{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T15:05:39Z","timestamp":1791990339917,"version":"4.4.0"},"reference-count":132,"publisher":"Public Library of Science (PLoS)","issue":"8","license":[{"start":{"date-parts":[[2021,8,26]],"date-time":"2021-08-26T00:00:00Z","timestamp":1629936000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000925","name":"National Health and Medical Research Council","doi-asserted-by":"publisher","award":["APP1178715"],"award-info":[{"award-number":["APP1178715"]}],"id":[{"id":"10.13039\/501100000925","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosntds.org"],"crossmark-restriction":false},"short-container-title":["PLoS Negl Trop Dis"],"abstract":"<jats:p>\n                    <jats:italic>Mycobacterium ulcerans<\/jats:italic>\n                    is the causative agent of Buruli ulcer, a rare but chronic debilitating skin and soft tissue disease found predominantly in West Africa and Southeast Australia. While a moderate body of research has examined the distribution of\n                    <jats:italic>M<\/jats:italic>\n                    .\n                    <jats:italic>ulcerans<\/jats:italic>\n                    , the specific route(s) of transmission of this bacterium remain unknown, hindering control efforts.\n                    <jats:italic>M<\/jats:italic>\n                    .\n                    <jats:italic>ulcerans<\/jats:italic>\n                    is considered an environmental pathogen given it is associated with lentic ecosystems and human-to-human spread is negligible. However, the pathogen is also carried by various mammals and invertebrates, which may serve as key reservoirs and mechanical vectors, respectively. Here, we examine and review recent evidence from these endemic regions on potential transmission pathways, noting differences in findings between Africa and Australia, and summarising the risk and protective factors associated with Buruli ulcer transmission. We also discuss evidence suggesting that environmental disturbance and human population changes precede outbreaks. We note five key research priorities, including adoption of One Health frameworks, to resolve transmission pathways and inform control strategies to reduce the spread of Buruli ulcer.\n                  <\/jats:p>","DOI":"10.1371\/journal.pntd.0009678","type":"journal-article","created":{"date-parts":[[2021,8,26]],"date-time":"2021-08-26T13:27:08Z","timestamp":1629984428000},"page":"e0009678","update-policy":"https:\/\/doi.org\/10.1371\/journal.pntd.corrections_policy","source":"Crossref","is-referenced-by-count":53,"title":["Understanding the transmission of Mycobacterium ulcerans: A step towards controlling Buruli ulcer"],"prefix":"10.1371","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1241-8036","authenticated-orcid":true,"given":"Anthony J.","family":"Muleta","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3543-8243","authenticated-orcid":true,"given":"Rachael","family":"Lappan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Timothy P.","family":"Stinear","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7616-0594","authenticated-orcid":true,"given":"Chris","family":"Greening","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2021,8,26]]},"reference":[{"issue":"12","key":"pntd.0009678.ref001","doi-asserted-by":"crossref","first-page":"2183","DOI":"10.3201\/eid2512.190427","article-title":"Global epidemiology of Buruli ulcer, 2010\u20132017, and analysis of 2014 WHO programmatic targets","volume":"25","author":"TF Omansen","year":"2019","journal-title":"Emerg Infect Dis"},{"issue":"7","key":"pntd.0009678.ref002","doi-asserted-by":"crossref","first-page":"e912","DOI":"10.1016\/S2214-109X(19)30171-8","article-title":"Mapping the global distribution of Buruli ulcer: a systematic review with evidence consensus","volume":"7","author":"H Simpson","year":"2019","journal-title":"Lancet Glob Health"},{"key":"pntd.0009678.ref003","first-page":"59","article-title":"Epidemiology and disease burden of Buruli ulcer: a review","volume":"6","author":"K R\u00f6ltgen","year":"2015","journal-title":"Res Rep Trop Med"},{"issue":"1","key":"pntd.0009678.ref004","doi-asserted-by":"crossref","DOI":"10.1128\/CMR.00045-17","article-title":"Buruli ulcer, a prototype for ecosystem-related infection, caused by Mycobacterium ulcerans","volume":"31","author":"D Zingue","year":"2018","journal-title":"Clin Microbiol Rev"},{"issue":"12","key":"pntd.0009678.ref005","doi-asserted-by":"crossref","first-page":"e911","DOI":"10.1371\/journal.pntd.0000911","article-title":"Ecology and transmission of Buruli ulcer disease: a systematic review","volume":"4","author":"RW Merritt","year":"2010","journal-title":"PLoS Negl Trop Dis"},{"key":"pntd.0009678.ref006","unstructured":"World Health Organisation. Global leprosy (Hansen disease) update, 2019: time to step-up prevention initiatives. World Health Organisation; 2020 Sep 4. Contract No.: 36."},{"issue":"10","key":"pntd.0009678.ref007","doi-asserted-by":"crossref","first-page":"e2463","DOI":"10.1371\/journal.pntd.0002463","article-title":"The incubation period of Buruli ulcer (Mycobacterium ulcerans infection)","volume":"7","author":"JA Trubiano","year":"2013","journal-title":"PLoS Negl Trop Dis"},{"issue":"8","key":"pntd.0009678.ref008","article-title":"A major role for mammals in the ecology of Mycobacterium ulcerans","volume":"4","author":"JAM Fyfe","year":"2010","journal-title":"PLoS Negl Trop Dis"},{"issue":"4","key":"pntd.0009678.ref009","doi-asserted-by":"crossref","first-page":"e0005553","DOI":"10.1371\/journal.pntd.0005553","article-title":"Mycobacterium ulcerans low infectious dose and mechanical transmission support insect bites and puncturing injuries in the spread of Buruli ulcer","volume":"11","author":"JR Wallace","year":"2017","journal-title":"PLoS Negl Trop Dis"},{"issue":"3","key":"pntd.0009678.ref010","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0002756","article-title":"Mycobacterium ulcerans persistence at a village water source of Buruli ulcer patients","volume":"8","author":"MW Bratschi","year":"2014","journal-title":"PLoS Negl Trop Dis"},{"issue":"4","key":"pntd.0009678.ref011","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0002770","article-title":"Mycobacterium ulcerans fails to infect through skin abrasions in a guinea pig infection model: implications for transmission","volume":"8","author":"HR Williamson","year":"2014","journal-title":"PLoS Negl Trop Dis"},{"issue":"11","key":"pntd.0009678.ref012","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0001392","article-title":"Adequate wound care and use of bed nets as protective factors against Buruli ulcer: Results from a case control study in Cameroon","volume":"5","author":"J Landier","year":"2011","journal-title":"PLoS Negl Trop 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Dis"},{"issue":"12","key":"pntd.0009678.ref016","doi-asserted-by":"crossref","first-page":"e51074","DOI":"10.1371\/journal.pone.0051074","article-title":"Climate and landscape factors associated with Buruli ulcer incidence in Victoria, Australia","volume":"7","author":"J van Ravensway","year":"2012","journal-title":"PLoS ONE"},{"issue":"7","key":"pntd.0009678.ref017","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0000746","article-title":"Family relationship, water contact and occurrence of Buruli ulcer in Benin","volume":"4","author":"GE Sopoh","year":"2010","journal-title":"PLoS Negl Trop Dis"},{"issue":"2","key":"pntd.0009678.ref018","doi-asserted-by":"crossref","first-page":"e52","DOI":"10.1016\/S2542-5196(17)30026-8","article-title":"Unlocking of the secrets of Mycobacterium ulcerans disease transmission","volume":"1","author":"DP O\u2019Brien","year":"2017","journal-title":"Lancet Planet Health"},{"issue":"6","key":"pntd.0009678.ref019","article-title":"Snapshot fecal survey of domestic animals in rural Ghana for Mycobacterium ulcerans","volume":"2016","author":"NJ Tobias","year":"2016","journal-title":"PeerJ"},{"issue":"1","key":"pntd.0009678.ref020","doi-asserted-by":"crossref","first-page":"6778","DOI":"10.1038\/s41598-018-25278-y","article-title":"A protocol for culturing environmental strains of the Buruli ulcer agent, Mycobacterium ulcerans","volume":"8","author":"D Zingue","year":"2018","journal-title":"Sci Rep"},{"issue":"3","key":"pntd.0009678.ref021","doi-asserted-by":"crossref","first-page":"491","DOI":"10.4269\/ajtmh.19-0137","article-title":"Disseminated Mycobacterium ulcerans infection in wild grasscutters (Thryonomys swinderianus), C\u00f4te d\u2019Ivoire","volume":"101","author":"N Hammoudi","year":"2019","journal-title":"Am J Trop Med Hyg"},{"issue":"7","key":"pntd.0009678.ref022","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0003941","article-title":"A field study in Benin to investigate the role of mosquitoes and other flying insects in the ecology of Mycobacterium ulcerans","volume":"9","author":"B Zogo","year":"2015","journal-title":"PLoS Negl Trop Dis"},{"issue":"9","key":"pntd.0009678.ref023","doi-asserted-by":"crossref","first-page":"4623","DOI":"10.1128\/AEM.68.9.4623-4628.2002","article-title":"Aquatic insects as a vector for Mycobacterium ulcerans","volume":"68","author":"L Marsollier","year":"2002","journal-title":"Appl Environ Microbiol"},{"key":"pntd.0009678.ref024","doi-asserted-by":"crossref","DOI":"10.1155\/2017\/1324310","article-title":"Evidences of the low implication of mosquitoes in the transmission of Mycobacterium ulcerans, the causative agent of Buruli ulcer","volume":"2017","author":"R Djouaka","year":"2017","journal-title":"Can J Infect Dis Med Microbiol"},{"issue":"18","key":"pntd.0009678.ref025","doi-asserted-by":"crossref","first-page":"6215","DOI":"10.1128\/AEM.00340-10","article-title":"Interaction of Mycobacterium ulcerans with mosquito species: implications for 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Vandelannoote","year":"2014","journal-title":"Appl Environ Microbiol"},{"issue":"3","key":"pntd.0009678.ref038","doi-asserted-by":"crossref","first-page":"491","DOI":"10.3201\/eid2603.190573","article-title":"Stable and local reservoirs of Mycobacterium ulcerans inferred from the nonrandom distribution of bacterial genotypes, Benin","volume":"26","author":"C Coudereau","year":"2020","journal-title":"Emerg Infect Dis"},{"issue":"3","key":"pntd.0009678.ref039","doi-asserted-by":"crossref","first-page":"e0003681","DOI":"10.1371\/journal.pntd.0003681","article-title":"Whole genome comparisons suggest random distribution of Mycobacterium ulcerans genotypes in a Buruli ulcer endemic region of Ghana","volume":"9","author":"AS Ablordey","year":"2015","journal-title":"PLoS Negl Trop Dis"},{"issue":"6","key":"pntd.0009678.ref040","doi-asserted-by":"crossref","first-page":"e0003802","DOI":"10.1371\/journal.pntd.0003802","article-title":"Locally confined clonal complexes of Mycobacterium ulcerans in two Buruli ulcer endemic regions of Cameroon","volume":"9","author":"M Bolz","year":"2015","journal-title":"PLoS Negl Trop Dis"},{"issue":"4","key":"pntd.0009678.ref041","doi-asserted-by":"crossref","first-page":"1018","DOI":"10.1128\/JCM.37.4.1018-1023.1999","article-title":"Identification and characterization of IS2404 and IS2606: two distinct repeated sequences for detection of Mycobacterium ulcerans by PCR","volume":"37","author":"T Stinear","year":"1999","journal-title":"J Clin Microbiol"},{"issue":"15","key":"pntd.0009678.ref042","doi-asserted-by":"crossref","first-page":"4733","DOI":"10.1128\/AEM.02971-06","article-title":"Development and application of two multiplex real-time PCR assays for the detection of Mycobacterium ulcerans in clinical and environmental samples","volume":"73","author":"JAM Fyfe","year":"2007","journal-title":"Appl Environ 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Aboagye","year":"2016","journal-title":"Appl Environ Microbiol"},{"issue":"4","key":"pntd.0009678.ref051","doi-asserted-by":"crossref","first-page":"e0004671","DOI":"10.1371\/journal.pntd.0004671","article-title":"Genetic variation in autophagy-related genes influences the risk and phenotype of Buruli ulcer","volume":"10","author":"C Capela","year":"2016","journal-title":"PLoS Negl Trop Dis"},{"issue":"3","key":"pntd.0009678.ref052","doi-asserted-by":"crossref","first-page":"185","DOI":"10.1038\/sj.gene.6364281","article-title":"Susceptibility to Buruli ulcer is associated with the SLC11A1 (NRAMP1) D543N polymorphism","volume":"7","author":"Y Stienstra","year":"2006","journal-title":"Genes Immun"},{"issue":"5","key":"pntd.0009678.ref053","doi-asserted-by":"crossref","first-page":"837","DOI":"10.3201\/eid2305.160809","article-title":"Exposure risk for infection and lack of human-to-human transmission of Mycobacterium ulcerans disease, Australia","volume":"23","author":"DP 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Mycobacterium ulcerans in the environment predicts prevalence of Buruli ulcer in Benin","volume":"6","author":"HR Williamson","year":"2012","journal-title":"PLoS Negl Trop Dis"},{"issue":"2","key":"pntd.0009678.ref063","doi-asserted-by":"crossref","first-page":"350","DOI":"10.1007\/s00248-017-0946-6","article-title":"Seasonal pattern of Mycobacterium ulcerans, the causative agent of Buruli ulcer, in the environment in Ghana","volume":"74","author":"SY Aboagye","year":"2017","journal-title":"Microb Ecol"},{"issue":"9","key":"pntd.0009678.ref064","doi-asserted-by":"crossref","first-page":"e0006757","DOI":"10.1371\/journal.pntd.0006757","article-title":"The association of rainfall and Buruli ulcer in southeastern Australia","volume":"12","author":"A Yerramilli","year":"2018","journal-title":"PLoS Negl Trop Dis"},{"issue":"5","key":"pntd.0009678.ref065","doi-asserted-by":"crossref","first-page":"e0217643","DOI":"10.1371\/journal.pone.0217643","article-title":"Risk factors for human 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