Consensus statement ularemia, a bacterial zoono

EPIDEMIOLOGY

Geographic Distribution and Human Exposures

Tularemia occurs throughout much of North America and Eurasia.15,21,22,32 In the United States, human cases have been reported from every state except Hawaii; however, most cases occur in south-central and western states (es- pecially Missouri, Arkansas, Okla- homa, South Dakota, and Montana).33-35 In Eurasia, the disease is also widely en- demic, although the greatest numbers of human cases are reported from northern and central Europe, espe- cially Scandinavian countries and those of the former Soviet Union.36,37 Tula- remia is almost entirely a rural dis- ease, although urban and suburban ex- posures occasionally do occur.38-41

Throughout its range, F tularensis is

found in widely diverse animal hosts and habitats and can be recovered from contaminated water, soil, and vegeta- tion.15,20-22,32 A variety of small mam- mals, including voles, mice, water rats, squirrels, rabbits, and hares, are natu- ral reservoirs of infection. They ac- quire infection through bites by ticks, flies, and mosquitoes, and by contact with contaminated environments. Al- though enzootic cycles of F tularensis typically occur without notice, epizo- otics with sometimes extensive die- offs of animal hosts may herald out- breaks of tularemia in humans.16,22,42,43 Humans become infected with F tu- larensis by various modes, including bites by infective arthropods,42,44-47 han- dling infectious animal tissues or flu- ids,17,48,49 direct contact with or inges- tion of contaminated water, food, or soil,13,20,40,50,51 and inhalation of infec- tive aerosols.43,52-56 Persons of all ages

MANAGEMENT OF TULAREMIA AS A BIOLOGICAL WEAPON

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2764 JAMA, June 6, 2001—Vol 285, No. 21 (Reprinted)