The following information contains adaptations and excerpts from the US Army Center for Health Promotion and Preventive Medicine (USACHPPM) Tech Guide 244, The Medical NBC Battlebook.

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Characteristics. Tularemia is a zoonotic disease caused by Francisella tularensis, a 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. Less commonly, inhalation of contaminated dust, or ingestion of contaminated foods or water, may produce clinical disease. A biological attack with F. tularensis delivered by aerosol would primarily cause typhoidal tularemia, a syndrome expected to have a case fatality rate which may be higher than the 5-10% seen when the disease is acquired naturally.

Clinical Features. Under natural conditions, ulcerglandular tularemia generally occurs about 2 to 10 days after intradermal inoculation, and manifests as regional lymphadenopahty, fever, chaills, headache, and malaise, with or without a cutaneous ulcer. Gastrointestinal tularemia occurs after drinking contaminated water, and is characterized by abdominal pain, nausea, vomiting, and diarrhea. Bacteremia probably is common after primary intradermal, respiratory or gastrointestinal infection with F. tularensis and may result in septicemic or "typhoidal" tularemia. They typoidal form also may occur as a primary condition in 5-15% of naturally occurring cases. Clinical features include fever, prostration, and weight loss without adenopathy. Pneumonic tularemia is a severe, atypical, possibly fulminant, primary or secondary pneumonia. Primary pneumonia may follow direct inhalation of infectious aerosol, or may result from aspiration of organisms such as in cases of pharyngeal tularemia. Pneumonic tularemia causes fever, headache, malaise, substernal discomfort, and a non-productive cough. A biological attack with F. tularensis would most likely be delivered by aerosol causing primarily typhoidal tularemia Many exposed individuals would develop pneumonic tularemia (primary or secondary), but clinical pneumonia may be absent or non-evident. Case fatality rates may be higher than the 5-10% seen when the disease is acquired naturally.

Vaccine. A live, attenuated tularemia vaccine is available as an investigational new drug (IND). Its effectiveness in humans against the concentrated bacterial challenge expected in a biological attack is unproven.

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