The Expanding Global Footprint of Burkholderia pseudomallei and Melioidosis

Bart J. Currie Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia;
Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Program, Darwin, Northern Territory, Australia;

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Ella M. Meumann Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia;
Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Program, Darwin, Northern Territory, Australia;
Sullivan Nicolaides Pathology, Brisbane, Queensland, Australia

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Mirjam Kaestli Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia;

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In 2016 melioidosis was recognised as being endemic in 45 countries globally, but modeling suggested likely endemicity in a further 34 countries.1 This was 104 years after melioidosis and its causative bacterium Burkholderia pseudomallei were first described in Myanmar, with subsequent reported cases throughout last century mostly restricted to Southeast Asia and northern Australia.2

This century there has been a dramatic expansion of the documented global footprint of B. pseudomallei and melioidosis that predominantly reflects increased surveillance, with improved laboratory resources and methods for detecting B. pseudomallei in clinical specimens (most importantly blood cultures) and soil and water samples from environmental studies. Nevertheless, there are also indicators that B. pseudomallei and melioidosis are on the move into new locations and that melioidosis case numbers are increasing in some endemic regions.3,4 What remains unclear is how much the expanded endemic boundaries of melioidosis reflect unmasking of previously unrecognised long-standing presence of B. pseudomallei and how much is truly recent geographical spread.5

The genome of B. pseudomallei was first described in 2004,6 and bacterial genotyping has been central to accurate analysis of this developing story. Whole genome sequencing analysis suggested that B. pseudomallei evolved in the environment of Australia and subsequently spread into Southeast Asia across land bridges during the last Ice Age.7 This conclusion was reinforced by subsequent studies, which supported later spread from Asia to Madagascar and Africa (estimated at ∼2,000 years ago),8 and then from Africa to South and Central America estimated between 1650 and 1850.9

The spread of melioidosis to the Americas was estimated to be temporally linked to the slave trade,9 and anthropogenic spread of B. pseudomallei through movements of people, with their animals and plants, seems important at both a global scale as well as at continental, regional and local scales. B. pseudomallei is aerosolized during severe weather events and may travel short distances, but it is very susceptible to ultraviolet radiation.10 The robustness of the regional compartmentalization seen in global phylogeographic analyses suggests that long range dispersal of B. pseudomallei by aerosolization is unlikely. Other possibilities for long range dispersal include carriage of B. pseudomallei by birds migrating between continents on the great flyways spanning the earth’s hemispheres,11,12 and even by colonized marine mammals (the Free Willy hypothesis).13 Rivers and other waterways play an important role in regional dispersal, with recent studies from Laos showing that B. pseudomallei is washed out with eroded soil during heavy rainfall and then transported downstream by rivers.14

In this issue of the Journal, Gassiep and colleagues describe an unprecedented cluster of 14 locally acquired cases of human melioidosis over 15 months in Southeast Queensland, Australia, all below the Tropic of Capricorn (latitude 23.4°S).15 The cases occurred over 2 successive La Niña years, both with extensive flooding, with 11/14 cases reporting direct exposure to flood water or a flooded environment. The cases reflected the spectrum of melioidosis seen elsewhere: 12/14 were adults (all over 50 years old), 6 had diabetes, 7 presented with pneumonia, 10 were bacteremic, and 2 died.

The association of melioidosis with weather events and flooding has long been recognized, and the exceptional severity of the flooding on this occasion and the number of cases of melioidosis seen support prior studies that predicted increased melioidosis cases with anthropogenic climate change-driven increases in land and sea surface temperatures and forecast increases in the magnitude of severe rainfall events.16,17

There is a long history of veterinary melioidosis in Southern Queensland. After flooding of the Brisbane River (27°S) in 1974, bovine melioidosis occurred on a farm where cattle had been imported from north Queensland the previous year.18 Between 1981 and 1983, there were 159 cases of melioidosis in piggeries in the Burnett river region (25.5°S) after heavy rainfall and river flooding.19 As noted by Gassiep et al.,15 the last published case of human melioidosis from Southern Queensland was from 2008, again linked to local flooding.20 This was 13 years prior to the new cluster reported, and the late Dr Guard concluded that; “The Brisbane River valley appears to be a subtropical endemic area for melioidosis, and further sporadic cases can be expected”.20 Furthermore, sporadic cases in animals have continued to occur in the region subsequent to 2008, mostly associated with heavy rainfall.

Notably, the authors include in their analyses15 several publicly available B. pseudomallei genomes also from Southern Queensland and sequenced as part of earlier studies – SRR8790684 (MSHR0454 from the 1974 bovine case, ST257), ERR311060 (MSHR0840 from the blood culture from a 1999 Ipswich case, ST257), and SRR6075123 and SRR6075125 (MSHR8481 and MSHR8544, two isolates from a 2009 case from near Ipswich, ST1378).9,21,22 ST257 and ST1378 are therefore represented in both the recent cases reported by Gassiep and colleagues and in historical B. pseudomallei isolates dating back to 1974. These sequence types (STs) are closely related to each other based on whole genome sequencing, consistent with longstanding establishment of B. pseudomallei in Southern Queensland.

Genotyping results from 3 of the 14 human cases were presented for the recent cluster,15 and a more comprehensive One Health analysis of human, animal, and environmental B. pseudomallei isolates collected over the years is needed to further elucidate the molecular epidemiology of melioidosis in Southern Queensland.

There also remain intriguing uncertainties about the footprint of B. pseudomallei elsewhere across Australia, the continent from which the bacterium originated, evolved, and globally dispersed. The isolation of B. pseudomallei from a waterhole with links to local melioidosis cases in the desert of central Australia after heavy rainfall compels studies to define the southern, eastern, and western boundaries of environmental B. pseudomallei south of tropical northern Australia.23 The introduction to Darwin and subsequent dispersal of ST562, an Asian-linked B. pseudomallei, remains to be explained.12 The 51-year persistence of a single clone of B. pseudomallei (ST284) in temperate Western Australia (31.6°S)24 is an extraordinary and concerning example of the ability of B. pseudomallei to survive under diverse environmental conditions.25

There have been considerable advances in recent years in mapping the presence of B. pseudomallei and the magnitude of melioidosis in India,26 Sri Lanka,27 Africa,28 and South America.29,30 Environmental sampling established that B. pseudomallei is ecologically established and widely dispersed in the environment in Puerto Rico.31

Accounts of melioidosis in the continental United States reveal a rapidly changing situation. The Centers for Disease Control and Prevention reported an outbreak of non-travel-associated melioidosis in the United States in 2021, including four cases (2 fatal) across four States.32 Genotyping showed that all infections were caused by the same strain of B. pseudomallei, and subsequently an identical strain of B. pseudomallei was cultured from an aromatherapy spray product imported from India, an endemic region. Genotyping of B. pseudomallei linked another non-travel-associated melioidosis case in the United States to infection from a freshwater home aquarium that contained imported tropical fish, most likely originating from Singapore.33 However, B. pseudomallei from some other USA non-travel-associated melioidosis cases showed genotypes in the “Americas” clade,34 supporting earlier modeling that proposed that the boundaries of endemic B. pseudomallei could extend into the southern USA.1

In 2022, endemicity of B. pseudomallei and melioidosis in the USA was finally confirmed, with B. pseudomallei isolated from soil and water samples from Mississippi and linked epidemiologically and on bacterial whole genome sequencing to 2 local cases of melioidosis.35

As elsewhere globally, only further clinical and extensive environmental surveillance across the Gulf States will determine the extent and magnitude of B. pseudomallei and melioidosis in the USA. As further genomic data accumulate, phylogeographic analyses should enable estimation of the timing and geographical spread of B. pseudomallei populations in the USA.

The finding of endemic melioidosis in the USA should provide further impetus to ongoing vaccine studies for melioidosis. To date the drivers of melioidosis vaccine initiatives have been primarily to protect military personnel and against the biothreat scenario of hypothetical exposure to weaponized B. pseudomallei. However importantly, a vaccine would likely reduce melioidosis burden and be cost-effective in at-risk groups (particularly those with diabetes) in endemic countries.36 In addition, the finding in northern Australia that melioidosis is a disease of socioeconomic disadvantage37 is likely to equally apply to the southern USA as well as elsewhere globally. As for many other infectious and non-infectious diseases, strategies to address socioeconomic inequity are needed, supporting the call for tackling melioidosis through holistic health care which addresses the social determinants of health.37

REFERENCES

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    • Search Google Scholar
    • Export Citation
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    Dance DAB , 1991. Melioidosis: the tip of the iceberg? Clin Microbiol Rev 4: 5260.

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    Limmathurotsakul D , Wongratanacheewin S , Teerawattanasook N , Wongsuvan G , Chaisuksant S , Chetchotisakd P , Chaowagul W , Day NP , Peacock SJ , 2010. Increasing incidence of human melioidosis in Northeast Thailand. Am J Trop Med Hyg 82: 11131117.

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    • Export Citation
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    Currie BJ et al., 2021. The Darwin Prospective Melioidosis Study: a 30-year prospective, observational investigation. Lancet Infect Dis 21: 17371746.

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    • Export Citation
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    Currie BJ , 2015. Melioidosis: evolving concepts in epidemiology, pathogenesis, and treatment. Semin Respir Crit Care Med 36: 111125.

    • Search Google Scholar
    • Export Citation
  • 6.

    Holden MT et al., 2004. Genomic plasticity of the causative agent of melioidosis, Burkholderia pseudomallei. Proc Natl Acad Sci USA 101: 1424014245.

    • Search Google Scholar
    • Export Citation
  • 7.

    Pearson T et al., 2009. Phylogeographic reconstruction of a bacterial species with high levels of lateral gene transfer. BMC Biol 7: 78.

  • 8.

    Sarovich DS et al., 2016. Phylogenomic analysis reveals an Asian origin for African Burkholderia pseudomallei and further supports melioidosis endemicity in Africa. MSphere 1: e00089-15.

    • Search Google Scholar
    • Export Citation
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    Chewapreecha C et al., 2017. Global and regional dissemination and evolution of Burkholderia pseudomallei. Nat Microbiol 2: 16263.

  • 10.

    Sagripanti JL , Levy A , Robertson J , Merritt A , Inglis TJ , 2009. Inactivation of virulent Burkholderia pseudomallei by sunlight. Photochem Photobiol 85: 978986.

    • Search Google Scholar
    • Export Citation
  • 11.

    Hampton V et al., 2011. Melioidosis in birds and Burkholderia pseudomallei dispersal, Australia. Emerg Infect Dis 17: 13101312.

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    Meumann EM , Kaestli M , Mayo M , Ward L , Rachlin A , Webb JR , Kleinecke M , Price EP , Currie BJ , 2021. Emergence of Burkholderia pseudomallei sequence type 562, Northern Australia. Emerg Infect Dis 27: 10571067.

    • Search Google Scholar
    • Export Citation
  • 13.

    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
  • 14.

    Zimmermann RE , Ribolzi O , Pierret A , Rattanavong S , Robinson MT , Newton PN , Davong V , Auda Y , Zopfi J , Dance DAB , 2018. Rivers as carriers and potential sentinels for Burkholderia pseudomallei in Laos. Sci Rep 8: 8674.

    • Search Google Scholar
    • Export Citation
  • 15.

    Gassiep I et al., 2023. Expanding the geographic boundaries of melioidosis in Queensland, Australia. Am J Trop Med Hyg 108: 12151219.

  • 16.

    Kaestli M , Grist EP , Ward L , Hill A , Mayo M , Currie BJ , 2016. The association of melioidosis with climatic factors in Darwin, Australia: a 23-year time-series analysis. J Infect 72: 687697.

    • Search Google Scholar
    • Export Citation
  • 17.

    Birnie E , Biemond JJ , Wiersinga WJ , 2022. Drivers of melioidosis endemicity: epidemiological transition, zoonosis, and climate change. Curr Opin Infect Dis 35: 196204.

    • Search Google Scholar
    • Export Citation
  • 18.

    Ketterer PJ , Donald B , Rogers RJ , 1975. Bovine melioidosis in South-Eastern Queensland. Aust Vet J 51: 395398.

  • 19.

    Ketterer PJ , Webster WR , Shield J , Arthur RJ , Blackall PJ , Thomas AD , 1986. Melioidosis in intensive piggeries in south eastern Queensland. Aust Vet J 63: 146149.

    • Search Google Scholar
    • Export Citation
  • 20.

    Guard RW , Morero PJ , Yi W , Mackay MJ , 2009. Melioidosis in south-eastern Queensland. Med J Aust 191: 290.

  • 21.

    Munckhof WJ , Mayo MJ , Scott I , Currie BJ , 2001. Fatal human melioidosis acquired in a subtropical Australian city. Am J Trop Med Hyg 65: 325328.

    • Search Google Scholar
    • Export Citation
  • 22.

    Sarovich DS , Webb JR , Pitman MC , Viberg LT , Mayo M , Baird RW , Robson JM , Currie BJ , Price EP , 2018. Raising the stakes: loss of efflux pump regulation decreases meropenem susceptibility in Burkholderia pseudomallei. Clin Infect Dis 67: 243250.

    • Search Google Scholar
    • Export Citation
  • 23.

    Yip TW , Hewagama S , Mayo M , Price EP , Sarovich DS , Bastian I , Baird RW , Spratt BG , Currie BJ , 2015. Endemic melioidosis in residents of desert region after atypically intense rainfall in central Australia, 2011. Emerg Infect Dis 21: 10381040.

    • Search Google Scholar
    • Export Citation
  • 24.

    Webb JR , Buller N , Rachlin A , Golledge C , Sarovich DS , Price EP , Mayo M , Currie BJ , 2020. A persisting nontropical focus of Burkholderia pseudomallei with limited genome evolution over five decades. mSystems 5: 10.

    • Search Google Scholar
    • Export Citation
  • 25.

    Wuthiekanun V , Amornchai P , Langla S , White NJ , Day NPJ , Limmathurotsakul D , 2020. Survival of Burkholderia pseudomallei and pathogenic Leptospira in cola, beer, energy drinks, and sports drinks. Am J Trop Med Hyg 103: 249252.

    • Search Google Scholar
    • Export Citation
  • 26.

    Mohapatra PR , Mishra B , 2022. Burden of melioidosis in India and South Asia: challenges and ways forward. Lancet Regional Health Southeast Asia 2: 100004.

    • Search Google Scholar
    • Export Citation
  • 27.

    Jayasinghearachchi HS , Corea EM , Jayaratne KI , Fonseka RA , Muthugama TA , Masakorala J , Ramasinghe RY , De Silva AD , 2021. Biogeography and genetic diversity of clinical isolates of Burkholderia pseudomallei in Sri Lanka. PLoS Negl Trop Dis 15: e0009917.

    • Search Google Scholar
    • Export Citation
  • 28.

    Birnie E et al., 2022. Melioidosis in Africa: time to raise awareness and build capacity for its detection, diagnosis, and treatment. Am J Trop Med Hyg 106: 394397.

    • Search Google Scholar
    • Export Citation
  • 29.

    Gee JE et al., 2021. Genomic diversity of Burkholderia pseudomallei in Ceara, Brazil. MSphere 6: e01259-20.

  • 30.

    Duarte C et al., 2021. Genomic diversity of Burkholderia pseudomallei isolates, Colombia. Emerg Infect Dis 27: 655658.

  • 31.

    Hall CM et al., 2019. Burkholderia pseudomallei, the causative agent of melioidosis, is rare but ecologically established and widely dispersed in the environment in Puerto Rico. PLoS Negl Trop Dis 13: e0007727.

    • Search Google Scholar
    • Export Citation
  • 32.

    Gee JE et al., 2022. Multistate outbreak of melioidosis associated with imported aromatherapy spray. N Engl J Med 386: 861868.

  • 33.

    Dawson P et al., 2021. Human melioidosis caused by novel transmission of Burkholderia pseudomallei from freshwater home aquarium, United States. Emerg Infect Dis 27: 30303035.

    • Search Google Scholar
    • Export Citation
  • 34.

    Cossaboom CM et al., 2020. Melioidosis in a resident of Texas with no recent travel history, United States. Emerg Infect Dis 26: 12951299.

    • Search Google Scholar
    • Export Citation
  • 35.

    CDC , 2022. Melioidosis Locally Endemic in Areas of the Mississippi Gulf Coast after Burkholderia pseudomallei Isolated in Soil and Water and Linked to Two Cases—Mississippi, 2020 and 2022. Available at: https://emergency.cdc.gov/han/2022/han00470.asp. Accessed April 13, 2023.

  • 36.

    Luangasanatip N , Flasche S , Dance DAB , Limmathurotsakul D , Currie BJ , Mukhopadhyay C , Atkins T , Titball R , Jit M , 2019. The global impact and cost-effectiveness of a melioidosis vaccine. BMC Med 17: 129.

    • Search Google Scholar
    • Export Citation
  • 37.

    Hanson J , Smith S , Stewart J , Horne P , Ramsamy N , 2021. Melioidosis: a disease of socioeconomic disadvantage. PLoS Negl Trop Dis 15: e0009544.

    • Search Google Scholar
    • Export Citation

Author Notes

Address correspondence to Bart J. Currie, Menzies School of Health Research, PO Box 41096, Casuarina, NT 0811, Australia. E-mail: bart.currie@menzies.edu.au

Authors’ addresses: Bart J. Currie, Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia, and Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Program, Darwin, NT, Australia, E-mail: bart.currie@menzies.edu.au. Ella M. Meumann, Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia, Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Program, Darwin, NT, Australia, and Sullivan Nicolaides Pathology, Brisbane, Qld, Australia, E-mail: ella.meumann@menzies.edu.au. Mirjam Kaestli, Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia, E-mail: mirjam.kaestli@cdu.edu.au.

  • 1.

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

    • Search Google Scholar
    • Export Citation
  • 2.

    Dance DAB , 1991. Melioidosis: the tip of the iceberg? Clin Microbiol Rev 4: 5260.

  • 3.

    Limmathurotsakul D , Wongratanacheewin S , Teerawattanasook N , Wongsuvan G , Chaisuksant S , Chetchotisakd P , Chaowagul W , Day NP , Peacock SJ , 2010. Increasing incidence of human melioidosis in Northeast Thailand. Am J Trop Med Hyg 82: 11131117.

    • Search Google Scholar
    • Export Citation
  • 4.

    Currie BJ et al., 2021. The Darwin Prospective Melioidosis Study: a 30-year prospective, observational investigation. Lancet Infect Dis 21: 17371746.

    • Search Google Scholar
    • Export Citation
  • 5.

    Currie BJ , 2015. Melioidosis: evolving concepts in epidemiology, pathogenesis, and treatment. Semin Respir Crit Care Med 36: 111125.

    • Search Google Scholar
    • Export Citation
  • 6.

    Holden MT et al., 2004. Genomic plasticity of the causative agent of melioidosis, Burkholderia pseudomallei. Proc Natl Acad Sci USA 101: 1424014245.

    • Search Google Scholar
    • Export Citation
  • 7.

    Pearson T et al., 2009. Phylogeographic reconstruction of a bacterial species with high levels of lateral gene transfer. BMC Biol 7: 78.

  • 8.

    Sarovich DS et al., 2016. Phylogenomic analysis reveals an Asian origin for African Burkholderia pseudomallei and further supports melioidosis endemicity in Africa. MSphere 1: e00089-15.

    • Search Google Scholar
    • Export Citation
  • 9.

    Chewapreecha C et al., 2017. Global and regional dissemination and evolution of Burkholderia pseudomallei. Nat Microbiol 2: 16263.

  • 10.

    Sagripanti JL , Levy A , Robertson J , Merritt A , Inglis TJ , 2009. Inactivation of virulent Burkholderia pseudomallei by sunlight. Photochem Photobiol 85: 978986.

    • Search Google Scholar
    • Export Citation
  • 11.

    Hampton V et al., 2011. Melioidosis in birds and Burkholderia pseudomallei dispersal, Australia. Emerg Infect Dis 17: 13101312.

  • 12.

    Meumann EM , Kaestli M , Mayo M , Ward L , Rachlin A , Webb JR , Kleinecke M , Price EP , Currie BJ , 2021. Emergence of Burkholderia pseudomallei sequence type 562, Northern Australia. Emerg Infect Dis 27: 10571067.

    • Search Google Scholar
    • Export Citation
  • 13.

    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
  • 14.

    Zimmermann RE , Ribolzi O , Pierret A , Rattanavong S , Robinson MT , Newton PN , Davong V , Auda Y , Zopfi J , Dance DAB , 2018. Rivers as carriers and potential sentinels for Burkholderia pseudomallei in Laos. Sci Rep 8: 8674.

    • Search Google Scholar
    • Export Citation
  • 15.

    Gassiep I et al., 2023. Expanding the geographic boundaries of melioidosis in Queensland, Australia. Am J Trop Med Hyg 108: 12151219.

  • 16.

    Kaestli M , Grist EP , Ward L , Hill A , Mayo M , Currie BJ , 2016. The association of melioidosis with climatic factors in Darwin, Australia: a 23-year time-series analysis. J Infect 72: 687697.

    • Search Google Scholar
    • Export Citation
  • 17.

    Birnie E , Biemond JJ , Wiersinga WJ , 2022. Drivers of melioidosis endemicity: epidemiological transition, zoonosis, and climate change. Curr Opin Infect Dis 35: 196204.

    • Search Google Scholar
    • Export Citation
  • 18.

    Ketterer PJ , Donald B , Rogers RJ , 1975. Bovine melioidosis in South-Eastern Queensland. Aust Vet J 51: 395398.

  • 19.

    Ketterer PJ , Webster WR , Shield J , Arthur RJ , Blackall PJ , Thomas AD , 1986. Melioidosis in intensive piggeries in south eastern Queensland. Aust Vet J 63: 146149.

    • Search Google Scholar
    • Export Citation
  • 20.

    Guard RW , Morero PJ , Yi W , Mackay MJ , 2009. Melioidosis in south-eastern Queensland. Med J Aust 191: 290.

  • 21.

    Munckhof WJ , Mayo MJ , Scott I , Currie BJ , 2001. Fatal human melioidosis acquired in a subtropical Australian city. Am J Trop Med Hyg 65: 325328.

    • Search Google Scholar
    • Export Citation
  • 22.

    Sarovich DS , Webb JR , Pitman MC , Viberg LT , Mayo M , Baird RW , Robson JM , Currie BJ , Price EP , 2018. Raising the stakes: loss of efflux pump regulation decreases meropenem susceptibility in Burkholderia pseudomallei. Clin Infect Dis 67: 243250.

    • Search Google Scholar
    • Export Citation
  • 23.

    Yip TW , Hewagama S , Mayo M , Price EP , Sarovich DS , Bastian I , Baird RW , Spratt BG , Currie BJ , 2015. Endemic melioidosis in residents of desert region after atypically intense rainfall in central Australia, 2011. Emerg Infect Dis 21: 10381040.

    • Search Google Scholar
    • Export Citation
  • 24.

    Webb JR , Buller N , Rachlin A , Golledge C , Sarovich DS , Price EP , Mayo M , Currie BJ , 2020. A persisting nontropical focus of Burkholderia pseudomallei with limited genome evolution over five decades. mSystems 5: 10.

    • Search Google Scholar
    • Export Citation
  • 25.

    Wuthiekanun V , Amornchai P , Langla S , White NJ , Day NPJ , Limmathurotsakul D , 2020. Survival of Burkholderia pseudomallei and pathogenic Leptospira in cola, beer, energy drinks, and sports drinks. Am J Trop Med Hyg 103: 249252.

    • Search Google Scholar
    • Export Citation
  • 26.

    Mohapatra PR , Mishra B , 2022. Burden of melioidosis in India and South Asia: challenges and ways forward. Lancet Regional Health Southeast Asia 2: 100004.

    • Search Google Scholar
    • Export Citation
  • 27.

    Jayasinghearachchi HS , Corea EM , Jayaratne KI , Fonseka RA , Muthugama TA , Masakorala J , Ramasinghe RY , De Silva AD , 2021. Biogeography and genetic diversity of clinical isolates of Burkholderia pseudomallei in Sri Lanka. PLoS Negl Trop Dis 15: e0009917.

    • Search Google Scholar
    • Export Citation
  • 28.

    Birnie E et al., 2022. Melioidosis in Africa: time to raise awareness and build capacity for its detection, diagnosis, and treatment. Am J Trop Med Hyg 106: 394397.

    • Search Google Scholar
    • Export Citation
  • 29.

    Gee JE et al., 2021. Genomic diversity of Burkholderia pseudomallei in Ceara, Brazil. MSphere 6: e01259-20.

  • 30.

    Duarte C et al., 2021. Genomic diversity of Burkholderia pseudomallei isolates, Colombia. Emerg Infect Dis 27: 655658.

  • 31.

    Hall CM et al., 2019. Burkholderia pseudomallei, the causative agent of melioidosis, is rare but ecologically established and widely dispersed in the environment in Puerto Rico. PLoS Negl Trop Dis 13: e0007727.

    • Search Google Scholar
    • Export Citation
  • 32.

    Gee JE et al., 2022. Multistate outbreak of melioidosis associated with imported aromatherapy spray. N Engl J Med 386: 861868.

  • 33.

    Dawson P et al., 2021. Human melioidosis caused by novel transmission of Burkholderia pseudomallei from freshwater home aquarium, United States. Emerg Infect Dis 27: 30303035.

    • Search Google Scholar
    • Export Citation
  • 34.

    Cossaboom CM et al., 2020. Melioidosis in a resident of Texas with no recent travel history, United States. Emerg Infect Dis 26: 12951299.

    • Search Google Scholar
    • Export Citation
  • 35.

    CDC , 2022. Melioidosis Locally Endemic in Areas of the Mississippi Gulf Coast after Burkholderia pseudomallei Isolated in Soil and Water and Linked to Two Cases—Mississippi, 2020 and 2022. Available at: https://emergency.cdc.gov/han/2022/han00470.asp. Accessed April 13, 2023.

  • 36.

    Luangasanatip N , Flasche S , Dance DAB , Limmathurotsakul D , Currie BJ , Mukhopadhyay C , Atkins T , Titball R , Jit M , 2019. The global impact and cost-effectiveness of a melioidosis vaccine. BMC Med 17: 129.

    • Search Google Scholar
    • Export Citation
  • 37.

    Hanson J , Smith S , Stewart J , Horne P , Ramsamy N , 2021. Melioidosis: a disease of socioeconomic disadvantage. PLoS Negl Trop Dis 15: e0009544.

    • Search Google Scholar
    • Export Citation
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