We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Consensus Statement |

Tularemia as a Biological Weapon Medical and Public Health Management

David T. Dennis, MD, MPH; Thomas V. Inglesby, MD; Donald A. Henderson, MD, MPH; John G. Bartlett, MD; Michael S. Ascher, MD; Edward Eitzen, MD, MPH; Anne D. Fine, MD; Arthur M. Friedlander, MD; Jerome Hauer, MHS; Marcelle Layton, MD; Scott R. Lillibridge, MD; Joseph E. McDade, PhD; Michael T. Osterholm, PhD, MPH; Tara O'Toole, MD, MPH; Gerald Parker, PhD, DVM; Trish M. Perl, MD, MSc; Philip K. Russell, MD; Kevin Tonat, DrPH, MPH; for the Working Group on Civilian Biodefense
JAMA. 2001;285(21):2763-2773. doi:10.1001/jama.285.21.2763.
Text Size: A A A
Published online

Objective The Working Group on Civilian Biodefense has developed consensus-based recommendations for measures to be taken by medical and public health professionals if tularemia is used as a biological weapon against a civilian population.

Participants The working group included 25 representatives from academic medical centers, civilian and military governmental agencies, and other public health and emergency management institutions and agencies.

Evidence MEDLINE databases were searched from January 1966 to October 2000, using the Medical Subject Headings Francisella tularensis, Pasteurella tularensis, biological weapon, biological terrorism, bioterrorism, biological warfare, and biowarfare. Review of these references led to identification of relevant materials published prior to 1966. In addition, participants identified other references and sources.

Consensus Process Three formal drafts of the statement that synthesized information obtained in the formal evidence-gathering process were reviewed by members of the working group. Consensus was achieved on the final draft.

Conclusions A weapon using airborne tularemia would likely result 3 to 5 days later in an outbreak of acute, undifferentiated febrile illness with incipient pneumonia, pleuritis, and hilar lymphadenopathy. Specific epidemiological, clinical, and microbiological findings should lead to early suspicion of intentional tularemia in an alert health system; laboratory confirmation of agent could be delayed. Without treatment, the clinical course could progress to respiratory failure, shock, and death. Prompt treatment with streptomycin, gentamicin, doxycycline, or ciprofloxacin is recommended. Prophylactic use of doxycycline or ciprofloxacin may be useful in the early postexposure period.

Figures in this Article

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?


Figure 1. Cervical Lymphadenitis in a Patient With Pharyngeal Tularemia
Graphic Jump Location
Patient has marked swelling and fluctuant suppuration of several anterior cervical nodes. Infection was acquired by ingestion of contaminated food or water. Source: World Health Organization.
Figure 2. Chest Radiograph of a Patient With Pulmonary Tularemia
Graphic Jump Location
Infiltrates in left lower lung, tenting of diaphragm, probably caused by pleural effusion, and enlargement of left hilum. Source: Armed Forces Institute of Pathology.
Figure 3. Gram Stain Smears of the Agents of Anthrax (Bacillus anthracis), Plague (Yersinia pestis), and Tularemia (Francisella tularensis), Demonstrating Comparative Morphology, Size, and Staining Characteristics
Graphic Jump Location
A, B anthracis is a large (0.5-1.2 µm × 2.5-10.0 µm), chain-forming, gram-positive rod that sporulates under certain conditions (Gram stain of organism from culture; original magnification ×250); B, Y pestis is a gram-negative, plump, non–spore-forming, bipolar-staining bacillus that is approximately 0.5-0.8 µm × 1-3 µm (Gram stain of smear from infected tissue; original magnification ×250); C, F tularensis is a small (0.2 µm × 0.2-0.7 µm), pleomorphic, poorly staining, gram-negative coccobacillus (Gram stain of organism from culture; original magnification ×500) (inset, direct immunofluorescence of smear of F tularensis; original magnification ×400. Sources: A and B, Sherif Zaki, Centers for Disease Control and Prevention; C, Armed Forces Institute of Pathology.
Figure 4.Francisella tularensis Growth at 72 Hours After Inoculation
Graphic Jump Location
These Francisella tularensis colonies show characteristic opalescence on cysteine heart agar with sheep blood (cultured at 37°C for 72 hours). Source: Centers for Disease Control and Prevention.



Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

734 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles