Health Alert
CASE OF TULAREMIA REPORTED IN DELAWARE

The Division of Public Health (DPH) alerts the medical community to the first reported and confirmed case of Tularemia in the past eight (8) years. The case is a 45 year-old male hospitalized in Kent County since September 28, 2011. Delaware has not had a confirmed case of Tularemia since 2003. In the United States, an estimated 125 to 150 cases are reported annually.

Reporting

Tularemia is a reportable disease in Delaware. Laboratories and healthcare providers are required to report any diagnosed case to DPH, Bureau of Epidemiology (1-888-295-5156 or 1-302-744-1033) as soon as possible by telephone. Information tracked includes date of onset, method of diagnosis, underlying medical conditions, clinical course, treatment, occupation, travel history and any known exposures within 10 days prior to the onset of illness.

Background

Symptoms of Tularemia usually appear 3 to 5 days after exposure to the bacteria, but can take as long as 14 days. Symptoms may include: sudden fever, chills, headaches, diarrhea, muscle aches, joint pain, dry cough & progressive weakness. People can also develop pneumonia with chest pain, cough & difficulty breathing. Other symptoms of Tularemia depend upon how a person was exposed to the bacteria. These symptoms can include ulcers on the skin or in the mouth, swollen and painful lymph glands, swollen and painful eyes and a sore throat.

Transmission

Tularemia is caused by Francisella tularensis bacterium, which causes disease inanimals and humans. Infected rodents, rabbits, and hares die in large numbers during outbreaks. Tularemia is not known to be spread from person to person. Humans can become infected through several routes including:

• By tick bite (dog tick, wood tick & lone star tick) or deer fly bite (in western USA), which usually causes ulceroglandular or glandular tularemia.
• By handling infected animal tissue particularly when hunting or skinning infected rabbits, muskrats, prairie dogs and other rodents. Domestic cats are very susceptible to tularemia and have been known to transmit the bacteria to humans.
• By inhaling dust or aerosols contaminated with F. tularensis bacteria. This can occur during farming or landscaping activities, especially when machinery (e.g. tractors or mowers) runs over an infected animal or carcass. This can result in pneumonic tularemia, one of the most severe forms of the disease.
• By drinking untreated water contaminated with the bacteria introduced by animal contact. This may cause oropharyngeal tularemia.

Diagnosis

• Physicians who suspect tularemia should promptly collect appropriate specimens (listed below) and alert the laboratory to the need for special diagnostic and safety procedures. Rapid diagnostic testing for tularemia is not widely available.
• A culture of F. tularensis from a specimen is the definitive diagnostic procedure for tularensis. Appropriate specimens include swabs or scrapping of skin lesions, lymph node aspirates or biopsies, pharyngeal washings, sputum specimens, or gastric aspirates, depending on the form of illness. Blood cultures are often negative.
• A presumptive diagnosis of tularemia may be made by direct fluorescent antibody, immunohistochemical staining, or polymerase chain reaction (PCR) on appropriate specimens.
• The diagnosis of tularemia can also be established serologically by demonstrating a 4-fold increase in specific antibody titers between acute and convalescent sera. Convalescent sera are best drawn at least 4 weeks after illness onset; hence this method is not useful for clinical management.

Treatment

• Streptomycin is the drug of choice based on experience, efficacy and FDA approval. Gentamicin is considered an acceptable alternative, but some series have reported a lower primary success rate. Treatment with aminoglycosides should be continued for 10 days.
• Tetracyclines may be a suitable alternative to aminoglycosides for patients who are not very sick. Tetracyclines are static agents and should be given for at least 14 days to avoid relapse.
• Ciprofloxacin and other fluoroquinolones are not FDA-approved for treatment of tularemia but have shown good efficacy in vitro, in animals, and in humans.
• The US currently does not have a vaccine for Tularemia.

Prevention

Tularemia occurs naturally in many parts of the United States. Use of insect repellent containing DEET on skin, or treating clothing with repellent containing permethrin, can prevent insect bites. Use care and wear gloves when handling sick or dead animals. Be sure to cook food thoroughly and drink water from a safe source. Note any change in the behavior of pets (especially rodents, rabbits, and hares) or livestock, and consult a veterinarian if they develop unusual symptoms.

Additional Information

For more specific information, please visit the CDC website or call the number as listed below.

• http://www.cdc.gov/tularemia/faq/
• DPH Bureau of Epidemiology: 1-888-295-5156

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