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    Map of water plants and cases in Yap, Federated States of Micronesia.

  • 1.

    Wiersinga WJ, Currie BJ, Peacock SJ, 2012. Melioidosis. N Engl J Med 367: 10351044.

  • 2.

    Cheng AC, Currie BJ, 2005. Melioidosis: epidemiology, pathophysiology, and management. Clin Microbiol Rev 18: 383416.

  • 3.

    Currie BJ, Ward L, Cheng AC, 2010. The epidemiology and clinical spectrum of melioidosis: 540 cases from the 20 year Darwin prospective study. PLoS Negl Trop Dis 4: e900.

    • Search Google Scholar
    • Export Citation
  • 4.

    Chantratita N et al. 2007. Biological relevance of colony morphology and phenotypic switching by Burkholderia pseudomallei. J Bacteriol 189: 807817.

    • Search Google Scholar
    • Export Citation
  • 5.

    Limmathurotsakul D et al. 2016. Predicted global distribution of Burkholderia pseudomallei and burden of melioidosis. Nat Microbiol 1: 15008.

  • 6.

    Doker TJ et al. 2015. Contact investigation of melioidosis cases reveals regional endemicity in Puerto Rico. Clin Infect Dis 60: 243250.

  • 7.

    Lanciotti RS, Kosoy OL, Laven JJ, Velez JO, Lambert AJ, Johnson AJ, Stanfield SM, Duffy MR, 2008. Genetic and serologic properties of Zika virus associated with an epidemic, Yap State, Micronesia, 2007. Emerg Infect Dis 14: 12321239.

    • Search Google Scholar
    • Export Citation
  • 8.

    Alexander AD, Huxsoll DL, Warner AR Jr., Shepler V, Dorsey A, 1970. Serological diagnosis of human melioidosis with indirect hemagglutination and complement fixation tests. Appl Microbiol 20: 825833.

    • Search Google Scholar
    • Export Citation
  • 9.

    Limmathurotsakul D et al. 2013. Systematic review and consensus guidelines for environmental sampling of Burkholderia pseudomallei. PLoS Negl Trop Dis 7: e2105.

    • Search Google Scholar
    • Export Citation
  • 10.

    Smith CM, Hill VR, 2009. Dead-end hollow-fiber ultrafiltration for recovery of diverse microbes from water. Appl Environ Microbiol 75: 52845289.

    • Search Google Scholar
    • Export Citation
  • 11.

    Mull B, Hill VR, 2012. Recovery of diverse microbes in high turbidity surface water samples using dead-end ultrafiltration. J Microbiol Methods 91: 429433.

    • Search Google Scholar
    • Export Citation
  • 12.

    Godoy D, Randle G, Simpson AJ, Aanensen DM, Pitt TL, Kinoshita R, Spratt BG, 2003. Multilocus sequence typing and evolutionary relationships among the causative agents of melioidosis and glanders, Burkholderia pseudomallei and Burkholderia mallei. J Clin Microbiol 41: 20682079.

    • Search Google Scholar
    • Export Citation
  • 13.

    Brook MD, Currie B, Desmarchelier PM, 1997. Isolation and identification of Burkholderia pseudomallei from soil using selective culture techniques and the polymerase chain reaction. J Appl Microbiol 82: 589596.

    • Search Google Scholar
    • Export Citation
  • 14.

    Inglis TJ, Rolim DB, Rodriguez JL, 2006. Clinical guideline for diagnosis and management of melioidosis. Rev Inst Med Trop Sao Paulo 48: 14.

  • 15.

    United States Department of Agriculture Soil Conservation Service, 1983. Soil survey of Islands of Yap, Federated States of Micronesia. Available at: https://www.nrcs.usda.gov/Internet/FSE_MANUSCRIPTS/pacific_basin/PB934/0/yap.pdf. Accessed February 2014.

    • Search Google Scholar
    • Export Citation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

 

 

Differentiating New from Newly Detected: Melioidosis in Yap, Federated States of Micronesia

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  • 1 Bacterial Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;
  • | 2 Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georgia;
  • | 3 Yap Memorial Hospital, FSM Department of Health and Social Affairs, Yap, Federated States of Micronesia;
  • | 4 Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia

Melioidosis is a bacterial infection caused by exposure to water or soil that contains Burkholderia pseudomallei (Bp). Burkholderia pseudomallei is endemic to many tropical and subtropical areas of the world. In 2013, the first case of melioidosis was recognized in Yap, the Federated States of Micronesia. Six additional cases were identified in the subsequent 3 years. An investigation was initiated to understand the epidemiology of melioidosis in Yap. Serum from family and community members of the identified cases were tested for antibodies to Bp. Archived serum from a 2007 Zika serosurvey were also tested for antibodies to Bp. Sequencing of bacterial isolates was performed to understand bacterial phylogeny. Soil and water were tested for the presence of Bp in the environment by culture and PCR. None of the affected patients had a history of travel to melioidosis-endemic countries. Two of the 34 (5.8%) samples from the field investigation and 67 (11.7%) of the historical samples demonstrated serologic evidence of prior Bp exposure. No Bp were detected from 30 soil or water samples. Genotype analysis showed highly related Bp isolates that were unique to Yap. Melioidosis is likely to be endemic to Yap; however, it has only recently been recognized by the clinical community in country. Further investigation is needed to understand the local sites that harbor Bp and represent the highest risk to the community.

INTRODUCTION

Melioidosis is an infectious disease caused by Burkholderia pseudomallei (Bp), a Gram-negative bacillus. Infection usually occurs through ingestion, inhalation of aerosolized bacteria, or direct cutaneous inoculation with contaminated soil or water. The most common clinical presentation is acute pneumonia, but can range from cutaneous abscesses to septicemia.1,2 Up to 80% of patients who become ill with melioidosis have preexisting risk factors, including diabetes, excessive alcohol use, and chronic lung disease.3 Unfortunately, misidentification of melioidosis cases occurs because symptoms are nonspecific. In addition, the bacteria can show varying morphologies when grown in culture,4 which can be easily misidentified by laboratory personnel.

Melioidosis is endemic in Southeast Asia and northern Australia, but cases also occur in other tropical and subtropical areas of the world. The true magnitude of the distribution of the bacteria remains unknown, and it has been estimated that it is underreported in the 45 countries in which it is known to be endemic.5 Although a formal definition of endemicity has not been agreed on, identification of the bacteria in the environment coupled with presumably local acquisition of disease (i.e., no history of travel to an endemic location) has been suggested.6 Using this definition, an additional 34 countries are thought to be endemic for melioidosis.5

There were no documented cases of melioidosis in the literature before 2013 from the island state of Yap, in the Federated States of Micronesia (FSM). Melioidosis cases are most frequently seen in countries that lie between 20°N and 20°S of the equator1; Yap lies within these latitudes. In many ways, Yap has the characteristics of a location where Bp is endemic, including its latitude, soil composition, and climate.5

Between July 2013 and July 2016, a total of seven cases of melioidosis were documented in Yap. These were the first cases of melioidosis identified in FSM and all were fatal, raising concern among the health officials, the government, and the general populace. Public health officials on Yap contacted the Bacterial Special Pathogens Branch (BSPB) at the Centers for Disease Control and Prevention (CDC) to request assistance with the investigation of these fatal cases. Two onsite investigations took place; the first in February 2014 after the initial identification of three cases and the second in August 2016 after an additional four cases occurred. During the response, case information and samples were collected to evaluate the presence of Bp in Yap. In addition, serum samples collected in 2007 as part of an island-wide serosurvey during a Zika outbreak were tested to evaluate historical exposure to Bp. This report describes the cases, the two onsite epidemiologic investigations, and the response to the newly identified cases of melioidosis in Yap.

METHODS

In February 2014, the epidemiology team performed in-depth interviews with the family and friends of the first three affected individuals, focusing on locations and activities with possible exposure to contaminated soil or water. Blood specimens were collected from family and friends who consented for serologic testing. During the follow-up investigation in August 2016, BSPB conducted detailed clinical records review and exposure evaluation for each of the seven cases.

Historical samples collected during a 2007 Zika outbreak investigation were obtained for Bp serologic testing. The 2007 Zika study collected blood from 200 randomly selected households of the 1,276 on Yap and enrolled all household members 3 years and older.7 The original consent allowed testing stored samples for exposure to other pathogens. All serum samples were tested at the Zoonosis and Select Agent Laboratory at CDC for the presence of antibodies to Bp by indirect hemagglutination assay.8

Soil and water samples were collected at sites where the first three cases had high levels of exposure, and from the public water system.9 Samples from the initial investigation consisted of 100 mL of water and soil from selected locations. During the follow-up investigation in August 2016, 100 L samples of water were ultra-filtrated to concentrate bacteria before shipping.10 Investigators collected water from the three public water systems.

Ten grams of soil was mixed with 10 mL of Galimands broth and incubated at 37°C for 48 hours. The top layer of the enrichment broth was extracted using the Zymo Research Soil Microbe DNA MiniPrep (Tustin, CA) kit as well as plated onto Ashdown agar plates. Water samples were concentrated in the field using dead-end filtration as previously described.11 The filters were then shipped to CDC Atlanta, where samples were recovered by back-flushing filters. The eluant from the filters was plated on Ashdown’s agar, inoculated into Galimand’s broth, and tested directly by the InBios Active Melioidosis Detect™ (InBios AMD, Seattle, WA) lateral flow test (InBios). Enrichment broths from water were treated the same as the soil protocol. Plates were incubated at 37°C for 7 days and examined daily for suspicious colonies. All DNA extractions were tested using real-time PCR.

Rapid clinical testing became available in March 2014 after the InBios AMD rapid test was provided to the hospital by CDC. Samples were tested with this assay and all samples were confirmed by culture. The isolates were genotyped using multiple locus sequence typing based on the sequences of seven housekeeping genes,12 and single nucleotide polymorphisms (SNPs) were determined using draft genome sequences generated with Illumina technology and analyzed with Parsnp (Harvest 1.3).

ArcMap (version 10.2.1, Environmental Systems Research Institute, Inc., Redlands, CA) was used to map the seven case households. R statistical software (version 3.4.2, The R Foundation, Vienna, Austria) was used to randomly shift the GPS coordinates of the households to preserve confidentiality. The GPS locations of households with one or more positive titer (≥ 1:40) for Bp antibodies from the 2007 Zika serum survey and the locations of the water samples obtained during the follow-up investigation in 2016 were also mapped.

RESULTS

Case reports.

The first documented melioidosis case on Yap occurred in July of 2013 in a 40-year-old man with a history of poorly controlled type two diabetes and chronic alcohol and marijuana use. The patient presented with a fever, headache and body pains, tachycardia, hyponatremia, hyperglycemia, and thrombocytopenia (Table 1). His white blood cell count was normal with elevated band neutrophils. The initial diagnosis was septicemia of unknown cause and the patient was started on ceftriaxone. After admission, his health continued to deteriorate, and flagyl, doxycycline, chloramphenicol, and vancomycin were added. On day three of hospitalization, he developed a pustular skin rash that covered his full body. A blood culture drawn the day prior grew what was initially identified as Pseudomonas sp. This identification was questioned when the laboratory staff observed a change in colony morphology after several days in culture. The isolate was transferred to the reference laboratory on Guam and was ultimately identified as Bp. The patient died 14 days after admission from multi-organ failure.

Table 1

Laboratory values at the time of admission for seven cases of melioidosis in Yap, Federated States of Micronesia

Case 1Case 2Case 3Case 4Case 5Case 6Case 7
Temperature,°F103.5104.6101.497.895.597.7104.2
Pulse, bpm1181301328090100150
Blood pressure120/80110/6080/5080/60140/9060/40140/80
Glu, mg/dL29713942202410307
Hb A1C, %14.06.69.913.011.8
K, mg/dL4.04.44.94.14.43.74.0
Na, mg/dL125130122122119131117
Cr, mg/dL1.70.924.72.40.70.981.4
ALT, U/L728
AST, U/L634
Hb, g%18.511.114.11210.011.414
Hct, %50.533.440.524.230.933.639.7
WBC, ×103/µL9.311.31.07.716.638.47.7
Neutrophils, %849178.877899391
Band, % of neutrophils242727
Seg, %71679388
Platelets, ×103/µL681274784260315136
ESR37371251

ALT = alanine transaminase; A1C = hemoglobin; AST = aspartate transaminase; bpm = beats per minute; Cr = creatinine; ESR = erythrocyte sedimentation rate; °F = degrees Fahrenheit; Glu = blood glucose; Hb = hemoglobin; Hct = hemocrit; K = potassium; Na = sodium; Seg = segmented neutrophils; WBC = white blood cell.

Bold values are outside of normal limits for that particular test.

The second and third cases of melioidosis on Yap occurred in January 2014 in two previously healthy brothers aged 14 and 18 years. They presented for care within 3 days of each other, with fever, tachycardia, headache, chills, and bilateral lower back pain. Chest X-ray of the younger brother showed a right lower lobe fluffy infiltrate with possible effusion; chest X-ray of the older brother showed a right lower lobe infiltrate. Both were hyponatremic and thrombocytopenic on admission, and were started on antibiotics. The younger brother died 3 days after admission, whereas the older died on the day of admission, both from respiratory failure. Blood cultures from both patients grew Bp.

The fourth case occurred in September 2014 in a 71-year-old retired diabetic man who presented to the hospital complaining of shortness of breath, generalized weakness, bilateral leg swelling, and bloody stools. He was thrombocytopenic and hyponatremic, with elevated liver function tests and creatinine. He was admitted for a gastrointestinal bleed and new onset congestive heart failure (CHF) and was started on diuretics and antihypertensives. A chest X-ray on the second day of admission showed a right perihilar opacity and enlarged heart as well as a small right upper lobe density and slight pleural effusion consistent with CHF. On day four, the patient developed spiking fevers. A sputum culture was obtained and azithromycin was started. On day eight, the patient began experiencing severe dysphagia and hemoptysis and was started on IV ceftriaxone. On day 11, a repeat chest X-ray showed an increased right apical density and several nonspecific diffuse opacities bilaterally that prompted a diagnosis of hospital-acquired pneumonia. Blood culture was obtained, ceftriaxone was discontinued, and the patient was started on vancomycin, gentamicin, and meropenem. The patient further deteriorated over the next day and pipercillin–tazobactam and albuterol were added; however, in the afternoon the patient went into cardiac arrest and passed away. The blood culture from the eleventh day of admission later grew Bp.

Case five occurred in November 2014 in a 59-year-old diabetic man. He presented to the outpatient department with a complaint of generalized weakness and loss of appetite for 2 weeks. His blood chemistry revealed hyperglycemia and hyponatremia. The patient was given IV fluids for dehydration and, after refusing admission, returned home. Four days later, the patient returned to the outpatient department with new right flank pain. Blood tests revealed an elevated WBC count and worsening hyperglycemia and hyponatremia. The patient was admitted and ceftriaxone administered; he remained afebrile and clinically stable, but continued to complain of lower back pain. On the third day of admission, meropenem was initiated after urine tested positive for Bp by the InBios AMD rapid test. On day four, he became apneic and was pronounced dead. Urine culture later confirmed Bp.

A sixth case was identified in August 2015 in a 54-year-old diabetic man with schizophrenia. He presented with 3 weeks of generalized weakness, dizziness, loss of appetite, and hemoptysis. He was afebrile, tachycardic, and hypotensive, and his WBC count was elevated. Chest examination revealed bilateral crepitation and chest X-ray showed bilateral consolidation and apical infiltrates, with multiple cavitary lesions in the left apex. He was admitted with a diagnosis of severe pneumonia, with a differential that included pulmonary tuberculosis and lung cancer. Ceftriaxone and gentamicin were initiated on admission. On day three, the patient was noted to be agitated and confused and was later found apneic and expired despite resuscitation attempts. The InBios AMD rapid test was positive for Bp from the blood sample collected on the second day of admission. Sputum culture obtained on day two of hospitalization later grew Bp.

The seventh case occurred in June 2016 in a 48-year-old diabetic man. He presented to the outpatient department with weakness and chills; his CBC was unremarkable and he refused admission; so he was given IV fluids and sent home. Six days later, the patient returned, with complaints of fever with chills, tachycardia, severe lower back pain, and shortness of breath. His oxygen saturation was 95% on room air. He was hyponatremic and hyperglycemic. He was admitted and initiated on ceftriaxone. On day two, the patient developed severe shortness of breath and meropenem was started. Chest X-ray showed right middle lobe infiltration. The following day, he was transferred to the intensive care unit where a pustular skin rash was noted over his body. He became progressively unresponsive, requiring intubatation and eventually suffering a fatal cardiac arrest. Blood culture obtained on the day of admission and the InBios AMD rapid blood test were positive for Bp.

Interviews.

Three household members of the first case and 11 household members and 17 close contacts of the second and third cases were interviewed during the first visit using a standardized form. All three cases were reported to have occurred immediately after a period of extended rainfall. All cases had extensive exposure to wet soil, including gardening around their homes and at community centers. Information from these interviews was used to inform the choice of soil sampling locations.

Based on short interviews with family members of the seven cases, all but the first case reported drinking from non-chlorinated community water supply sites. None of the seven cases had ever traveled to a location where Bp is endemic.

Serosurvey.

A total of 34 serum samples were collected during the initial investigation, and 574 samples were tested from the 2007 serum survey. Two (5.9%) samples from the field investigation and 67 (11.7%) of the historical samples demonstrated positive titers (≥ 1:40). Positive cases were distributed throughout the island (Figure 1). The two family members who were found to be exposed based on serology did not report close contact with the case patients, who were living and gardening in different areas.

Figure 1.
Figure 1.

Map of water plants and cases in Yap, Federated States of Micronesia.

Citation: The American Journal of Tropical Medicine and Hygiene 101, 2; 10.4269/ajtmh.19-0253

Environmental survey.

Only one of the three water systems on Yap is chlorinated and this system has two storage tanks. Analysis of the chlorine level in water from one of the central Yap State Public Service Company, Yap, Federated States of Micronesia (YSPSC), tanks demonstrated no residual free chlorine although water from the second tank at the distribution point at the Yap Memorial Hospital and at the most distant distribution point showed levels considered adequate for purification (> 0.2 mg/L). None of the water at the case homes was chlorinated, either because of being on an unchlorinated water system or as a result of receiving water from the YSPSC tank that had no residual free chlorine.

Eight unfiltered 100 mL water samples and twelve concentrated 100 L water samples were collected during the two investigations. These included samples from all three public water systems, the two water-bottling companies on Yap, and a shallow well used for drinking water by case six (Figure 1). An additional three, 100-mL water samples were collected from the home of cases two and three, as well as from their church. A total of 30 soil samples were collected. No Bp was detected by culture or PCR from any of the water or soil samples.

Genotyping.

The genome from the bacteria isolated from case one was used in a core SNP analysis to compare with a panel of Bp isolates from around the world and was found to group with genomes from the Asia Pacific region. Multiple locus sequence typing revealed that all isolates were ST 1,045, which appears unique to Yap. Draft genomes are available at NCBI under BioProject PRJNA528470.

DISCUSSION

This report describes an in-depth investigation into the presence of Bp in Yap that includes patient interviews, serum surveys, environmental sampling, and genotyping. It includes the findings from two on-site investigations and a retrospective analysis of serum collected 6 years before the start of this investigation to test for evidence of prior Bp exposure. The investigation aimed to understand if Bp introduction on the island occurred recently or was long-standing and unrecognized before the first diagnosed case. Our investigation suggested that melioidosis was not newly introduced, but had been an unrecognized pathogen on the island before these documented cases.

To classify melioidosis as endemic, proposed criteria require evidence of locally acquired clinical disease and isolation of the bacteria from the environment. Serologic evidence of infection in the local population adds additional support.6 This investigation has provided information that supports endemicity in Yap, including documented local acquisition of clinical disease and evidence of both current and historical seropositivity; however, Bp was not isolated from the environment. The small volume of water that was tested during the initial visit may have limited our ability to isolate bacteria. Previous work on environmental isolation of Bp has shown that the bacteria can be particularly difficult to isolate from the environment, even in locations where it is known to be highly prevalent.13

Also, influencing our understanding of the epidemiology of Bp in Yap is the role of the laboratory in this investigation. Before the first case of melioidosis in 2013, the laboratory staff in Yap had no experience with this infection. Burkholderia pseudomallei is a bacterium that is frequently misidentified as an environmental contaminant14 and has a variety of colony morphologies which makes identification difficult. After the identification of the first case, the laboratory staff learned how to recognize Bp, and report that they probably misidentified the organism in the past. This new capacity to recognize and diagnose melioidosis likely resulted in the apparent recent spike of melioidosis cases in Yap.

We believe that even without isolation of the bacteria from environmental samples, the evidence presented here suggests melioidosis is endemic to Yap. The historical serum samples would indicate exposure to Bp in the island’s population before the first recognized case. In addition, the geographic location and soil conditions reported by the U.S. Geological Service fit those of a location where Bp may be endemic.15 Finally, none of the cases reported here had a history of travel to another endemic region, and most had never traveled outside of Yap state.

CONCLUSION

In this report, we describe the first identified cases of melioidosis on Yap and the associated investigation. We also provide several pieces of evidence suggesting melioidosis is endemic in Yap, which further indicates that melioidosis is not new to Yap, but instead is a recently recognized infection. We expect that future investigations focusing on environment isolation, if conducted, will confirm endemicity of Bp in Yap. Information regarding the environmental source could potentially provide direction on what public health interventions, if any, authorities could undertake to reduce risk of infection. In addition, continued aggressive investigation of future cases will be critical to better define the epidemiology of the disease.

Until further studies are conducted to better define the risk of melioidosis in Yap, public health messaging has been developed that assumes this disease is endemic. The messaging provides information for the local people regarding how they can protect themselves from infection, and education and support to medical staff so that they can recognize and appropriately treat potential melioidosis cases.

Acknowledgments:

We would like to thank Cyril Lyinnel and Dana Haberling for their support in this project.

REFERENCES

  • 1.

    Wiersinga WJ, Currie BJ, Peacock SJ, 2012. Melioidosis. N Engl J Med 367: 10351044.

  • 2.

    Cheng AC, Currie BJ, 2005. Melioidosis: epidemiology, pathophysiology, and management. Clin Microbiol Rev 18: 383416.

  • 3.

    Currie BJ, Ward L, Cheng AC, 2010. The epidemiology and clinical spectrum of melioidosis: 540 cases from the 20 year Darwin prospective study. PLoS Negl Trop Dis 4: e900.

    • Search Google Scholar
    • Export Citation
  • 4.

    Chantratita N et al. 2007. Biological relevance of colony morphology and phenotypic switching by Burkholderia pseudomallei. J Bacteriol 189: 807817.

    • Search Google Scholar
    • Export Citation
  • 5.

    Limmathurotsakul D et al. 2016. Predicted global distribution of Burkholderia pseudomallei and burden of melioidosis. Nat Microbiol 1: 15008.

  • 6.

    Doker TJ et al. 2015. Contact investigation of melioidosis cases reveals regional endemicity in Puerto Rico. Clin Infect Dis 60: 243250.

  • 7.

    Lanciotti RS, Kosoy OL, Laven JJ, Velez JO, Lambert AJ, Johnson AJ, Stanfield SM, Duffy MR, 2008. Genetic and serologic properties of Zika virus associated with an epidemic, Yap State, Micronesia, 2007. Emerg Infect Dis 14: 12321239.

    • Search Google Scholar
    • Export Citation
  • 8.

    Alexander AD, Huxsoll DL, Warner AR Jr., Shepler V, Dorsey A, 1970. Serological diagnosis of human melioidosis with indirect hemagglutination and complement fixation tests. Appl Microbiol 20: 825833.

    • Search Google Scholar
    • Export Citation
  • 9.

    Limmathurotsakul D et al. 2013. Systematic review and consensus guidelines for environmental sampling of Burkholderia pseudomallei. PLoS Negl Trop Dis 7: e2105.

    • Search Google Scholar
    • Export Citation
  • 10.

    Smith CM, Hill VR, 2009. Dead-end hollow-fiber ultrafiltration for recovery of diverse microbes from water. Appl Environ Microbiol 75: 52845289.

    • Search Google Scholar
    • Export Citation
  • 11.

    Mull B, Hill VR, 2012. Recovery of diverse microbes in high turbidity surface water samples using dead-end ultrafiltration. J Microbiol Methods 91: 429433.

    • Search Google Scholar
    • Export Citation
  • 12.

    Godoy D, Randle G, Simpson AJ, Aanensen DM, Pitt TL, Kinoshita R, Spratt BG, 2003. Multilocus sequence typing and evolutionary relationships among the causative agents of melioidosis and glanders, Burkholderia pseudomallei and Burkholderia mallei. J Clin Microbiol 41: 20682079.

    • Search Google Scholar
    • Export Citation
  • 13.

    Brook MD, Currie B, Desmarchelier PM, 1997. Isolation and identification of Burkholderia pseudomallei from soil using selective culture techniques and the polymerase chain reaction. J Appl Microbiol 82: 589596.

    • Search Google Scholar
    • Export Citation
  • 14.

    Inglis TJ, Rolim DB, Rodriguez JL, 2006. Clinical guideline for diagnosis and management of melioidosis. Rev Inst Med Trop Sao Paulo 48: 14.

  • 15.

    United States Department of Agriculture Soil Conservation Service, 1983. Soil survey of Islands of Yap, Federated States of Micronesia. Available at: https://www.nrcs.usda.gov/Internet/FSE_MANUSCRIPTS/pacific_basin/PB934/0/yap.pdf. Accessed February 2014.

    • Search Google Scholar
    • Export Citation

Author Notes

Address correspondence to Leisha D. Nolen, 1600 Clifton Rd. NE, Atlanta, GA 30320. E-mail: xdf8@cdc.gov

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Funding: The Centers for Disease Control and Prevention baseline funding supported this work.

Authors’ addresses: Leisha D. Nolen, Arctic Investigations Program, Centers for Disease Control and Prevention, Anchorage, AK. E-mail: xdf8@cdc.gov. Eric Lirow and Maria Marfel, Yap Memorial Hospital, FSM Department of Health and Social Affairs, Yap, Federated States of Micronesia, E-mails: elirow@fsmhealth.fm and mmarfel@fsmhealth.fm. Jay E. Gee, Mindy G. Elrod, Cari B. Kolton, Lindy Liu, William A. Bower, and David D. Blaney, Bacterial Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA. E-mails: xzg4@cdc.gov, wzg0@cdc.gov, fts3@cdc.gov, fuz3@cdc.gov, wab4@cdc.gov, and znr5@cdc.gov. Marissa K. Person, Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA. E-mail: wnu6@cdc.gov.

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