Approximately 200 cases of tularemia in humans are reported annually in the United States, mostly in persons living in the south-central and western states. Tularemia is an occupational risk for farmers, foresters, and veterinarians, and is listed by the US Centers for Disease Control and Prevention (CDC) as one of the six category A, or high-priority, biological warfare agents. Nearly all cases of tularemia occur in rural areas and are associated with the bites of infected ticks, mosquitoes, and biting flies or with the handling of infected rodents, rabbits, or hares. Less commonly, tularemia can be contracted through ingestion of contaminated food or water or by inhalation. Release of the bacteria in a aerosolized form is the most likely method to be used in bioterrorism. Tularemia is extremely infectious. Relatively few bacteria are required to cause the disease, which is why it is an attractive weapon for use in bioterrorism.

There are currently no specific OSHA standards or directives for tularemia.

OSHA Standards

This section highlights OSHA standards, preambles to final rules (background to final rules), and directives (instructions for compliance officers) generally applicable to emergency response activities associated with a bioterrorist attack and the use of personal protective equipment (PPE). Refer to OSHA's Emergency Preparedness and Response and Personal Protective Equipment (PPE) Safety and Health Topics Pages for additional information.

Note: Twenty-five states, Puerto Rico and the Virgin Islands have OSHA-approved State Plans and have adopted their own standards and enforcement policies. For the most part, these States adopt standards that are identical to Federal OSHA. However, some States have adopted different standards applicable to this topic or may have different enforcement policies.

General Industry (29 CFR 1910)

• 1910 Subpart H, Hazardous materials [related topic page]
  • 1910.120, Hazardous waste operations and emergency response [related topic page]
    • 1910.120(q), Emergency response program to hazardous substance releases
      
      
• 1910 Subpart I, Personal protective equipment
  • 1910.132, General requirements [related topic page]

Preambles to Final Rules

• Hazardous Waste Operations and Emergency Response (1989)
  • Intro to 29 CFR Part 1910, Hazardous Waste Operations and Emergency Response
  • I. Background
  • II. Summary and Explanation of the Standard
  • VII. State Plan States
  • VIII. Federal and State Coverage of the Public Sector and Volunteers
    
    
• Search all available preambles to final rules.

Directives

• Inspection Procedures for 29 CFR 1910.120 and 1926.65, Paragraph (q): Emergency Response to Hazardous Substance Releases. CPL 02-02-073, (2007, August 27). Also available as a 444 KB PDF, 119 pages. Updates enforcement procedures for compliance officers who need to conduct inspections of emergency response operations. It defines additional terms and expands on training requirements for emergency responders and other groups such as skilled support personnel. This OSHA instruction revises CPL 02-02-059, issued April 24, 1998.
  
  
• Search all available directives.

Hazards Recognition

Tularemia, also known as "rabbit fever" or "deer fly fever," is caused by the Francisella tularensis bacterium. As few as 10 of these organisms can cause the disease. Humans become infected through a variety of environmental exposures. Exposure may lead to a severe and sometimes fatal illness. The following references aid in recognizing disease characteristics and hazards associated with tularemia.

Disease Recognition

• Tularemia. Centers for Disease Control and Prevention (CDC). Offers fact sheets and overviews, information about infection control, laboratory testing, and surveillance and investigations.
  • Frequently Asked Questions (FAQ) About Tularemia. Provides answers about disease transmission, occurrence, symptoms, diagnosis and terrorist use.
    
    
• Tularemia Outbreak in Prairie Dogs in Texas. Centers for Disease Control and Prevention (CDC), Office of Communications, (2002, August 6). Covers the investigation by officials from the CDC and the Texas Department of Health of an outbreak of tularemia in wild prairie dogs at a commercial facility in Texas that distributes the animals in the United States and other countries.
  
  
• Tularemia - United States, 1990-2000. Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR) 51(09):182-4, (2002, March 8). Covers reported cases of tularemia occurring in the United States from 1990-2000. Also provides background information on tularemia including symptoms and diagnosis.
  
  
• Tularemia. University of Minnesota (UM), Center for Infectious Disease Research and Policy (CIDRAP). Provides links the latest news and information available about tularemia.
  • Tularemia: Current, comprehensive information on pathogenesis, microbiology, epidemiology, diagnosis, and treatment. Provides an overview of tularemia and includes agent information, clinical symptoms, pathogenesis, microbiology, and epidemiology.
    
    
• Tularemia. MedlinePlus Health Information, (2002, August 14). Includes illustrations, definitions, disease causes, incidence, and risk factors.
  
  
• Hornick, R. "Tularemia Revisited." New England Journal of Medicine 345(2001, November 29): 1637-1639. Covers basic information about tularemia and presents a review of recent outbreaks in the United States.
  
  
• Current Description of Tularemia. University of California Los Angeles (UCLA), Department of Epidemiology, (2001). Provides a description of tularemia, including its occurrence and mode of transmission.

Bioterrorist Threat Evaluation

On September 11, 2001, following the terrorist incidents in New York City and Washington, DC, the Centers for Disease Control and Prevention (CDC) recommended heightened surveillance for any unusual disease occurrence or increased numbers of illnesses that might be associated with intentional release of a biological agent.

Tularemia, in aerosol form, is considered a possible bioterrorism agent. Although it is not easy to disseminate, it takes only a small amount of inhaled bacterium to cause infection. The following references provide information about evaluating the threat of tularemia as a biological weapon.

• "Abstract: "Consensus Statement:Tularemia as a Biological Weapon"." Abstracted from Dennis, D., et al. Journal of the American Medical Association (JAMA) 285.21(2001, June 6): 2763-2773. Contains information about the history of tularemia and its use in biological warfare, as well as its epidemiology, microbiology, pathogenesis, diagnosis, vaccination, and treatment. Also discusses infection control and decontamination procedures. Links to full text version.

Medical Response

Tularemia presents as a systemic febrile illness and diagnosis may be made by culture of body fluid or serologic tests. Tularemia is easily treatable with antibiotics as long as victims receive treatment quickly. If a patient is not treated, the fatality rate can exceed 30 percent. Isolation is not recommended for tularemia patients because it is not transmitted from person to person.

It is a United States Public Health Service requirement that all suspected tularemia cases be reported to state and local health departments and the diagnosis confirmed by the Centers for Disease Control and Prevention (CDC).

• Tärnvik A, and Chu, MC. "New Approaches to diagnosis and therapy of Tularemia." Annals of the New York Academy of Science 1105(2007, June): 378-404. Concludes that the clinical handling of tularemia is currently facilitated by new achievements in molecular diagnostics and, at least with regard to type B tularemia, by the introduction of quinolones for therapy.
  
  
• Medical Treatment and Response to Suspected Tularemia: Information for Healthcare Providers During Biologic Emergencies. New York City Department of Health, Bureau of Communicable Disease, (2000, July). Provides information on epidemiology, diagnosis, and treatment with a bioterrorism perspective.
  
  
• Evans M.E., and A.M. Friedlander. "Tularemia." Textbook of Military Medicine: Medical Aspects of Chemical and Biological Warfare [56 KB PDF, 10 pages].(1997). Provides a thorough medical description of the disease including epidemiology, pathogenesis, symptoms, diagnosis, and treatment.
  
  
• Clinical Pathway: Pneumonic Tularemia [243 KB PDF, 3 pages]. University of Minnesota (UM), Center for Infectious Disease Research and Policy (CIDRAP), (2002). Provides step-by-step procedures for patient evaluation and treatment.

Control and Prevention

Workers should avoid bites by ticks and blood-feeding flies, and also avoid touching wild animal tissue. Cases of tularemia require prompt identification and treatment to prevent fatalities. The following references provide information about the control and prevention of tularemia exposure.

• Tularemia [225 KB PDF, 2 pages]. US Army Center for Health Promotion and Preventive Medicine (USACHPPM), (2006, April). Includes a list of precautions that reduce the risk of becoming infected with tularemia.
  
  
• Current Description of Tularemia, Methods of Control. University of California Los Angeles (UCLA), Department of Epidemiology, (2000). Describes various measures that can prevent and control the transmission of tularemia.
  
  
• Tularemia. Washington State Department of Health.
  • Tularemia – Reporting and Surveillance and Guidelines [86 KB PDF, 8 pages]. (2011, January). Provides methods of control including preventive measures, infection control, and epidemic and bioterrorism measures.
    
    
• Tularemia: Current, comprehensive information on pathogenesis, microbiology, epidemiology, diagnosis, and treatment. University of Minnesota (UM), Center for Infectious Disease Research and Policy (CIDRAP), (2010, March 16). Provides an overview of tularemia and includes the following sections relative to control and prevention:
  • Vaccine
  • Hospital Infection Control (Including Autopsies and Burial)
    
    
• Personal Protective Equipment (PPE). OSHA Safety and Health Topics Page.

Additional Information

Related Safety and Health Topics Pages

• Biological Agents
  
  
• Bioterrorism
  
  
• Emergency Preparedness and Response

Other Resources

• Report an Emergency. Centers for Disease Control and Prevention (CDC), (2003, February 13). Provides a list of health department websites and emergency notification procedures for use by health officials and healthcare providers.
  
  
• Tularaemia. World Health Organization (WHO), Epidemic and Pandemic Alert and Response (EPR). Lists outbreaks reported to WHO from 2000 to 2002.

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