The changing epidemiology of pediatric aseptic meningitis in Daejeon, Korea from 1987 to 2003

Aseptic meningitis is a relatively common disease of childhood and recent data suggest that it is most frequently caused by enteroviruses [1, 2]. Although globally aseptic meningitis occurs year-round, there is a marked seasonality, with an incidence peak in the summer months in temperate climates. In Korea, epidemics of aseptic meningitis have occurred approximately every 3 years since the early 1990s. Whilst there have been a number of studies addressing the clinical characteristics and the causative agents of these epidemics [3–15], long term epidemiologic studies of aseptic meningitis are rare. A variety of enteroviruses have been suggested as the predominant causative agents for each Korean epidemic, with enterovirus 71 or echovirus 30 in 1990 [6], echovirus 9 in 1993 [7], echovirus 30 in 1997 [11], echovirus 6 in 1998 [11], coxsackievirus B5 in 2001 and echovirus 13 in 2002 [12–14].

In this study, we describe the epidemiologic characteristics of pediatric aseptic meningitis during a 17 year period, from 1987 to 2003, in Daejeon, South Korea, with particular emphasis on the two largest epidemics, in 1997 and 2002.

We retrospectively analyzed a total of 2201 medical records of pediatric patients with aseptic meningitis patients admitted to The Catholic University of Korea, Daejeon St. Mary's Hospital from January 1987 to December 2003. Daejeon, located in central Korea, is one of the largest cities with a population of over 1.4 million. The majority of the patients with aseptic meningitis were admitted to one of four general hospitals in Daejeon. There were no significant changes of medical facilities or the social environment during the study period. Epidemic years were defined as those with more than 100 patients per year and at least a two-fold increase in cases compared to the previous year. The diagnosis of aseptic meningitis was made on the basis of: (i) clinical symptoms and signs of meningitis, such as fever, vomiting, headache, and meningeal irritation, (ii) cerebral spinal fluid (CSF) pleocytosis (≥ 5 leukocytes/mm³) with normal CSF protein and sugar levels and (iii) negative results on bacterial culture and latex particle agglutination test. Studies to identify viral pathogens were not routinely undertaken in these hospitals, especially during epidemics, as the available data suggests that causative agents other than enteroviruses are relatively rare [6, 7, 11–15]. Other non-enteroviral causes of meningitis occurring during the study period were excluded from the current analysis. These included cases of mumps meningitis (n = 66; 1989–1998) [16], bacterial meningitis (n = 40; 1992–2002) [17] and herpes meningo-encephalitis (n = 3). We analyzed the age and gender of patients, together with monthly and annual frequency. In addition, we evaluated the frequency of neurological complications among the patients hospitalized for more than 10 days. The epidemiologic features of the patients from the two years with the highest incidence, 1997 and 2002, were also compared.

Although there have been a number of studies of aseptic meningitis in Korea [3–15], there are few epidemiologic studies of this scope and duration. Historically, aseptic meningitis appears to have been relatively unusual in Korea prior to the 1980s, but this may partly reflect ascertainment bias and diagnostic methods. Chung et al. described 104 cases of childhood meningitis from 1960–1967, with 41 cases of aseptic meningitis cases and 63 bacterial meningitis cases [3]. Rheu et al. reported an increasing incidence of aseptic meningitis in the Wonju area of Korea from 1966 to 1983; among the total of 200 cases of aseptic meningitis, there were 1–3 cases per year from 1966–1971, 6–23 cases per year in 1972–1982, and 40 cases in 1983 [4]. Similar findings are reported from Busan during the 1980s, with 5–19 cases annually between 1980 and 1988, 30 cases in 1989 and 56 cases in 1990 [5]. These results suggest that the nationwide epidemics of aseptic meningitis in Korea started in the early 1990s. The striking change in epidemiology at this time, with the occurrence of epidemics, may partly reflect improved diagnosis and increased awareness. In addition, changes in herd immunity may have contributed to an increased population susceptibility to epidemics of virus transmitted by the fecal-oral route. Public health improvements that accompanied this period of marked economic growth in Korea may have reduced sporadic exposure to enteroviruses and led to a large non-immune population. Similar patterns have been observed in the rapidly declining seroprevalence of hepatitis A in Korea. Hepatitis A, which is a kind of enteroviruses and also spread by the fecal-oral route, currently has a seroprevalence in Korean children < 15 years old of almost zero [18, 19].

In this study, epidemics of aseptic meningitis in Daejeon mirrored the nationwide epidemics in 1990 [5, 6], 1993 [7, 8], 1996 [9], 1997 [10], 2001 and 2002 [12–14]. A nationwide study of 5090 patients in 1993 showed that the epidemic of aseptic meningitis commenced in the southern regions in spring, and then gradually moved to the northern regions (including Seoul), reaching a peak incidence in summer and then waned by late fall [8]. Similar patterns have been observed in other epidemics in Korea [5, 6] and may reflect the geographical and social environment with a large and mobile population contributing to the nationwide spread of the disease. Aseptic meningitis is generally commoner in males with a male-to-female ratio of 1.2–2.3 to 1 [4–13], as observed in the current study.

Globally the age distribution during epidemics of aseptic meningitis varies, possibly due to different causative agents and specific herd immunity that results from varying socio-economic environments and other factors. For example, in the United States, the peak age for children with aseptic meningitis is reported to be < 1 year old [1, 2, 20], whereas in five South African epidemics in the 1980s, the mean age of children with echovirus meningitis was 4–5 years of age, whereas those with coxsackie B meningitis were most commonly <1 year old [21]. In Japan, Yamashita et al. analyzed 8595 cases of aseptic meningitis from 1981–1991. There were two peak ages of < 1 year and 4–7 years, with varying age distributions according to the causative virus in each epidemic [22]. Although Korea and Japan have similar geographical, racial and socio-economic environments, the period of marked Korean economic growth occurred later than in Japan. The Korean epidemiologic data from the 1990s is similar to those from the 1980s in Japan [22, 23], possibly reflecting similar changes in important determinants of epidemiology.

The pattern of age distribution in an aseptic meningitis epidemic may reflect herd immunity from past infection with the same causative virus. Aseptic meningitis is rare in younger adults in Korea, whereas adults aged 20 and 40 years have an incidence similar to children in the United States [20]. In addition, there were differences in incidence in infants (< 1 year old) with each epidemic, suggesting that herd immunity from previous infections with enteroviruses is reflected in protective transplacental antibodies. Maternal (transplacental) antibodies are detected in over half of the infants aged 6 months, and may persist for up to 12 months after birth. Thus a high incidence in both infants and adults suggests a new epidemic strain with low herd immunity.

Previous studies in Korea have reported that enteroviruses predominate in each nationwide epidemic (Table 1). Enteroviruses include more than 70 serotypes, but only a few serotypes typically cause aseptic meningitis in any given community and during any given year. This may be due to differences in the background rate of infection in a community (herd immunity), in host immunity and possibly in the viral strain's neurotropism. Recently, echovirus 13 meningitis epidemics have been reported in Europe in 2000 [24, 25], in the United States in 2001 [26], and in Korea in 2002 [12–14]. The genotype of echovirus 13 isolated in Korea in 2002 is almost identical to that isolated in Japan and Germany [14]. Thus, aseptic meningitis epidemics from an enteroviral strain may spread globally.

Children with enteroviral meningitis generally recover without complications, but rarely the disease can cause neurologic sequelae [1, 2, 8]. The clinical manifestations and outcome may differ with the enterovirus serotype. For example, a more severe clinical course and worse outcome with enterovirus 71 infections have been reported both in Korea and in other countries [27, 28]. In the current study, 16 children (0.7%) with aseptic meningitis had neurological complications; 2 children in 1990, 4 in 1993, 4 in 1997, and 1 child each in six other years. No single epidemic resulted in a significantly larger number of neurologic sequelae, although the denominator was small as the outcome was generally excellent.

Aseptic meningitis appears to have been a rare disease in Korea during the 1960s and 1970s. Since 1990, outbreaks of aseptic meningitis have occurred every 1–3 years in Daejeon in keeping with nation-wide epidemics. The changing epidemiology may reflect improvements in public health, characteristics of the predominant etiologic agents and changes in herd immunity. In particular, the incidence of aseptic meningitis in children less than one year of age in each epidemic may be indicative of the agent-specific immunity of the parental generation.