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

focal, intensely suppurative necrosis that becomes granulomatous. After inhalational exposure,
hemorrhagic inflammation of the airways develops and progresses to bronchopneumonia.
Pleuritis with adhesions, and effusion and hilar lymphadenopathy are common.
Illness begins with fever, headache, chills and rigors, generalized body aches, coryza, and sore
throat. There may be a dry or slightly productive cough and substernal pain or tightness with or
without objective signs of pneumonia. These findings are followed by sweats, fever, chills,
progressive weakness, malaise, anorexia, and weight loss. These signs and symptoms would be
similar to those caused by Q fever, but the progression of illness would be expected to be slower
and the case-fatality rate lower than in inhalational plague or anthrax.
Diagnosis. Francisella tularensis can be isolated from respiratory secretions and, sometimes,
from blood in cases of inhalational infection. Gram stain, fluorescent antibody, or
immunohistochemical stains (performed in designated reference laboratories in the National
Public Health Laboratory Network) may demonstrate the organism in secretions, exudates, or
biopsy specimens. If tularemia is suspected, the laboratory should be informed to minimize risks
of transmission to laboratory personnel. Routine diagnostic procedures can be performed in
Biosafety Level 2 conditions. Cultures in which F. tularensis is suspected should be examined in
a biological safety cabinet. Manipulation of cultures and other procedures that might produce
aerosols or droplets (e.g., grinding, centrifuging, vigorous shaking, animal studies) should be
conducted under Biosafety Level 3 conditions. Bodies of patients who die of tularemia should be
handled using standard precautions. Autopsy procedures likely to produce aerosols or droplets
should be avoided. Clothing or linens contaminated with body fluids of patients with tularemia
should be disinfected per standard hospital procedure.
Treatment. In case of a bioterrorist event, antimicrobial susceptibility testing of isolates should
be conducted quickly and treatment altered according to test results and clinical response. For
treatment recommendations in children before test results are known, see Table 4.6.
Control measures. Treatment with streptomycin, gentamicin, doxycycline, or ciprofloxacin
started during the incubation period of tularemia and continued daily for 14 days can protect
against symptomatic infection. Therefore, if an attack is discovered before individuals become
ill, those who have been exposed should be treated prophylactically with oral doxycycline or
ciprofloxacin for 14 days. If an attack is discovered only after individuals become ill, a fever
watch should begin for those who potentially have been exposed. Treatment (as outlined above)
should begin in those who develop an otherwise unexplained fever or flu-like illness within 14
days of presumed exposure.
Postexposure prophylactic treatment of those in close contact with tularemia patients is not
recommended because person-to-person transmission is not known to occur. Standard
precautions should be used in caring for hospitalized patients.
Reporting. Initial suspicion of a bioterrorist event involving F. tularensis will likely involve
identification of more than one case in a nonendemic area. If this happens, immediately contact
the local and State health departments and hospital infection control practitioner. If they are
unavailable, contact the CDC at 770-488-7100.
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