Activities of Daily Living Associated with Acquisition of Melioidosis in Northeast Thailand: A Matched Case-Control Study

Abstract

Background

Melioidosis is a serious infectious disease caused by the Category B select agent and environmental saprophyte, Burkholderia pseudomallei. Most cases of naturally acquired infection are assumed to result from skin inoculation after exposure to soil or water. The aim of this study was to provide evidence for inoculation, inhalation and ingestion as routes of infection, and develop preventive guidelines based on this evidence.

Methods/Principal Findings

A prospective hospital-based 1∶2 matched case-control study was conducted in Northeast Thailand. Cases were patients with culture-confirmed melioidosis, and controls were patients admitted with non-infectious conditions during the same period, matched for gender, age, and diabetes mellitus. Activities of daily living were recorded for the 30-day period before onset of symptoms, and home visits were performed to obtain drinking water and culture this for B. pseudomallei. Multivariable conditional logistic regression analysis based on 286 cases and 512 controls showed that activities associated with a risk of melioidosis included working in a rice field (conditional odds ratio [cOR] = 2.1; 95% confidence interval [CI] 1.4–3.3), other activities associated with exposure to soil or water (cOR = 1.4; 95%CI 0.8–2.6), an open wound (cOR = 2.0; 95%CI 1.2–3.3), eating food contaminated with soil or dust (cOR = 1.5; 95%CI 1.0–2.2), drinking untreated water (cOR = 1.7; 95%CI 1.1–2.6), outdoor exposure to rain (cOR = 2.1; 95%CI 1.4–3.2), water inhalation (cOR = 2.4; 95%CI 1.5–3.9), current smoking (cOR = 1.5; 95%CI 1.0–2.3) and steroid intake (cOR = 3.1; 95%CI 1.4–6.9). B. pseudomallei was detected in water source(s) consumed by 7% of cases and 3% of controls (cOR = 2.2; 95%CI 0.8–5.8).

Conclusions/Significance

We used these findings to develop the first evidence-based guidelines for the prevention of melioidosis. These are suitable for people in melioidosis-endemic areas, travelers and military personnel. Public health campaigns based on our recommendations are under development in Thailand.

Author Summary

Melioidosis is a serious infectious disease caused by the environmental saprophyte, Burkholderia pseudomallei. The infection is potentially preventable, but developing prevention guidelines is hampered by a lack of evidence on which to base them. The purpose of this study was to provide evidence for inoculation, inhalation and ingestion as routes of infection. To achieve this, we undertook a matched case-control study and performed home visits to obtain drinking water and culture this for B. pseudomallei. We found that activities associated with increased risk of developing melioidosis included working in a rice field, other activities associated with exposure to soil or water, an open wound, eating food contaminated with soil or dust, drinking untreated water, outdoor exposure to rain, water inhalation, current smoking and steroid intake. Presence of B. pseudomallei in drinking water source(s) doubled the odds of acquiring melioidosis. This is the first study to show that ingestion is an important route of human B. pseudomallei infection, and that exposure to rain is an independent risk factor for melioidosis. We used this finding to develop the first evidence-based guidelines for the prevention of melioidosis. These are suitable for people in melioidosis-endemic areas, travelers and military personnel.