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Increased incidence of meningococcal disease in HIV-infected individuals associated with higher case-fatality ratios in South Africa

Cohen, Cheryla,b; Singh, Elvirab; Wu, Henry Me,f; Martin, Staceyf; de Gouveia, Lindaa; Klugman, Keith Pa,c,d; Meiring, Susana; Govender, Nelesha,c; von Gottberg, Annea,cfor the Group for Enteric, Respiratory and Meningeal disease Surveillance in South Africa (GERMS-SA)

doi: 10.1097/QAD.0b013e32833a2520
Epidemiology and Social

Objectives: We aimed to compare the incidence of meningococcal disease amongst HIV-infected and uninfected individuals and to evaluate whether HIV is a risk factor for mortality and bacteremia amongst patients with meningococcal disease.

Design: Cohort surveillance study.

Methods: We conducted laboratory-based surveillance for meningococcal disease in Gauteng Province, South Africa. HIV status and outcome data were obtained at sentinel sites. Incidence in HIV-infected and uninfected persons was calculated assuming a similar age-specific HIV prevalence in tested and untested individuals. Risk factors for death and bacteremia (as compared with meningitis) were evaluated using multivariable logistic regression.

Results: From 2003 to 2007, 1336 meningococcal cases were reported. Of 504 patients at sentinel sites with known outcome, 308 (61%) had HIV serostatus data. HIV prevalence amongst cases of meningococcal disease was higher than the population HIV prevalence in all age groups. The incidence of meningococcal disease in HIV-infected individuals was elevated in all age groups with an age-adjusted relative risk of 11.3 [95% confidence interval (CI) 8.9–14.3, P < 0.001]. The case-fatality ratio (CFR) was 20% (27/138) amongst HIV-infected and 11% (18/170) amongst HIV-uninfected individuals [odds ratio (OR) 2.1, 95% CI 1.1–3.9]. On multivariable analysis, CFR was greater amongst patients with bacteremia (35%, 29/82) compared with meningitis (7%, 16/226) (OR 7.8, 95% CI 3.4–17.7). HIV infection was associated with increased odds of bacteremia (OR 2.7, 95% CI 1.5–5.0).

Conclusion: HIV-infected individuals may be at increased risk of meningococcal disease. The increased CFR in HIV-infected patients may be explained by their increased odds of bacteremia compared to meningitis.

aNational Institute for Communicable Diseases (NICD), a division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa

bSchool of Public Health, South Africa

cSchool of Pathology, University of the Witwatersrand, Johannesburg, South Africa

dHubert Department of Global Health, Rollins School of Public Health, and Division of Infectious Diseases, School of Medicine, Emory University, Atlanta, Georgia, USA

eEpidemic Intelligence Service Program, Office of Workforce and Career Development, USA

fDivision of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Received 24 December, 2009

Revised 11 March, 2010

Accepted 20 March, 2010

Correspondence to Cheryl Cohen, Epidemiology and Surveillance Unit, National Institute for Communicable Diseases, Private Bag X4, Sandringham 2131, Gauteng, South Africa. Tel: +27 11 386 6593; fax: +27 11 882 9979; e-mail:

© 2010 Lippincott Williams & Wilkins, Inc.