Commentary: Opportunities to decrease mortality and long-term sequellae associated with meningococcal disease in Africa.

Epidemics of meningitis primarily due to Neisseria meningitidis serogroup A have posed a recurring public health challenge in countries in the Sub-Saharan African 'meningitis belt' for at least 100 years. 1,2 In this region, sporadic infections occur in annual cycles with large-scale epidemics superimposed periodically. These epidemics frequently result in attack rates of 250 to 500 cases per 100 000 population, but rates can exceed 1000 cases per 100 000 population (1%). In 1996, the largest recorded epidemic of meningococcal meningitis occurred in West Africa; more than 153 655 cases primarily from five African countries paralysed medical care systems and exhausted vaccine supplies. 3 Case-fatality rates from meningococcal disease in Africa are usually reported as 8–12%, but ill patients may not reach medical care and community studies have reported substantially higher mortality. 4 In additional to substantial mortality, many survivors of meningococcal disease are left permanently impaired by hearing loss, loss of limbs or mental retardation but studies of the magnitude of these sequellae are scare, particularly in developing countries. The research by Hodgson et al. published in this issue of the International Journal of Epidemiology takes on the important but difficult task of assessing sequellae among patients with meningococcal meningitis in Africa. 5 This study examined only patients with meningitis and did not evaluate patients with meningococcaemia who have significantly higher case fatality. 6,7 In the study by Hodgson et al., 5 hearing impairment, diagnosed by audiology, was the major sequella and the only significant objective difference identified between patients with meningitis and controls. The rate of severe and moderate hearing loss at 1.6% was actually lower than has been reported in other studies of sequellae among survivors in developed countries. 7–9 There is evidence that the hearing loss associated with bacterial meningitis improves with time 8 so part of this difference may be explained by the timing of testing. Another explanation may rest in the unusual age distribution of patients in this study. During meningococcal epidemics, the age distribution shifts towards older age; however, most studies have reported at least 20% of patients less than one year of age. 10 In this study, no patient was less than 2 years of age which may represent an ascertainment bias and could certainly impact the results. Hodgson et al. 5 evaluated psychiatric, neuropsychological and behavioural problems using a structured questionnaire. They did not use more sophisticated testing which may have …