Mycobacterium ulcerans is recognised as the third most common mycobacterial infection worldwide. It causes necrotising infections of skin and soft tissue and is classified as a neglected tropical disease by the World Health Organization (WHO). However, despite extensive research, the environmental reservoir of the organism and mode of transmission of the infection to humans remain unknown. This limits the ability to design and implement public health interventions to effectively and consistently prevent the spread and reduce the incidence of this disease. In recent years, the epidemiology of the disease has changed. In most endemic regions of the world, the number of cases reported to the WHO are reducing, with a 64% reduction in cases reported worldwide in the last 9 years. Conversely, in a smaller number of countries including Australia and Nigeria, reported cases are increasing at a rapid rate, new endemic areas continue to appear, and in Australia cases are becoming more severe. The reasons for this changing epidemiology are unknown. We review the epidemiology of M. ulcerans disease worldwide, and document recent changes. We also outline and discuss the current state of knowledge on the ecology of M. ulcerans, possible transmission mechanisms to humans and what may be enabling the spread of M. ulcerans into new endemic areas.

This paper hypothesizes that arsenic in drinking water indirectly contributes to Buruli ulcer (BU), a skin disease caused by Mycobacterium ulcerans (MU) infection. Samples of groundwater and surface water used as drinking water by the population in Ghana's Amansie West district (part of which has a high prevalence of BU), were collected near rural settlements and analysed for arsenic. Arsenic concentration levels per settlement were compared with BU prevalence. A positive exposure-response relationship was obtained between arsenic in surface water and BU (r2 = 0.82). However, there is no significant exposure-response relation between groundwater and BU.