Defining new Buruli ulcer endemic areas in urban southeastern Australia using bacterial genomics-informed possum excreta surveys

Buruli ulcer (BU) in southeastern Australia is a zoonosis caused by infection with Mycobacterium ulcerans . Australian native possums are a major wildlife reservoir and infected possums shed M. ulcerans in their excreta, with mosquitoes being the major transmitting vector in this region. BU is geographically restricted and this feature, combined with an average 4.8-month incubation period, makes tracking M. ulcerans environmental spread and timely identification of new BU endemic areas challenging. While human movement complicates transmission tracing, we used the highly territorial behaviour of native possums and high-resolution pathogen genomics to confidently identify new BU endemic areas in Melbourne’s inner northwest and southern suburbs of Geelong. Using pathogen genomic phylodynamic modelling, we estimated that M. ulcerans was introduced to these areas 2-6 years before the emergence of human BU cases. This study shows how possum excreta surveys combined with pathogen genome data can pinpoint new BU endemic areas, thus providing critical local knowledge for targeted public health interventions to reduce exposure risk and ensure early diagnosis.