1. BW Agents: Tularemia J.A. Sliman, MD, MPH LCDR MC(FS) USN Preventive Medicine Resident Johns Hopkins Bloomberg School of Public Health

2. Tularemia Francisella tularensis –Small, gram-negative coccobacillus Zoonotic disease from contact with infected animals or bites from infected arthropods Viable for weeks in soil and water, carcasses and hides

3. Tularemia AKA: rabbit fever or deerfly fever Stable for years in frozen rabbit meat Named for Tulare County, CA, where isolation work done in 1900s, and Dr. Edward Francis, USPHS, who isolated it.

4. BW History Easily deliverable wet or dry First weaponized by U.S. in early 1950s Weaponized by Former Soviet Union –1942: several thousand Red Army and Wehrmacht troops on the Eastern Front develop pulmonic tularemia

5. Human Disease Normally contracted by handling contaminated animal products or excreta Various forms are: ulceroglandular, glandular, typhoidal, oculoglandular, pharyngeal and pneumonic

6. Human Disease Incubation period 2 - 10 days (avg. 3 - 5) Usually requires fewer than 50 organisms to cause disease Most cases are ulceroglandular.

7. Ulceroglandular tularemia 80% of cases Skin or mucous membrane contact with fluids of infected animal Ulcerated skin lesion with fever, chills, headache, malaise and painful regional lymphadenopathy

8. Ulceroglandular tularemia Glandular type occurs without skin lesion –5-10% of cases Oculoglandular type presents as a painful conjunctivitis (1-2 % of cases) Oropharyngeal form – confined to throat with acute exudative pharyngo-tonsillitis

9. Typhoidal Tularemia Likely form of BW attack Occurs after inhalation, intradermal or gastrointestinal contact (usually no exposure history) Presents with fever, prostration, & weight loss and progresses to atypical pneumonia

10. Pneumonic tularemia Seen in up to 80% of typhoidal cases and 15% of ulceroglandular cases CFR(untreated) = 5% for ulceroglandular form and 35% for typhoidal form Recovery followed by permanent immunity

11. Diagnosis Staining and cultures usually useless Serology the only consistent tool Titers peak 4 - 8 weeks after exposure So, clinical diagnosis is the best method.

12. Medical Management Streptomycin 1g IV q12h f14d Gent, tetracycline also effective Person-to-person spread unusual Respiratory isolation not required

13. Medical Management Live attenuated vaccine is available Prophylactic therapy for likely exposures –Tetracycline 500mg po qid f14d

14. Tularemia Flu-like syndrome with painful regional lymphadenopathy and progressing to atypical pneumonia Clinical diagnosis Tetracycline 500mg po qid f2 wks