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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;285:2763-2773.

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.

Author Affiliations: National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga (Drs Dennis, Lillibridge, and McDade); Center for Civilian Biodefense Studies, Johns Hopkins University Schools of Medicine (Drs Inglesby, Bartlett, and Perl) and Public Health (Drs Henderson, O'Toole, and Russell), Baltimore, Md; Viral and Rickettsial Diseases Laboratory, California Department of Health Services, Berkeley (Dr Ascher); US Army Medical Research Institute of Infectious Diseases, Ft Detrick, Md (Drs Eitzen, Friedlander, and Parker); Bureau of Communicable Disease, New York City Health Department (Drs Fine and Layton), and Kroll Associates (Mr Hauer), New York, NY; ican Inc, Eden Prairie, Minn (Dr Osterholm); and Office of Emergency Preparedness, Department of Health and Human Services, Rockville, Md (Dr Tonat).

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