Meningococcal septicaemia and meningitis are common causes of death in children and young adults. In fatal cases, the time from onset to death is often short. We analysed case fatality rates for meningococcal disease between 1963 and 1998 to determine whether they have decreased.
Methods and results
We used data on meningococcal disease from the Oxford record linkage study database, which includes anonymised statistical abstracts of records of admission to hospital and death certificates in a defined population of 0.35 million people from 1963, 0.9 million from 1966, 1.9 million from 1974, and 2.5 million from 1987 to 1998. We calculated incidence of meningococcal disease and case fatality rates and assessed the significance of trends over time with logistic regression.
From 1963 to 1998, 1223 people had a record of admission to hospital for meningococcal meningitis or meningococcal septicaemia and 25 for other diagnoses—mainly meningitis or septicaemia without specification of an organism and a death certificate that specified meningococcal disease. The median age of these 1248 was 6 years; 255 (20%) were < 1 year old, 422 (34%) were 1-9 years old, 279 (22%) were 10-19 years old, 290 (23%) were ≥ 20 years old, and the ages of two were unknown; 116 died within 30 days and five more within 365 days of admission.
Analysis of the database showed that a further 25 people had died from meningococcal disease. Fifteen died in a hospital in the region but had no record of admission; they had probably been brought in dead or died soon after arrival at hospital without a formal admission. Ten had died at residential addresses. The median age of the 25 was 16 years, and 11 (44%) were aged at least 20 years. Of all 146 people who died, 25 (17%) died without admission to hospital, 41 (28%) died on the day of admission, and 40 (27%) died the day after admission.
Incidence has risen substantially in recent years (table). Case fatality rates have not significantly declined over time (P = 0.31 for cases admitted to hospital, and P = 0.28 for all cases). We found no significant trends in case fatality rates within individual age groups (see tables on bmj.com). For those admitted to hospital, case fatality rates at 30 days were similar in the teaching hospital (8.9%; 95% confidence interval 5.6% to 12.2%) and non-teaching hospitals (9.4%; 7.6% to 11.3%), and in males and females.
Table 1.
Cases of meningococcal disease* from the Oxford record linkage study database, number of deaths within 30 days and case fatality rate per 100 000, 1963-98
|
Cases admitted to hospital
|
All cases
|
||||||
|---|---|---|---|---|---|---|---|
| Time period | No of cases | No of deaths | Case fatality rate (95% CI) | No of cases | Incidence per 100 000 population (95% CI) | No of deaths† | Case fatality rate (95% CI) |
| 1963-8 | 41 | 5 | 12.2 (2.2 to 22.2) | 42 | 1.23 (0.86 to 1.60) | 6 | 14.3 (3.7 to 24.9) |
| 1969-73 | 72 | 6 | 8.3 (1.9 to 14.7) | 74 | 1.72 (1.33 to 2.11) | 8 | 10.8 (3.7 to 17.9) |
| 1974-8 | 108 | 12 | 11.1 (5.2 to 17.0) | 111 | 1.24 (1.01 to 1.47) | 15 | 13.5 (7.2 to 19.9) |
| 1979-83 | 113 | 11 | 9.7 (4.3 to 15.2) | 113 | 1.09 (0.89 to 1.29) | 11 | 9.7 (4.3 to 15.2) |
| 1984-8 | 147 | 16 | 10.9 (5.8 to 15.9) | 152 | 1.33 (1.12 to 1.54) | 21 | 13.8 (8.3 to 19.3) |
| 1989-93 | 303 | 25 | 8.3 (5.2 to 11.3) | 308 | 2.40 (2.13 to 2.67) | 30 | 9.7 (6.4 to 13.1) |
| 1994-8 | 464 | 41 | 8.8 (6.3 to 11.4) | 473 | 3.55 (3.23 to 3.87) | 50 | 10.6 (7.8 to 13.3) |
| 1963-98 | 1248 | 116 | 9.3 (7.7 to 10.9) | 1273 | 1.97 (1.86 to 2.07) | 141 | 11.1 (9.4 to 12.8) |
| P value for trend‡ | 0.31 | <0.001 | 0.28 | ||||
International Classification of Diseases, 9th revision, code 036 and 10th revision code A39.
Includes 25 people who died outside hospital or who had no record of hospital admission.
P values refer to the change in annual rates 1963-98 from logistic regression modelling. Visual inspection of the annual incidence and further modelling showed little change in incidence during 1963-88 (P=0.10) and a significant increase during 1989-98 (P<0.001).
Comment
Case fatality rates for meningococcal disease in the Oxford region have not fallen since the late 1960s. Others have also reported no recent reduction in case fatality rates in population based studies,1-3 although recent declines in a specialist paediatric unit have been described.4 In our study, a relatively high percentage of people who died outside hospital, or on arrival, were adults and perhaps had been less closely observed than children in their illness outside hospital. Our case fatality rate of 11% is the same as that found in a study based on multiple source case ascertainment and case note review in an adjacent health region in 1969-74.4 In that study, 22% of all deaths, compared to 17% in this study, occurred without admission to hospital or in people who were dead on arrival.5
The time from onset to death is usually rapid. This, and the fact that death rates have not declined, emphasises the need for vigilance in making the diagnosis and the importance of prevention through immunisation and, when appropriate, chemoprophylaxis for contacts.
Supplementary Material
Tables for specific age groups are on bmj.com
Contributors: MJG designed the study and wrote the manuscript. SER did the analyses and wrote the manuscript. DY programmed the Oxford record linkage study database. MJG and SER are guarantors.
Funding: SER receives funding from the Department of Health as part of its funding for the National Centre for Health Outcomes Development; and the Unit of Health-Care Epidemiology is funded by the Research and Development Directorate of the Department of Health and Social Care (South). The views expressed in this paper are those of the authors and not necessarily those of the Department of Health.
Competing interests: None declared.
References
- 1.Wylie PA, Stevens D, Drake W III, Stuart J, Cartwright K. Epidemiology and clinical management of meningococcal disease in west Gloucester-shire: retrospective, population based study. BMJ 1997;315: 774-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Sorensen HT, Steffensen FH, Schonheyder HC, Nielsen GL, Hansen I, Madsen KM, et al. Trend in incidence and case fatality of meningococcal disease over 16 years in northern Denmark. Eur J Clin Microbiol Infect Dis 1998;17: 690-4. [DOI] [PubMed] [Google Scholar]
- 3.Booy R, Habibi P, Nadel S, de Munter C, Britto J, Morrison A, et al. Meningococcal Research Group. Reduction in case fatality rate from meningococcal disease associated with improved healthcare delivery. Arch Dis Child 2001;85: 386-90. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Goldacre MJ. Acute bacterial meningitis in childhood: incidence and mortality in a defined population. Lancet 1976;1: 28-31. [DOI] [PubMed] [Google Scholar]
- 5.Goldacre MJ. Acute bacterial meningitis: where do children die? Int J Epidemiol 1976;5: 343-7. [DOI] [PubMed] [Google Scholar]
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