Cross-agency collaboration: A tularemia investigation in Virginia

Background/Purpose: This study describes collaboration in the investigation of a case of pulmonary tularemia. Because Francisella tularensis can be used as biological warfare agent, this event represented a potential public health emergency. Study Design: This is an investigation of a tularemia case and associated contacts. Results/Outcomes: In September 2011, a previously healthy active-duty male in Virginia presented with a febrile respiratory illness, was admitted to a military intensive care unit for acute respiratory distress syndrome, and intubated. Further questioning of the patient's family revealed exposure to a rabbit at home one week prior to illness onset and his antibiotic coverage was broadened to include coverage for atypical pathogens. Using standard precautions, the hospital laboratory initially identified an uncommon Haemophilus species, later determined to be Francisella tularensis by the state laboratory, and the diagnosis of pulmonic tularemia was made. Patient history and information from the Federal Bureau of Investigation ruled out use of a bioweapon. Using an approach similar to the Incident Command System, civilian health departments, veterinary experts, and military medicine assets all collaborated to identify other hospital-based and community contacts, provide chemoprophylaxis as needed, and communicate with stakeholders. We recovered no rabbits for testing and identified no additional cases. The patient recovered without sequelae. Conclusions: Although only one patient was affected, this investigation demonstrates effective collaboration of various agencies during a potential public health emergency.