John R. Wallace

Ecology and transmission of Buruli ulcer disease: a systematic review.

Buruli ulcer is a neglected emerging disease that has recently been reported in some countries as the second most frequent mycobacterial disease in humans after tuberculosis. Cases have been reported from at least 32 countries in Africa (mainly west), Australia, Southeast Asia, China, Central and South America, and the Western Pacific. Large lesions often result in scarring, contractual deformities, amputations, and disabilities, and in Africa, most cases of the disease occur in children between the ages of 4–15 years. This environmental mycobacterium, Mycobacterium ulcerans, is found in communities associated with rivers, swamps, wetlands, and human-linked changes in the aquatic environment, particularly those created as a result of environmental disturbance such as deforestation, dam construction, and agriculture. Buruli ulcer disease is often referred to as the “mysterious disease” because the mode of transmission remains unclear, although several hypotheses have been proposed. The above review reveals that various routes of transmission may occur, varying amongst epidemiological setting and geographic region, and that there may be some role for living agents as reservoirs and as vectors of M. ulcerans, in particular aquatic insects, adult mosquitoes or other biting arthropods. We discuss traditional and non-traditional methods for indicting the roles of living agents as biologically significant reservoirs and/or vectors of pathogens, and suggest an intellectual framework for establishing criteria for transmission. The application of these criteria to the transmission of M. ulcerans presents a significant challenge.

A Major Role for Mammals in the Ecology of Mycobacterium ulcerans

Background Mycobacterium ulcerans is the causative agent of Buruli ulcer (BU), a destructive skin disease found predominantly in sub-Saharan Africa and south-eastern Australia. The precise mode(s) of transmission and environmental reservoir(s) remain unknown, but several studies have explored the role of aquatic invertebrate species. The purpose of this study was to investigate the environmental distribution of M. ulcerans in south-eastern Australia. Methodology/Principal Findings A range of environmental samples was collected from Point Lonsdale (a small coastal town southwest of Melbourne, Australia, endemic for BU) and from areas with fewer or no reported incident cases of BU. Mycobacterium ulcerans DNA was detected at low levels by real-time PCR in soil, sediment, water residue, aquatic plant biofilm and terrestrial vegetation collected in Point Lonsdale. Higher levels of M. ulcerans DNA were detected in the faeces of common ringtail (Pseudocheirus peregrinus) and common brushtail (Trichosurus vulpecula) possums. Systematic testing of possum faeces revealed that M. ulcerans DNA could be detected in 41% of faecal samples collected in Point Lonsdale compared with less than 1% of faecal samples collected from non-endemic areas (p<0.0001). Capture and clinical examination of live possums in Point Lonsdale validated the accuracy of the predictive value of the faecal surveys by revealing that 38% of ringtail possums and 24% of brushtail possums had laboratory-confirmed M. ulcerans skin lesions and/or M. ulcerans PCR positive faeces. Whole genome sequencing revealed an extremely close genetic relationship between human and possum M. ulcerans isolates. Conclusions/Significance The prevailing wisdom is that M. ulcerans is an aquatic pathogen and that BU is acquired by contact with certain aquatic environments (swamps, slow-flowing water). Now, after 70 years of research, we propose a transmission model for BU in which terrestrial mammals are implicated as reservoirs for M. ulcerans.

The Potential to Determine a Postmortem Submersion Interval Based on Algal/Diatom Diversity on Decomposing Mammalian Carcasses in Brackish Ponds in Delaware*

Abstract:  Recently botanical evidence has been studied to determine if it is useful in forensic investigations. This study was performed to examine stillborn piglet decomposition in a brackish water environment and to semi‐quantitatively document stages of decomposition, degree day accumulation per stage as well as the algal/diatom diversity useful in determining a postmortem submersion interval (PMSI). Piglets and ceramic tiles were submerged in brackish ponds and sampled on a regular basis to document algal diversity and succession between substrates and stages of decomposition. Significantly greater weight was lost from piglet carcasses during the early floating and advanced floating decay stages. Seasonal effects were observed in degree‐day accumulations. Diatom diversity was significantly greater on piglet carcasses compared to tile substrates. Algal diversity decreased over time on the piglet carcasses as well as the stage of decomposition. A significant relationship and strong correlation between algal diversity found on the piglet substrate with time was observed. Our results indicate that more research is needed to examine the potential to use diatoms in not only determining manner of death but also the duration of time (PMSI) a victim may have been immersed in an aquatic environment.

Persistent Association of Mycobacterium ulcerans with West African Predaceous Insects of the Family Belostomatidae

ABSTRACT A number of studies have suggested that Mycobacterium ulcerans, the etiological agent of Buruli ulcer, may be transmitted to humans by insect bites. M. ulcerans has been isolated from a predaceous aquatic insect, and PCR detection of M. ulcerans DNA in aquatic environments suggests that the organism is widely distributed within many invertebrate taxa and functional feeding groups. Thus, M. ulcerans may be concentrated through different trophic links. However, the specific environmental niche of M. ulcerans and route of transmission to humans remain a mystery. In this study, a biologically relevant infection model in which M. ulcerans-infected mosquito larvae were fed to a species of predaceous hemiptera (African Belostomatidae) was used to demonstrate the persistent colonization of M. ulcerans and subsequent transmission of bacteria to naïve prey. The association of M. ulcerans with specific anatomical compartments showed that M. ulcerans accumulates preferentially on the exoskeleton. In contrast, few organisms were found in dissected guts or salivary glands. No difference was found between the ability of wild-type M. ulcerans and an M. ulcerans isogenic mycolactone-negative mutant to colonize belostomatids. These data show that African belostomatids can successfully be colonized by M. ulcerans and support the trophic transfer of M. ulcerans within the environment.

Evaluation of VNTR typing for the identification of Mycobacterium ulcerans in environmental samples from Victoria, Australia

Reliable molecular detection of Mycobacterium ulcerans in environmental samples is essential to study the ecology and transmission of this important human pathogen. Variable number tandem repeat (VNTR) typing is a valuable method for distinguishing M. ulcerans isolates from different geographic regions and for distinguishing M. ulcerans from other members of the Mycobacterium marinum/M. ulcerans complex, but its application to environmental samples has not yet been evaluated systematically. This study compares the sensitivity and specificity of PCR detection of 13 VNTR loci to determine the best loci for the analysis of environmental samples. This study demonstrates that VNTR typing using selected loci can be a useful addition to established molecular methods for detecting M. ulcerans in the environment and highlights some of the issues encountered when using molecular methods to detect microorganisms in environmental samples. When applied to environmental samples collected from an endemic region in Victoria, Australia, VNTR typing confirmed that the strain of M. ulcerans being detected was indistinguishable from the strain causing disease in humans in that region.

Pig Decomposition in Lotic Aquatic Systems: The Potential Use of Algal Growth in Establishing a Postmortem Submersion Interval (PMSI)

While algal community composition has been examined as a qualitative indicator of postmortem submersion interval (PMSI), there have been no quantitative studies on using algal growth rates as PMSI estimators. The present study was undertaken to examine pig decomposition in streams and to develop a more quantitative approach to estimate a PMSI. Pigs and ceramic tiles were completely submerged and regularly sampled for periphyton growth. Five stages of decomposition were identified for the submerged pig carcasses according to physical characteristics. Algal growth rates, measured quantitatively as a function of chlorophyll-a concentration, were greater on pigs compared with tiles; however, microhabitat (pools versus riffles) did not significantly influence algal growth. Additionally, there was a strong correlation between algal growth rate and time on pigs and tile substrates. This strong correlation was observed after significant rain events. Our study documents for the first time a quantitative technique to determine the length of time a corpse has been submerged in water. We suggest that algal growth rates may be a useful quantitative indicator in criminal investigations involving corpses that are completely submerged in stream or riverine habitats.

Interaction of Mycobacterium ulcerans with Mosquito Species: Implications for Transmission and Trophic Relationships

ABSTRACT Mycobacterium ulcerans is the causative agent of Buruli ulcer, a severe necrotizing skin disease that causes significant morbidity in Africa and Australia. Person-to-person transmission of Buruli ulcer is rare. Throughout Africa and Australia infection is associated with residence near slow-moving or stagnant water bodies. Although M. ulcerans DNA has been detected in over 30 taxa of invertebrates, fish, water filtrate, and plant materials and one environmental isolate cultured from a water strider (Gerridae), the invertebrate taxa identified are not adapted to feed on humans, and the mode of transmission for Buruli ulcer remains an enigma. Recent epidemiological reports from Australia describing the presence of M. ulcerans DNA in adult mosquitoes have led to the hypothesis that mosquitoes play an important role in the transmission of M. ulcerans. In this study we have investigated the potential of mosquitoes to serve as biological or mechanical vectors or as environmental reservoirs for M. ulcerans. Here we show that Aedes aegypti, A. albopictus, Ochlerotatus triseriatus, and Culex restuans larvae readily ingest wild-type M. ulcerans, isogenic toxin-negative mutants, and Mycobacterium marinum isolates and remain infected throughout larval development. However, the infections are not carried over into the pupae or adult mosquitoes, suggesting an unlikely role for mosquitoes as biological vectors. By following M. ulcerans through a food chain consisting of primary (mosquito larvae), secondary (predatory mosquito larva from Toxorhynchites rutilus septentrionalis), and tertiary (Belostoma species) consumers, we have shown that M. ulcerans can be productively maintained in an aquatic food web.

Climate and Landscape Factors Associated with Buruli Ulcer Incidence in Victoria, Australia

Background Buruli ulcer (BU), caused by Mycobacterium ulcerans (M. ulcerans), is a necrotizing skin disease found in more than 30 countries worldwide. BU incidence is highest in West Africa; however, cases have substantially increased in coastal regions of southern Australia over the past 30 years. Although the mode of transmission remains uncertain, the spatial pattern of BU emergence in recent years seems to suggest that there is an environmental niche for M. ulcerans and BU prevalence. Methodology/Principal Findings Network analysis was applied to BU cases in Victoria, Australia, from 1981–2008. Results revealed a non-random spatio-temporal pattern at the regional scale as well as a stable and efficient BU disease network, indicating that deterministic factors influence the occurrence of this disease. Monthly BU incidence reported by locality was analyzed with landscape and climate data using a multilevel Poisson regression approach. The results suggest the highest BU risk areas occur at low elevations with forested land cover, similar to previous studies of BU risk in West Africa. Additionally, climate conditions as far as 1.5 years in advance appear to impact disease incidence. Warmer and wetter conditions 18–19 months prior to case emergence, followed by a dry period approximately 5 months prior to case emergence seem to favor the occurrence of BU. Conclusions/Significance The BU network structure in Victoria, Australia, suggests external environmental factors favor M. ulcerans transmission and, therefore, BU incidence. A unique combination of environmental conditions, including land cover type, temperature and a wet-dry sequence, may produce habitat characteristics that support M. ulcerans transmission and BU prevalence. These findings imply that future BU research efforts on transmission mechanisms should focus on potential vectors/reservoirs found in those environmental niches. Further, this study is the first to quantitatively estimate environmental lag times associated with BU outbreaks, providing insights for future transmission investigations.

Mycolactone gene expression is controlled by strong SigA-like promoters with utility in studies of Mycobacterium ulcerans and Buruli ulcer.

Mycolactone A/B is a lipophilic macrocyclic polyketide that is the primary virulence factor produced by Mycobacterium ulcerans, a human pathogen and the causative agent of Buruli ulcer. In M. ulcerans strain Agy99 the mycolactone polyketide synthase (PKS) locus spans a 120 kb region of a 174 kb megaplasmid. Here we have identified promoter regions of this PKS locus using GFP reporter assays, in silico analysis, primer extension, and site-directed mutagenesis. Transcription of the large PKS genes mlsA1 (51 kb), mlsA2 (7 kb) and mlsB (42 kb) is driven by a novel and powerful SigA-like promoter sequence situated 533 bp upstream of both the mlsA1 and mlsB initiation codons, which is also functional in Escherichia coli, Mycobacterium smegmatis and Mycobacterium marinum. Promoter regions were also identified upstream of the putative mycolactone accessory genes mup045 and mup053. We transformed M. ulcerans with a GFP-reporter plasmid under the control of the mls promoter to produce a highly green-fluorescent bacterium. The strain remained virulent, producing both GFP and mycolactone and causing ulcerative disease in mice. Mosquitoes have been proposed as a potential vector of M. ulcerans so we utilized M. ulcerans-GFP in microcosm feeding experiments with captured mosquito larvae. M. ulcerans-GFP accumulated within the mouth and midgut of the insect over four instars, whereas the closely related, non-mycolactone-producing species M. marinum harbouring the same GFP reporter system did not. This is the first report to identify M. ulcerans toxin gene promoters, and we have used our findings to develop M. ulcerans-GFP, a strain in which fluorescence and toxin gene expression are linked, thus providing a tool for studying Buruli ulcer pathogenesis and potential transmission to humans.

Lack of effects of Bacillus sphaericus (Vectolex®) on nontarget organisms in a mosquito-control program in southeastern Wisconsin: A 3-year study

ABSTRACT A 3-year study (2000–2002) in southeastern Wisconsin was conducted to assess the effects of Bacillus sphaericus applied for mosquito control on nontarget wetland invertebrates. The experimental design consisted of control and treatment sites (that were applied by helicopter with Vectolex® CG), each in 2 vegetation habitat types: reed canary grass marsh (Phalaris arundinacea) and cattail marsh (Typha spp.). In each of these areas, a predetermined number of timed (30-sec) D-frame aquatic net samples containing vegetation, detritus, and invertebrates were collected 1 day before spraying and 72 h after spraying to detect for effects. We examined and compared 5 bioassessment measures to determine if there was an effect of B. sphaericus on nontarget organisms during each of the sampling years. The metrics tested were 1) mean taxa richness (the mean number of all taxa), 2) mean diversity (combines taxa richness and abundances in a summary statistic; i.e., Shannon Index [H′]), 3) Diptera richness (minus mosquitoes) as a proportion of all other taxa richness (Diptera/others richness), 4) Diptera abundance (minus mosquitoes) as a proportion of all other invertebrate abundance (Diptera/others abundance), and 5) functional group changes in percent collector–gatherers, collector–filterers, scrapers, shredders, and predators. When Vectolex was applied during 6 treatments at the labeled dosage rate in the above habitats in Brookfield, WI, no detrimental effects to nontarget organisms could be attributed to this microbial insecticide. Much of the variation in the control vs. treatment and pre vs. post plots was attributed to factors other than the effects of B. sphaericus on nontarget organisms, such as the time of sampling, natural variation that occurs in such diverse habitats as canary grass and cattail marshes, and water depth, which varied among years.