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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.
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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.

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Figures

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
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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
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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
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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.

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