{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,13]],"date-time":"2026-01-13T16:18:30Z","timestamp":1768321110927,"version":"3.49.0"},"reference-count":34,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2026,1,13]],"date-time":"2026-01-13T00:00:00Z","timestamp":1768262400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Pathogens"],"abstract":"<jats:p>Tularemia is a well-known zoonotic disease around the world, with particularly high rates in certain geographic areas of the U.S. Though the disease is regularly reported, it is classified as a rare condition owing to the relatively low number of cases detected annually. Interestingly, however, the number of cases in the U.S. has shown a positive upward trend through time. The aim of this study was to summarize, interpret, compare, and contextualize temporal trends in tularemia epidemiology at the national scale within the U.S. utilizing long-term data sets encompassing the 23-year span from 2000 to 2022. We used two secondary data sets: (1) case data reports from the National Notifiable Disease Surveillance System (NNDSS) of the Centers for Disease Control and Prevention (CDC) and (2) the National Inpatient Sample (NIS) of hospitalization discharge records. In addition to investigating patterns, we were interested in the utility of using hospital discharge records as a means of indirect epidemiological surveillance of this rare disease. Both data sets highlight the high variability in annual cases through time but underscore the highest risk of disease among patients classified as White and male, as well as the extraordinarily high rates among American Indian\/Alaska Native populations, particularly those with pulmonary tularemia disease. Descriptive epidemiological summaries and statistical comparisons are provided across the time series for sex, age, ethnoracial identity, and geography; hospitalization characteristics are also described. Our desire to use case rates from hospitalization records as a surrogate for CDC case incidence rates did not provide the desired precision, though hospital discharge records do provide valuable and useful information necessary to estimate general high-risk groups for tularemia through time.<\/jats:p>","DOI":"10.3390\/pathogens15010086","type":"journal-article","created":{"date-parts":[[2026,1,13]],"date-time":"2026-01-13T10:13:51Z","timestamp":1768299231000},"page":"86","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Descriptive Temporal Epidemiology of Tularemia Using Case Reports and Hospitalization Data in the United States, 2000\u20132022"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8756-5607","authenticated-orcid":false,"given":"Chad L.","family":"Cross","sequence":"first","affiliation":[{"name":"School of Veterinary Medicine, Texas Tech University, Amarillo, TX 79106, USA"},{"name":"UNLV Parasitology & Vector Biology (PARAVEC) Laboratory, School of Public Health, University of Nevada, Las Vegas, NV 89154, USA"},{"name":"TTTSVM Parasitology & Vector Biology (PARAVEC) Laboratory, School of Veterinary Medicine, Texas Tech University, Amarillo, TX 79106, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7786-4240","authenticated-orcid":false,"given":"Bryson","family":"Carrier","sequence":"additional","affiliation":[{"name":"TTTSVM Parasitology & Vector Biology (PARAVEC) Laboratory, School of Veterinary Medicine, Texas Tech University, Amarillo, TX 79106, USA"},{"name":"School of Kinesiology, University of Michigan, Ann Arbor, MI 48109, USA"},{"name":"Department of Natural Sciences, Oregon Institute of Technology, Klamath Fall, OR 97601, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3107-6214","authenticated-orcid":false,"given":"Louisa A.","family":"Messenger","sequence":"additional","affiliation":[{"name":"UNLV Parasitology & Vector Biology (PARAVEC) Laboratory, School of Public Health, University of Nevada, Las Vegas, NV 89154, USA"},{"name":"TTTSVM Parasitology & Vector Biology (PARAVEC) Laboratory, School of Veterinary Medicine, Texas Tech University, Amarillo, TX 79106, USA"},{"name":"Department of Environmental & Global Health, School of Public Health, University of Nevada, Las Vegas, NV 89154, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,1,13]]},"reference":[{"key":"ref_1","unstructured":"(2026, January 09). Biosecurity and Biodefense Resource\u2014Federation of American Scientists. Available online: https:\/\/biosecurity.fas.org\/resource\/factsheets\/tularemia.htm."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"S1","DOI":"10.1093\/cid\/ciad681","article-title":"Tularemia: A Storied History, An Ongoing Threat","volume":"78","author":"Nelson","year":"2024","journal-title":"Clin. Infect. Dis."},{"key":"ref_3","unstructured":"(2025, November 25). NIAID Biodefense Pathogens|NIAID: National Institute of Allergy and Infectious Diseases, Available online: https:\/\/www.niaid.nih.gov\/research\/niaid-biodefense-pathogens."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1152","DOI":"10.15585\/mmwr.mm735152a1","article-title":"Tularemia\u2014United States, 2011\u20132022","volume":"73","author":"Rich","year":"2025","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"227","DOI":"10.15585\/mmwr.mm7413a3","article-title":"Notes from the Field: Increase in Human and Animal Tularemia Cases\u2014Minnesota, 2024","volume":"74","author":"Bye","year":"2025","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_6","unstructured":"(2025, November 25). CDC Clinical Care of Tularemia, Available online: https:\/\/www.cdc.gov\/tularemia\/hcp\/clinical-care\/index.html."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"974","DOI":"10.1002\/eji.201040923","article-title":"Persistence of Cell-Mediated Immunity Three Decades after Vaccination with the Live Vaccine Strain of Francisella tularensis","volume":"41","author":"Rietz","year":"2011","journal-title":"Eur. J. Immunol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"S38","DOI":"10.1093\/cid\/ciad690","article-title":"Treatment Outcome of Severe Respiratory Type B Tularemia Using Fluoroquinolones","volume":"78","author":"Magnusson","year":"2024","journal-title":"Clin. Infect. Dis."},{"key":"ref_9","first-page":"963","article-title":"Tularemia\u2014United States, 2001\u20132010","volume":"62","author":"Nelson","year":"2013","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_10","unstructured":"(2025, September 29). CDC WONDER, Available online: https:\/\/wonder.cdc.gov\/."},{"key":"ref_11","unstructured":"(2025, September 29). National Notifiable Diseases Surveillance System (NNDSS)\u2014Health, United States, Available online: https:\/\/www.cdc.gov\/nchs\/hus\/sources-definitions\/nndss.htm."},{"key":"ref_12","unstructured":"AHRQ (2025). Healthcare Cost and Utilization Project (HCUP). 2000\u20132022, Agency for Healthcare Research and Quality."},{"key":"ref_13","unstructured":"(2022, October 25). HCUP Partners, Available online: https:\/\/www.hcup-us.ahrq.gov\/partners.jsp."},{"key":"ref_14","unstructured":"(2024, October 03). HCUP-US NIS Overview, Available online: https:\/\/hcup-us.ahrq.gov\/nisoverview.jsp."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Cross, C.L., Carrier, B., Alcala, M.A.A., and Messenger, L.A. (2024). Descriptive Epidemiology of Soil-Transmitted Helminth Infections in the United States: Using Big Data to Characterize Patients and Analyze Parasitic Disease Trends. Pathogens, 13.","DOI":"10.3390\/pathogens13121091"},{"key":"ref_16","unstructured":"(2025, November 18). S0101: AGE AND SEX\u2014Census Bureau Table, Available online: https:\/\/data.census.gov\/table\/ACSST1Y2017.S0101?y=2017."},{"key":"ref_17","unstructured":"(2025, November 25). Consumer Price Index Data from 1913 to 2025. Available online: https:\/\/www.usinflationcalculator.com\/inflation\/consumer-price-index-and-annual-percent-changes-from-1913-to-2008\/."},{"key":"ref_18","unstructured":"(2025, December 10). Tularemia\u2014Symptoms, Causes, Treatment|NORD. Available online: https:\/\/rarediseases.org\/rare-diseases\/tularemia\/."},{"key":"ref_19","unstructured":"(2025, December 10). Tularemia in Animals\u2014Generalized Conditions. Available online: https:\/\/www.msdvetmanual.com\/generalized-conditions\/tularemia\/tularemia-in-animals."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1080\/01652176.2023.2277753","article-title":"Tularemia\u2014A Re-Emerging Disease with Growing Concern","volume":"43","author":"Sharma","year":"2023","journal-title":"Vet. Q."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"609","DOI":"10.1016\/j.tmaid.2014.10.007","article-title":"An Overview: Tularemia and Travel Medicine","volume":"12","author":"Doganay","year":"2014","journal-title":"Travel Med. Infect. Dis."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"236","DOI":"10.1186\/s13023-023-02839-7","article-title":"Epidemiological Research on Rare Diseases Using Large-Scale Online Search Queries and Reported Case Data","volume":"18","author":"Zhang","year":"2023","journal-title":"Orphanet J. Rare Dis."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1165","DOI":"10.1007\/s15010-024-02218-9","article-title":"Tularemia on the Rise in Switzerland? A One Health Approach Is Needed!","volume":"52","author":"Buettcher","year":"2024","journal-title":"Infection"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Janse, I., van der Plaats, R.Q.J., de Roda Husman, A.M., and van Passel, M.W.J. (2018). Environmental Surveillance of Zoonotic Francisella tularensis in the Netherlands. Front. Cell Infect. Microbiol., 8.","DOI":"10.3389\/fcimb.2018.00140"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1","DOI":"10.15585\/mmwr.rr7402a1","article-title":"Tularemia Antimicrobial Treatment and Prophylaxis: CDC Recommendations for Naturally Acquired Infections and Bioterrorism Response\u2014United States, 2025","volume":"74","author":"Nelson","year":"2025","journal-title":"MMWR Recomm. Rep."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"510","DOI":"10.1126\/science.adw4964","article-title":"Collateral Effects of COVID-19 Pandemic Control on the US Infectious Disease Landscape","volume":"390","author":"Brett","year":"2025","journal-title":"Science"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"863","DOI":"10.1086\/597261","article-title":"Molecular Epidemiology of Francisella tularensis in the United States","volume":"48","author":"Kugeler","year":"2009","journal-title":"Clin. Infect. Dis."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1113","DOI":"10.3201\/eid1207.051504","article-title":"Epidemiologic and Molecular Analysis of Human Tularemia, United States, 1964\u20132004","volume":"12","author":"Staples","year":"2006","journal-title":"Emerg. Infect. Dis."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1637","DOI":"10.1056\/NEJM200111293452211","article-title":"Tularemia Revisited","volume":"345","author":"Hornick","year":"2001","journal-title":"N. Engl. J. Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1601","DOI":"10.1056\/NEJMoa011374","article-title":"An Outbreak of Primary Pneumonic Tularemia on Martha\u2019s Vineyard","volume":"345","author":"Feldman","year":"2001","journal-title":"N. Engl. J. Med."},{"key":"ref_31","unstructured":"(2025, December 22). American Indian Health Disparities. NICOA\u2014National Indian Council on Aging. Available online: https:\/\/www.nicoa.org\/elder-resources\/health-disparities\/."},{"key":"ref_32","unstructured":"(2025, December 22). Inadequate Healthcare for American Indians in the United States. Available online: https:\/\/ballardbrief.byu.edu\/issue-briefs\/inadequate-healthcare-for-american-indians-in-the-united-states."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"2194","DOI":"10.1038\/s41436-021-01241-7","article-title":"Can You Hear Us Now? The Impact of Health-Care Utilization by Rare Disease Patients in the United States","volume":"23","author":"Singh","year":"2021","journal-title":"Genet. Med."},{"key":"ref_34","first-page":"221","article-title":"The Inherent Challenges of Using Large Datasets in Healthcare Research: Experiences of an Interdisciplinary Team","volume":"35","author":"Kaulfus","year":"2017","journal-title":"Comput. Inform. Nurs."}],"container-title":["Pathogens"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-0817\/15\/1\/86\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,13]],"date-time":"2026-01-13T10:21:04Z","timestamp":1768299664000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-0817\/15\/1\/86"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,13]]},"references-count":34,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1]]}},"alternative-id":["pathogens15010086"],"URL":"https:\/\/doi.org\/10.3390\/pathogens15010086","relation":{},"ISSN":["2076-0817"],"issn-type":[{"value":"2076-0817","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,13]]}}}