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Consensus Statement |

Hemorrhagic Fever Viruses as Biological Weapons:  Medical and Public Health Management

Luciana Borio, MD; Thomas Inglesby, MD; C. J. Peters, MD; Alan L. Schmaljohn, PhD; James M. Hughes, MD; Peter B. Jahrling, PhD; Thomas Ksiazek, DVM, PhD; Karl M. Johnson, MD; Andrea Meyerhoff, MD; Tara O'Toole, MD, MPH; Michael S. Ascher, MD; John Bartlett, MD; Joel G. Breman, MD, DTPH; Edward M. Eitzen, Jr, MD, MPH; Margaret Hamburg, MD; Jerry Hauer, MPH; D. A. Henderson, MD, MPH; Richard T. Johnson, MD; Gigi Kwik, PhD; Marci Layton, MD; Scott Lillibridge, MD; Gary J. Nabel, MD, PhD; Michael T. Osterholm, PhD, MPH; Trish M. Perl, MD, MSc; Philip Russell, MD; Kevin Tonat, DrPH, MPH; for the Working Group on Civilian Biodefense
JAMA. 2002;287(18):2391-2405. doi:10.1001/jama.287.18.2391.
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Objective To develop consensus-based recommendations for measures to be taken by medical and public health professionals if hemorrhagic fever viruses (HFVs) are used as biological weapons against a civilian population.

Participants The Working Group on Civilian Biodefense included 26 representatives from academic medical centers, public health, military services, governmental agencies, and other emergency management institutions.

Evidence MEDLINE was searched from January 1966 to January 2002. Retrieved references, relevant material published prior to 1966, and additional sources identified by participants were reviewed.

Consensus Process Three formal drafts of the statement that synthesized information obtained in the evidence-gathering process were reviewed by the working group. Each draft incorporated comments and judgments of the members. All members approved the final draft.

Conclusions Weapons disseminating a number of HFVs could cause an outbreak of an undifferentiated febrile illness 2 to 21 days later, associated with clinical manifestations that could include rash, hemorrhagic diathesis, and shock. The mode of transmission and clinical course would vary depending on the specific pathogen. Diagnosis may be delayed given clinicians' unfamiliarity with these diseases, heterogeneous clinical presentation within an infected cohort, and lack of widely available diagnostic tests. Initiation of ribavirin therapy in the early phases of illness may be useful in treatment of some of these viruses, although extensive experience is lacking. There are no licensed vaccines to treat the diseases caused by HFVs.

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Figure 1. Maculopapular Rash in Marburg Disease
Graphic Jump Location
A nonpruritic maculopapular rash (resembling the rash of measles) may occur in up to 50% of patients infected with the Ebola or Marburg viruses within the first week of illness. The rash is more common in light-colored skin and desquamates on resolution. Reprinted with permission from Thieme (Martini GA, Knauff HG, Schmidt HA, et al. A hitherto unknown infectious disease contracted from monkeys. Ger Med Mon. 1968;13:457-470).
Figure 2. Erythematous Rash in Bolivian Hemorrhagic Fever
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This macular, flushed, erythematous rash that blanches with pressure may be associated with infections caused by arenaviruses. The rash most commonly involves the face and thorax and may desquamate on convalescence. Reprinted with permission from Current Science/Current Medicine (Peters CJ, Zaki SR, Rollin PE. Viral hemorrhagic fevers. In: Fekety R, vol ed. Atlas of Infectious Diseases, Volume VIII. Philadelphia, Pa: Churchill Livingstone; 1997:10.1-10.26).
Figure 3. Ocular Manifestations in Bolivian Hemorrhagic Fever
Graphic Jump Location
Ocular manifestations associated with hemorrhagic fever viruses range from conjunctival injection to subconjunctival hemorrhage, as seen in this patient. Reprinted with permission from Current Science/Current Medicine (Peters CJ, Zaki SR, Rollin PE. Viral hemorrhagic fevers. In: Fekety R, vol ed. Atlas of Infectious Diseases, Volume VIII. Philadelphia, Pa: Churchill, Livingstone; 1997:10.1-10.26).

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