We initiated an epidemiological investigation following the death of a previously healthy 17 year-old boy with neuro-melioidosis. A case was defined as a culture-confirmed melioidosis patient from Udupi district admitted to hospital A from January 2013 - July 2018. For the case control study, we enrolled a subset of cases admitted to hospital A from January 2017- July 2018. A control was resident of Udupi district admitted to hospital A in July  2018 with a non-infectious condition. Using a matched case-control design, we compared each case to 3 controls using age and sex groups. We assessed for risk factors related to water storage, activities of daily living, injuries and environmental exposures (three months prior to hospitalization), using conditional regression analysis. We identified 50 cases with case fatality rate 16%. Uncontrolled diabetes mellitus was present in 84% cases and 66% of cases occurred between May and October (rainy season). Percutaneous inoculation through exposure to stagnant water and injury leading to breakage in the skin were identified as an important mode of transmission. We used these findings to develop a surveillance case definition and initiated training of the district laboratory for melioidosis diagnosis.

For cases, we collected clinical and laboratory data and created a line list without patient identifiers. Clinical data was available for patients attending the hospital after 2016. All controls were selected from the hospital admission records. We collected risk factor data for both cases and controls.

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