Melioidosis in South Asia: The hidden endemicity we can no longer ignore

 Melioidosis, caused by Burkholderia pseudomallei, remains one of the most overlooked tropical infections—deadly, yet curable. Despite its discovery more than a century ago, this disease continues to hide behind the masks of tuberculosis, pneumonia, or sepsis, killing silently in regions where it is least recognized. In 2016, modelling studies estimated that South Asia accounts for nearly 44% of the global burden of melioidosis. (Limmathurotsakul et al., 2016) Yet only a handful of countries—India, Sri Lanka, and Bangladesh—routinely diagnose and report human cases. In contrast, neighbouring nations such as Pakistan, Nepal, Bhutan, and Afghanistan have scarcely detected any cases, not because the disease is absent, but because it remains unseen — buried beneath diagnostic inexperience, limited laboratory capacity, and low clinical suspicion.

The paradox is striking - while these countries share similar climatic, agricultural, and socioeconomic profiles, the ability to detect B. pseudomallei varies drastically. The challenge is not the complexity of the organism but the simplicity of its neglect. In much of South Asia, clinicians have little exposure to the disease’s protean manifestations, and microbiology laboratories often lack the tools or protocols to identify B. pseudomallei, which is easily mistaken for common contaminants. In standard medical textbooks, melioidosis receives barely a paragraph—an invisibility that perpetuates its underdiagnosis.

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https://www.sciencedirect.com/science/article/pii/S2666517425001750