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).
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.
David T. Dennis, Thomas V. Inglesby, Donald A. Henderson, John G. Bartlett, Michael S. Ascher, Edward Eitzen, Anne D. Fine, Arthur M. Friedlander, Jerome Hauer, Marcelle Layton, Scott R. Lillibridge, Joseph E. McDade, Michael T. Osterholm, Tara O'Toole, Gerald Parker, Trish M. Perl, Philip K. Russell, Kevin Tonat, for the Working Group on Civilian Biodefense. Tularemia as a Biological WeaponMedical and Public Health Management. JAMA. 2001;285(21):2763–2773. doi:10.1001/jama.285.21.2763