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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;283:2281-2290.

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 In addition, participants identified other unpublished references and sources.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.

Author Affiliations: Center for Civilian Biodefense Studies, Johns Hopkins University Schools of Medicine (Drs Inglesby, Bartlett, and Perl) and Public Health (Drs Henderson, O'Toole, Russell, and Schoch-Spana and Mr Koerner), Baltimore, Md; National Center for Infectious Diseases, Centers for Disease Control and Prevention, Fort Collins, Colo (Dr Dennis), and Atlanta, Ga (Dr McDade); Viral and Rickettsial Diseases Laboratory, California Department of Health Services, Berkeley (Dr Ascher); United States Army Medical Research Institute of Infectious Diseases, Frederick, Md (Drs Eitzen, Friedlander, and Parker); Science Application International Corporation, McLean, Va (Mr Hauer); Office of Communicable Disease, New York City Health Department, New York, NY (Drs Fine and Layton); Office of Emergency Preparedness, Department of Health and Human Services, Rockville, Md (Dr Tonat); and Infection Control Advisory Network Inc, Eden Prairie, Minn (Dr Osterholm).

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