A Pediatric Bioterror Tabletop in the Windy City

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A Pediatric Bioterror Tabletopin theWindy City

• By
• Paul Rega, M.D., F.A.C.E.P.

2
Tuesday, 4AM

• EDs around town
• Busier than usual, nothing special
• Adults
• Cough, fever
• Eye infection
• 1 day old leg laceration
• Nausea, vomiting, diarrhea in 22 yo
• Chest pains
• Ankle sprain
• Couple of weak and dizzies in middle aged
• Slurred speech in middle aged
• Family mom, Pop, 6 8yo with N V

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Tuesday, 4AM

• Childrens Hospital
• 2 sore throats
• 2 siblings (10 13) with N V no fever
• Tired-looking 5yo with blurred vision
• 3 yo with URI and low fever
• Bump on head
• Painful sprained knee
• Fever and rash in 10 mo old
• 2 ED returns for vomiting
• Family of 5 with N, V (not 5 month old)

4
Prior Weekend

• Cubs-White Sox game Saturday, Sunday
• Annual Mexican-American Food Festival Sunday
• Lake Michigan Regatta Saturday
• Tens of thousands of Chicagoans enjoying the sun
  and fun activities of the weekend.

5
Tuesday, 6AM

• Increased EMS traffic
• 35 yo Difficulty swallowing
• 65yo MVA
• 46yo difficulty breathing
• General hospitals
• ED return of 28yo (NV) with droopy eyelids and
  difficulty seeing
• 3 middle-aged with difficulty speaking
• 2 young adults with weakness and short of breath

6
Tuesday, 6AM

• Childrens Hospital
• Two admitted children with gastroenteritis and
  dehydration on the floor required emergency
  respiratory ventilation and are being transferred
  to ICU

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Botulinum Toxin (Clostridium botulinum)
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Tests for Sensitivity to Antitoxin

• Skin test 0.1 mL of 1100 saline dilution of
  antitoxin IC (0.05 mL of 11000 solution in
  patients with allergies).
• Fatalities
• Epinephrine 11000 within reach
• Prophylactic?
• Eye test 1 drop of a 110 NS dilution
• Simpler
• More specific
• Safer

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Tuesday, 8AM

• EDs reaching capacity
• Waiting rooms 2 hour wait
• Complaints The usual for a Tuesday morning
  coupled with more than usual number of patients
  with GI complaints and/or bulbar palsies
• More than usual number of patients with
  increasing difficulty breathing requiring
  intubation and ventilation

14
Tuesday, 8AM

• Local news reports indicate unusually high number
  of EMS traffic and hospital admissions.
• More later

15
Tuesday, 9AM

• All hospitals activate their disaster protocols.

16
Tuesday, 10 AM

• All EDs at capacity
• Waiting room wait times 4-5 hours

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Tuesday, 1130 AM

• Cook County Public Health Commissioner declares a
  Public Health Emergency
• Botulism epidemic
• Food-borne?
• Air-borne?
• Terrorism vs. accidental?

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Tuesday, 100 PM

• Hitherto unknown hate organization announces to a
  local radio station that it has contaminated
  nacho sauce with botulinum toxin over the
  weekend.
• Includes ballpark, food festival, and regatta

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Tuesday, 130 PM

• Announcement by Public Health and FBI of a
  bioterror attack upon Chicago and its citizens

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Tuesday, 2PM

• All hospital switchboards are flooded with phone
  calls from nervous citizens.

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Tuesday, 3PM

• CDC agrees to release Botulinum antitoxin to
  Chicago.

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Tuesday, 7PM

• First supply of antitoxin arrives in Chicago for
  distribution

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Wednesday, 830 AM

• Arrival of first cache of ventilators from
  Strategic National Stockpile at OHare

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Wednesday, 9 AM

• SitRep 1
• Probable cases
• 4,232 adults
• 10 deaths (3 antitoxin-related)
• 2,589 children
• 3 deaths (1 antitoxin-related)
• EMS traffic and hospital admissions continues at
  same heightened rate over past 24 hours.
• Hospitals in disaster mode
• Overcapacity
• Infrastructure absenteeism 22

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Thursday, 9 AM

• SitRep 2
• Probable cases
• 5,387 adults
• 10 deaths (3 antitoxin-related)
• 3,567 children
• 3 deaths (1 antitoxin-related)
• EMS traffic and hospital admissions have
  stabilized.
• Hospitals in disaster mode
• Overcapacity
• Infrastructure absenteeism 20
• DMATs/MRC arriving later today

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References

• Anonymous. Botulism Current, comprehensive
  information on pathogenesis, microbiology,
  epidemiology, diagnosis, and treatment.
  www.cidrap.umn.edu/cidrap/content/bt/botulism/biof
  acts/botulismfactsheet.html. Accessed 7/2/05.
• Wein LM, Liu Y. Analyzing a bioterror attack on
  the food supply The case of botulinum toxin in
  milk. PNAS 2005 102 (28)9984-9989.
• Botulism. www.bt.cdc.gov/agent/botulism/index.asp
  . Accessed 7/2/05.

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References

• Chan-Tack KM, Bartlett. Botulism.
  www.emedicine.com/med/topic238.htm. Accessed
  7/1/05.
• Frattarelli DAC, Abdel-Haq NM. Botulism.
  www.emedicine.com/ped/topic273.htm. Accessed
  7/1/05.
• Kim J. CBRNE - Botulism. www.emedicine.com/ped/top
  ic64.htm. Accessed 6/29/05.
• Rega P. Bio-Terry A Stat Manual to Identify and
  Treat Diseases of Biological Terrorism. MASCAP,
  Inc., Maumee, OH. 2000, 2003.

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References

• Botulism Antitoxin Trivalent A, B, and E
  (Equine). www.rxmed.com/b.main/b2.pharmaceutical/b
  2.prescribe.html. Accessed 7/2/05.
• Bossi P, Tegnell A, et al. Bichat Guidelines for
  the Clinical Management of Botulism and
  Bioterrorism-Related Botulism. Eurosurveillance
  2004 9(12) www.eurosurveillance.org/em/v09n12/09
  12-230.asp. Accessed 5/21/05.
• Cieslak TJ, Henretig FM. Bioterrorism.
  Pediatric Annals 2003 32154-165.