The n e w e ng l a n d j o u r na l of
original article
From the Centers for Disease Control and
Prevention (M.C.T., C.G.W., N.E.M., E.R.Z.,
M.M.L., E.S., A.S.) and the Georgia De-
partment of Human Resources (M.M.F.)
both in Atlanta; Minnesota Department
of Health, Minneapolis (R.L.); Connecti-
cut Department of Public Health, Hart-
ford (J.L.H.); Johns Hopkins University
Bloomberg School of Public Health, Bal-
timore (L.H.H.); School of Public Health,
University of California at Berkeley,
Berkeley (A.R.); University of Rochester
School of Medicine and Dentistry, Roch-
ester, NY (N.M.B.); Vanderbilt University
School of Medicine, Nashville (A.S.C.,
W.S.); and Oregon Public Health Division,
Portland (A.T.). Address reprint requests
to Dr. Thigpen at: 3150 Rampart Rd., Fort
Collins, CO 80521, or at mthigpen@cdc
.gov or thigpenm@kh.cdc.gov.
N Engl J Med 2011;364:2016-25.
Copyright 2011 Massachusetts Medical Society.
2016
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m e dic i n e
Bacterial Meningitis in the United States,
19982007
Michael C. Thigpen, M.D., Cynthia G. Whitney, M.D., M.P.H.,
Nancy E. Messonnier, M.D., Elizabeth R. Zell, M.Stat., Ruth Lynfield, M.D.,
James L. Hadler, M.D., M.P.H., Lee H. Harrison, M.D., Monica M. Farley, M.D.,
Arthur Reingold, M.D., Nancy M. Bennett, M.D., Allen S. Craig, M.D.,
William Schaffner, M.D., Ann Thomas, M.D., Melissa M. Lewis, M.P.H.,
Elaine Scallan, Ph.D., and Anne Schuchat, M.D.,
for the Emerging Infections Programs Network
A BS T R AC T
Background
The rate of bacterial meningitis declined by 55% in the United States in the early
1990s, when the Haemophilus influenzae type b (Hib) conjugate vaccine for infants was
introduced. More recent prevention measures such as the pneumococcal conjugate
vaccine and universal screening of pregnant women for group B streptococcus (GBS)
have further changed the epidemiology of bacterial meningitis.
Methods
We analyzed data on cases of bacterial meningitis reported among residents in eight
surveillance areas of the Emerging Infections Programs Network, consisting of ap-
proximately 17.4 million persons, during 19982007. We defined bacterial meningitis
as the presence of H. influenzae, Streptococcus pneumoniae, GBS, Listeria monocytogenes, or
Neisseria meningitidis in cerebrospinal fluid or other normally sterile site in association
with a clinical diagnosis of meningitis.
Results
We identified 3188 patients with bacterial meningitis; of 3155 patients for whom
outcome data were available, 466 (14.8%) died. The incidence of meningitis changed
by 31% (95% confidence interval [CI], 33 to 29) during the surveillance period,
from 2.00 cases per 100,000 population (95% CI, 1.85 to 2.15) in 19981999 to 1.38
cases per 100,000 population (95% CI 1.27 to 1.50) in 20062007. The median age of
patients increased from 30.3 years in 19981999 to 41.9 years in 20062007 (P<0.001
by the Wilcoxon rank-sum test). The case fatality rate did not change significantly:
it was 15.7% in 19981999 and 14.3% in 20062007 (P=0.50). Of the 1670 cases re-
ported during 20032007, S. pneumoniae was the predominant infective species (58.0%),
followed by GBS (18.1%), N. meningitidis (13.9%), H. influenzae (6.7%), and L. monocyto-
genes (3.4%). An estimated 4100 cases and 500 deaths from bacterial meningitis
occurred annually in the United States during 20032007.
Conclusions
The rates of bacterial meningitis have decreased since 1998, but the disease still often
results in death. With the success of pneumococcal and Hib conjugate vaccines in
reducing the risk of meningitis among young children, the burden of bacterial men-
ingitis is now borne more by older adults. (Funded by the Emerging Infections Pro-
grams, Centers for Disease Control and Prevention.)
n engl j med 364;21 nejm.org may 26, 2011
The New England Journal of Medicine
Copyright 2011 Massachusetts Medical Society. All rights reserved.
 Bacterial Meningitis in the United States
S
tudies in the 1970s and 1980s showed
that five pathogens (Haemophilus influenzae,
Streptococcus pneumoniae, Neisseria meningitidis,
group B streptococcus [GBS], and Listeria monocy-
togenes) caused more than 80% of cases of bacte-
rial meningitis.1-4 Between 1986 and 1995, the
incidence of bacterial meningitis from these five
pathogens declined by 55%, largely owing to the
use of the H. influenzae type b (Hib) conjugate vac-
cine for infants, which was introduced in the Unit-
ed States in 1990.5 Since then, additional inter-
ventions to prevent invasive disease from these
pathogens have been introduced6-8 (see also Table
1 in the Supplementary Appendix, available with
the full text of this article at NEJM.org). With the
introduction of the heptavalent protein-polysac-
charide pneumococcal conjugate vaccine (PCV7) in
2000, invasive pneumococcal disease declined by
75% among children under 5 years of age and by
31% among adults 65 years or older.9,10 Since the
age of the patient guides empirical antimicrobial
therapy for purulent meningitis,11 the effect of
prevention strategies on the current epidemiolo-
gy of bacterial meningitis remains important to
define.
We used data from two active laboratory- and
population-based surveillance systems of the
Emerging Infections Programs (EIP) Network
the Active Bacterial Core surveillance (ABCs) and
the Foodborne Diseases Active Surveillance Net-
work (FoodNet) to describe trends in the in-
cidence of bacterial meningitis from 1998 to 2007
and to describe the epidemiology of meningitis
for 20032007 in order to provide a baseline for
the evaluation of future interventions.
Me thods
Data Collection
To describe trends in the incidence of bacterial
meningitis, we analyzed ABCs surveillance data
on culture-confirmed invasive infection with
H.inf luenzae, S. pneumoniae, N. meningitidis, or GBS
and FoodNet surveillance data on culture-con-
firmed invasive infection with L. monocytogenes.
The infections were reported between January 1,
1998, and December 31, 2007, at the following
EIP sites: California (San Francisco county), Con-
necticut (entire state), Georgia (20-county Atlan-
ta area), Maryland (6-county Baltimore area),
Minnesota (7-county MinneapolisSt. Paul area),
New York (7-county Rochester area), Oregon
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(3-county Portland area), and Tennessee (5 urban
counties). These eight sites encompassed an esti-
mated 17,383,935 persons (6.4% of the total U.S.
population), according to the 1998 census.
Between 1998 and 2003, additional counties
were added to EIP sites in Minnesota, New York,
and Tennessee. To assess the epidemiology of
bacterial meningitis from less-common pathogens
across a 5-year period (between January 1, 2003,
and December 31, 2007), we used this expanded
surveillance area, with an estimated population of
22,870,454 persons (7.9% of the total U.S. popula-
tion), according to the 2003 census.
The methods of ABCs have been published pre-
viously.12,13 ABCs defines a case of bacterial men-
ingitis as the presence of H. influenzae, S. pneumoniae,
N. meningitidis, or GBS in cerebrospinal fluid or an-
other normally sterile site in association with a
clinical diagnosis of meningitis made by the
primary health care provider in a resident of a
surveillance area. FoodNet receives data on all
culture-confirmed cases of L. monocytogenes infec-
tion.14,15 Since FoodNet does not collect informa-
tion on clinical meningitis, we included in this
study only cases from the FoodNet database in
which L. monocytogenes was isolated from a cerebro-
spinal fluid specimen.
All surveillance methods remained consistent
between 1998 and 2007. ABCs sites sent available
isolates to reference laboratories for organism-
specific subtyping; pneumococcal and GBS iso-
lates underwent antimicrobial-susceptibility test-
ing.12 PCV7 strains included pneumococcal
serotypes 4, 6B, 9V, 14, 8C, 19F, and 23F; all
other serotypes were considered non-PCV7 types.
Strains considered to be 13-valent pneumococcal
conjugate vaccine (PCV13) strains included the
PCV7 serotypes as well as serotypes 1, 3, 5, 6A,
7F, and 19A; all other serotypes were considered
to be non-PCV13 types. Serogroups found in quad-
rivalent meningococcal conjugate vaccine (MCV4)
or quadrivalent meningococcal polysaccharide
vaccine (MPSV4) included A, C, W135, and Y; all
others were considered to be nonvaccine types.
Statistical Analysis
We used SAS software, version 9.1 (SAS Institute),
for analyses. We calculated the rates of bacterial
meningitis for each year from 1998 through 2007,
expressed as the number of cases per 100,000
population, by using U.S. Census annual popula-
tion estimates, adjusted for race and age, for the
2017
 The n e w e ng l a n d j o u r na l
surveillance sites. We used chi-square analyses to
test for significant linear trends over time and
the Wilcoxon ranksum test to compare medians
across years.
To estimate the burden of bacterial meningitis
in the United States in 20032007, we used ob-
served rates of bacterial meningitis for each age
group or race, calculated from the ABCs and
FoodNet data, and applied the observed rates to
the total U.S. population. Race was categorized
as black, white, or other (including American
Indian or Alaska Native and Asian or Pacific Is-
lander). For each surveillance site and age group,
cases for which race was unknown and cases
caused by S. pneumoniae or N. meningitidis infection
for which serotype or serogroup information was
unknown were assigned according to the distri-
butions of cases for which race or serotype or
serogroup, respectively, were known.
We calculated case fatality rates using only data
from patients with a known outcome (98.9% of
patients). A P value of less than 0.05 was consid-
ered to indicate statistical significance. Methods
are described further in the Supplementary Ap-
pendix.
R e sult s
Rates of Bacterial Meningitis, 19982007
From 1998 through 2007, we identified 3188 cases
of bacterial meningitis due to H. influenzae, S. pneu-
moniae, N. meningitidis, GBS, or L. monocytogenes.
The incidence of bacterial meningitis caused by
these pathogens changed during this period by
31% (95% confidence interval [CI], 33 to 29),
from 2.00 cases per 100,000 population (95% CI,
1.85 to 2.15) in 19981999 to 1.38 cases per
100,000 population (95% CI, 1.27 to 1.50) in 2006
2007 (Table 1). Throughout the surveillance peri-
od, incidences remained highest for patients un-
der 2 months of age and for black patients of any
age. Incidences declined significantly over the sur-
veillance period within all age groups except for
patients under 2 months of age. The median age of
patients increased from 30.3 years during 1998
1999 to 41.9 years during 20062007 (P<0.001).
Between 19981999 and 20062007, no significant
change in the case fatality rate was observed (15.7%
and 14.3%, respectively; P=0.50).
Infection with S. pneumoniae accounted for 1813
cases of bacterial meningitis and for 321 deaths
among the 1796 cases for which outcome data
2018 n engl j med 364;21 nejm.org may 26, 2011
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of m e dic i n e
were available (case fatality rate, 17.9%). Between
19981999 and 20062007, the incidence of S. pneu-
moniae meningitis changed by 26% (95% CI, 29
to 23), from 1.09 cases per 100,000 population
(95% CI, 0.98 to 1.20) in 19981999 to 0.81 cases
per 100,000 population (95% CI, 0.72 to 0.90) in
20062007 (Table 2). This overall decline included
a change of 62% (95% CI 66 to 58) among
children 2 to 23 months of age, from 9.7 cases per
100,000 population (95% CI, 7.7 to 11.9) in 1998
1999 to 3.7 cases per 100,000 population (95% CI,
2.5 to 5.1) in 20062007. The overall case fatality
rate did not change significantly; it was 17.9% in
19981999 and 14.7% in 20062007 (P=0.26).
The incidence of meningitis from S. pneumoniae
PCV7 serotypes changed by 92% overall (95%
CI, 93 to 91), from 0.61 cases per 100,000 popu-
lation (95% CI, 0.48 to 0.64) in 19981999 to 0.05
cases per 100,000 population (95% CI, 0.03 to 0.07)
in 20062007 (Table 2). However, the incidence of
bacterial meningitis from non-PCV7 serotypes
increased by 61% (95% CI, 54 to 69), from 0.48
cases per 100,000 population (95% CI, 0.45 to 0.60)
in 19981999 to 0.77 cases per 100,000 popula-
tion (95% CI, 0.67 to 0.84) in 20062007.
The pathogen N. meningitidis was identified in
549 cases of bacterial meningitis; of the 547 cases
for which outcome data were available, 55 were
fatal (case fatality rate, 10.1%). The incidence of
N. meningitidis meningitis changed by 58% over-
all (95% CI, 61 to 54), from 0.44 cases per
100,000 population (95% CI, 0.37 to 0.51) in
19981999 to 0.19 cases per 100,000 population
(95% CI, 0.14 to 0.24) in 20062007. The rates of
meningococcal meningitis caused by serogroups
B, C, and Y changed by 55% (95% CI, 60 to 49),
65% (95% CI 69% to 60%), and 52% (95% CI
59% to 45%), respectively. The number of cases
per 100,000 population that were due to serogroup
B declined from 0.13 (95% CI, 0.09 to 0.16) in
19981999 to 0.06 (95% CI, 0.04 to 0.09) in 2006
2007; the number of cases due to serogroup C
declined from 0.19 (95% CI, 0.14 to 0.23) to 0.07
(95% CI, 0.04 to 0.09); and the number of cases
due to serogroup Y declined from 0.10 (95% CI,
0.05 to 0.11) to 0.05 (95% CI, 0.02 to 0.05).
Between 1998 and 2007, a total of 534 cases
of meningitis from GBS infection were reported
to ABCs; of the 522 cases for which outcome data
were available, 58 were fatal (case fatality rate,
11.1%). Overall, rates of GBS meningitis did not
change significantly during the surveillance pe-
 Table 1. Incidence of Bacterial Meningitis in the United States, 19982007, Stratified According to Age Group, Race, and Pathogen.*

Percent Change, 2006

2007 vs. 19981999
Characteristic 19981999 20002001 20022003 20042005 20062007 (95% CI)
no. of cases per 100,000 population (95% CI)
Age group
<2 Mo 73.46 (56.45 to 94.35) 88.28 (69.69 to 109.95) 56.59 (42.13 to 74.45) 77.27 (60.58 to 96.90) 80.69 (63.53 to 101.42) 10 (1 to 20)
223 Mo 14.20 (11.85 to 16.91) 11.49 (9.45 to 13.92) 6.56 (5.06 to 8.38) 6.95 (5.47 to 8.89) 6.91 (5.30 to 8.77) 51 (55 to 48)
210 Yr 1.55 (1.20 to 1.96) 1.48 (1.16 to 1.88) 0.94 (0.68 to 1.27) 1.07 (0.79 to 1.43) 0.56 (0.36 to 0.82) 64 (68 to 59)
1117 Yr 1.03 (0.71 to 1.43) 0.87 (0.60 to 1.22) 0.62 (0.39 to 0.94) 0.56 (0.34 to 0.86) 0.43 (0.25 to 0.71) 58 (64 to 51)
1834 Yr 0.99 (0.79 to 1.22) 0.86 (0.68 to 1.07) 0.70 (0.54 to 0.89) 0.76 (0.59 to 0.97) 0.66 (0.50 to 0.86) 33 (38 to 27)
3549 Yr 1.23 (1.01 to 1.48) 1.30 (1.08 to 1.55) 1.08 (0.89 to 1.31) 0.91 (0.74 to 1.13) 0.95 (0.76 to 1.16) 23 (29 to 17)
5064 Yr 2.15 (1.75 to 2.57) 1.83 (1.49 to 2.21) 2.09 (1.75 to 2.48) 1.79 (1.49 to 2.14) 1.73 (1.44 to 2.06) 19 (25 to 14)
65 Yr 2.64 (2.13 to 3.16) 2.20 (1.76 to 2.72) 2.21 (1.78 to 2.71) 1.51 (1.16 to 1.94) 1.92 (1.53 to 2.38) 27 (32 to 22)
All ages 2.00 (1.85 to 2.15) 1.82 (1.69 to 1.97) 1.49 (1.38 to 1.62) 1.41 (1.30 to 1.54) 1.38 (1.27 to 1.50) 31 (33 to 29)
Race
White 1.71 (1.55 to 1.87) 1.58 (1.43 to 1.73) 1.28 (1.15 to 1.42) 1.27 (1.14 to 1.41) 1.28 (1.14 to 1.40) 25 (28 to 23)
Black 4.07 (3.57 to 4.62) 3.85 (3.40 to 4.35) 3.12 (2.72 to 3.57) 2.62 (2.28 to 3.03) 2.41 (2.13 to 2.84) 41 (44 to 37)
Other 1.55 (0.98 to 2.23) 0.68 (0.37 to 1.18) 0.76 (0.44 to 1.25) 0.67 (0.39 to 1.14) 0.46 (0.25 to 0.86) 70 (75 to 64)

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The New England Journal of Medicine

Pathogen
Bacterial Meningitis in the United States

Streptococcus pneumoniae 1.09 (0.98 to 1.20) 1.03 (0.93 to 1.13) 0.93 (0.83 to 1.03) 0.76 (0.68 to 0.85) 0.81 (0.72 to 0.90) 26 (29 to 23)
Neisseria meningitidis 0.44 (0.37 to 0.51) 0.37 (0.31 to 0.44) 0.23 (0.19 to 0.29) 0.22 (0.17 to 0.27) 0.19 (0.14 to 0.24) 58 (61 to 54)
Group B streptococcus 0.24 (0.20 to 0.30) 0.30 (0.25 to 0.36) 0.21 (0.17 to 0.26) 0.27 (0.22 to 0.32) 0.25 (0.21 to 0.31) 4 (3 to 12)

Copyright 2011 Massachusetts Medical Society. All rights reserved.

Haemophilus influenzae 0.12 (0.09 to 0.17) 0.10 (0.07 to 0.14) 0.10 (0.07 to 0.13) 0.10 (0.07 to 0.14) 0.08 (0.05 to 0.11) 35 (42 to 27)
Listeria monocytogenes 0.10 (0.08 to 0.16) 0.03 (0.01 to 0.05) 0.03 (0.01 to 0.05) 0.05 (0.04 to 0.10) 0.05 (0.03 to 0.08) 46 (53 to 39)

* CI denotes confidence interval.

Race was obtained from medical records. Other includes American Indian or Alaska Native, Asian or Pacific Islander, or other race. Within a site and age group, cases with missing

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data for race were assumed to have a distribution of race similar to that among cases with available data.

2019
 2020
Table 2. Incidence of Bacterial Meningitis from Streptococcus pneumoniae in the United States, 19982007, Stratified According to Age Group or Age Group and Serotype.*

Percent Change,
20062007 vs. 1998
Characteristic 19981999 20002001 20022003 20042005 20062007 1999 (95% CI)
no. of cases per 100,000 population (95% CI)
Age group
223 Mo 9.69 (7.68 to 11.87) 7.24 (5.51 to 9.04) 3.32 (2.29 to 4.67) 3.59 (2.51 to 4.96) 3.67 (2.53 to 5.12) 62 (66 to 58)
The

210 Yr 0.54 (0.34 to 0.80) 0.80 (0.57 to 1.10) 0.47 (0.29 to 0.71) 0.54 (0.35 to 0.81) 0.36 (0.21 to 0.57) 34 (43 to 22)
1117 Yr 0.20 (0.08 to 0.42) 0.26 (0.12 to 0.49) 0.22 (0.10 to 0.43) 0.25 (0.12 to 0.47) 0.21 (0.09 to 0.42) 7 (18 to 38)
1834 Yr 0.40 (0.28 to 0.55) 0.37 (0.26 to 0.52) 0.37 (0.25 to 0.51) 0.38 (0.26 to 0.54) 0.27 (0.17 to 0.40) 33 (41 to 24)
3549 Yr 0.83 (0.65 to 1.04) 0.90 (0.72 to 1.11) 0.80 (0.63 to 1.00) 0.65 (0.50 to 0.83) 0.76 (0.60 to 0.96) 8 (15 to 0)
5064 Yr 1.47 (1.16 to 1.84) 1.36 (1.08 to 1.70) 1.69 (1.39 to 2.05) 1.37 (1.10 to 1.67) 1.34 (1.09 to 1.63) 9 (15 to 1)
65 Yr 1.88 (1.48 to 2.36) 1.63 (1.26 to 2.09) 1.77 (1.39 to 2.22) 0.87 (0.61 to 1.20) 1.43 (1.10 to 1.83) 24 (30 to 18)
All ages 1.09 (0.98 to 1.20) 1.03 (0.93 to 1.13) 0.93 (0.83 to 1.03) 0.76 (0.68 to 0.85) 0.81 (0.72 to 0.90) 26 (29 to 23)
Age group and serotype
<5 Yr
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The New England Journal of Medicine

of

PCV7 serotype 3.37 (2.46 to 3.91) 2.56 (1.61 to 2.78) 0.51 (0.27 to 0.86) 0.31 (0.13 to 0.60) 0.07 (0.01 to 0.30) 98 (98 to 97)
Non-PCV7 serotype 0.87 (0.76 to 1.65) 1.17 (1.11 to 2.15) 0.94 (0.61 to 1.41) 1.68 (1.23 to 2.26) 1.67 (1.17 to 2.19) 92 (68 to 119)

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65 Yr
PCV7 serotype 0.77 (0.49 to 1.05) 0.78 (0.54 to 1.12) 0.49 (0.30 to 0.74) 0.23 (0.10 to 0.41) 0.11 (0.04 to 0.27) 85 (88 to 81)

Copyright 2011 Massachusetts Medical Society. All rights reserved.

m e dic i n e

Non-PCV7 serotype 1.12 (0.84 to 1.53) 0.85 (0.58 to 1.18) 1.28 (0.95 to 1.67) 0.63 (0.43 to 0.94) 1.31 (1.00 to 1.70) 18 (7 to 29)
Any age
PCV7 serotype 0.61 (0.48 to 0.64) 0.58 (0.44 to 0.59) 0.30 (0.23 to 0.33) 0.16 (0.11 to 0.19) 0.05 (0.03 to 0.07) 92 (93 to 91)
Non-PCV7 serotype 0.48 (0.45 to 0.60) 0.45 (0.43 to 0.57) 0.63 (0.56 to 0.72) 0.60 (0.53 to 0.69) 0.77 (0.67 to 0.84) 61 (54 to 69)

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* There were too few cases in the age group of under 2 months to determine trends: five cases in 19981999, five cases in 20002001, two cases in 20022003, three cases in 20042005,
and two cases in 20062007. CI denotes confidence interval, and PCV7 heptavalent protein-polysaccharide pneumococcal conjugate vaccine.
 Bacterial Meningitis in the United States

riod; there were 0.24 cases per 100,000 popula- cause (Fig. 1A). The case fatality rate was 6.9%
tion (95% CI, 0.20 to 0.30) in 19981999 and 0.25 among pediatric patients on average; nearly 10%
cases (95% CI, 0.21 to 0.31) in 20062007. Rates had underlying immunocompromising or chron-
of GBS meningitis among patients under 2 months ic medical conditions (Table 3).
of age did not change significantly after the in- Isolates were available for serotyping in 187
troduction of universal GBS screening of preg- of the 203 pediatric cases (92.1%) caused by S. pneu-
nant women; the rate was 65.2 cases per 100,000 moniae. PCV7 serotypes accounted for 15.5% of
population (95% CI, 53.8 to 78.3) in 19982001 these pediatric cases overall and 13.0% of cases
and 62.5 (95% CI, 53.6 to 72.5) in 20022007 in the 2-to-23-month age group. The case fatality
(relative change, 4%; 95% CI 10 to 2), al- rate was similar among children infected with
though most cases (86.5%) in 20022007 were PCV7 isolates and those infected with non-PCV7
late-onset (7 days of age) and would not have isolates (10.7% and 7.6%, respectively; P=0.58).
been affected by the intrapartum antimicrobial Among patients under 5 years of age, the most
prophylaxis. common serotypes were 19A (in 26.1% of cases),
ABCs received 187 reports of H. influenzae men- 7F (11.2%), 10A (6.7%), and 22F (6.0%). PCV13
ingitis cases, 13 of which were fatal (case fatality serotypes accounted for 60.0% of cases in chil-
rate, 7.0%); 9.4% of cases were caused by serotype dren between 2 and 23 months of age and 57.2%
b. The overall incidence of H. influenzae meningitis in children of any age.
changed by 35% (95% CI, 42 to 27) between Isolates were available for serogroup testing in
19981999 and 20062007, from 0.12 cases per 105 of the 107 pediatric cases (98.1%) caused by
100,000 population (95% CI, 0.09 to 0.17) to 0.08 N. meningitidis. Serogroups B, C, and Y were most
(95% CI, 0.05 to 0.11). commonly identified (in 59.1%, 21.0%, and 11.4%
During the surveillance period, L. monocytogenes of cases, respectively). Serogroup B caused 70.5%
caused 105 cases of bacterial meningitis and 19 of the cases among children under 11 years of
deaths (case fatality rate, 18.1%). The incidence age. Serogroups included in a quadrivalent me-
changed by 46% (95% CI, 53 to 39), from 0.10 ningococcal vaccine (MCV4 or MPSV4) accounted
cases per 100,000 population (95% CI, 0.08 to for 66.7% of infections among children 11 to 17
0.16) in 19981999 to 0.05 (95% CI, 0.03 to 0.08) years of age.
in 20062007. The change among patients under ABCs received 222 case reports of GBS men-
2 months of age was 36% (95% CI, 51 to 16), ingitis, and isolates were available for serotyping
from 10.1 cases per 100,000 population (95% CI, in 139 of the cases (62.6%). Serotypes III, IA, and
4.6 to 19.8) in 19981999 to 6.5 (95% CI, 2.3 to V accounted for 43.0%, 30.8%, and 15.9% of cases
14.7) in 20062007. in the first 2 months of life, respectively. H. in-
fluenzae isolates were available for serotyping in
Epidemiology of Bacterial Meningitis, 2003 41 of 42 cases of meningitis (97.6%); 11 of these
2007 cases (26.8%) were nontypable. Serotypes f and
EIP sites reported 1670 cases of bacterial menin- b were identified in 14 and 5 cases, respectively. A
gitis from 2003 through 2007. Death occurred in total of 13 cases of L. monocytogenes meningitis
215 cases (13.0%); S. pneumoniae accounted for were reported in children, including 10 (76.9%) in
70.7% of these 215 deaths. We estimate that an children under 2 months of age.
average of 4100 cases of bacterial meningitis, in-
cluding 500 that were fatal, occurred annually in Adult Cases
the United States during 20032007 (Fig. 1 in the We identified 1083 cases of bacterial meningitis
Supplementary Appendix). in adults; S. pneumoniae was the most common
pathogen (Fig. 1B). The overall adult case fatality
Pediatric Cases rate was 16.4%, and the rate increased linearly
We identified 587 cases of bacterial meningitis with increasing age (8.9% among patients 18 to
among children. GBS accounted for 86.1% of cases 34 years of age vs. 22.7% among those 65 years,
among those under 2 months of age, and N. men- P<0.001).
ingitidis caused 45.9% of cases among those 11 to Isolates were available for serotyping in 680 of
17 years of age. Among the other pediatric age the 765 adult cases (88.9%) caused by S. pneumoniae.
groups, S. pneumoniae was the most common PCV7 and PCV13 serotypes accounted for 16.0%

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 The n e w e ng l a n d j o u r na l of m e dic i n e

of the 125 adult cases of bacterial meningitis

Listeria monocytogenes GBS Haemophilus influenzae (93.6%) caused by N. meningitidis. Serogroups B and
Neisseria meningitidis Streptococcus pneumoniae C were the predominant causes of cases among
A Children adults 18 to 34 years of age (accounting for 34.4%
100 and 45.9% of cases, respectively); in cases in adults
90 35 years of age or older, serogroups B and Y were
the most common (each serogroup accounted for
Percentage of Total Cases

80
70 30.4% of cases). Serogroups included in MCV4 or
60 MPSV4 accounted for 62.8% of infections among
50 patients 18 to 55 years of age.
40 Among the 80 adult cases caused by GBS, iso-
30 lates were available for laboratory analysis in 43
20 cases (53.8%). Serotypes IA and V accounted for
10 37.2% and 25.6% of these cases, respectively. Of
0
<2 Mo 223 210 1117 All pediatric
the 69 adult cases from H. influenzae, 61 (88.4%)
Mo Yr Yr cases had isolates available for serotyping. A majority
Age Group (73.8%) of the H. influenzae isolates were not able
to be serotyped. Serotypes e and f were the most
No. of Cases 201 212 113 61 587
common serotypes identified (with each found in
B Adults 11.5% of cases). The case fatality rate was sig-
100 nificantly higher among adult meningitis cases
90 from typable H. influenzae than among cases from
nontypable H. influenzae (18.8% vs. 2.2%, P=0.02).
Percentage of Total Cases

80
70 In 13 of the 44 reported cases of adult L. mono-
60 cytogenes meningitis (29.5%), serotyping could be
50 performed, and 8 isolates were of serotype 4B.
40 Only one case of L. monocytogenes meningitis oc-
30 curred in a pregnant woman, and none occurred
20
in a patient with human immunodeficiency virus
10
(HIV) infection.
0
1834 3549 5064 65 All adult
Yr Yr Yr Yr cases Discussion
Age Group
Our findings indicate that the incidence of bacte-
No. of Cases 192 291 377 223 1083
rial meningitis caused by H. influenzae, S. pneumoni-
Figure 1. Proportions of the 1670 Cases of Bacterial Meningitis Reported ae, GBS, L. monocytogenes, or N. meningitidis decreased
in 20032007 Caused by Each Pathogen, According to Age Group. in the past decade, primarily due to declines in
Panel A shows data for children, and Panel B shows data for adults. Over- the rate of S. pneumoniae meningitis. Rates of bac-
all, Streptococcus pneumoniae was the predominant cause of bacterial men- terial meningitis decreased most sharply among
ingitis (accounting for 58.0% of cases), followed by group B streptococcus children, causing the median age at diagnosis of
(GBS) (18.1%), Neisseria meningitidis (13.9%), Haemophilus influenzae
bacterial meningitis to increase. However, the over-
(6.7%), and Listeria monocytogenes (3.4%).
all case fatality rate was not significantly reduced,
since there has been little change in the case fa-
and 41.6% of the meningitis cases, respectively, and tality rate of pneumococcal meningitis. The tim-
meningitis from PCV7 serotypes of S. pneumoniae ing of the decline in the incidence of bacterial
had a higher case fatality rate than those caused by meningitis, as well as the change in causative se-
non-PCV7 serotypes (25.9% vs. 16.2%, P=0.02). rotypes, suggests that the use of PCV7 contribut-
Among patients 65 years of age or older, the most ed to the changes observed, as has been suggested
common S. pneumoniae serotypes were 3 (in 9.2% of previously in reports about pathogen-specific
cases), 11A (7.0%), 19A (7.0%), and 23A (7.0%); causes of meningitis.16-18
PCV13 accounted for only 39.4% of the serotypes Despite significant declines in the incidence of
causing meningitis in this older age group. pediatric bacterial meningitis, the incidence among
Isolates were available for confirmation in 117 infants under 2 months of age, which is the group

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 Bacterial Meningitis in the United States

Table 3. Characteristics of Patients with Bacterial Meningitis Identified by the Emerging Infections Programs Network, 20032007.

Neisseria Haemophilus Group B Listeria Streptococcus

Characteristic meningitidis influenzae Streptococcus monocytogenes pneumoniae All
percent of patients
Pediatric patients N=107 N=42 N=222 N=13 N=203 N=587
Male sex 62.6 61.9 49.5 46.2 54.7 54.5
Race*
White 69.2 71.4 47.3 30.8 59.1 56.7
Black 17.8 16.7 42.3 38.5 25.6 30.2
Other 2.8 9.5 3.2 0.0 3.0 3.4
Underlying medical condition
Immunocompromising condition 1.3 6.5 0.0 6.9 3.0
Chronic condition 8.8 9.7 3.6 9.1 6.7
Prematurity only 1.3 3.2 11.9 2.3 5.9
None 88.8 80.6 84.5 81.7 84.4
Case fatality rate
All pediatric patients 3.8 0 7.3 7.7 9.4 6.9
Pediatric patients <2 yr 2.5 0 7.5 0 7.7 6.3
Adult patients N=125 N=69 N=80 N=44 N=765 N=1083
Male sex 48.8 46.4 40.0 56.8 49.9 49.1
Race*
White 52.8 62.3 45.0 70.5 54.5 54.8
Black 20.8 24.6 33.8 11.4 29.8 28.0
Other 4.8 2.9 2.5 6.8 2.0 2.6
Underlying medical condition or risk
group
Immunocompromising condition 11.3 15.0 22.7 25.0 22.5
Chronic condition 18.6 36.7 36.4 35.1 32.7
Smoking 14.4 8.3 7.6 8.4 8.7
Age 65 yr only 2.1 8.3 4.5 7.0 7.4
None 53.6 31.7 28.8 24.5 28.7
Case fatality rate
All adult patients 10.4 7.2 20.8 20.5 17.5 16.4
Adult patients 50 yr 9.1 5.1 30.0 24.2 18.3 18.0

* Race was obtained from medical records. Other includes American Indian or Alaska Native, Asian or Pacific Islander, and other race. Data
on race were not available for some patients; therefore the percentages do not sum to 100%.
For underlying medical conditions, immunocompromising conditions include multiple myeloma, sickle cell disease, asplenia, organ trans-
plantation, immunoglobulin deficiency, immunosuppressive therapy, human immunodeficiency virus or the acquired immunodeficiency
syndrome (HIVAIDS), leukemia, Hodgkins disease, lupus, the nephrotic syndrome, and chronic kidney disease. Chronic conditions in-
clude asthma or chronic obstructive pulmonary disease, diabetes, cirrhosis, alcohol abuse, atherosclerotic cardiovascular disease, conges-
tive heart failure, burns, cerebrospinal fluid leak, injection-drug use, and cerebrovascular accident (as well as presence of hydrocephalus or
ventriculoperitoneal shunt in children). Some conditions were added for study during the surveillance period; not all were identified a priori.
Patients with more than one condition were counted for only one, according to the following hierarchy: immunocompromising condition,
chronic condition, smoker only (if adult), and prematurity or age of 65 years or older only. Data from the New York site are not included,
since cases of HIVAIDS are not reported at that site. Data for patients with bacterial meningitis from L. monocytogenes infection are also
not reported, since FoodNet does not consistently record underlying medical conditions for these patients.

at greatest risk for bacterial meningitis, did not
decrease. The major causative organism in this
vulnerable age group remains GBS, with infec-
tion manifested as late-onset disease 7 or more
days after birth. Although intrapartum antibiotic
prophylaxis has markedly reduced the risk of
early-onset infection, such measures have had
no effect on the risk of late-onset disease.19
One hopeful observation in the pediatric pop-
ulation is the 36% decrease in the rate of L. mono-

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 The n e w e ng l a n d j o u r na l
cytogenes meningitis during this period. In contrast
to other causes of bacterial meningitis, almost all
listeriosis cases are foodborne, most commonly
associated with ready-to-eat meat products.20-23
The incidence of listeriosis during pregnancy,
which may result in adverse fetal outcomes (e.g.,
spontaneous abortion or preterm delivery), has
shown a marked decrease in recent years, possibly
because of reductions in L. monocytogenes contami-
nation of ready-to-eat foods21,24,25 or decreased
consumption of high-risk foods by pregnant wom-
en due to educational efforts.26 Among older chil-
dren and young adults, N. meningitidis remained a
major cause of bacterial meningitis, despite the
fact that rates declined significantly between
1998 and 2007. Since the declines were similar
among all major serogroups, and since MCV4 and
MPSV4 do not include N. meningitidis serogroup B,
these declines most likely represent secular trends
rather than a vaccine effect.17 As the proportion
of children receiving MCV4 continues to increase,
we expect additional reductions in the incidence
of meningococcal disease (especially from N. men-
ingitidis serogroups C and Y).
The incidence of bacterial meningitis also de-
clined among adults, including those 65 years of
age or older. Rates of adult meningitis may decline
further, as children are vaccinated with the newly
licensed PCV13.27,28 However, in contrast to the
findings for cases of meningitis in children, chron-
ic and immunocompromising conditions were
common among adults with bacterial meningitis.
Given that medical conditions such as HIV infec-
tion (a risk factor for some causes of meningitis)
show no signs of decline in the United States,29
reducing the meningitis burden among adults may
prove difficult without consideration of the use of
new pneumococcal vaccines for adults.
We present the results for the most common
causes of community-acquired bacterial menin-
gitis over a 10-year period in a population of more
than 17 million persons, yet these findings most
likely underestimate the true burden of bacterial
meningitis, for three main reasons. First, EIP sites
only identify patients with culture-confirmed cas-
es of meningitis. Therefore, identification of cases
depends on the diagnostic and therapeutic prac-
tices of those caring for patients (e.g., the fre-
quency of lumbar punctures or the timing of ini-
tiation of antibiotic therapy). Diagnostic methods
for identifying culture-negative cases of meningi-
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of m e dic i n e
tis, such as polymerase-chain-reaction assays, are
not uniformly available at all EIP sites, and there-
fore such data are not included here. Second, ABCs
and FoodNet do not cover all possible causal
pathogens of bacterial meningitis; for instance,
Escherichia coli and staphylococcus species are not
included yet have been identified previously as
clinically significant causes.3 Although techniques
for antimicrobial testing and for serotype and
serogroup testing used by the Centers for Disease
Control and Prevention (CDC) remained consistent
during the surveillance period, individual hospi-
tals may have adopted more sensitive antibacterial
isolation techniques (i.e., liquid-based rather than
agar-based culture). However, this variation would
result in underestimation of the decline in the
incidence of meningitis during the surveillance
period. Third, the surveillance systems used in the
study do not routinely collect information on bac-
terial meningitis acquired in health care settings,
which may account for up to 40% of cases.30
Although the epidemiology of bacterial men-
ingitis has evolved from 1998 to 2007, the rank
order of causative pathogens has changed rela-
tively little. For clinicians, these results suggest
that current treatment guidelines for bacterial
meningitis targeting the major pathogenic causes
are still appropriate.11 After the introduction of
PCV7, rates of bacterial meningitis among chil-
dren 1 to 23 months of age have declined signifi-
cantly, ranging from 7.7 to 8.4 cases per 100,000
population between 2002 and 2007, surpassing
the Healthy People 2010 goal of reducing the
incidence to 8.6 cases per 100,000 population.31
However, this achievement only reemphasizes the
need for interventions targeting neonates and
elderly persons, the two populations in which the
meningitis burden remains greatest. Administra-
tion of GBS vaccines and new meningococcal
vaccines could reduce the risk of bacterial menin-
gitis among infants. However, these vaccines are
still in the early stages of development. PCV13
has recently been licensed in the United States for
pediatric use and may be licensed in the future
for adults if shown to be efficacious, safe, and im-
munogenic.32 However, because PCV13 and newer
vaccines being developed against meningitis
caused by GBS or N. meningitidis infection may not
cover many causal isolates, other approaches will
most likely be required to markedly reduce the
meningitis burden in the very young and very old.
 Bacterial Meningitis in the United States

Presented in part at the 43rd annual meeting of the Infectious
Diseases Society of America, San Francisco, October 69, 2005.
Supported by the Emerging Infections Programs, Centers for
Disease Control and Prevention, Atlanta.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
We thank Jessica MacNeil, Tracy Pondo, Carolyn Wright, and
Tami Skoff for their contributions to the ABCs system for purposes
of this study; Delois Jackson, Varja Sakota, and other members of
the CDCs Streptococcus Laboratory for streptococcal typing; and
the participating clinical laboratories and ABCs and FoodNet sur-
veillance staff within each EIP site who made this study possible.

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