6-60
with patients. At a minimum, mask either the casualty or the health-care team and close contacts. Wear gloves
when touching the patient.
Prevention: Report any suspected case immediately to public health officials. Vaccinia vaccine is effective at
preventing smallpox. Immunize those exposed to smallpox promptly. Those immunized within the first several
days after exposure may be protected against the development of smallpox. Vaccinia Immune Globulin (VIG)
is not useful in smallpox victims.
Follow-up Actions
Evacuation/Consultant Criteria: Consult early with preventive medicine experts. Isolate and do not evacuate
patient. Quarantine contacts for 17 days (incubation period) to ensure they will not be secondary cases.
Biological Agents: Tularemia
Introduction: Tularemia is caused by infection with Francisella tularensis, a gram-negative coccobacillary
organism. Although several forms are known, the pneumonic or typhoidal forms of the disease would likely
occur after intentional aerosol delivery. See also ID: Tularemia.
Subjective: Symptoms
Fever, malaise, fatigue, cough, shortness of breath and abdominal pain.
Objective: Signs
Using Basic Tools: Fever, tachycardia, tachypnea, dyspnea, cyanosis, diaphoresis, rales, hypotension, and
abdominal tenderness and pneumonia and sepsis later.
Using Advanced Tools: CXR: Increased markings and consolidation of pneumonia Lab: Gram-stain of
sputum may demonstrate short gram-negative rods; blood cultures.
Assessment:
Differential Diagnosis - other forms of pneumonia (both conventional etiologies and other potential
biological weapons: plague, staphylococcal enterotoxins); sepsis caused by other gram-negative bacteria,
typhoid fever, anthrax.
Plan:
Treatment
Primary: Intravenous gentamicin (1.5 mg/kg every 8 hours), oxygen, intravenous fluids, antipyretics.
Alternative: IV streptomycin, doxycycline, tetracycline, or ciprofloxacin if gentamicin is unavailable.
Primitive: Oral doxycycline or ciprofloxacin if IV therapy is not possible.
Patient Education
General: Tularemia is not typically contagious; caregivers need only employ standard precautions when
dealing with patients.
Prevention: Start asymptomatic persons thought to have been exposed to tularemia via aerosol on oral
doxycycline (100 mg every 12 hours). Oral ciprofloxacin (500 mg every 12 hours) is an acceptable
substitute. Try other fluoroquinolones or tetracycline if doxycycline or ciprofloxacin is unavailable.
Follow-up Actions
Evacuation/Consultant Criteria: Evacuate patients promptly. Consult preventive medicine or infectious
disease experts early.
Biological Agents: Viral Hemorrhagic Fevers
Introduction: The viral hemorrhagic fevers (VHFs) are a diverse group of diseases caused by viruses of
at least four families. They share a propensity to cause bleeding but otherwise vary considerably in their