Epidemiology and clinical characteristics of tularemia in Oklahoma, 1979 to 1985

Mutation of wbtJ, a N-formyltransferase involved in O-antigen synthesis, results in biofilm formation, phase variation and attenuation in Francisella tularensis

Two clinically important subspecies, Francisella tularensis subsp. tularensis (type A) and F. tularensis subsp. holarctica (type B) are responsible for most tularaemia cases, but these isolates typically form a weak biofilm under in vitro conditions. Phase variation of the F. tularensis lipopolysaccharide (LPS) has been reported in these subspecies, but the role of variation is unclear as LPS is crucial for virulence. We previously demonstrated that a subpopulation of LPS variants can constitutively form a robust biofilm in vitro, but it is unclear whether virulence was affected. In this study, we show that biofilm-forming variants of both fully virulent F. tularensis subspecies were highly attenuated in the murine tularaemia model by multiple challenge routes. Genomic sequencing was performed on these strains, which revealed that all biofilm-forming variants contained a lesion within the wbtJ gene, a formyltransferase involved in O-antigen synthesis. A ΔwbtJ deletion mutant recapitulated the biofilm, O-antigen and virulence phenotypes observed in natural variants and could be rescued through complementation with a functional wbtJ gene. Since the spontaneously derived biofilm-forming isolates in this study were a subpopulation of natural variants, reversion events to the wbtJ gene were detected that eliminated the phenotypes associated with biofilm variants and restored virulence. These results demonstrate a role for WbtJ in biofilm formation, LPS variation and virulence of F. tularensis.

Ecology of Tularemia in Central US Endemic Region

Tularemia is a zoonotic disease that occurs in the Northern Hemisphere caused by the gammabacterium Francisella tularensis. The most severe form of human tularemia occurs in the central USA and involves a rabbit enzootic cycle, ixodid tick vectors, and F. tularensis subspecies tularensis genotype A1. Enzootic tularemia is thought to have a spring-summer seasonality corresponding to the questing activity of its primary tick vectors. Domestic cats, another common incidental host, acquire the infection by preying on infected rabbits. The seasonality of tularemia in cats, which demonstrate a bimodal seasonal incidence curve with peaks in the spring and late summer-fall, may serve as a surrogate for the seasonality of the disease in its enzootic host. Human tularemia shows a unimodal late spring, early summer peak, which correlates to the seasonal questing activity of tick vectors of human tularemia. This difference in seasonality suggests that different tick species or tick life stages are involved in maintenance of the enzootic rabbit-tick cycle.

Vaccination evokes gender-dependent protection against tularemia infection in C57BL/6Tac mice

Francisella tularensis (Ft) is a Category A biothreat agent for which there currently is no FDA-approved vaccine. Thus, there is a substantial effort underway to develop an effective tularemia vaccine. While it is well established that gender can significantly impact susceptibility to primary infection, the impact of gender on vaccine efficacy is not well established. Thus, development of a successful vaccine against tularemia will require an understanding of the impact gender has on vaccine-induced protection against this organism. In this study, a role for gender in vaccine-induced protection following Ft challenge is identified for the first time. In the present study, mucosal vaccination with inactivated Ft (iFt) LVS elicited gender-based protection in C57BL/6Tac mice against respiratory challenge with Ft LVS. Specifically, vaccinated male mice were more susceptible to subsequent Ft LVS challenge. This increased susceptibility in male mice correlated with increased bacterial burden, increased tissue inflammation, and increased proinflammatory cytokine production late in post-challenge infection. In contrast, improved survival of iFt-vaccinated female mice correlated with reduced bacterial burden and enhanced levels of Ft-specific Abs in serum and broncho-alveolar lavage (BAL) fluid post-challenge. Furthermore, vaccination with a live attenuated vaccine consisting of an Ft LVS superoxide dismutase (SodB) mutant, which has proven efficacious against the highly virulent Ft SchuS4 strain, demonstrated similar gender bias in protection post-Ft SchuS4 challenge. Of particular significance is the fact that these are the first studies to demonstrate that gender differences impact disease outcome in the case of lethal respiratory tularemia following mucosal vaccination. In addition, these studies further emphasize the fact that gender differences must be a serious consideration in any future tularemia vaccine development studies.

Tularemia vaccine development: paralysis or progress?

Francisella tularensis (Ft) is a gram-negative intercellular pathogen and category A biothreat agent. However, despite 15 years of strong government investment and intense research focused on the development of a US Food and Drug Administration-approved vaccine against Ft, the primary goal remains elusive. This article reviews research efforts focused on developing an Ft vaccine, as well as a number of important factors, some only recently recognized as such, which can significantly impact the development and evaluation of Ft vaccine efficacy. Finally, an assessment is provided as to whether a US Food and Drug Administration-approved Ft vaccine is likely to be forthcoming and the potential means by which this might be achieved.

Tularemia: current diagnosis and treatment options

Tularemia is an infection caused by Francisella tularensis with a worldwide distribution and diverse clinical manifestations. Limitations in both culture and serologic testing have led to substantial research into new diagnostic techniques and their clinical application, with PCR testing as the best example. This review focuses on the utility of culture, PCR and serologic testing for tularemia. In addition, we also review the evidence to support different therapeutic options for tularemia, highlighting both the most effective supporting evidence for therapeutic recommendations as well as gaps in current knowledge. We conclude the article with suggestions regarding potential areas for future research.

Bacterial Infections

In Osier’s time, bacterial pneumonia was a dreaded event, so important that he borrowed John Bunyan’s characterization of tuberculosis and anointed the pneumococcus, as the prime pathogen, “Captain of the men of death.”1 One hundred years later much has changed, but much remains the same. Pneumonia is now the sixth most common cause of death and the most common lethal infection in the United States. Hospital-acquired pneumonia is now the second most common nosocomial infection.2 It was documented as a complication in 0.6% of patients in a national surveillance study,3 and has been reported in as many as 20% of patients in critical care units.4 Furthermore, it is the leading cause of death among nosocomial infections.5 Leu and colleagues6 were able to associate one third of the mortality in patients with nosocomial pneumonia to the infection itself. The increase in hospital stay, which averaged 7 days, was statistically significant. It has been estimated that nosocomial pneumonia produces costs in excess of $500 million each year in the United States, largely related to the increased length of hospital stay.

A call for renewed research on tick-borne Francisella tularensis in the Arkansas-Missouri primary national focus of tularemia in humans

Arkansas-Missouri has emerged as the primary U.S. focus of tularemia, which is caused by the National Institute of Allergy and Infectious Diseases Category A Priority Pathogen Francisella tularensis, over the past 30 yr. There are several pieces of indirect evidence suggesting that a key role of ticks in the transmission of F. tularensis to humans in Arkansas-Missouri is the primary reason why tularemia has remained a prominent disease of humans in this two-state area while fading away from other central or eastern states after a general decline in rabbit-associated tularemia cases. The primary tick vector(s) in Arkansas-Missouri can, based on a comparison of seasonal patterns of human tularemia cases and peak host-seeking activity of commonly human-biting tick species and life stages, be narrowed down to Amblyomma americanum (L.) nymphs, A. americanum adults, or Dermacentor variabilis (Say) adults. Unfortunately, currently available data cannot be used to further elucidate the relative roles of these ticks as vectors of F. tularensis to humans in Arkansas-Missouri. To address the fact that we do not know which tick species is the primary vector of F. tularensis to humans in the most prominent U.S. focus of tularemia, we need to determine (1) relative contributions of different tick species and life stages as human biters in Arkansas-Missouri; (2) natural rates of infection with F. tularensis tularensis (type A) and F. tularensis holarctica (type B) of the most prominent human-biting ticks in areas of Arkansas-Missouri hyperendemic for tularemia; (3) experimental vector efficiency of these ticks for both F. tularensis tularensis and F. tularensis holarctica; and (4) presence of infection with F. tularensis tularensis or F tularensis holarctica in ticks collected from humans in Arkansas-Missouri.

Clinicopathologic aspects of animal and zoonotic diseases of bioterrorism

We live in an era of emerging infectious diseases and the threat of bioterrorism. Most of the infectious agents of modern concern, from plague to avian influenza H5N1, are zoonotic diseases: infectious agents that reside in quiet animal reservoir cycles that are transmitted occasionally to humans. The public health, health care, and veterinary communities have an enormous challenge in the early recognition, reporting, treatment, and prevention of zoonotic diseases. An intimate understanding of the natural ecology, geographic distribution, clinical signs, lesions, and diagnosis of these diseases is essential for the early recognition and control of these diseases.