Pediatric Terrorism and Disaster Preparedness: A ... - PHE Home

• Bubonic plague usually is transmitted by bites of infected rodent fleas and uncommonly
by direct contact with tissues and fluids of infected rodents or other mammals, including
domestic cats.
• Septicemic plague occurs most often as a complication of bubonic plague but may result
from direct contact with infectious materials or the bite of an infected flea.
• Primary pneumonic plague is acquired by inhalation of respiratory droplets from a human
or animal with respiratory plague or from exposure to laboratory aerosols.
• Secondary pneumonic plague arises from hematogenous seeding of the lungs with Y.
pestis in patients with bubonic or septicemic plague.
The incubation period is 2–6 days for bubonic plague and 2–4 days for primary pneumonic
plague.
Signs and symptoms. A bioterrorist incident involving plague would most likely occur through
aerosolization and result in pneumonic involvement. The incubation period after flea-borne
transmission is 2–8 days. Incubation after aerosolization would be expected to be shorter (1–3
days). Clinical features of pneumonic plague include fever, cough with mucopurulent sputum
(gram-negative rods may be seen on Gram stain), hemoptysis, and chest pain. A chest radiograph
will show evidence of bronchopneumonia.
Diagnosis. Plague is characterized by massive growth of Y. pestis in affected tissues, especially
lymph nodes, spleen, and liver. The organism has a bipolar (safety-pin) appearance when viewed
with Wayson or Gram stains. If plague organisms are suspected, the laboratory examining the
specimens should be informed to minimize risks of transmission to laboratory personnel.
Handling of specimens should be coordinated with local or State health departments and
undertaken in Biosafety Level 2 or Level 3 laboratories.
A positive fluorescent antibody test result for the presence of Y. pestis in direct smears or
cultures of a bubo aspirate, sputum, CSF, or blood specimen provides presumptive evidence of Y.
pestis infection. A single seropositive result by passive hemagglutination assay or enzyme
immunoassay in an unimmunized patient who has not had plague previously also provides
presumptive evidence of infection. Seroconversion and/or a four-fold difference in antibody titer
between two serum specimens obtained 1 to 3 months apart provides serologic confirmation. The
diagnosis of plague usually is confirmed by culture of Y. pestis from blood, bubo aspirate, or
another clinical specimen. PCR assay or immunohistochemical staining for rapid diagnosis of Y
pestis is available in some reference or public health laboratories. Isolates suspected as Y. pestis
should be reported immediately to the State health department and submitted to the Division of
Vector-Borne Infectious Diseases of the CDC. For additional information, see
http://www.cdc.gov/ncidod/dvbid/plague/diagnosis.htm
http://www.bt.cdc.gov/Agent/Plague/ype_la_cp_121301.pdf.
Treatment. Streptomycin sulfate (30 mg/kg/day, IM, divided BID-TID) is the treatment of
choice for most children. Gentamicin sulfate in standard dosages for age given IM or IV is an
equally effective alternative to streptomycin. Tetracycline, doxycycline, or chloramphenicol is
also effective. Tetracycline or doxycycline should not be given to children younger than age 8
unless the benefits of use outweigh the risks of dental staining. Chloramphenicol is the preferred
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