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PlagueProphylaxisVaccine. No vaccine is currently available for prophylaxis of plague. A licensed, killed whole-cell vaccine was available in the U.S. from 1946 until November 1998. It offered protection against bubonic plague, but was not effective against aerosolized Y. pestis. Presently, an F1-V antigen (fusion protein) vaccine is in development at USAMRIID. It protected mice for a year against an inhalational challenge, and is now being tested in primates. Immunoprophylaxis. There is no passive immunoprophylaxis (i.e., immune globulin) available for pre- or postexposure management of plague. Preexposure prophylaxis: No antibiotics are licensed by the FDA for use before exposure to plague. However, chemoprophylaxis with doxycycline (or ciprofloxacin) may protect against plague based upon in vitro susceptibilities. Postexposure prophylaxis: Face-to-face contacts (within 2 meters) of patients with pneumonic plague or persons possibly exposed to a plague aerosol (i.e., in a plague BW attack) should be given antibiotic prophylaxis for 7 days or the duration of risk of exposure plus 7 days. If fever or cough occurs in these individuals, a full treatment course with antibiotics should be started. Preferred empiric prophylaxis:
Alternatives
Other tetracyclines and fluoroquinolones antibiotics could potentially be substituted for doxycycline and ciprofloxacin, respectively. Trimethoprim-sulfamethoxazole may represent a second-line alternative, should susceptibilities allow. Chemoprophylaxis is generally not recommended after contact with bubonic or septicemic plague patients; however, individuals making such contacts, especially if sharing the same environment in which the patient received a natural exposure, should be observed for symptoms for a week. If symptoms occur, start treatment antibiotics while awaiting results of diagnostic studies. Postexposure Prophylaxis for Pneumonic PlagueAntibiotic prophylaxis (with tetracycline, doxycycline, or trimethoprim-sulfamethoxazole) following exposure to a person with primary or secondary pneumonic plague has been recommended as a public health control measure (see References: ACIP/CDC 1996). Prophylaxsis also is recommended for laboratory workers who may have been exposed to an infectious aerosol via a laboratory accident (see References: Worsham 2007). Tetracycline and doxycycline are approved by the FDA for this indication. Clinical experience with the fluoroquinolones for prophylaxis against pneumonic plague is limited; however, animal studies have suggested efficacy in this setting (see References: Russell 1996). Few data are available on the efficacy of postexposure prophylaxis in this setting; however, according to a CDC report published in 1984, more than 2,000 persons had been placed on prophylactic antibiotics, and no cases of person-to-person transmission had been reported (see References: CDC 1984). In fact, the CDC has not received any reports of person-to-person Y pestis transmission in the United States since the last US outbreak of pneumonic plague in Los Angeles in the 1920s. The Working Group on Civilian Biodefense developed consensus-based recommendations in 2000 for treatment and postexposure prophylaxis of pneumonic plague during a bioterrorist attack (see References: Inglesby 2000). The working group made the following recommendations:
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