The hidden burden of melioidosis in Nepal: a paradigm for the urgent need to implement a simple laboratory algorithm to detect Burkholderia pseudomallei in low-resource endemic areas

Melioidosis is an emerging infectious disease affecting humans and animals and is caused by Burkholderia pseudomallei, a Gram-negative bacillus present in the soil and surface water of tropical and subtropical regions [1]. There is growing evidence that the disease is massively underdiagnosed in many low- and middle-income countries. It is suggested that around 44% of the predicted total 165,000 annual cases worldwide occur in South Asian countries, including Nepal [2]. Owing to occupational exposure, rural farming populations are at a particular risk of melioidosis, especially during the rainy season. Other risk factors include aging and Melioidosis is an emerging infectious disease affecting humans and animals and is caused by Burkholderia pseudomallei, a Gram-negative bacillus present in the soil and surface water of tropical and subtropical regions [1]. There is growing evidence that the disease is massively underdiagnosed in many low- and middle-income countries. It is suggested that around 44% of the predicted total 165,000 annual cases worldwide occur in South Asian countries, including Nepal [2]. Owing to occupational exposure, rural farming populations are at a particular risk of melioidosis, especially during the rainy season. Other risk factors include aging and comorbidities, such as diabetes mellitus, alcoholism, and chronic kidney and lung disease [1]. Diabetes is, by far, the most important among those and present in up to 70% of cases [3]. Infected individuals might present with an extremely wide clinical spectrum, ranging from undiagnosed fever and localized infections in soft tissues and bones to severe pneumonia and septicemia, with case fatality rates from under 10% to 40% and higher [1]. Early diagnosis is essential because B. pseudomallei is inherently multiresistant to many commonly used empiric drugs. Once melioidosis is diagnosed, specific treatment can reduce mortality significantly [4]. No vaccine has been developed yet. Surprisingly, melioidosis is not on the World Health Organization list of neglected diseases, although the estimated disability-adjusted life years are much higher than many of the neglected tropical diseases on the World Health Organization list, such as dengue, schistosomiasis, or intestinal nematodes [5].comorbidities, such as diabetes mellitus, alcoholism, and chronic kidney and lung disease [1]. Diabetes is, by far, the most important among those and present in up to 70% of cases [3]. Infected individuals might present with an extremely wide clinical spectrum, ranging from undiagnosed fever and localized infections in soft tissues and bones to severe pneumonia and septicemia, with case fatality rates from under 10% to 40% and higher [1]. Early diagnosis is essential because B. pseudomallei is inherently multiresistant to many commonly used empiric drugs. Once melioidosis is diagnosed, specific treatment can reduce mortality significantly [4]. No vaccine has been developed yet. Surprisingly, melioidosis is not on the World Health Organization list of neglected diseases, although the estimated disability-adjusted life years are much higher than many of the neglected tropical diseases on the World Health Organization list, such as dengue, schistosomiasis, or intestinal nematodes [5].