Tularemia in New York City: When do we need to suspect bioterrorism?

Abstract

ISSUE: Tularemia (Tu), known as rabbit fever, is a Category A agent of bioterrorism (BT). It was last seen in New York City (NYC) in 1998. This NYC medical center has been preparing for a BT event, and its emergency management preparedness program proved to be successful when a patient was admitted with Tu around the time of the Republican National Convention (RNC) being held in NYC. PROJECT: The medical center has been conducting nuclear, biologic and chemical (NBC) preparedness training since 2002 for all its healthcare workers (HCWs). The hospital emergency incident command system (HEIC) is used in the event of an emergency. NBC training provides education, communication, guidelines, and response plans to ensure safety and cooperation in the event of an attack. Our plan was tested when the diagnosis of Tu was made after the patient was discharged. RESULTS: A 20-year-old woman from Staten Island presented to the emergency department in August 2004 with an enlarged submandibular lymph node, pneumonia, and a pleural effusion. Pleural fluid and blood cultures grew gram-negative bacilli that were difficult to identify. Close cooperation with the NYC Department of Health identified the bacilli as Francisella tularensis . Because the case occurred around the time of the RNC and Tu is rare in NYC, there was concern as to whether this was a BT sentinel event. A thorough investigation revealed that the infection was naturally acquired. The patient's dog had captured a wild rabbit and then licked the woman's face. The woman survived, and no other cases were reported. Laboratory HCWs who handled the culture plates were contacted and evaluated for risk exposure. Antibiotic prophylaxis was deemed not necessary since specimens had not been handled by any HCW for almost 2 weeks. A fever watch was instituted and the laboratory HCWs were followed by employee health services. None developed any symptoms. LESSONS LEARNED: It is imperative to have an emergency plan in place. Our NBC training program allowed us to facilitate identification, apply precautions, alleviate fears, and communicate with all appropriate agencies in a timely and successful manner. NBC training also ensured that the laboratory had an employee roster with names and phone numbers readily available so that lab HCWs could be notified quickly—this was especially important since notification occurred on a Friday night.