Download NAME OF DISEASE HEALTH ALERT

[Insert Health Department Name]
[Insert Unit Name[
[Insert Street]
[Insert City, State and Zip Code
[Insert Logo]
Phone: [insert number]Fax: [insert number
[Email Address], [Website p
TULAREMIA HEALTH ALERT
[INSERT DATE]
[Insert short description why Health Alert is being released (e.g., Two cases of tularemia disease have been
identified).]
This Health Alert and additional information on tularemia is posted on [insert website name] at [insert web link].
ACTIONS REQUESTED OF ALL CLINICIANS:
1.
2.
3.
4.
5.
6.
Consider tularemia in patients with unexplained febrile illness.
Inquire about exposures.
Report suspected and confirmed cases to [insert unit/department name] at [insert phone number]..
As directed by [insert unit/department name], test suspected cases.
Provide treatment and chemoprophylaxis as described below.
Implement infection control measures.
INCIDENT SUMMARY
[Insert event-specific background information (e.g., Suspected aerosol release of tularemia toxin).]
DESCRIPTION
Tularemia is a zoonotic disease caused by Francisella tularensis, a non-sporulating, non-motile, aerobic gramnegative coccobacillus, which can persist for long periods of time in water, mud, and decaying animal carcasses.
There are several forms of human tularemia disease, depending on how the infection is acquired, with symptoms
affecting the area of infection. The most common naturally occurring subspecies of F. tularensis in the USA is
tularensis (type A), which typically results in a more severe illness. It is one of the most infectious pathogenic
bacteria known, requiring inhalation or inoculation of as few as 10 organisms to cause disease. Human tularemia
cases have occurred in all regions of the United States, with the highest number of cases occurring in Arkansas,
Missouri, Oklahoma, and Martha’s Vineyard, Massachusetts. Certain activities, such as hunting, trapping,
butchering, and farming are most likely to cause exposures to F. tularensis.
Tularemia is considered to be a dangerous potential biological weapon because of its extreme infectivity, ease of
dissemination, and its capacity to cause illness and death. F. tularensis could be used as a bioweapon in a
number of ways, but aerosol release would have the greatest adverse medical and public health consequences.
Categories of urgency levels
Health Alert: Conveys the highest level of importance; warrants immediate action or attention.
Health Advisory: Provides important information for a specific incident or situation; may not require immediate action.
Health Update: Provides updated information regarding an incident or situation; unlikely to require immediate action.
[Insert Health Department Name]
CASE DEFINITION
The following definitions should be used to identify exposed persons and cases in the event of an aerosol
release. Testing, treatment, and implementation of infection control measures should be based upon these
definitions.
TULAREMIA: CASE DEFINITION
Categorization
Definition

1. Exposed
Person
2. Suspect Case
2. Probable
Case
2. Confirmed
Case
Being at [insert location of exposure] during [insert date range of exposure (Note:
Incubation period usually is within 14 days).]
 Consider adding natural exposure (i.e., contact with animal tissue or fluids, occupational
or recreational exposure, or travel to tularemia endemic area).
Meets:
 Exposed person case definition and fever (>100.4ºF or 38.0ºC); OR
 Has clinical symptoms compatible with one of the distinct forms of tularemia;
 Ulceroglandular (cutaneous ulcer with regional lymphadenopathy)
 Glandular (regional lymphadenopathy with no ulcer)
 Oculoglandular (conjunctivitis with preauricular lymphadenopathy)
 Oropharyngeal (stomatitis or pharyngitis or tonsillitis and cervical lymphadenopathy)
 Intestinal (intestinal pain, vomiting, and diarrhea)
 Pneumonic (primary pleuropulmonary disease)
 Typhoidal (febrile illness without early localizing signs and symptoms
 Has clinical symptoms compatible with one of the distinct forms of tularemia; AND
 Laboratory results indicative of presumptive infection, including:
 Elevated serum antibody titer(s) to F. tularensis antigen (without documented
fourfold or greater change) in a patient with no history of tularemia vaccination; OR
 Detection of F. tularensis in a clinical specimen by fluorescent assay
 Has clinical symptoms compatible with one of the distinct forms of tularemia; AND:
 Confirmatory laboratory results, including:
 Isolation of F. tularensis in a clinical specimen; OR
 Fourfold or greater change in serum antibody titer to F. tularensis antigen
CLINICAL FEATURES
It is important to recognize tularemia because poor outcomes are associated with delayed medical care.
Different forms of tularemia occur, and are determined by route of infection. An aerosol release of F. tularensis
is expected to principally cause pneumonic tularemia, which is associated with the most severe disease.
However, it could also cause ocular, ulceroglandular, glandular, or oropharyngeal tularemia.
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[Insert Health Department Name
TULAREMIA: CLINICAL FEATURES AFTER AEROSOL RELEASE
Incubation
Period
Transmission1,3
Signs &
Symptoms
Laboratory
Findings
3-5 days (range 1-14 days)



Inhalation of infectious aerosol (Pneumonic or Oropharyngeal)
Contact of infectious aerosol with conjunctiva (Oculoglandular)
Contact of infectious aerosol with breaks in skin surface (Glandular or Ulceroglandular)
Pneumonic Tularemia
 Acute febrile illness, progressing to bronchiolitis, pleuropneumonia, or hilar
lymphadenitis.
Oropharyngeal tularemia
 Exudative pharyngitis or tonsillitis (sometimes with ulceration) or less commonly
stomatitis.
 Pronounced cervical or retropharyngeal adenopathy may occur.
Oculoglandular tularemia
 Conjunctive ulceration, accompanied by pronounced chemosis, vasculitits, and regional
lymphadenitis.
Ulceroglandular tularemia
 Ulceration at the site of inoculation, with subsequent lymphadenopathy in the proximal
draining lymph nodes (e.g., preauricular).
Glandular
 Lymphadenopathy without ulceration.
Complications of untreated infection:
 Hematogenous spread to other organs
 Sepsis
 Meningitis
 Leukocytosis; differential may be normal
 Liver enzymes and/or CK may be abnormal
 Lobar, segmental, or subsegmental opacities on CXR, often with pleural involvement
(pneumonic tularemia)
 Sputum gram stain is often not helpful (pneumonic tularemia)
Naturally occurring forms of tularemia may be transmitted in the following ways:
 Bite of infected arthropod (tick, deerfly, mosquito)
 Contact with animal tissue or fluids (especially rabbits, hares, voles, mice, water rats, squirrels, and beavers)
 Contact or ingestion of contaminated water, food, or soil
 Inhalation of contaminated aerosols (including dust from contaminated hay, or aerosols generated by lawn
mowing and brush cutting)
 Contact or inhalation of infected materials in a laboratory setting
REPORTING
Immediately report all cases of tularemia (including suspect cases) to your facility’s infection control
practitioner AND to the [Insert Department/Unit Name]: [Insert Phone Number]. The health department can
authorize and facilitate testing, and will initiate the public health response as needed. Please either ask family
members or close contacts of patients for their telephone contact information, or ask these individuals to stay at
the hospital for public health interview and potential intervention.
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[Insert Health Department Name
INFECTION CONTROL
For any case of tularemia (including suspect cases) in a healthcare setting (hospital, emergency department,
nursing facility, or outpatient clinic):
1. Immediately notify your institution’s infection control practitioner.
2. Immediately notify [Insert Department/Unit Name]: [Insert Phone Number].
3. Utilize the following infection control precautions:
Infection Control for Caregivers
Person-to-person transmission of tularemia has not been documented; therefore, Standard Precautions are
considered adequate for patients with tularemia.
See http://www.sfcdcp.org/document.html?id=317 for key features of standard infection control
precautions
Laboratory Staff
Laboratory staff are especially vulnerable to infection, either by accidentally inoculating themselves or by
inhaling aerosolized organisms. Staff should receive training in handling specimens potentially containing F.
tularensis and must use appropriate infection control when handling specimens.
Decontamination
Commercially available bleach or a 1:10 dilution of household bleach and water is considered adequate for
disinfecting contaminated surfaces. After direct exposure to powder or liquid aerosols containing F. tularensis,
body surfaces and clothing should be washed with soap and water.
LABORATORY & DIAGNOSTIC TESTING
Consider testing symptomatic persons. Asymptomatic persons need not be tested.
If you are testing or considering testing for tularemia:
1. Immediately notify:
a. [Insert Department/Unit Name]: [Insert Phone Number]. The health department can authorize
and facilitate testing and will initiate the public health response as needed; AND
b. Your hospital laboratory and infection control practitioner that tularemia is under suspicion;
AND
2. If testing is deemed necessary:
a. Use appropriate precautions when obtaining diagnostic specimens.
b. Specimens to be obtained should include (see table for further details):
i. Blood: Collect per institution’s protocol for blood culture.
ii. Serum: Collect acute and convalescent specimens per institution’s protocol.
iii. Sputum/throat: Collect routine throat culture using a swab or expectorated sputum
collected into a sterile, leak proof container.
iv. Bronchial/tracheal wash: Collect per institution’s procedure in an area dedicated to
collecting respiratory specimens under isolation/containment circumstances (i.e.
isolation chamber/bubble).
v. Other: Ulcer, other tissue specimens per institution’s protocol.
c. Submit specimens to your hospital laboratory, and notify them to test for tularemia. If needed,
your lab will submit specimens to the public health laboratory for testing.
Standard tests for detection of F. tularensis include: serology (antibody detection), staining of secretions,
exudates or biopsies (direct fluorescent antibody stain or immunohistochemical stain), isolation by culture, and
light microscopy. Most often, diagnosis of tularemia occurs by serological testing, which may require collection
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of acute and convalescent serum specimens to detect change in titer. Bacterial culturing may require pharyngeal
washings, sputum specimens, or gastric washings in addition to blood (due to higher yield).
Sample
Blood
Ulcer, other
tissue
specimens
Respiratory,
other
secretions/
exudates
Specimen Collection
Culture: Collect volume and number of sets per established laboratory protocol.
Serology: Collect acute-phase serum during first week of illness, and store at 4oC until
tularemia can be ruled out. If tularemia not ruled out, collect convalescent-phase serum 14
days or more after illness onset (antibodies appear in most patients by 2 weeks after onset
and levels peak at 4-5 weeks).
Follow standard protocol for biopsy (preferred), scraping, aspirate, or swab.
Respiratory specimens (pleural fluid, sputum), gastric washings, or corneal scraping
(oculoglandular tularemia) can be sent for culture. Follow standard protocol.
TREATMENT AND CHEMOPROPHYLAXIS
Treatment
The treatment of choice for all forms of tularemia is streptomycin. Gentamicin, which is more widely available,
is an acceptable alternative. Tetracycline and chloramphenicol have been used to treat tularemia; however, as
these drugs are bacteriostatic, relapses occur more often than with the aminoglycosides. Bioterrorist use of an F.
tularensis strain resistant to conventional antibiotic therapy is of concern and should be considered, particularly
if patients deteriorate despite early initiation of antibiotic therapy.
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[Insert Health Department Name
Supportive care of patients is also critical, including fluid management and hemodynamic monitoring as
indicated. Some patients may require intensive care with respiratory support owing to complications of gramnegative sepsis. In a contained casualty setting where the medical care delivery system can effectively manage
the number of patients, parenteral antibiotics should be administered (Table 1, above). Therapy may be
switched to oral antimicrobials when clinically indicated. In a mass casualty setting where the medical care
delivery system is not able to meet the demands for patient care, use of oral antibiotics may be necessary (Table
2, below).
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Post-Exposure Prophylaxis
Exposed persons should receive prophylaxis. Antibiotic prophylaxis should begin as soon as possible and
preferably within 24 hours after exposure to an infectious aerosol containing F. tularensis (Table 2). Postexposure prophylactic antibiotic treatment of close contacts of tularemia patients is not recommended since
human-to-human transmission of F. tularensis is not known to occur.
Vaccination
A live, attenuated vaccine was used in the USA until recently to protect laboratory workers at high risk for F.
tularensis exposure. However, the vaccine currently is unavailable and is under review by the FDA.
ADDITIONAL RESOURCES
 [Add your health department name and link.]
 CDC Emergency Preparedness & Response Bioterrorism Site: www.bt.cdc.gov/bioterrorism
 Working Group on Civilian Biodefense: http://jama.ama-assn.org/cgi/content/short/285/21/2763
 Health Protection Agency Deliberate Release:
http://www.hpa.org.uk/HPA/Topics/InfectiousDiseases/InfectionsAZ/1197637044441/
REFERENCES
Dennis DT et al, for the Working Group on Civilian Biodefense. Tularemia as a medical and public health management.
JAMA 2001 Jun 6;285(21):2763-73.
CDC. Case definitions for infectious conditions under public health surveillance. MMWR 1997;46(RR10):1-55
http://www.cdc.gov/mmwr/preview/mmwrhtml/00047449.htm.
CIDRAP. Tularemia: Current, comprehensive information on pathogenesis, microbiology,
epidemiology, diagnosis, treatment, and prophylaxis. June 16, 2005. www.cidrap.umn.edu/cidrap/content/bt.
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