India's One Health Mission Could Transform Mycetoma Response Through Environmental Surveillance

A 60-year-old farmer in India developed mycetoma twice—once in his foot after a cow's hoof gored him, again in his buttock years later when a thorn pierced his skin while he worked. Lab tests at a Kolkata research institute identified two different soil fungi as the culprits, yet both produced the same disease. The case, documented in 2021, raised a question that still puzzles scientists: why does exposure to these organisms sometimes lead to infection and sometimes does not?

Mycetoma, also called Madura Foot, is a neglected tropical disease that strikes agricultural workers and herders across low- and middle-income countries. The infection begins when bacteria or fungi from soil and plant matter enter tissue through puncture wounds or cuts. What starts as a minor injury gradually destroys tissue and bone, often progressing to swelling, discharge, and eventually amputation if left untreated. In 77 percent of cases, the lower limbs are affected. Among more than 80 organisms capable of causing mycetoma, 69 are fungi—and in 2022, the World Health Organization designated eumycetoma-causing fungi as high-priority pathogens.

In Rajasthan, a 65-year-old farmer named Baburam Bishnoi has worked barefoot in his bajra and wheat fields for decades, his skin constantly exposed to soil-dwelling bacteria and fungi. At some point, he contracted mycetoma. Minor granules on his right foot gradually became deep swelling and discharge, worsening each rainy season. "During the rains, the skin starts peeling off," Bishnoi told SciDev.Net, describing how rainwater inflamed his foot as he labored. When the infection flared in 2024, a rural pharmacist dismissed it with generic pills. Bishnoi endured months of worsening pain and discharge while continuing to work until he finally reached MDM Hospital in Jodhpur, where he was diagnosed with eumycetoma and admitted for treatment that disrupted his farming.

India is now developing its National One Health Mission, approved in February 2024, which aims to integrate disease surveillance across human, animal, and environmental sectors. The country has already demonstrated this approach works: leptospirosis, a bacterial infection spread through animal urine, has a dedicated control program combining surveillance with collaboration across veterinary and agriculture departments. Cases of leptospirosis in Gujarat fell from 916 in 2011 to 22 in 2024, with deaths dropping from 177 to five over the same period. Yet mycetoma, despite being recorded in India since 1842 and declared a neglected tropical disease by the WHO in 2016, has no comparable national surveillance mechanism. The WHO states that surveillance systems for mycetoma do not exist.

The disease's ecology reveals why environmental surveillance matters. Fungal mycetoma thrives in arid regions like Sudan and northern India, while bacterial mycetoma predominates in humid tropical areas such as Mexico. Within India itself, Rajasthan—which reports the highest number of cases nationally—shows this pattern clearly. Western Rajasthan, particularly around Jodhpur, reports more fungal infections, while eastern areas like Bharatpur, which are more humid, see more bacterial cases. For decades, these soil and rainfall dynamics kept the disease locked into predictable regions. But that is changing. As irrigation from the Indira Gandhi canal transformed parts of the Thar Desert into greener, more humid farmland, researchers documented a shift in mycetoma types. The ratio of fungal to bacterial cases fell from 4:1 in 2001 to less than 2:1 in 2005. More recently, data from S.N. Medical College in Jodhpur, which serves as the nodal center for mycetoma care in west Rajasthan and reports two to three cases monthly, suggests the balance has shifted to roughly 3:2 from 3:1 before 2010. "The likely reason is the changing climate patterns in west Rajasthan, which is turning humid by the day," said Yogi Raj Joshi, additional principal at the college. "However, this can be ascertained only after an empirical survey."

Arunaloke Chakrabarti, former president of the International Society for Human and Animal Mycology, explained the stakes: "Mycetoma is essentially an environmental disease with factors like dryness, temperature, and population behaviour affecting disease prevalence. Mycetoma agents seem to thrive at higher temperatures. With changes in environmental conditions, we need to understand whether that could influence where the disease occurs." Yet significant knowledge gaps persist. Ahmed Fahal, founder of the Mycetoma Research Centre at Soba University Hospital in Khartoum and head of the WHO collaborating centre on mycetoma, posed the unanswered questions: "Why doesn't everyone exposed to the causative organisms develop mycetoma? Why is there no history of trauma in many patients? How exactly does the infection take place?"

Environmental DNA sequencing in endemic Sudanese villages found Madurella mycetomatis—a mycetoma-causing fungus—in all patients' households, especially in soil, animal dung, and mud house walls. Animal dung acts as a rich medium for these organisms to grow, though the contamination likely originates from soil rather than the animals' intestines. Several countries now report eumycetoma infections in horses, tigers, cattle, dogs, and cats, with some fungal species identical to those infecting humans. A 2025 case report from the University of California described a kidney transplant recipient who developed mycetoma caused by Raghukumaria, a fungus previously found only in mangrove wood and never known to infect humans. Researchers traced the infection to the patient's disaster relief work in Caribbean mangroves over a decade earlier, warning that more frequent floods could expand marine fungal habitats and increase exposure risks, particularly for immunocompromised people.

India's actual mycetoma caseload remains unknown due to limited surveillance. A literature review analyzing 19,494 cases globally from 1876 to 2019 found the highest numbers from Sudan (10,608), followed by Mexico (4,155), and India (1,116). Yet India's NOHM, while bringing together over 16 ministries and departments, does not currently prioritize neglected tropical diseases. The National Centre for Disease Control's One Health programs focus primarily on zoonoses like rabies and leptospirosis, while dedicated programs for other NTDs like lymphatic filariasis and leprosy operate separately. Mycetoma remains outside both frameworks. Chakrabarti, who heads the PGI Chandigarh-based Fungal Infection Study Forum, called for systemic change: "Without funds, voluntary work cannot go on for long. This disease affects marginalised populations, and until the government decides to make it a priority, its real impact will remain invisible. Like Sudan, we need a laboratory dedicated to mycetoma here." Fahal echoed the need for coordination: "We need a comprehensive system involving clinicians, epidemiologists, statisticians and environmental experts to work together for a One Health surveillance system dedicated to mycetoma." Until mycetoma is made a notifiable disease requiring case reporting to health authorities, researchers will continue piecing together how environmental changes are reshaping the disease's geography from published studies and hospital records alone.