Prevalence and Mortality of Cryptococcal Meningitis in Africa from 1950 to 2017 and Associated Epidemiological Mapping of C. neoformans and C. gattii Species Complexes: A Systematic Review and Meta-Analysis

Background: Despite an abundance of studies and landmark clinical trials conducted in Africa, no systematic analysis of published data has been done to ascertain the true burden of cryptococcal meningitis (CM) in different regions and its aetiologies. We aimed to establish the prevalence, incidence and mortality associated with CM and its aetiological causes in Africa. Methods: We searched PubMed, Embase, ISI Web of Science, Africa Index Medicus, and CINAHL for studies involving adults and/or children published between 1st January 1950 and 31st December 2017 and reporting data on prevalence, incidence, mortality, and aetiology of CM in Africa, with no language restriction. Random-effect meta-analysis was used to derive pooled prevalence, mortality and incidence. Findings: In 111 studies included, 53 reported on prevalence, 63 on mortality, 5 on incidence and 14 on molecular data. The prevalence and mortality of CM in Africa were 10.3% (95%CI 7.7 - 13.2) in 37,072 participants and 47.7% (95%CI 41.0 - 54.5) in 6,011 cases respectively between 1990 and 2017. The incidence of CM was 4.8 per 100,000 person-years at risk. The recurrence rate of CM was 1.2% (95%CI 0.0 - 3.8). Prevalence and mortality were higher in individuals with mean age Interpretation: The prevalence and mortality of CM remain unacceptably high in Africa, stressing the need for stronger actions to improve access to diagnosis and treatment both for CM and HIV on the continent. Funding Statement: The authors state: "None." Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: This study is registered with PROSPERO, number CRD42017081312.