the global attention to childhood resilience, particularly in light of significant events such as the COVID-19 pandemic,Reference Thibodeau-Nielsen, Palermo and White6 the September 11, 2001 attacks,Reference Gil-Rivas, Holman and Silver10 and the increasing frequency of natural disasters due to climate change,Reference Masten and Narayan4 understanding how children recover from these crises has become a critical area of focus. Although research on childhood resilience has gained traction, there are still considerable gaps in understanding the factors that contribute to resilience, especially in diverse populations and varying contexts.Reference Masten1 Studies have consistently highlighted the need for further investigation into how mental health, social support, and family dynamics impact resilience post-disaster Reference Arshad, Mughal and Giallo2, Reference Thibodeau-Nielsen, Palermo and White6. This review aims to assess the current state of knowledge, identify gaps, and provide insights into protective strategies and interventions to bolster resilience among children facing disasters. Understanding these factors is crucial for developing effective policies and programs to support children’s recovery in the aftermath of crises and to build resilience within communities at risk of recurring disasters.Reference Mao and Agyapong5
Methods
This scoping review followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines.Reference Tricco, Lillie and Zarin21 The search strategy was designed to locate relevant studies across 4 major databases: PubMed, Scopus, CINAHL Complete, and MEDLINE. A combination of keywords and controlled vocabulary was used to ensure the search captured a wide range of studies on child resilience in disaster contexts. For example, the search string in PubMed included terms such as “(child OR adolescent) AND (resilience OR coping) AND (disaster OR earthquake OR pandemic) AND (social support OR mental health).” The search terms also included phrases such as resilience of children in disasters, child resilience AND disaster AND socioeconomic, adolescent resilience during disasters, and child resilience during the pandemic. To focus on contemporary research, filters were applied to include only studies published in English from 2002-2023.
We used Google Scholar as a supplementary tool to ensure no relevant research was overlooked. This approach helped mitigate the risk of missing key research that may not have been captured in the more rigorous databases. We limited the search to the first 10 pages of Google Scholar based on prior evidence suggesting that the relevance of results typically declines beyond this threshold.Reference Arshad, Mughal and Giallo2 All retrieved articles were imported into reference management software, and 17 duplicates were removed. Additionally, the reference lists of the included studies were examined to identify any studies not captured by the original search.
Table 1 summarizes the literature search strategy, including concept area keywords and the number of records retrieved from each database. Bolded keywords included in Table 1, such as children, adolescents, resilience, disaster, and pandemic, represent the primary search terms used to capture relevant studies. Non-bolded terms, such as child, youth, resiliency, and COVID-19, were included to broaden the search and account for alternative terminologies. This strategy ensured a comprehensive and targeted search for child and adolescent resilience studies in disaster and pandemic contexts.
Literature search strategy
The inclusion criteria required studies to focus on children aged 0-18 who had experienced a natural or man-made disaster. Studies that exclusively focused on PTSD, post-war trauma, or refugee trauma were excluded because these areas of research typically require specialized interventions that diverge from the broader resilience-focused framework of this review. The aim was to explore general resilience factors applicable to natural disaster contexts rather than specific trauma-related disorders. In addition, studies that focused on the development of resilience measurement tools, theoretical frameworks, reviews, or case studies were excluded. While useful for different purposes, these studies did not provide empirical data necessary for mapping the factors that directly contribute to resilience in children facing natural disasters. These criteria were established to ensure the studies selected for the review provided robust, relevant insights into the factors that influence child resilience in the specific context of natural disasters, supporting the goal of identifying areas for intervention and policy development. Articles that passed title and abstract screening went through a full-text review to ensure all criteria were met.
A formal quality assessment tool was not employed in this scoping review; this is consistent with the scoping review methodology, which prioritizes mapping the existing literature rather than critically appraising each study.Reference Tricco, Lillie and Zarin21 The focus was identifying the breadth of evidence available on resilience in children during disasters. However, studies were reviewed to ensure they met the eligibility criteria, including relevance to resilience factors in disaster contexts, adequate population size, and robust study design. These elements helped ensure that the included studies provided valuable insights into the key factors influencing resilience without conducting a formal quality appraisal.
Data extraction was performed using a structured form that collected essential study characteristics, including the author, publication year, country, study design, sample size, and population characteristics. Specific data on resilience-related factors—including social support, family dynamics, mental health outcomes, and socioeconomic conditions—were also collected, as these elements significantly influence children’s ability to cope with disaster situations. The data extraction process was independently conducted by 2 reviewers to reduce bias, with discrepancies resolved through discussion or by consulting a third reviewer.
Results
Study Selection
The search initially identified 8298 articles, with 1051 articles from PubMed, 539 from CINAHL Complete, 1569 from MEDLINE, and 5139 from SCOPUS. After removing 17 duplicate records, 8037 unique articles remained for title and abstract screening. During this initial screening, articles were excluded based on predefined inclusion criteria, which required studies to focus on child resilience in the context of disasters or pandemics and to contain empirical data. Following the title and abstract screening, 244 articles underwent a full-text review and 228 were excluded. Common reasons for exclusion at this phase included studies not centered on children or adolescents, articles focusing solely on PTSD or disaster education, and studies that primarily involved the development of resilience assessment tools rather than empirical findings on resilience factors.
Additionally, reviews, policy reports, and case studies that lacked direct empirical data were excluded, as were studies that concentrated on resilience measurement procedures without exploring broader resilience-building factors. Ultimately, 16 articles met the final inclusion criteria and were retained for analysis. The PRISMA flow diagram (Figure 1) illustrates the study selection process, detailing the number of records identified, screened, and included in the final review.
Literature search synopsis.
Study characteristics
The 16 studies included in this review spanned various geographic regions, study designs, and populations, with research conducted in countries such as the United States, Canada, China, Japan, Tibet, Korea, and Indonesia. The studies focused on children and adolescents between the ages of 3-18, although the average age and specific age groups varied across studies.Reference Arshad, Mughal and Giallo2, Reference Lu, Yang and Niu13 Most included studies were observational, utilizing retrospective cohort or cross-sectional designs. Some studies, such as McDonald-Harker et al. used a mixed-methods approach, incorporating both quantitative measures (e.g., surveys) and qualitative interviews to provide a more comprehensive understanding of resilience factors. Resilience was assessed using various tools, including the Connor-Davidson Resilience Scale (CD-RISC), the Children and Youth Resilience Measure (CYRM), and mental health measures such as the Patient Health Questionnaire-9 (PHQ-9) and the Strengths and Difficulties Questionnaire (SDQ). These measures provided a framework for understanding the various aspects of resilience and the factors that influence it. To facilitate understanding of the data presented, we have included a detailed table (Table 2) that summarizes the characteristics and findings of each study, categorized by theme.
Literature summary
Findings
Mental health
Of the 16 studies, 6 focused on mental health outcomes and their relationship to resilience in children during and after disasters.Reference Okuyama, Funakoshi and Tomita18, Reference Wang, Ge and Wan7, Reference Lu, Yang and Niu13, Reference Laksmita, Chung and Liao15, Reference Spinelli, Lionetti and Setti17, Reference Tso, Wong and Tung19 These studies consistently found that higher resilience scores were associated with fewer symptoms of anxiety, depression, and psychological distress. Okuyama et al. followed high school students for 3 years after the Great East Japan Earthquake and found that resilience levels fluctuated over time.Reference Okuyama, Funakoshi and Tomita18 Initially, resilience was negatively associated with depression, indicating that students with higher resilience exhibited fewer depressive symptoms in the early stages of recovery. However, this protective effect diminished over time, especially among those who had experienced the death of a family member.
Wang et al. conducted a latent profile analysis on children following an earthquake in China, categorizing participants based on their resilience and depression levels.Reference Wang, Ge and Wan7 The study found that resilience was associated with a reduced risk of negative mental health outcomes, with most participants classified in the “mild depression/high resilience” category. Nevertheless, some participants showed co-occurrence of high resilience with severe depression, suggesting that resilience does not uniformly prevent adverse mental health outcomes. Lu et al.Reference Lu, Yang and Niu13 examined Tibetan adolescents 5 years after the Yushu earthquake and found that resilience was positively associated with regular physical exercise and good health. The study suggested that lifestyle factors might enhance resilience and reduce the likelihood of developing anxiety or depression after a disaster.
Spinelli et al.Reference Spinelli, Lionetti and Setti17 investigated children aged 2-14 in Italy and observed that supportive parenting practices contributed to children’s resilience and mental well-being during prolonged crises. Tso et al. examined vulnerability and resilience in children during the COVID-19 pandemic in China.Reference Tso, Wong and Tung19 The study found that children with higher resilience reported fewer psychological problems, such as emotional and behavioral difficulties. Factors such as family harmony and positive parenting were linked to increased resilience and better mental health outcomes. Laksmita et al. explored predictors of resilience among Indonesian adolescent disaster survivors and identified that resilience was inversely related to mental disorders.Reference Laksmita, Chung and Liao15 Adolescents with higher resilience exhibited fewer symptoms of depression and anxiety, indicating that resilience serves as a protective factor against mental health issues in disaster contexts.
Social support
Social support emerged as a significant factor influencing resilience in children across 8 studies included in this reviewReference Arshad, Mughal and Giallo2, Reference McDonald-Harker, Drolet and Sehgal9, Reference McDonald-Harker11, Reference Lu, Yang and Niu13, Reference Laksmita, Chung and Liao15, Reference Spinelli, Lionetti and Setti17, Reference Terranova, Morris and Myers22, Reference Wang, Chen and Zhai23. In 2 separate studies, McDonald-Harker et al.Reference McDonald-Harker, Drolet and Sehgal9, Reference McDonald-Harker11 examined children affected by natural disasters in Canada. The first studyReference McDonald-Harker, Drolet and Sehgal9 focused on children and youth impacted by the 2016 Fort McMurray wildfires, finding that higher levels of support from caregivers and peers were associated with better emotional and psychological outcomes. The presence of supportive relationships helped children cope with disaster-related stress by offering emotional comfort and practical help. The second study,Reference McDonald-Harker11 investigated factors contributing to resilience among children and youth following the 2013 Alberta floods, highlighting the importance of social support from family and community members. Social support from family and community members significantly contributed to resilience, as social networks fostered a sense of belonging and provided resources that facilitated adaptation to post-disaster environments.
Similarly, Arshad et alReference Arshad, Mughal and Giallo2 demonstrated that maternal social support during pregnancy and early childhood was a strong predictor of resilience in children affected by a natural disaster, highlighting the importance of caregiver mental health and social support systems. Lu et al.Reference Lu, Yang and Niu13 assessed Tibetan adolescent earthquake survivors and found that social support appraisals were positively associated with resilience levels, with support from non-family members like teachers contributing significantly. Laksmita et al.Reference Laksmita, Chung and Liao15 identified social support as a protective factor for Indonesian adolescent disaster survivors, mitigating mental health disorders and promoting courageous coping strategies.
Further supporting these findings, a longitudinal study on Chinese adolescents exposed to the Wenchuan earthquake found that social support mediated the relationship between gratitude and resilience, reducing internalizing and externalizing symptoms over time. Adolescents who reported higher levels of gratitude experienced greater social support, which in turn bolstered resilience.Reference Wang, Chen and Zhai23
Terranova et alReference Terranova, Morris and Myers22 found that supportive family environments were directly linked to resilience and emotional regulation in preschool children following a hurricane in the US, emphasizing the crucial role of positive family dynamics. Spinelli et alReference Spinelli, Lionetti and Setti17 studied the impact of parenting stress during the COVID-19 outbreak in Italy. The article noted that higher parental involvement and lower household chaos were associated with better emotion regulation in children, thereby enhancing resilience during prolonged crises.
Family dynamics
Five studiesReference Arshad, Mughal and Giallo2, Reference McDonald-Harker, Drolet and Sehgal9, Reference McDonald-Harker11, Reference Spinelli, Lionetti and Setti17, Reference Terranova, Morris and Myers22 focused on the role of family dynamics in children’s resilience during disasters. Terranova et al. examined preschool children’s adjustment following a hurricane and observed that supportive family functioning was associated with children’s emotional regulation and resilience post-disasterReference Terranova, Morris and Myers22. McDonald-Harker et al. reported that positive caregiver relationships correlated with higher resilience levels in children.Reference McDonald-Harker, Drolet and Sehgal9 In a separate study, McDonald-Harker et al. investigated children impacted by floods and found similar associations between strong family relationships and resilience, in which strong family cohesion and supportive relationships were linked to higher resilience.Reference McDonald-Harker11 Moreover, the mental well-being of caregivers significantly affected children’s resilience, indicating that caregiver stress could impede children’s adaptive capacities. Another study found that higher levels of maternal social support were associated with greater child resilience.Reference Arshad, Mughal and Giallo2 Effective family functioning, characterized by positive communication and emotional support within the family, was linked to better resilience outcomes in children.
Socioeconomic status
Four studies in this scoping review examined the role of socioeconomic status (SES) in children’s resilience to disasters.Reference Meltzer, Zacher and Merdjanoff16, Reference Tso, Wong and Tung19, Reference Arshad, Mughal and Giallo2, Reference Jackson, Stevenson and Larson12 These studies identified associations between SES and various challenges to resilience. Meltzer et al. (2021) investigated the impact of cumulative natural disaster exposure on adolescents’ psychological well-being.Reference Meltzer, Zacher and Merdjanoff16 The study found a 1.41 (95% CI 1.05, 1.88) increased probability of psychological distress for every additional disaster a child experienced after adjusting for race/ethnicity, annual household income, parental education level, housing stability, family functionality, parental coping, and mental health. Those who experienced psychological distress were more likely to be older, female, belong to low-income families, have caregivers with only a high school degree or less, live in unstable housing, have low family functionality, and have caregivers with poor parental coping and mental component scores. Moreover, racial and ethnic minorities and those of lower socioeconomic status were no more likely to suffer from cumulative disaster exposure than their high-income counterparts.
Arshad et al. identified maternal social support and family income as key factors influencing children’s ability to recover from the disasterReference Arshad, Mughal and Giallo2. During the COVID-19 pandemic, Tso et al. found that children from lower SES households experienced higher levels of psychological distress.Reference Tso, Wong and Tung19 Families with financial strain and increased caregiver stress were more susceptible to adverse psychological outcomes during the pandemic. Finally, Jackson et al. (2021) studied the relationship between outdoor activities and resilience among adolescents during the pandemic, noting that lower SES was associated with reduced participation in outdoor activities, which in turn impacted subjective well-being and resilience.
COVID-19-related studies
Five included studies focused specifically on the impact of the COVID-19 pandemic on children’s resilience.Reference Thibodeau-Nielsen, Palermo and White6, Reference Jackson, Stevenson and Larson12, Reference Spinelli, Lionetti and Setti17, Reference Tso, Wong and Tung19, Reference Zhang, Zhou and Xia20 These studies provided insights into how prolonged social isolation, disrupted routines, and heightened family stress affected resilience during the pandemic. Spinelli et al.Reference Spinelli, Lionetti and Setti17 assessed parenting stress during the COVID-19 pandemic in Italy and noted that increased parental involvement and reduced household chaos were linked to better emotion regulation in children. Thibodeau-Nielsen et al. (2021) found that pandemic-related pretend play acted as a protective factor against emotional distress, with children who engaged in play demonstrating higher resilience. Jackson et al. (2021) showed that outdoor activities and peer interaction, even during lockdown, contributed to better mental health outcomes and increased resilience in adolescents. Zhang et al. (2020) further emphasized the importance of structured routines and outdoor time in maintaining children’s resilience throughout the pandemic. These findings suggest that while the pandemic posed unique challenges, adaptive behaviors such as play, and outdoor activities served as important resilience-building strategies.
The 16 studies included in this review highlight the multidimensional nature of resilience in children during disasters. The thematic analysis points to mental health, social support, family dynamics, and socioeconomic status as key factors that influence resilience. Furthermore, the impact of the COVID-19 pandemic on resilience highlights the need for adaptive strategies that foster resilience in prolonged disaster scenarios. Some studies were included in multiple thematic sections due to their relevance to more than 1 aspect of resilience. For example, Arshad et al. contributed to the SES and social support themes, as this article examined how socioeconomic factors and maternal social support jointly influence child resilience.Reference Arshad, Mughal and Giallo2 Similarly, McDonald-Harker et al. addressed both social support and family dynamics, reflecting the interrelated nature of these factors in determining children’s ability to cope with disasters.Reference McDonald-Harker, Drolet and Sehgal9, Reference McDonald-Harker11 This thematic overlap demonstrates the multifaceted and interconnected determinants of resilience in children.
Limitations
This scoping review offers a synthesis of studies on resilience in children during and after disasters. It provides insights into the nature of resilience, encompassing mental health, social support, family dynamics, and socioeconomic factors. However, several limitations should be acknowledged. First, the relatively sparse number of studies specifically focused on children or adolescents reflects a gap in the literature, as much of the existing research concentrates on adults, communities, or health care professionals. This limited the pool of available evidence and may affect the comprehensiveness of the review. Second, many of the included studies were cross-sectional, limiting our ability to assess long-term resilience outcomes. Longitudinal studies are needed to explore how resilience evolves in children exposed to multiple disasters. Additionally, several studies relied on self-reported data from caregivers, which may introduce bias. Future research should focus on gathering data directly from children to better understand their perspectives on resilience. Finally, the scope of this review was limited to studies written in English, which may have excluded relevant research from other languages.
Discussion
This scoping review synthesizes key factors influencing resilience in children during and after natural disasters. The review focuses on mental health, social support, family dynamics, and socioeconomic status. By examining 16 studies, this review highlights factors that contribute to child resilience in disaster settings and provides important implications for policymakers, health care providers, educators, and community leaders involved in disaster preparedness and response.
Several studies found that higher resilience was associated with fewer mental health symptoms, such as anxiety and depression.Reference Wang, Ge and Wan7, Reference Okuyama, Funakoshi and Tomita18 Resilience appears to act as a protective buffer against the psychological impacts of disaster exposure.Reference Lu, Yang and Niu13 However, resilience is not always sufficient to prevent severe mental health conditions. For example, some children with high resilience still exhibited severe depressionReference Wang, Ge and Wan7. This aligns with previous research, which suggests resilience may mitigate, but not eliminate, the risk of mental health disorders in disaster-exposed children.Reference Masten and Narayan4
Social support emerged as a significant determinant of resilience across studies.Reference Arshad, Mughal and Giallo2, Reference McDonald-Harker, Drolet and Sehgal9 Children with strong social support networks—particularly from caregivers and peers—demonstrated enhanced coping abilities and greater resilience in the face of disasters.Reference Thibodeau-Nielsen, Palermo and White6 Social support provides both emotional and practical assistance, which is crucial for children navigating the challenges posed by disasters.Reference Masten1 These findings highlight the value of interventions that strengthen social ties and provide emotional and material support to children and families during crises.Reference Jackson, Stevenson and Larson12
Stable family dynamics and positive caregiver-child relationships played a pivotal role in fostering resilience among children during and after disasters.Reference Terranova, Morris and Myers22 Children from supportive, well-functioning families were better able to regulate their emotions and exhibited higher levels of resilience. Family-centered interventions, particularly those that support caregiver mental health, are critical for improving resilience outcomes in disaster-exposed children.Reference Spinelli, Lionetti and Setti17 This emphasizes the importance of focusing on the family unit in disaster response programs.Reference Lu, Yang and Niu13
While low socioeconomic status (SES) increases vulnerability to disaster impacts, evidence suggests family functionality and social support may play more critical roles in fostering resilience than SES alone.Reference Niazi, Rana and Arshad14 Children from low-SES backgrounds with strong family and community support networks often displayed higher resilience than more affluent counterparts without such support.Reference Mao and Agyapong5 This finding is crucial for policymakers as it highlights the need to strengthen social and family networks, especially in low-income communities.Reference McDonald-Harker, Drolet and Sehgal9
The COVID-19 pandemic provided new insights into resilience during prolonged crises. Several studies pointed to the importance of structured routines, outdoor activities, and play in promoting resilience during the pandemic.Reference Thibodeau-Nielsen, Palermo and White6, Reference Jackson, Stevenson and Larson12 Adaptive behaviors such as maintaining routines and engaging in outdoor activities helped children cope with the stress and uncertainty of prolonged social isolation.Reference Zhang, Zhou and Xia20 These findings align with resilience literature emphasizing the importance of routine and social interaction in maintaining emotional well-being during crises.Reference Masten1
This review addressed the question: What are the key factors that influence resilience in children during and after disasters? The results indicate that mental health, social support, family dynamics, and socioeconomic status are pivotal in establishing resilience. The findings demonstrate the multifaceted nature of resilience, which involves individual characteristics and broader environmental and social factors. Additionally, the review aimed to provide actionable insights for disaster preparedness and recovery efforts tailored to children.
Conclusion
The results of this scoping review illustrate the multifaceted nature of resilience in children during disaster situations, with mental health, social support, family dynamics, and socioeconomic status emerging as key factors. Mental health interventions should be prioritized in disaster settings, with a focus on providing timely psychological support to children and families.Reference Mao and Agyapong5 Additionally, strengthening social support systems through community-based interventions is essential in formal settings and informal peer and family networks.Reference McDonald-Harker, Drolet and Sehgal9 Family-centered approaches that address caregiver mental health are also critical for fostering resilience in children.Reference Spinelli, Lionetti and Setti17 Addressing socioeconomic disparities is also critical, as low-income communities often lack access to essential resources for recovery.Reference Mao and Agyapong5 Tailored interventions targeting these communities can help ensure that all children receive adequate support during and after disasters.Reference Mao and Agyapong5 Future research should continue exploring these factors across diverse populations and various types of disasters to inform evidence-based policies and interventions that build and sustain resilience in children. This review highlights the importance of integrated, multi-level strategies that support individual children and the broader social and economic environments in which they live.Reference Masten and Narayan4
Author contribution
Roxanna Shabahang: Conducted data collection and analysis and revised the article for intellectual content; Ana-Sofia Arena: Revised article for intellectual content; Irene Navis: Conceived of the study and revised the article for intellectual content; Deborah Kuhls: Revised article for intellectual content; Christopher Newton: Revised article for intellectual content; Rita V. Burke: Conceived of the study, oversaw data analysis and interpretation, and revised the article for intellectual content.
Funding statement
The project was supported by Award Number 6 U3REP190616-01-02 from the Office of the Assistant Secretary for Preparedness and Response (ASPR). The contents are solely the responsibility of the authors and do not necessarily represent the official views of ASPR or the Department of Health and Human Services.
