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Background: Buruli ulcer can cause disfigurement and long-term loss-of-function. It is under-diagnosed and under-reported, and its current distribution is unclear. We aimed to synthesise and evaluate data on BU prevalence and distribution. Methods: We conducted a systematic review of BU prevalence, and used an evidence consensus framework to describe and evaluate evidence for BU distribution worldwide. We searched online databases from inception to 06/08/2018 for records of BU and M. ulcerans detection, with no limits on study type, date, or location. We included population-based surveys presenting BU prevalence estimates in the systematic review, extracting prevalence estimates with 95% CIs. We extracted geographical data on the occurrence of BU cases and M. ulcerans detection from studies of any type. Occurrence records, reports to WHO and the Global Infectious Diseases and Epidemiology Network, and national BU surveillance data were included in an evidence consensus framework to grade the strength of evidence for BU endemicity. This study is registered with PROSPERO, number CRD42018116260. Findings: 2,763 titles met the search criteria. We extracted prevalence estimates from ten studies and occurrence data from 208. Prevalence estimates within study areas ranged from 3.2- 26.9 per 10,000. There was evidence of BU in 32 countries and consensus on presence in 12. Interpretation: The global distribution of BU is uncertain, and potentially wider than currently recognised. These maps represent the strongest available evidence on BU distribution to date, and have many potential applications, from directing surveillance activities to informing burden estimates.

Mapping the Global Distribution of Buruli Ulcer Through a Systematic Review with an Evidence Consensus Approach