{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T12:48:16Z","timestamp":1787316496582,"version":"build-2736575974"},"reference-count":92,"publisher":"American Society of Tropical Medicine and Hygiene","issue":"4","license":[{"start":{"date-parts":[[2026,4,1]],"date-time":"2026-04-01T00:00:00Z","timestamp":1775001600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,4,1]]},"abstract":"<jats:title>ABSTRACT.<\/jats:title>\n                  <jats:p>\n                    Echinococcoses are neglected zoonotic diseases caused by larval cestodes of the genus\n                    <jats:italic>Echinococcus<\/jats:italic>\n                    . Regions of the United States rarely experience locally acquired infections, and most contemporary cases are presumed to be imported, predominantly from hyperendemic regions such as Central and East Asia, the Middle East, and North Africa. However, significant knowledge gaps remain regarding the current disease burden within the US healthcare system. The epidemiology, baseline clinical features, and outcomes are summarized for patients diagnosed with cystic echinococcosis (CE) or alveolar echinococcosis (AE) in the present study using retrospective, deidentified data from the TriNetX research network, a federated database that encompasses 89 healthcare organizations and more than 126 million patients (1997\u20132024). Individuals with\n                    <jats:italic>Echinococcus<\/jats:italic>\n                    infection were identified using\n                    <jats:italic>International Classification of Diseases, 10th Revision<\/jats:italic>\n                    , code B67, and demographic characteristics, geographic distribution, medical and surgical interventions, and mortality were assessed from 2003 to 2023. More than 36,000 patients with any B67 diagnosis were identified, of whom 728 had codes specific to CE, and 75 had codes specific to AE. There were more CE cases in the Southern United States, whereas most AE were reported in the Northeastern United States. Many patients were asymptomatic, with limited use of diagnostic imaging or serologic testing. Antiparasitic medication or surgical procedures were recorded most commonly in AE patients (18%), with mortality rates between 28% and 38% at 20 years post-index. Although locally acquired AE and CE appear to be emerging in the Northeastern United States, the overall prevalence remains low nationwide. The authors advocate for heightened awareness of echinococcoses among US-based clinicians and recommend prospective surveillance studies to improve clinical outcomes and understanding of local transmission risks.\n                  <\/jats:p>","DOI":"10.4269\/ajtmh.25-0453","type":"journal-article","created":{"date-parts":[[2026,2,3]],"date-time":"2026-02-03T14:32:56Z","timestamp":1770129176000},"page":"662-671","source":"Crossref","is-referenced-by-count":1,"title":["A Multicenter Retrospective Study of Cystic and Alveolar Echinococcosis Patients in the United States (1997\u20132024)"],"prefix":"10.4269","volume":"114","author":[{"given":"Treana","family":"Mayer","sequence":"first","affiliation":[{"name":"Department of Microbiology, Immunology, & Pathology, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, Colorado;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mary Ellen","family":"Krienke","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Anschutz Medical Center, University of Colorado, Aurora, Colorado;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel B.","family":"Chastain","sequence":"additional","affiliation":[{"name":"Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, Georgia;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christine M.","family":"Budke","sequence":"additional","affiliation":[{"name":"Department of Veterinary Integrative Biosciences, Texas A&M University, College Station, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nelson I.","family":"Agudelo Higuita","sequence":"additional","affiliation":[{"name":"University of Oklahoma Health Campus, Oklahoma City, Oklahoma;"},{"name":"Instituto de Enfermedades Infecciosas y Parasitologia Antonio Vidal, Tegucigalpa, Honduras"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susan","family":"VandeWoude","sequence":"additional","affiliation":[{"name":"Department of Microbiology, Immunology, & Pathology, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, Colorado;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andr\u00e9s F.","family":"Henao-Mart\u00ednez","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Anschutz Medical Center, University of Colorado, Aurora, Colorado;"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2795","reference":[{"key":"b1","series-title":"BMJ","first-page":"e3866","article-title":"Diagnosis, treatment, and management of echinococcosis","volume":"344","author":"McManus","year":"2012"},{"key":"b2","article-title":"Fact Sheets: Echinococcosis.","year":"2021"},{"key":"b3","series-title":"Parasite","first-page":"73","article-title":"Echinococcus multilocularis in North America: The great unknown","volume":"21","author":"Massolo","year":"2014"},{"key":"b4","series-title":"J Wildl Dis","first-page":"332","article-title":"Echinococcus species infections among wild canids in Pennsylvania, USA","volume":"59","author":"Garrett","year":"2023"},{"key":"b5","series-title":"J Vet Diagn Invest","first-page":"746","article-title":"Alveolar echinococcosis in a dog in Missouri, USA","volume":"34","author":"Kuroki","year":"2022"},{"key":"b6","series-title":"PLoS Negl Trop Dis","first-page":"e0006712","article-title":"Echinococcus in wild canids in Qu\u00e9bec (Canada) and Maine (USA)","volume":"12","author":"Schurer","year":"2018"},{"key":"b7","series-title":"Clin Infect Dis","first-page":"1117","article-title":"First European haplotype of Echinococcus multilocularis identified in the United States: An emerging disease?","volume":"72","author":"Polish","year":"2021"},{"key":"b8","series-title":"J Am Vet Med Assoc","first-page":"1041","article-title":"Intestinal echinococcosis in a dog from Missouri","volume":"256","author":"Kuroki","year":"2020"},{"key":"b9","series-title":"Am J Trop Med Hyg","first-page":"245","article-title":"Genetic analysis of Echinococcus multilocularis originating from a patient with alveolar echinococcosis occurring in Minnesota in 1977","volume":"79","author":"Yamasaki","year":"2008"},{"key":"b10","series-title":"Food Waterborne Parasitol","first-page":"39","article-title":"Echinococcus across the north: Current knowledge, future challenges","volume":"4","author":"Davidson","year":"2016"},{"key":"b11","series-title":"Am J Trop Med Hyg","first-page":"1863","article-title":"Epidemiological and clinical characteristics of alveolar echinococcosis: An emerging infectious disease in Alberta, Canada","volume":"104","author":"Houston","year":"2021"},{"key":"b12","series-title":"J Infect Dis","first-page":"1015","article-title":"Molecular evidence for local acquisition of human alveolar echinococcosis in Saskatchewan, Canada","volume":"223","author":"Schurer","year":"2021"},{"key":"b13","series-title":"Proc Biol Sci","first-page":"20230128","article-title":"It\u2019s a small world for parasites: Evidence supporting the North American invasion of European Echinococcus multilocularis.","volume":"290","author":"Santa","year":"2023"},{"key":"b14","series-title":"Int J Infect Dis","first-page":"125","article-title":"Echinococcosis: A review","volume":"13","author":"Moro","year":"2009"},{"key":"b15","series-title":"Pediatr Infect Dis J","first-page":"e295","article-title":"An 8-year-old California girl with asymptomatic hepatic cysts","volume":"41","author":"Passarelli","year":"2022"},{"key":"b16","series-title":"Emerg Infect Dis","first-page":"1057","article-title":"Cystic echinococcosis in Northern New Hampshire, USA","volume":"29","author":"AlSalman","year":"2023"},{"key":"b17","series-title":"Int J Circumpolar Health","first-page":"72","article-title":"Zoonotic infections in Alaska: Disease prevalence, potential impact of climate change and recommended actions for earlier disease detection, research, prevention and control","volume":"2013","author":"Hueffer","year":"2013"},{"key":"b18","series-title":"Current Topics in Echinococcosis","author":"Flisser","year":"2015"},{"key":"b19","series-title":"IDCases","first-page":"e00632","article-title":"Echinococcus granulosus hydatid cyst in rural Manitoba, Canada: Case report and review of the literature","volume":"18","author":"Grocholski","year":"2019"},{"key":"b20","article-title":"WHO\/OIE Manual on Echinococcosis in Humans and Animals.","year":"2001"},{"key":"b21","series-title":"Acta Trop","first-page":"1","article-title":"Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans","volume":"114","author":"Brunetti","year":"2010"},{"key":"b22","series-title":"Emerg Infect Dis","first-page":"230","article-title":"Echinococcus spp. tapeworms in North America","volume":"24","author":"Cerda","year":"2018"},{"key":"b23","series-title":"PLoS Negl Trop Dis","first-page":"e1524","article-title":"Human echinococcosis mortality in the United States, 1990\u20132007","volume":"6","author":"Bristow","year":"2012"},{"key":"b24","series-title":"Clin Microbiol Rev","first-page":"e00075-18","article-title":"Echinococcosis: Advances in the 21st century","volume":"32","author":"Wen","year":"2019"},{"key":"b25","series-title":"Ther Adv Infect Dis","first-page":"20499361231171478","article-title":"Liver cystic echinococcosis: A parasitic review","volume":"10","author":"Govindasamy","year":"2023"},{"key":"b26","series-title":"Acta Parasitol","first-page":"161","article-title":"Echinococcus granulosus sensu lato genotypes in different hosts worldwide: A systematic review","volume":"67","author":"Manterola","year":"2022"},{"key":"b27","series-title":"The Causes and Impacts of Neglected Tropical and Zoonotic Diseases: Opportunities for Integrated Intervention Strategies","author":"Hotez","year":"2011"},{"key":"b28","series-title":"Parasit Vectors","first-page":"128","article-title":"Cystic echinococcosis in cattle and sheep caused by Echinococcus granulosus sensu stricto genotypes G1 and G3 in the USA","volume":"17","author":"Jesudoss Chelladurai","year":"2024"},{"key":"b29","series-title":"EcoHealth","first-page":"169","article-title":"Exploring risk for echinococcosis spillover in northern Minnesota tribal communities","volume":"18","author":"Bernstein","year":"2021"},{"key":"b30","series-title":"GMS Infect Dis","first-page":"Doc01","article-title":"Comprehensive diagnosis and treatment of alveolar echinococcosis: A single-center, long-term observational study of 312 patients in Germany","volume":"5","author":"Gr\u00fcner","year":"2017"},{"key":"b31","series-title":"N Engl J Med","first-page":"384","article-title":"European Echinococcus multilocularis identified in patients in Canada","volume":"381","author":"Massolo","year":"2019"},{"key":"b32","series-title":"N Engl J Med","first-page":"1902","article-title":"European haplotype of Echinococcus multilocularis in the United States","volume":"387","author":"Polish","year":"2022"},{"key":"b33","series-title":"J Parasitol","first-page":"357","article-title":"Novel report of the European variant of Echinococcus multilocularis in coyotes (Canis latrans) in New York state","volume":"109","author":"Conlon","year":"2023"},{"key":"b34","series-title":"J Vet Diagn Invest","first-page":"742","article-title":"Alveolar echinococcosis in a dog in the eastern United States","volume":"32","author":"Zajac","year":"2020"},{"key":"b35","year":"2019"},{"key":"b36","series-title":"PLoS Negl Trop Dis","first-page":"e0008382","article-title":"Source attribution of human echinococcosis: A systematic review and meta-analysis","volume":"14","author":"Torgerson","year":"2020"},{"key":"b37","series-title":"Am J Trop Med Hyg","first-page":"375","article-title":"Watch and wait approach for inactive echinococcal cyst of the liver: An update","volume":"99","author":"Lissandrin","year":"2018"},{"key":"b38","series-title":"Adv Parasitol","first-page":"259","article-title":"The echinococcoses: Diagnosis, clinical management and burden of disease","volume":"96","author":"Kern","year":"2017"},{"key":"b39","series-title":"PLoS Negl Trop Dis","first-page":"e0004154","article-title":"Surveillance of human echinococcosis in Castilla-Leon (Spain) between 2000\u20132012","volume":"9","author":"Lopez-Bernus","year":"2015"},{"key":"b40","series-title":"Front Neurol","first-page":"537565","article-title":"Clinical features, radiological characteristics, and outcomes of patients with intracranial alveolar echinococcosis: A case series from Tibetan areas of Sichuan Province, China","volume":"11","author":"Li","year":"2020"},{"key":"b41","series-title":"Indian J Surg","first-page":"771","article-title":"Postoperative complications and recurrence of abdominal echinococcosis rupture: Case series with follow-up","volume":"85","author":"Manterola","year":"2023"},{"key":"b42","series-title":"Int J Morphol","first-page":"386","article-title":"Extra-visceral retroperitoneal echinococcosis. Case series with follow-up","volume":"39","author":"Manterola","year":"2021"},{"key":"b43","series-title":"Am J Trop Med Hyg","first-page":"628","article-title":"Complications associated with initial clinical presentation of cystic echinococcosis: A 20-year cohort analysis","volume":"101","author":"Collado-Aliaga","year":"2019"},{"key":"b44","series-title":"Ann Saudi Med","first-page":"46","article-title":"Documentation and coding of medical records in a tertiary care center: A pilot study","volume":"25","author":"Farhan","year":"2005"},{"key":"b45","series-title":"Health Inf Manag","first-page":"28","article-title":"Health records as the basis of clinical coding: Is the quality adequate? A qualitative study of medical coders\u2019 perceptions","volume":"49","author":"Alonso","year":"2020"},{"key":"b46","article-title":"Ending the Neglect to Attain the Sustainable Development Goals: A Framework for Monitoring and Evaluating Progress of the Road Map for Neglected Tropical Diseases 2021\u20132030.","year":"2020"},{"key":"b1","series-title":"BMJ","first-page":"e3866","article-title":"Diagnosis, treatment, and management of echinococcosis","volume":"344","author":"McManus","year":"2012"},{"key":"b2","article-title":"Fact Sheets: Echinococcosis.","year":"2021"},{"key":"b3","series-title":"Parasite","first-page":"73","article-title":"Echinococcus multilocularis in North America: The great unknown","volume":"21","author":"Massolo","year":"2014"},{"key":"b4","series-title":"J Wildl Dis","first-page":"332","article-title":"Echinococcus species infections among wild canids in Pennsylvania, USA","volume":"59","author":"Garrett","year":"2023"},{"key":"b5","series-title":"J Vet Diagn Invest","first-page":"746","article-title":"Alveolar echinococcosis in a dog in Missouri, USA","volume":"34","author":"Kuroki","year":"2022"},{"key":"b6","series-title":"PLoS Negl Trop Dis","first-page":"e0006712","article-title":"Echinococcus in wild canids in Qu\u00e9bec (Canada) and Maine (USA)","volume":"12","author":"Schurer","year":"2018"},{"key":"b7","series-title":"Clin Infect Dis","first-page":"1117","article-title":"First European haplotype of Echinococcus multilocularis identified in the United States: An emerging disease?","volume":"72","author":"Polish","year":"2021"},{"key":"b8","series-title":"J Am Vet Med Assoc","first-page":"1041","article-title":"Intestinal echinococcosis in a dog from Missouri","volume":"256","author":"Kuroki","year":"2020"},{"key":"b9","series-title":"Am J Trop Med Hyg","first-page":"245","article-title":"Genetic analysis of Echinococcus multilocularis originating from a patient with alveolar echinococcosis occurring in Minnesota in 1977","volume":"79","author":"Yamasaki","year":"2008"},{"key":"b10","series-title":"Food Waterborne Parasitol","first-page":"39","article-title":"Echinococcus across the north: Current knowledge, future challenges","volume":"4","author":"Davidson","year":"2016"},{"key":"b11","series-title":"Am J Trop Med Hyg","first-page":"1863","article-title":"Epidemiological and clinical characteristics of alveolar echinococcosis: An emerging infectious disease in Alberta, Canada","volume":"104","author":"Houston","year":"2021"},{"key":"b12","series-title":"J Infect Dis","first-page":"1015","article-title":"Molecular evidence for local acquisition of human alveolar echinococcosis in Saskatchewan, Canada","volume":"223","author":"Schurer","year":"2021"},{"key":"b13","series-title":"Proc Biol Sci","first-page":"20230128","article-title":"It\u2019s a small world for parasites: Evidence supporting the North American invasion of European Echinococcus multilocularis.","volume":"290","author":"Santa","year":"2023"},{"key":"b14","series-title":"Int J Infect Dis","first-page":"125","article-title":"Echinococcosis: A review","volume":"13","author":"Moro","year":"2009"},{"key":"b15","series-title":"Pediatr Infect Dis J","first-page":"e295","article-title":"An 8-year-old California girl with asymptomatic hepatic cysts","volume":"41","author":"Passarelli","year":"2022"},{"key":"b16","series-title":"Emerg Infect Dis","first-page":"1057","article-title":"Cystic echinococcosis in Northern New Hampshire, USA","volume":"29","author":"AlSalman","year":"2023"},{"key":"b17","series-title":"Int J Circumpolar Health","first-page":"72","article-title":"Zoonotic infections in Alaska: Disease prevalence, potential impact of climate change and recommended actions for earlier disease detection, research, prevention and control","volume":"2013","author":"Hueffer","year":"2013"},{"key":"b18","series-title":"Current Topics in Echinococcosis","author":"Flisser","year":"2015"},{"key":"b19","series-title":"IDCases","first-page":"e00632","article-title":"Echinococcus granulosus hydatid cyst in rural Manitoba, Canada: Case report and review of the literature","volume":"18","author":"Grocholski","year":"2019"},{"key":"b20","article-title":"WHO\/OIE Manual on Echinococcosis in Humans and Animals.","year":"2001"},{"key":"b21","series-title":"Acta Trop","first-page":"1","article-title":"Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans","volume":"114","author":"Brunetti","year":"2010"},{"key":"b22","series-title":"Emerg Infect Dis","first-page":"230","article-title":"Echinococcus spp. tapeworms in North America","volume":"24","author":"Cerda","year":"2018"},{"key":"b23","series-title":"PLoS Negl Trop Dis","first-page":"e1524","article-title":"Human echinococcosis mortality in the United States, 1990\u20132007","volume":"6","author":"Bristow","year":"2012"},{"key":"b24","series-title":"Clin Microbiol Rev","first-page":"e00075-18","article-title":"Echinococcosis: Advances in the 21st century","volume":"32","author":"Wen","year":"2019"},{"key":"b25","series-title":"Ther Adv Infect Dis","first-page":"20499361231171478","article-title":"Liver cystic echinococcosis: A parasitic review","volume":"10","author":"Govindasamy","year":"2023"},{"key":"b26","series-title":"Acta Parasitol","first-page":"161","article-title":"Echinococcus granulosus sensu lato genotypes in different hosts worldwide: A systematic review","volume":"67","author":"Manterola","year":"2022"},{"key":"b27","series-title":"The Causes and Impacts of Neglected Tropical and Zoonotic Diseases: Opportunities for Integrated Intervention Strategies","author":"Hotez","year":"2011"},{"key":"b28","series-title":"Parasit Vectors","first-page":"128","article-title":"Cystic echinococcosis in cattle and sheep caused by Echinococcus granulosus sensu stricto genotypes G1 and G3 in the USA","volume":"17","author":"Jesudoss Chelladurai","year":"2024"},{"key":"b29","series-title":"EcoHealth","first-page":"169","article-title":"Exploring risk for echinococcosis spillover in northern Minnesota tribal communities","volume":"18","author":"Bernstein","year":"2021"},{"key":"b30","series-title":"GMS Infect Dis","first-page":"Doc01","article-title":"Comprehensive diagnosis and treatment of alveolar echinococcosis: A single-center, long-term observational study of 312 patients in Germany","volume":"5","author":"Gr\u00fcner","year":"2017"},{"key":"b31","series-title":"N Engl J Med","first-page":"384","article-title":"European Echinococcus multilocularis identified in patients in Canada","volume":"381","author":"Massolo","year":"2019"},{"key":"b32","series-title":"N Engl J Med","first-page":"1902","article-title":"European haplotype of Echinococcus multilocularis in the United States","volume":"387","author":"Polish","year":"2022"},{"key":"b33","series-title":"J Parasitol","first-page":"357","article-title":"Novel report of the European variant of Echinococcus multilocularis in coyotes (Canis latrans) in New York state","volume":"109","author":"Conlon","year":"2023"},{"key":"b34","series-title":"J Vet Diagn Invest","first-page":"742","article-title":"Alveolar echinococcosis in a dog in the eastern United States","volume":"32","author":"Zajac","year":"2020"},{"key":"b35","year":"2019"},{"key":"b36","series-title":"PLoS Negl Trop Dis","first-page":"e0008382","article-title":"Source attribution of human echinococcosis: A systematic review and meta-analysis","volume":"14","author":"Torgerson","year":"2020"},{"key":"b37","series-title":"Am J Trop Med Hyg","first-page":"375","article-title":"Watch and wait approach for inactive echinococcal cyst of the liver: An update","volume":"99","author":"Lissandrin","year":"2018"},{"key":"b38","series-title":"Adv Parasitol","first-page":"259","article-title":"The echinococcoses: Diagnosis, clinical management and burden of disease","volume":"96","author":"Kern","year":"2017"},{"key":"b39","series-title":"PLoS Negl Trop Dis","first-page":"e0004154","article-title":"Surveillance of human echinococcosis in Castilla-Leon (Spain) between 2000\u20132012","volume":"9","author":"Lopez-Bernus","year":"2015"},{"key":"b40","series-title":"Front Neurol","first-page":"537565","article-title":"Clinical features, radiological characteristics, and outcomes of patients with intracranial alveolar echinococcosis: A case series from Tibetan areas of Sichuan Province, China","volume":"11","author":"Li","year":"2020"},{"key":"b41","series-title":"Indian J Surg","first-page":"771","article-title":"Postoperative complications and recurrence of abdominal echinococcosis rupture: Case series with follow-up","volume":"85","author":"Manterola","year":"2023"},{"key":"b42","series-title":"Int J Morphol","first-page":"386","article-title":"Extra-visceral retroperitoneal echinococcosis. Case series with follow-up","volume":"39","author":"Manterola","year":"2021"},{"key":"b43","series-title":"Am J Trop Med Hyg","first-page":"628","article-title":"Complications associated with initial clinical presentation of cystic echinococcosis: A 20-year cohort analysis","volume":"101","author":"Collado-Aliaga","year":"2019"},{"key":"b44","series-title":"Ann Saudi Med","first-page":"46","article-title":"Documentation and coding of medical records in a tertiary care center: A pilot study","volume":"25","author":"Farhan","year":"2005"},{"key":"b45","series-title":"Health Inf Manag","first-page":"28","article-title":"Health records as the basis of clinical coding: Is the quality adequate? A qualitative study of medical coders\u2019 perceptions","volume":"49","author":"Alonso","year":"2020"},{"key":"b46","article-title":"Ending the Neglect to Attain the Sustainable Development Goals: A Framework for Monitoring and Evaluating Progress of the Road Map for Neglected Tropical Diseases 2021\u20132030.","year":"2020"}],"container-title":["The American Journal of Tropical Medicine and Hygiene"],"original-title":[],"link":[{"URL":"https:\/\/www.ajtmh.org\/view\/journals\/tpmd\/114\/4\/article-p662.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.ajtmh.org\/downloadpdf\/journals\/tpmd\/114\/4\/article-p662.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/www.ajtmh.org\/downloadpdf\/journals\/tpmd\/114\/4\/article-p662.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,1]],"date-time":"2026-04-01T19:21:43Z","timestamp":1775071303000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ajtmh.org\/view\/journals\/tpmd\/114\/4\/article-p662.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,1]]},"references-count":92,"journal-issue":{"issue":"4"},"URL":"https:\/\/doi.org\/10.4269\/ajtmh.25-0453","relation":{},"ISSN":["0002-9637","1476-1645"],"issn-type":[{"value":"0002-9637","type":"print"},{"value":"1476-1645","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,1]]}}}