In the absence of another more likely etiology, a person with any of the following clinical manifestations, often accompanied by fever:
Regional lymphadenopathy in absence of cutaneous ulcer (glandular tularemia), OR
Regional lymphadenopathy with cutaneous ulcer (ulceroglandular tularemia), OR
Conjunctivitis AND lymphadenopathy in the head or neck (oculoglandular tularemia), OR
Cervical lymphadenopathy AND pharyngitis, tonsilitis, or stomatitis (oropharyngeal tularemia), OR
Pneumonic: primary pleuropulmonary disease
Pulmonary disease such as pleural effusion, hilar adenopathy, pulmonary nodule, or pneumonia (pneumonic tularemia), OR
Acute illness lacking localized signs and symptoms, characterized by fever (subjective or objective) AND one or more non-specific symptoms such as headache, myalgia, fatigue/malaise, or gastrointestinal illness (typhoidal tularemia), OR
Other rare clinical manifestation(s) known to be associated with tularemia such as meningitis, septic arthritis, or endocarditis
Laboratory Criteria
Confirmatory Laboratory Evidence:
Culture and identification of F. tularensis confirmed by a Laboratory Response Network (LRN) laboratory, OR
Fourfold or greater change in serum antibody titer between acute and convalescent specimens 2, OR
Change from a negative IgG AND a negative IgM serologic test result to F. tularensis antigen on an acute specimen to either a positive IgG, a positive IgM, or both on a convalescent specimen 2, 3, 4
Presumptive Laboratory Evidence:
Detection of F. tularensis DNA directly from a clinical or autopsy specimen by molecular testing (e.g., PCR or sequencing assay), OR
Demonstration of F. tularensis antigen in tissue (e.g., by immunohistochemical staining)
Supportive Laboratory Evidence:
Positive IgG and/or IgM serologic test detecting antibodies to F. tularensis antigen (without documented fourfold or greater change or without prior negative result) in a patient with no history of tularemia vaccination3
**Note: The categorical labels used here to stratify laboratory evidence are intended to support the standardization of case classifications for public health surveillance. The categorical labels should not be used to interpret the utility or validity of any laboratory test methodology.
Epidemiologic Linkage Criteria
Within 21 days of illness onset or, when clinical information is not available, within 21 days of specimen collection:
Tier 1
Known contact (including potential aerosol exposure) with an animal with direct laboratory detection or isolation of F. tularensis OR
Known handling of an F. tularensis isolate in a laboratory setting
Tier 2
History of a known or suspected tick or deerfly bite, OR
Contact with an animal suspected to have tularemia (e.g., hunting or veterinary care), OR
Activities with potential for aerosol-generating exposure (e.g., landscaping, mowing, or high-pressure spraying), OR
Consumption of material potentially contaminated with F. tularensis, OR
Shared exposure with another confirmed or probable tularemia case (i.e., part of a cluster), OR
Other activities in occupational or recreational settings that could be linked to F. tularensis exposure
Vital Records Criteria
A person whose death certificate lists tularemia as a cause of death or a significant condition contributing to death.
Case Classification
Confirmed:
Meets confirmatory laboratory evidence AND meets clinical criteria, OR
Meets confirmatory laboratory evidence AND meets Tier 1 or Tier 2 epidemiologic linkage criteria.
Probable:
Meets presumptive laboratory evidence AND meets the clinical criteria, OR
Meets presumptive laboratory evidence AND meets Tier 1 or Tier 2 epidemiologic linkage criteria, OR
Meets supportive laboratory evidence AND meets clinical criteria AND meets Tier 2 epidemiologic linkage criteria, OR
Meets supportive laboratory evidence AND meets Tier 1 epidemiologic linkage criteria, OR
Meets clinical criteria AND meets Tier 1 epidemiologic linkage criteria.
Suspect:
Meets confirmatory laboratory evidence OR presumptive laboratory evidence OR supportive laboratory evidence, OR
Meets clinical criteria AND meets Tier 2 epidemiologic linkage evidence, OR
Meets vital records criteria.
Criteria to Distinguish a New Case of Tularemia from Reports or Notifications which Should Not be Enumerated as a New Case for Surveillance
A person with a previously reported confirmed or probable case of tularemia may be enumerated as a new case when there is evidence of new clinically
compatible acute illness after completing treatment for previous infection AND new laboratory evidence. As duration of antibodies to F. tularensis is not known,
a person with persistently positive serologic tests in absence of new clinical or epidemiologic linkage criteria should not be enumerated as a new case.
Note: To see the Classification Table: Criteria for defining a case of tularemia, go to the following link below and go to pages 12 - 14.