Presence of low levels of Francisella
tularensis in the
Washington D.C. area, September 30,
2005
CDC has become aware that from September 24th
through September 25th environmental air monitors in SW Washington
D.C., more specifically the Capitol Mall area, signaled the low level presence
of Francisella tularensis, the bacterium that causes Tularemia, also
known as “rabbit fever.”
At this time, public health agencies have no reports of any
related human or animal illnesses. This announcement is a precautionary
measure to assure that clinicians are aware of the situation and are able to
recognize, test, and report any suspected cases to the appropriate medical and
public health authorities.
This is a national alert because the Capitol Mall area is a
highly-trafficked tourist destination, and on Saturday, September 24th,
was the site of several very well attended outdoor events.
Clinical Presentations
The clinical presentations most likely to occur after an
aerosol exposure to F. tularensis are pneumonic, oculoglandular and
oropharyngeal. The usual incubation period is 3-5 days, but in rare instances
can be longer. The disease is not communicable from person to person and can
be effectively treated with readily available antimicrobials.
Preliminary Case Definition
Onset from Monday September 26 through October 5 of an acute
febrile illness associated with at least one of the following:
· conjunctivitis with preauricular
lymphadenopathy (oculoglandular)
· stomatitis or pharygitis or
tonsillitis and cervical lymphadenopathy (oropharyngeal)
· cough, shortness of breath, pleuritic
chest pain (pneumonic),
which is not otherwise explained in a resident or visitor to
the National Capitol Region on Saturday or Sunday, September 24-25.
Human Diagnostic Specimens
Clinical specimens may include:
· Bronchial/tracheal washes or
aspirates, sputum, trans-thoracic lung aspirates, or pleural fluid collection
· Swabs of visible lesions or affected
areas (e.g., conjunctiva or pharynx)
· Aspirates from lymph nodes
· Whole blood or blood cultures are
acceptable specimens, but are generally positive in cases of severe illness
only.
Laboratory Testing (Culture)
Microbiology laboratory personnel should be alerted when F.
tularensis is clinically suspected, so that appropriate laboratory
precautions can be taken.
F. tularensis is a fastidious, slow-growing organism that requires cysteine
for growth.
F. tularensis may be cultured on the following:
· cysteine supplemented agar including
chocolate agar (CA)
· cysteine heart agar with 9% chocolatized
blood (CHAB)
· buffered charcoal yeast extract
(BYCE)
· Thayer-Martin agar
Culture plates should be held for
5-7 days at 35-370C (C02 is acceptable) and checked for
growth daily.
F. tularensis can be isolated from nutrient
enriched specimens (tissues) on sheep blood agar (SBA), but the organism will
usually fail to thrive with passage on SBA. Growth on CHAB provides for
presumptive identification of F. tularensis as the organism shows
characteristic growth on this media (green, opalescent, raised, shiny colonies
at 24-48 hours).
Note: Specimens for recovery of live bacteria, should be
collected before antibiotics are administered
Prophylaxis
CDC does not recommend mass or targeted prophylaxis at this
time because:
· the usual incubation period has
passed without an increase in suspicious illnesses in the area, and air
sampling since September 25th has been negative
· infection is readily treatable and
generally has a low mortality rate with medical care
· infection cannot be transmitted to
others
Treatment
Adults
Preferred choices:
Streptomycin, 1g IM twice daily
Gentamicin, 5 mg/kg IM or IV once daily†
Alternative choices:
Doxycycline, 100 mg IV twice daily
Ciprofloxacin, 400 mg IV twice daily†
Children
Preferred choices:
Streptomycin, 15 mg/kg IM twice daily (should not exceed 2 gm/d)
Gentamicin, 2.5 mg/kg IM or IV 3 times daily†
Alternative choices:
Doxycycline,
If weight >= 45 kg, 100 mg IV
If weight < 45 kg, give 2.2 mg/kg IV twice daily
Ciprofloxacin, 15 mg/kg IV twice daily‡
Pregnant Women
Preferred choices:
Gentamicin, 5 mg/kg IM or IV once daily†
Streptomycin, 1 g IM twice daily
Alternative choices:
Doxycycline, 100 mg IV twice daily
Ciprofloxacin, 400 mg IV twice daily†
One antibiotic, appropriate for treatment for
patient age, should be chosen from among the alternatives. Treatment with
streptomycin, gentamicin, or ciprofloxacin should be continued for 10 days;
treatment with doxycycline should be continued for 14-21 days. Persons
beginning treatment with intramuscular (IM) or intravenous (IV) doxycycline,
ciprofloxacin can switch to oral antibiotic administration when clinically
indicated.
†Not a U.S. Food and Drug Administration-approved use.
‡Ciprofloxacin dosage should not exceed 1 g/d in children.
Additional information about Tularemia can be found on the
CDC website:
http://www.bt.cdc.gov/agent/tularemia/