The Epidemiology of Meningitis among Adults in a South African Province with a High HIV Prevalence, 2009-2012

Abstract

IntroductionMeningitis is a major cause of mortality in southern Africa. We aimed to describe the aetiologies and frequencies of laboratory-confirmed fungal and bacterial meningitis among adults in a South African province with an 11% HIV prevalence, over 4 years.MethodsWe conducted a retrospective, observational study of secondary laboratory data, extracted on all cerebrospinal fluid (CSF) specimens submitted to public-sector laboratories in Gauteng province from 2009 through 2012. We calculated cause-specific incidence rates in the general and HIV-infected populations and used Poisson regression to determine if trends were significant.ResultsWe identified 11,891 (10.7%) incident cases of meningitis from 110,885 CSF specimens. Cryptococcal meningitis, tuberculous meningitis and pneumococcal meningitis accounted for 62.3% (n = 7,406), 24.6% (n = 2,928) and 10.1% (n = 1,197) of cases over the four-year period. The overall incidence (cases per 100,000 persons) of cryptococcal meningitis declined by 23% from 24.4 in 2009 to 18.7 in 2012 (p <0.001) and decreased by 19% among HIV-infected persons from 178.2 to 144.7 (p <0.001). Tuberculous meningitis decreased by 40% from 11.3 in 2009 to 6.8 in 2012 (p <0.001) and decreased by 36% among HIV-infected persons from 54.4 to 34.9 (p <0.001). Pneumococcal meningitis decreased by 41% from 4.2 in 2009 to 2.5 in 2012 (p <0.001) and decreased by 38% among HIV-infected persons from 28.0 to 17.5 (p <0.001). Among cases of other bacterial meningitis (248/11,891, 2.1%), Neisseria meningitidis (n = 93), Escherichia coli (n = 72) and Haemophilus influenzae (n = 20) were the most common organisms identified.ConclusionsIn this high HIV-prevalence province, cryptococcal meningitis was the leading cause of laboratory-confirmed meningitis among adults. Over a 4-year period, there was a significant decrease in incidence of cryptococcal, tuberculous and pneumococcal meningitis. This coincided with expansion of the national antiretroviral treatment programme, enhanced tuberculosis control programme and routine childhood immunisation with pneumococcal conjugate vaccines.

National coverage of reflex cryptococcal antigen screening: A milestone achievement in the care of persons with advanced HIV disease

“…[1,2] The burden of cryptococcal meningitis has remained high in SA among severely immunosuppressed HIV-positive patients, despite substantial improvements in antiretroviral treatment (ART) coverage over the past decade. [3] Approximately one-third of patients entering HIV care in the SA public sector in 2016 had advanced HIV disease (defined as a CD4+ T-lymphocyte count <200 cells/µL), and 17% had a CD4+ count <100 cells/µL. [4] In 2011, the World Health Organization (WHO) recommended that countries consider integrating cryptococcal antigen (CrAg) screening into HIV programmes to detect cryptococcal disease at an earlier point in its trajectory, followed by pre-emptive antifungal treatment to reduce AIDS deaths.…”

Tuberculous Meningitis in Children and Adults: New Insights for an Ancient Foe

“…Overall, tuberculous meningitis comprises 1–2% of incident cases of active tuberculosis. In settings with concurrent epidemics of HIV and tuberculosis, M. tuberculosis is now a leading cause of bacterial meningitis, alongside pathogens such as Neisseria meningitidis, Haemophilus influenzae , or Streptococcus pneumoniae [8, 9]. Approximately one half of all tuberculous meningitis infections lead to severe disability or death [10].…”

Short‐course amphotericin B in addition to sertraline and fluconazole for treatment of HIV‐associated cryptococcal meningitis in rural Tanzania

“…Cryptococcal meningitis is the leading cause of adult meningitis in sub‐Saharan Africa, estimated to cause 15% of AIDS‐related deaths . Limited access to first‐line antifungals (amphotericin B and flucytosine) contributes to this high mortality.…”