Transactions of the Royal Society of Tropical Medicine and Hygiene (2008) 102/S1, S1 S4 available at www.sciencedirect.com
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The global distribution of Burkholderia pseudomallei and melioidosis: an update Bart J. Curriea,b, *, David A.B. Dancec , Allen C. Chenga a
Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia Northern Territory Clinical School, Flinders University, Darwin, Northern Territory, Australia c Health Protection Agency, Plymouth, UK b
KEYWORDS Melioidosis Burkholderia pseudomallei Global distribution Epidemiology Ecology Disease outbreak
Summary While Southeast Asia and northern Australia are well recognized as the major endemic regions for melioidosis, recent reports have expanded the endemic zone. Severe weather events and environmental disasters such as the 2004 Asian tsunami have unmasked locations of sporadic cases and have reconfirmed endemicity in Indonesia. The endemic region now includes the majority of the Indian subcontinent, southern China, Hong Kong and Taiwan. Sporadic cases have occurred in Brazil and elsewhere in the Americas and in island communities such as New Caledonia, in the Pacific Ocean, and Mauritius in the Indian Ocean. Some of the factors that are critical to further elucidating the global distribution of Burkholderia pseudomallei and melioidosis include improved access to diagnostic laboratory facilities and formal confirmation of the identity of bacterial isolates from suspected cases. © 2008 Published by Elsevier Ltd on behalf of Royal Society of Tropical Medicine and Hygiene.
1. Global distribution of Burkholderia pseudomallei 1.1. The endemic regions of Asia and Australasia The data supporting the known global distribution of Burkholderia pseudomallei and melioidosis were comprehensively summarized in 1991 1 and updated in 2005. 2 Recent reports enable a further revision and reconfirm known foci from the early melioidosis literature of the 1900s (Figure 1). It is well recognized that Southeast Asia and northern Australia are the main endemic foci for melioidosis. Following the 2004 Asian tsunami there were increasing numbers of melioidosis cases in the region, 3 6 including a cluster of cases from Aceh, Indonesia. 7 Although Indonesia had been recognized as endemic for melioidosis in the early 20th century, 8 cases of melioidosis had not been reported from within Indonesia for some decades until this cluster. This may reflect a combination of a low, and possibly geographically restricted, presence of B. pseudomallei, and a lack of recognition relating to limited laboratory facilities in those locations harbouring B. pseudomallei. * Corresponding author. Tel.: +61 8 8922 8056; fax: +61 8 8927 5187. E-mail address:
[email protected] (B.J. Currie). 0035-9203/ $
Recent studies from southern India also reinforce evidence of the presence of melioidosis on the Indian subcontinent. 9,10 A tsunami-associated case in a patient returning from Sri Lanka echoes earlier occasional cases from that country. 11,12 Recent serology studies have supported the presence of melioidosis in Myanmar, 13 from where the original case of melioidosis arose in 1911. 14 However, indigenous cases have not been reported in the region since 1945. 15 Surveillance data have only recently documented the incidence of confirmed melioidosis in Laos, a country which is adjacent to the highly endemic Issan region of Thailand. 16,17 A serology study has also supported the likely occurrence of melioidosis in Timor Leste, 18 although no confirmed cases have been reported from that country. There have been increasing reports of melioidosis from Taiwan, 19 with associations found with severe weather events such as typhoons, 20 mirroring similar weatherrelated case-clusters in Australia. 21,22 In addition, a newly recognized focus of melioidosis has been studied in the Western Province of Papua New Guinea, with most cases being in children. 23,24 Several cases have now also been confirmed from the Pacific nation of New Caledonia. 25 In summary, it seems reasonable to assume that the endemic regions for melioidosis include northern Australia, Papua New Guinea, Southeast Asia, most of the Indian
see front matter © 2008 Published by Elsevier Ltd on behalf of Royal Society of Tropical Medicine and Hygiene.
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Fig. 1. Global map showing the categories of distribution of melioidosis and Burkholderia pseudomallei. Pink asterisks indicate three documented temperate outbreaks of melioidosis: France; southeast Queensland, Australia; and southwest Western Australia.
subcontinent and southern China, Hong Kong and Taiwan. Northeast Thailand, northern Australia, Singapore and parts of Malaysia are currently recognized as ‘highly endemic’ locations where many cases are diagnosed each year (Figure 2). With the introduction of better diagnostic facilities, other locations within the endemic region may well be found to have substantial burdens of morbidity and mortality from melioidosis.
1.2. The Americas In addition to cases in the USA in servicemen returned from Southeast Asia, melioidosis has been recognized for some decades to occur sporadically in the Caribbean, Central and South America 1,2 (Figure 1). A cluster of melioidosis cases has now been reported from the Ceara province in northeast Brazil, 26 and a case reported from
Fig. 2 Melioidosis in northern Australia, Southeast Asia and Asia, highlighting the highly endemic locations. Pink asterisks indicate two documented temperate outbreaks of melioidosis in Australia: southeast Queensland and southwest Western Australia.
The global distribution of Burkholderia pseudomallei and melioidosis: an update The Netherlands in a traveller was probably also acquired in that same province. 27 Two cases reported in the USA were thought to have been acquired in Honduras 28 and severe melioidosis sepsis in a diabetic individual in Puerto Rico was attributed to flooding during the rainy season. 29 The controversy over the 1973 ‘Oklahoma isolate’ from the USA has been resolved, 30 with that isolate being confirmed as a new species, named B. oklahomensis and not B. pseudomallei. 31 Inglis et al. have recently summarized the data on melioidosis in the Americas (see their Figure 1). 32 1.3. Africa Sporadic cases of melioidosis have also been reported from West and East Africa 1,2 (Figure 1). However, the true extent and magnitude of the presence of B. pseudomallei in Africa remains entirely unknown. Two cases have recently been reported to have been acquired in Madagascar, 33 and the first case has been reported from Mauritius. 34
2. Conclusions It is evident that often the recognition that a location harbours B. pseudomallei is the diagnosis of imported melioidosis in a person travelling from that location to a country with well-resourced diagnostic facilities. 27,28,33 This highlights the likelihood that other foci of melioidosis are yet to be recognised. Filling in the map of the full global distribution of B. pseudomallei is not possible without substantially increased surveillance and improved access to diagnostic laboratory facilities. Authors’ contributions: BJC, DABD and ACC contributed to the data collection and analysis; BJC drafted the initial paper and all authors contributed to the final manuscript discussion; ACC produced the Figures. All authors read and approved the final manuscript. BJC is guarantor of the paper. Funding: This work was supported by a Project Grant from the Australian National Health and Medical Research Council. AC is also supported by a NHMRC Training Fellowship. Conflicts of interest: None declared. Ethics approval: Permission for epidemiological studies of melioidosis was obtained from the Human Research Ethics Committee of the Menzies School of Health Research and the Northern Territory Department of Health and Community Services, Australia.
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