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THERAPY. Untreated bubonic plague has a case-fatality rate
commonly reported as around 50%; untreated primary septicemic
and pneumonic plague are invariably fatal. Streptomycin,
tetracyclines, and chloramphenical are highly effective if
begun early (with 8-24 hours in pneumonic plague). Intravenous
doxycycline (200 mg initially, followed by 100 mg q 12 hours),
intramuscular streptomycin (1 gm q 12 hours), or intravenous
chloramphenical (1 gm q 6 hours) for 10-14 days are recognized
as effective against naturally occurring strains. Prophylaxis
for contacts of pneumonic cases with doxycycline (100 mg po
bid) is necessary to prevent secondary transmission.
          
PROPHYLAXIS. A licensed, formalin-killed Y pestis vaccine is
marketed in the US, and has been utilized by US military
personnel for many years in highly plague-endemic areas.
Reactogenicity is moderately high, and immunity acquired after
a 3-dose primary series (0, 1, and 4-7 months) is sustained
only with boosters every 1-2 years. Live-attenuated vaccines
produced in other countries are generally regarded as highly
reactogenic, with a potential for reversion.

TOLAREMIA

CLINICAL SYNDROME

Tularemia is a zoonotic disease caused by Francisella
tularensis, a small, non spore-forming gram negative bacillus.
Humans acquire the disease under natural conditions through
inoculation of skin or mucous membranes with blood or tissue
fluids of infected animals, or bites of infected deerflies,
mosquitoes, or ticks. Rarely, ingestion of contaminated food
or water or inhalation of contaminated dusts may produce
clinical disease. A biological warfare attack with F
tularensis delivered by aerosol would primarily cause pneumonic
and typhoidal tularemia, syndromes expected to have
case-fatality rates much higher than 5-10% seen when disease is
acquired naturally.

Clinical Features. A variety of clinical forms of tularemia
are seen, dependinq upon the route of inoculation and virulence
of the strain. [(b)(1) sec 3.4 (b)(2)]

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