Global and regional risk of disabling sequelae from bacterial meningitis: a systematic review and meta-analysis

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Summary

Few data sources are available to assess the global and regional risk of sequelae from bacterial meningitis. We aimed to estimate the risks of major and minor sequelae caused by bacterial meningitis, estimate the distribution of the different types of sequelae, and compare risk by region and income. We systematically reviewed published papers from 1980 to 2008. Standard global burden of disease categories (cognitive deficit, bilateral hearing loss, motor deficit, seizures, visual impairment, hydrocephalus) were labelled as major sequelae. Less severe, minor sequelae (behavioural problems, learning difficulties, unilateral hearing loss, hypotonia, diplopia), and multiple impairments were also included. 132 papers were selected for inclusion. The median (IQR) risk of at least one major or minor sequela after hospital discharge was 19·9% (12·3–35·3%). The risk of at least one major sequela was 12·8% (7·2–21·1%) and of at least one minor sequela was 8·6% (4·4–15·3%). The median (IQR) risk of at least one major sequela was 24·7% (16·2–35·3%) in pneumococcal meningitis; 9·5% (7·1–15·3%) in Haemophilus influenzae type b (Hib), and 7·2% (4·3–11·2%) in meningococcal meningitis. The most common major sequela was hearing loss (33·9%), and 19·7% had multiple impairments. In the random-effects meta-analysis, all-cause risk of a major sequela was twice as high in the African (pooled risk estimate 25·1% [95% CI 18·9–32·0%]) and southeast Asian regions (21·6% [95% CI 13·1–31·5%]) as in the European region (9·4% [95% CI 7·0–12·3%]; overall I2=89·5%, p<0·0001). Risks of long-term disabling sequelae were highest in low-income countries, where the burden of bacterial meningitis is greatest. Most reported sequelae could have been averted by vaccination with Hib, pneumococcal, and meningococcal vaccines.

Introduction

Published reviews of bacterial meningitis incidence and case fatality hide the true impact of bacterial meningitis on families and communities. Survivors of bacterial meningitis are at risk from long-term disabling sequelae and impaired quality of life,1 but disabled children and adults are hidden from view in many societies, subjected to stigma and neglect, and undercounted in national and international statistics.2

Few data sources are available for paediatricians and public-health researchers to assess the long-term risk of disability associated with bacterial meningitis across countries and regions. There is also little information about the severity and distribution of the different types of sequelae. Additionally, the financial burden that families incur in caring for disabled individuals is commonly not calculated or is underestimated.3 Data are especially poor from low-income countries, where the risks of infection are highest and care is least accessible. Indeed, previous systematic reviews of the long-term outcomes from bacterial meningitis focused on studies from high-income countries.1, 4

The risk of sequelae from bacterial meningitis has probably changed since these systematic reviews were published because of improvements in antibiotics and supportive therapies to treat acute episodes of bacterial meningitis. Clinicians are now using highly sensitive tests to diagnose long-term disabling sequelae that would have previously remained undetected. Additionally, coverage of conjugate vaccines against the main causes of bacterial meningitis (Haemophilus influenzae type b [Hib], Streptococcus pneumoniae [pneumococcus], and Neisseria meningitidis [meningococcus]) has increased.5 These factors might influence risks of sequelae in different ways.

Our aims were to estimate the risks of major and minor sequelae caused by bacterial meningitis, to estimate the distribution of the different types of sequelae, and to compare sequelae risk by region and gross national income (GNI).

Section snippets

Search strategy and selection criteria

The initial search of Medline and WHOLIS databases aimed to be as inclusive as possible, and used the search terms “meningitis, bacterial”[Mesh] AND “complications”[Subheading], limited to human studies published between Jan 1, 1980 and Mar 1, 2008 (figure 1). We restricted our search up to March, 2008, to maintain consistency and comparability with other WHO Global Burden of Disease (GBD) and Child Health Epidemiology Reference Group publications aimed at producing estimates for the year 2008.6

Results

We selected 132 studies that were suitable for inclusion (figure 1).14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117

Discussion

We reported a median overall risk of long-term disabling sequelae in meningitis survivors after discharge from hospital of 20%. Risks of at least one major post discharge sequela ranged from 9% to 25% across the WHO regions, and were almost three times higher in Africa and Asia than in Europe. Major sequelae risk also increased significantly as GNI per head decreased. The overall global risk was similar to that found in previous reviews,1, 4 but our study differed by reporting disparities in

Search strategy and selection criteria

These are described in detail in the Methods section.

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