Epidemiology of adult meningitis during antiretroviral therapy scale-up in southern Africa: Results from the Botswana national meningitis survey

• Published in: The Journal of infection 2019-09, Vol.79 (3), p.212-219
• Main Authors: Tenforde, Mark W., Mokomane, Margaret, Leeme, Tshepo, Tlhako, Nametso, Tsholo, Katlego, Ramodimoosi, Chandapiwa, Dube, Bonno, Mokobela, Kelebeletse O., Tawanana, Ephraim, Chebani, Tony, Pilatwe, Tlhagiso, Hurt, William J., Mitchell, Hannah K., Molefi, Mooketsi, Mullan, Paul C., Guthrie, Brandon L., Farquhar, Carey, Steenhoff, Andrew P., Mine, Madisa, Jarvis, Joseph N.
• Format: Article
• Language: English
• Subjects: Adult; Africa, Southern - epidemiology; Age Factors; AIDS-Related Opportunistic Infections - epidemiology; AIDS-Related Opportunistic Infections - microbiology; Antiretroviral Therapy, Highly Active; Biomarkers; Cross-Sectional Studies; Cryptococcal meningitis; Female; HIV; HIV Infections - complications; HIV Infections - diagnosis; HIV Infections - drug therapy; HIV Infections - virology; Humans; Incidence; Male; Meningitis, Cryptococcal - diagnosis; Meningitis, Cryptococcal - epidemiology; Meningitis, Cryptococcal - microbiology; Middle Aged; Pneumococcal meningitis; Public Health Surveillance; Sub-Saharan Africa; TB meningitis
• ISSN: 0163-4453; 1532-2742
• DOI: 10.1016/j.jinf.2019.06.013

•Cryptococcal meningitis remains the most common cause of meningitis in Botswana.•No decline in pneumococcal or culture-negative meningitis was observed over time.•Despite a high national TB burden, few cases of TB meningitis are confirmed.•Most meningitis cases have no cause confirmed, highlighting diagnostic limitations. Data on meningitis epidemiology in high HIV-prevalence African settings following antiretroviral therapy scale-up are lacking. We described epidemiology of adult meningitis in Botswana over a 16-year period. Laboratory records for adults undergoing lumbar puncture (LP) 2000–2015 were collected, with complete national data 2013–2014. Cerebrospinal fluid (CSF) findings and linked HIV-data were described, and national incidence figures estimated for 2013–2014. Temporal trends in meningitis were evaluated. Of 21,560 adults evaluated, 41% (8759/21,560) had abnormal CSF findings with positive microbiological testing and/or pleocytosis; 43% (3755/8759) of these had no confirmed microbiological diagnosis. Of the 5004 microbiologically-confirmed meningitis cases, 89% (4432/5004) were cryptococcal (CM) and 8% (382/5004) pneumococcal (PM). Seventy-three percent (9525/13,033) of individuals undergoing LP with identifiers for HIV registry linkage had documented HIV-infection. Incidence of LP for meningitis evaluation in Botswana 2013–2014 was 142.6/100,000 person-years (95%CI:138.3–147.1); incidence of CM was 25.0/100,000 (95%CI:23.2–26.9), and incidence of PM was 2.7/100,000 (95%CI:2.4–3.1). In contrast to previously reported declines in CM incidence with ART roll-out, no significant temporal decline in pneumococcal or culture-negative meningitis was observed. CM remained the predominant identified aetiology of meningitis despite ART scale-up. A high proportion of cases had abnormal CSF with negative microbiological evaluation.