The evolving burden of childhood meningitis in low- and middle-income countries, 1990-2021: a decomposition and frontier analysis.

Despite vaccination advances, childhood meningitis remains a major global threat, disproportionately affecting low- and middle-income countries (LMICs). This study analyzes its burden trends from 1990 to 2021, with a focus on LMICs. Using data from the Global Burden of Disease Study 2021, we estimated mortality and disability-adjusted life years (DALYs) for children aged 0-14 years across 117 countries and territories grouped by low, low-middle, and middle Sociodemographic Index (SDI). Temporal trends were assessed with estimated annual percentage change (EAPC). We examined correlations between SDI and disease burden and applied decomposition analysis to attribute deaths and DALYs changes to aging, population growth, and epidemiological shifts. Frontier analysis was used to evaluate health system efficiency relative to SDI. Between 1990 and 2021, childhood meningitis deaths decreased in LMICs. Nevertheless, these regions accounted for 98.5% of global deaths in 2021, with low-SDI regions alone responsible for 61.0%. Streptococcus pneumoniae and Neisseria meningitidis were the leading pathogens. The disease burden was strongly inversely correlated with SDI, highlighting the key role of socioeconomic development. Decomposition analysis showed that in low-SDI regions, epidemiological improvements contributed substantially to mortality reduction (+ 513.02%), but were largely offset by population growth (- 417.38%), yielding only a modest net reduction. Frontier analysis revealed major health system inefficiencies in certain low-SDI countries, such as South Sudan and Nigeria.

conclusionThe concentrated burden of childhood meningitis in LMICs calls for context-specific strategies. Health system inefficiencies and rapid population growth threaten to offset intervention gains. Precision public health approaches that combine targeted vaccination, health system strengthening, and socioeconomic development are essential to reduce inequities and achieve global control goals. WHAT IS KNOWN: • Childhood meningitis remains a leading infectious cause of mortality and long-term disability globally, with the highest burden concentrated in low-income regions. • Significant progress has been made in vaccine development, leading to declines in mortality globally; yet implementation and coverage gaps persist in resource-limited settings. WHAT IS NEW: • Decomposition analysis quantifies for the first time how rapid population growth in low-SDI regions nearly cancels out the benefits of epidemiological improvements, whereas middle-SDI regions achieved reductions almost solely through epidemiological progress. • Frontier analysis identifies profound health system inefficiencies in specific low-SDI countries (e.g., South Sudan, Nigeria), where observed mortality and DALYs rates are higher than the optimum achievable given their SDI level.