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Consensus Statement |

Plague as a Biological Weapon:  Medical and Public Health Management

Thomas V. Inglesby, MD; David T. Dennis, MD, MPH; 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, MPH; John F. Koerner, MPH, CIH; Marcelle Layton, MD; Joseph 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; Monica Schoch-Spana, PhD; Kevin Tonat, DrPH, MPH; for the Working Group on Civilian Biodefense
JAMA. 2000;283(17):2281-2290. doi:10.1001/jama.283.17.2281.
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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 following the use of plague as a biological weapon against a civilian population.

Participants The working group included 25 representatives from major academic medical centers and research, government, military, public health, and emergency management institutions and agencies.

Evidence MEDLINE databases were searched from January 1966 to June 1998 for the Medical Subject Headings plague, Yersinia pestis, biological weapon, biological terrorism, biological warfare, and biowarfare. Review of the bibliographies of the references identified by this search led to subsequent identification of relevant references published prior to 1966. In addition, participants identified other unpublished references and sources. Additional MEDLINE searches were conducted through January 2000.

Consensus Process The first draft of the consensus statement was a synthesis of information obtained in the formal evidence-gathering process. The working group was convened to review drafts of the document in October 1998 and May 1999. The final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members.

Conclusions An aerosolized plague weapon could cause fever, cough, chest pain, and hemoptysis with signs consistent with severe pneumonia 1 to 6 days after exposure. Rapid evolution of disease would occur in the 2 to 4 days after symptom onset and would lead to septic shock with high mortality without early treatment. Early treatment and prophylaxis with streptomycin or gentamicin or the tetracycline or fluoroquinolone classes of antimicrobials would be advised.

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Figures

Figure 1. Peripheral Blood Smear From Patient With Septicemic Plague
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Smear shows characteristic bipolar staining of Yersinia pestis bacilli (Wright-Giemsa stain; magnification, ×1000). Figure from Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases, Fort Collins, Colo.
Figure 2. Patients With Naturally Occurring Plague
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A, Cervical bubo in patient with bubonic plague; B, petechial and ecchymotic bleeding into the skin in patient with septicemic plague; and C, gangrene of the digits during the recovery phase of illness of patient shown in B. In plague following the use of a biological weapon, presence of cervical bubo is rare; purpuric skin lesions and necrotic digits occur only in advanced disease and would not be helpful in diagnosing the disease in the early stages of illness when antibiotic treatment can be lifesaving. Figures from Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases, Fort Collins, Colo.
Figure 3. Chest Radiograph of Patient With Primary Pneumonic Plague
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Radiograph shows extensive lobar consolidation in left lower and left middle lung fields. Figure from Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases, Fort Collins, Colo.

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