On October 9, 2005 at 4:30 p.m. a tanker from Indonesia loaded with fertilizer exploded in the Baltimore shipyards.

On October 9, 2005 at 4:30 p.m. a tanker from Indonesia loaded with fertilizer exploded in the Baltimore shipyards. Among 783 shipyard workers who were on the job in various parts of the port, 56 workers were immediately killed and 102 injured. Emergency response to the blast consisted of 27 fire trucks with 122 fireman and 58 ambulances with 116 EMTs. The injured were transported to two hospitals that specialized in burn treatment (Johns Hopkins and Peter Brent Hospital) that received all of the victims of the blast. A strong wind off the Chesapeake Bay from the South blew smoke over the City causing about 650 chemical inhalation illnesses among residents of south Baltimore and affected 5,680 of 60,000 attendees at a professional football game held in the stadium near the port.
An additional 15 of the blast victims died from their injuries during the first 3 days following the explosion.
Within 72 hours following the ship explosion, 80 of the first responders, 2,569 citizens of south Baltimore, 13,608 citizens living in areas within and surrounding Baltimore as well as 5,306 residents living in Washington, D.C. and areas around the states of Maryland and Virginia showed one or more of the following sets of symptoms:

1A. Fever, swollen lymph nodes in the neck, sore throat with dysphagia and ulcers at the base of the tongue.
1B. Two to three days after onset of illness, blood culture of patients showing these symptoms revealed gram positive bacilli and patients developed thoracic swelling and a widened mediastinum – (see image on next slide) on chest x-ray with 30% of those showing these symptoms suffering from respiratory failure and hemodynamic collapse followed by death.
1C. Related to this set of symptoms, some patients showed severe edema in association with wounds caused during the blast that ulcerated after about 2 days with some swelling and inflammation of regional lymph nodes and resulting in a black eschar (a hard plaque of dead skin covering the ulcer). See image on second slide following this one.
1D. Additional people with these symptoms continue to emerge within the area covered by the explosion cloud but not outside this area over the next week.
1E. The number of new cases subsides after a very hard and prolonged rain storm that occurs in Baltimore and surrounding areas.
1F. Very few of the first responders showed this disease. See case table in third slide following this one.

2A. Fever, weakness, shortness of breath with rapidly developing pneumonia, chest pain and cough with gram negative rods seen in sputum samples.
2B. The number of people contracting the disease associated with these symptoms increases with time until quarantine and prophylactic antibiotics stem the outbreak.
2C. In the early stages of the outbreak before effective antibiotics have been identified and employed within 24 hours of the appearance of symptoms, over 90% of those affected died

3A. Fever, headache, muscle pain, shortness of breath, cough and chest pains. Patients not treated with antibiotics go on to develop pneumonia.
3B. Some patients show skin ulceration with regional lymph node swelling.
3C. A large percentage of those who were closest to the blast area showed conjunctivitis and swelling of lymph nodes in the head and neck area. Culture of sputum specimens or ocular swabs from these patients reveal a gram negative coccobacillus.
3D. Infections are confined to the first wave that is seen following the explosion in the shipyard.
3E. Few new cases erupt after the first round of infections. But those infected early during the outbreak before appropriate antibiotics are identified have suffered a fatality of 15%

4A. Within 12 days of the explosion patients from among first responders and residents living close to the port of Baltimore began to appear at area hospitals showing the following symptoms: fever, body pains and prostration.
4B. Within 2 to 3 days of these initial symptoms the patient develops a rash over the face that spreads to the extremities. This rash is identical in appearance wherever on the body it erupts and it goes through several structural permutations with significant pain and eventual scabbing. See image of rash on next slide.
4C. Mortality among those developing these symptoms ranges between 5 and 10%. Antibiotics are ineffectual, and this disease increases dramatically in the number of cases about every 15 days, affecting many people throughout Baltimore and beyond. Very few of the first responders showed infection with this agent

1. Name the disease(s) affecting Baltimore and surrounding areas?
2. Provide at least one antibiotic effective against the disease agent(s) – if it is (they are) susceptible to antibiotics?
3. What kind of epidemic is the involved agent(s) causing?
4. What caused this disease (s) to breakout in this location at this time?
5. Would this/these be considered endemic or epidemic diseases in the U.S.?
6. How could you prevent future outbreaks of this disease(s)?
7. Why were there such differences between first responders and citizens of Baltimore in the number of cases of two of the sets of symptoms described above?
8. Why did sickness appear outside of South Baltimore?
9. Zoonosis or anthroponosis?
10. Why do three sets of symptoms focus on the lungs and not the 4th set of symptoms?
11. Tell specifically how you would stop this epidemic(s)?
12. Why did the one set of symptoms virtually vanish following the rainstorm?

13. Why did the one set of symptoms only appear during the first 17 days in South Baltimore citizens and not show up in anyone after day 10 outside of south Baltimore?

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