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Increased Risk of Death in Human Immunodeficiency Virus-infected Children With Pneumococcal Meningitis in South Africa, 2003–2005

Nyasulu, Peter MSc (Med)*; Cohen, Cheryl FCP*,†; De Gouveia, Linda ND MT; Feldman, Charles DSc; Klugman, Keith P. PhD†,§,¶; von Gottberg, Anne FCP†,‖for the Group for Enteric, Respiratory and Meningeal Diseases Surveillance in South Africa (GERMS-SA)

The Pediatric Infectious Disease Journal: December 2011 - Volume 30 - Issue 12 - p 1075–1080
doi: 10.1097/INF.0b013e31822cca05
Pediatric HIV/AIDS

Background: Pneumococcal disease is a major global cause of morbidity and mortality. This study evaluated risk factors for mortality in children with pneumococcal meningitis and other invasive pneumococcal diseases (IPD).

Methods: The study population included patients <15 years of age with laboratory-confirmed IPD and available outcome data between January 1, 2003 and December 31, 2005 as reported to a national laboratory-based surveillance program. Meningitis was defined by having pneumococcus identified from cerebrospinal fluid culture, while other IPD included patients with pneumococci identified from other normally sterile site specimens. Risk factors for mortality were evaluated using multivariable logistic regression.

Results: A total of 2251 patients with IPD were reported from sentinel sites: 581 with laboratory-confirmed meningitis and 1670 with other IPD. The case-fatality ratio was 35% (205/581) among meningitis cases and 18% (300/1670) among other IPD cases (P < 0.001). Among individuals with available human immunodeficiency virus (HIV) status data, HIV coinfection was less likely among patients with meningitis compared with other IPD (74% [244/328] vs. 82% [880/1067] P < 0.001). On multivariable analysis, HIV-infected status (odds ratio [OR]: 5.34, 95% confidence interval [CI]: 2.32–12.29), Pitt bacteremia score ≥4 (OR: 3.08, 95% CI: 1.21–7.83) and age group <1 year (OR: 2.58, 95% CI: 1.21–5.51) were independent predictors of death among patients with meningitis. Among children with other IPD, malnutrition was an independent predictor of death while HIV infection was not independently associated with increased risk of death.

Conclusions: Pneumococcal meningitis is associated with a high case-fatality ratio among South African children and this is increased by HIV coinfection. Increasing access to antiretroviral therapy and a catch-up program for pneumococcal conjugate vaccine among HIV-infected and malnourished children could reduce this excess mortality.

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From the *School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; †National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa; ‡Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa; §Hubert Department of Global Health, Rollins School of Public Health, Atlanta, GA; and ¶Division of Infectious Diseases, School of Medicine, Emory University, Atlanta, GA; and ‖School of Pathology, University of the Witwatersrand, Johannesburg, South Africa.

Accepted for publication July 7, 2011.

The authors have no funding or conflicts of interest to disclose.

Address for correspondence: Peter Nyasulu, MSc, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, 2193, Johannesburg, South Africa. E-mail:

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© 2011 Lippincott Williams & Wilkins, Inc.