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


METHODS
We 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.


RESULTS
We 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.


CONCLUSIONS
In 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.
South African Field Epidemiology Training Programme, National Institute for Communicable Diseases, Johannesburg, South Africa.|School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.|National Institute for Communicable Diseases, Johannesburg, South Africa.
Erika
E
Britz
National Institute for Communicable Diseases, Johannesburg, South Africa.|Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
Olga
O
Perovic
National Institute for Communicable Diseases, Johannesburg, South Africa.|Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
Claire
C
von Mollendorf
National Institute for Communicable Diseases, Johannesburg, South Africa.|Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
Anne
A
von Gottberg
National Institute for Communicable Diseases, Johannesburg, South Africa.
Samantha
S
Iyaloo
National Institute for Communicable Diseases, Johannesburg, South Africa.
Vanessa
V
Quan
National Institute for Communicable Diseases, Johannesburg, South Africa.
Verushka
V
Chetty
National Institute for Communicable Diseases, Johannesburg, South Africa.
Charlotte
C
Sriruttan
National Institute for Communicable Diseases, Johannesburg, South Africa.
Nazir A
NA
Ismail
National Institute for Communicable Diseases, Johannesburg, South Africa.
Ananta
A
Nanoo
Division of Global Health Protection, U.S. Centers for Disease Control and Prevention, Pretoria, South Africa.
Alfred
A
Musekiwa
South African Field Epidemiology Training Programme, National Institute for Communicable Diseases, Johannesburg, South Africa.
Carl
C
Reddy
South African Field Epidemiology Training Programme, National Institute for Communicable Diseases, Johannesburg, South Africa.
Karien
K
Viljoen
National Institute for Communicable Diseases, Johannesburg, South Africa.|Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
Cheryl
C
Cohen
National Institute for Communicable Diseases, Johannesburg, South Africa.|Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
Nelesh P
NP
Govender
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