In this issue of The Lancet Global Health, the study by Sabine Lichtenegger and colleagues provides the first large-scale clinical and genomic confirmation of endemic Burkholderia pseudomallei transmission in Mali, Africa, expanding on previous evidence from Gabon. By documenting 31 paediatric cases, 14 (45%) of which occurred in infants aged 12 months or younger, with a mortality rate of 63% (12 of 19 children with available outcome data), the authors substantially advance our understanding of melioidosis in Africa. Their identification of genetically diverse strains through whole-genome sequencing shows long-standing environmental persistence of the pathogen, challenging previous assumptions of its recent introduction (as opposed to long-standing persistence) or restriction to sporadic cases. With a calculated incidence of 15·5 per 100 000 (95% CI 10·0-20·8) in the general population, comparable with highly endemic regions of Asia, this study suggests this part of Africa is a major global epicentre of melioidosis burden, likely ranking second only to Asia in terms of overall disease prevalence.

This work makes three seminal contributions to global health. First, it provides field evidence validating 2016 modelling projections of high environmental suitability in this part of Africa through field evidence. Second, it establishes gold-standard molecular confirmation through robust whole-genome phylogenetic analysis. Third, it quantifies a concerning mortality attributable in part to diagnostic limitations, a finding that echoes observations in Mexican paediatric clusters where delayed identification also proved fatal. As the largest African cohort documented to date, this study provides compelling evidence that melioidosis represents a substantial and under-recognised threat in this part of Africa.

Nevertheless, several crucial questions remain unanswered. The most urgent concern is the true extent of disease distribution: does Mali represent the tip of an epidemiological iceberg? Genetic diversity suggests widespread environmental colonisation, yet adjacent regions have little surveillance capacity. Environmental studies similar to those conducted in India, where soil isolates matched sibling cases, should be prioritised to map reservoirs. Another pressing question concerns age-specific vulnerability: why did infants aged 12 months or younger constitute nearly half of Mali's cohort? This exceeds proportions in endemic Asian areas, possibly indicating vertical transmission pathways or paediatric-specific exposures such as contaminated weaning foods and mechanisms requiring urgent investigation. Beyond this distinct paediatric epidemiology, genotype-phenotype correlations require exploration: do Mali's diverse strains exhibit novel virulence or antibiotic resistance markers? Whole-genome data should be mined for resistance determinants given B pseudomallei's intrinsic resistance to aminoglycosides and penicillin-class drugs, a key factor driving mortality in settings with limited therapeutic options.

This study fundamentally recontextualises melioidosis in Africa within global control efforts. Its findings resonate with evidence on three fronts: silent endemicity in unexpected regions (exemplified by indigenous Texas cases with environmental persistence), diagnostic deficiencies that enable undetected transmission (evidenced by Mexican gastrointestinal cases), and genetic adaptability that facilitates regional persistence (as shown in B pseudomallei's global sequence type 46 transmission). The high mortality rate underscores the lethality of unsuitable empirical regimens such as ceftriaxone or gentamicin.

Three key messages must drive policy action. First, diagnostic integration is a cornerstone of any effective response. Mali's cases were identified through basic biochemical screening (oxidase-positive and aesculin-negative gram-negative rods), a feasible first-step algorithm adaptable to resource-limited settings as highlighted in the methods section of the Article. This feasible first-step strategy aligns with the algorithm from Viet Nam, which uses a simple phenotypic method for practical identification in resource-limited settings. Second, therapy guidelines require Africa-specific revision. National protocols must replace ineffective cephalosporins-aminoglycosides with ceftazidime or carbapenems for sepsis management in suspected endemic zones. Third, sentinel surveillance networks must be established. Genomic tools should monitor strain evolution, particularly given evidence of transcontinental transmission, while environmental surveys should be conducted yearly to identify high-risk exposures.

The retrospective paediatric-focused design misses a major adult burden. Future efforts must expand surveillance to adults, particularly those aged older than 45 years with diabetes, who represent the group at highest risk as documented in post-hurricane outbreaks in Mexico. Prospective, multi-age studies coupled with environmental sampling are needed to define the complete clinical spectrum and transmission routes.

This study challenges decades of epidemiological neglect. Mali's tragedy, where children die from treatable infections due to diagnostic invisibility, demands three immediate actions: WHO classification of melioidosis as a neglected tropical disease to unlock resources, development of rapid point-of-care diagnostics building on existing immunoassay prototypes, and the implementation of diagnostic protocols that integrate biochemical screening for B pseudomallei, as advocated by Lichtenegger and colleagues, to prompt immediate initiation of appropriate empiric therapy (eg, with ceftazidime). Only then will Africa confront this stealth pathogen now proven to lurk in plain sight.

We declare no competing interests. This work was supported by the National Natural Science Fund Cultivating 530 Project of Hainan General Hospital (2022MSXM03), the Academic Enhancement Support Program of Hainan Medical University (XSTS2025105), and Hainan Province Clinical Medical Center. We used artificial intelligence-assisted technology (Deepseek) for language polishing and editing this manuscript. The authors are solely responsible for the scientific content, interpretation of data, and the accuracy of all references. Both authors have reviewed and edited the artificial intelligence-processed content and take full responsibility for the final version of the work.