---
title: "Viral meningitis in Ethiopia: enteroviruses dominate clinical cases and outcomes"
id: "plos-one-7-the-hidden-burden-of-viral-meningitis-in-ethiopia-etiology-and-clinical-outcomes"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-7-the-hidden-burden-of-viral-meningitis-in-ethiopia-etiology-and-clinical-outcomes"
content_type: "clinical_feed_article"
specialty: "Infectious Disease"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361291"
published_at: "2026-10-23T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Viral meningitis in Ethiopia: enteroviruses dominate clinical cases and outcomes
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-7-the-hidden-burden-of-viral-meningitis-in-ethiopia-etiology-and-clinical-outcomes
- **Specialty:** [Infectious Disease](https://medichelpline.com/clinical-feed/infectious-disease.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361291)
- **Published At:** 2026-10-23T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- Investigators conducted a multicenter molecular study across five Ethiopian tertiary hospitals, enrolling 430 patients suspected of meningitis but negative for bacterial PCR/culture. - Cerebrospinal fluid was collected and processed for viral nucleic acids; RT‑PCR and conventional PCR were used to detect **enteroviruses**, **HSV‑1**, **HSV‑2**, **Epstein‑Barr virus**, VZV, and mumps. - Viral nucleic acid was detected in 227/430 patients (52.8%); **enteroviruses** were found in 206 patients (47.9%), HSV‑1 in 12 (2.8%), HSV‑2 in 6 (1.4%), and EBV in 3 (0.7%); no VZV or mumps detections were reported. - Clinical presentations most commonly included fever, vomiting, lowered consciousness, and neck stiffness; these signs were more frequent among PCR-confirmed viral cases. - Outcomes were assessed with the **Glasgow Outcome Scale** (GOS); 29/430 patients (6.7%) had unfavorable outcomes (GOS 1–4), including one death in an enterovirus-positive patient. - Multivariable analysis showed independent associations between unfavorable outcome and male sex (AOR 2.684), longer duration from symptom onset to hospital visit (AOR 1.433 per unit reported), and antibiotic use prior to hospital presentation (AOR 2.784). - Being PCR-positive for a viral pathogen was not independently associated with unfavorable outcome in this cohort. - The cohort was predominantly pediatric (90.5% under 18 years). The authors noted the need for further identification and characterization of detected **enteroviruses** and acknowledged resource-limited diagnostic challenges in Ethiopia.
## Clinical Analysis & Structured Key Points
The hidden burden of viral meningitis in ethiopia: Etiology and clinical outcomes | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Peer Review Reader Comments Figures Figures Abstract Background Viral meningitis remains a significant global public health problem, particularly in resource-limited settings where the diagnosis of viral etiology is mainly based on clinical assessment. This study aimed to identify the common viral etiologies of meningitis, describe their associated clinical features, and assess patient outcomes among individuals suspected of meningitis without evidence of bacterial meningitis. Methods We conducted a multicenter study involving 430 patients clinically suspected of meningitis. Clinical data and cerebrospinal fluid samples (CSF) were collected following standard procedures. Viral nucleic acids were extracted from CSF specimens. Complementary DNA was prepared from viral RNA using reverse transcription. Viral nucleic acids were amplified and detected using qualitative conventional polymerase chain reactions. Patient outcomes were evaluated using the Glasgow Outcome Scale (GOS). Bivariate and multivariable logistic regression analyses were used to identify factors associated with unfavorable patient outcomes, with statistical significance set at a p -value < 0.05 at a 95% confidence level. Results The prevalence of viral meningitis was 52.8% (227/430). Enteroviruses were the most common, 47.9% (206/430), followed by herpes simplex virus-1, 2.8% (12/430), herpes simplex virus-2, 1.4% (6/430), and Epstein-Barr virus, 0.7% (3/430). Overall, 6.7% (29/430) of study participants experienced unfavorable outcomes (GOS = 1–4). Factors independently associated with unfavorable outcomes included sex (AOR = 2.684, 95% CI = 1.177–6.119), duration from disease onset to hospital visit (AOR = 1.433, 95% CI = 1.043–1.967), and history of antibiotic intake before hospital visit (AOR = 2.784, 95% CI = 1.270–6.104). Conclusions In this predominantly pediatric study, enteroviruses are the leading cause of viral meningitis in Ethiopia. Most study participants experienced favorable outcomes. Unfavorable outcomes were independently associated with sex, duration from disease onset to hospital visit, and history of antibiotic use before hospital visit. Further identification and characterization of Enteroviruses are warranted. Citation: Mesele DW, Ayele L, Aman J, Alemayehu DH, Alemu A, Gelaw A, et al. (2026) The hidden burden of viral meningitis in ethiopia: Etiology and clinical outcomes. PLoS One 21(10): e0361291. https://doi.org/10.1371/journal.pone.0361291 Editor: Tebelay Dilnessa, Debre Markos University, ETHIOPIA Received: July 21, 2026; Accepted: October 8, 2026; Published: October 23, 2026 Copyright: © 2026 Mesele et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The data used for this study are within the manuscript itself. Funding: The study was primarily funded by the European Union and Addis Ababa University (AAU). The European Union provided funding through the African Academy of Sciences under the African Research Initiative for Scientific Excellence Pilot Programme (ARISE-PP-FA-050). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Introduction Viral meningitis remains a significant global public health problem caused by viral infection of the meninges [ 1 , 2 ]. A wide range of viruses can cause meningitis, with enteroviruses (EVs) being the predominant causative agents worldwide and disproportionately affecting young children [ 3 , 4 ]. Herpes viruses (herpes simplex virus type 1 (HSV-1), herpes simplex virus type 2 (HSV-2), varicella-zoster virus (VZV), Epstein-Barr virus (EBV)) and mumps virus are also common pathogens [ 2 , 3 ]. The clinical manifestations of viral meningitis are usually similar for the different causative agents, mainly characterized by fever, headache, neck stiffness, altered level of consciousness, nausea, vomiting, and photophobia, which makes it difficult to diagnose the disease at early stages [ 3 , 5 ]. In children, these signs and symptoms are usually atypical, which further increases the risk of delay and misdiagnosis. As a result, empirical antimicrobial treatment is a common practice in this setting despite a high percentage of causative viral agents, which have no proven benefit for them [ 5 ]. In such a situation, laboratory confirmation is essential. Cerebrospinal fluid (CSF) analysis, particularly polymerase chain reaction (PCR), which detects viral DNA or RNA, is the gold standard for the diagnosis of viral meningitis. In recent years, advances in PCR have significantly improved detection [ 2 , 6 ]. Despite these advances, challenges remain in resource-limited settings like Ethiopia. Even though viral meningitis is usually self‑limiting, it can be severe and result in unfavorable outcomes, especially in extreme ages and immunocompromised patients [ 7 ]. The prognosis may also worsen with a delayed diagnosis. Timely diagnosis can help to reduce hospitalization rates, length of hospital stays, healthcare costs, and adverse effects of unnecessary antibiotics [ 5 , 8 ]. Certain factors, including age, sex, comorbidity, delay in hospital presentation, antibiotic intake before hospital visit, and infection with a certain herpes virus, have been associated with unfavorable outcomes [ 9 ]. In Ethiopia, the viral etiology of meningitis is rarely identified due to limited infrastructure and skilled personnel [ 4 , 5 ]. Existing studies are scarce and often limited by small sample sizes, and most were from repository samples, which may not accurately reflect the clinical reality of viral meningitis or could potentially bias the results. More importantly, routine viral meningitis diagnosis is clinical. Therefore, there is a critical need for a large, multicenter molecular epidemiology study to integrate molecular diagnostic techniques with routine methods for etiologic investigation to improve the clinical management of suspected meningitis patients. Thus, this study aimed to detect the etiology, clinical features, and outcomes of viral meningitis in Ethiopia. To the best of our knowledge, this study is the largest multicenter and most comprehensive study of viral meningitis in Ethiopia. Materials and methods Study setting The study was conducted from 01/08/2023–30/06/2024 at five tertiary-level hospitals in Ethiopia: University of Gondar Comprehensive Specialized Hospital (UoGCSH), Tikur Anbessa Specialized Hospital (TASH), Yekatit 12 Hospital Medical College (YE12HMC), All Africa Leprosy Rehabilitation and Training (ALERT) Comprehensive Specialized Hospital, and Hawassa University Comprehensive Specialized Hospital (HUCSH). These study sites are geographically distributed across Ethiopia to ensure broad national representation. Tikur Anbessa Specialized Hospital, ALERT Comprehensive Specialized Hospital, and YE12HMC are located in Addis Ababa, in central Ethiopia. University of Gondar Comprehensive Specialized Hospital is located in Gondar, in northwest Ethiopia. Hawassa University Comprehensive Specialized Hospital is located in Hawassa, in southern Ethiopia. Inclusion criteria Four hundred thirty meningitis-suspected patients who were PCR- and culture-negative for bacterial meningitis were included in this study. Specimen collection Cerebrospinal fluid samples were collected aseptically from the suspected patient. Depending on the age of the patient, lumbar punctures were done using a needle measuring 1.5 inches (3.8 cm) to 3.5 inches (8.9 cm). The CSF sample was collected using sterile plastic tubes (Sartstedt, Germany) by following the standard operating procedure (SOP) and transported to the laboratory within 30 minutes of collection. Approximately 0.5 mL of CSF was transferred to a Nunc® CryoTube inside a Biosafety Level 2 cabinet and stored at −80 °C until used for further experiments. Nucleic acid extraction and PCR Extraction of viral nucleic acid from CSF samples was performed according to the protocol provided with the High Pure viral nucleic acid Preparation Kit (Roche Life Sciences, Mannheim, Germany). The concentration and purity of DNA or RNA of the extract were determined using a Nanodrop Spectrophotometer (ND-1000; Nanodrop Technologies, Wilmington, DE) at 260, 260/280, and 260/230 nm. For amplifying the viral DNA target, Platinum Taq Hot Start PCR Master Mix (Thermo Fisher Scientific) was used. The final volume of each PCR reaction was 25 µL of [2.5 µL of 10X buffer, 1.2 µL of 50 mM MgCl 2 , 1 µL of dNTP master mix, 1 µL of each forward and reverse primer, 0.2 µL of Taq polymerase, 5 µL of target DNA, and 13.1 µL of nuclease-free water]. Conventional PCR was performed using the Bio-Rad T100 thermal cycler. Amplification involved an initial denaturation at 94 °C for 3 min, followed by 35 cycles of denaturation at 94 °C for 10 s, annealing at 60 °C for 30 s, and extension at 72 °C for 30 s, with a final extension step at 72 °C for 5 min. The PCR products were visualized using a 2.5% agarose gel with ethidium bromide under UV light in a CS-DARKROOM, Cleaver Scientific. For the RNA virus, a two-step reverse transcription polymerase chain reaction (RT-PCR) was conducted for the amplification of EVs and mumps. Enterovirus- and mumps-specific primers were used to detect all EVs and mumps [ Table 1 ]. Reverse transcription was performed in a 20 µL reaction composed of 0.2 µL of random hexamer, 1 µL of 10 mM dNTP, 1.8 µL ultra-pure water treated with 0.1% diethylpyrocarbonate (DEPC), 10 µL template RNA, 1 µL of 100 mM DTT, 1 µL of RNase inhibitor (40 units/µL), 0.8 µL of 10 × RT buffer, and 5 µL of Superscript IV. The reaction mixture was then incubated at 65 ° C for 5 minutes to synthesize cDNA, and the reaction was inactivated by incubating at 55 ° C for 50 minutes and 80 ° C for 10 minutes. Polymerase Chain Reaction amplification was done by adding 5 µL cDNA to 20 µL PCR master mix (consisting of 5 µL of 5 Green Go Taq Flexi Buffer, 2.5 µL 25 mM MgCl 2 , 0.5 µL 10 mM dNTP, 0.3 µL of forward and reverse primers each (10 µM), 0.1 µL Go-Taq G2 Flexi DNA polymerase, and 10.3 µL molecular grade water). The thermal cycling was adjusted to 94 ° C for 2 minutes, and 35 cycles of denaturation at 94 ° C for 30 seconds, followed by annealing at 58 ° C for 30 seconds and extension at 72 ° C for 30 seconds. The amplicon was visualized on a 2.5% agarose gel. This protocol was obtained from the Go-Taq G2 Flexi DNA polymerase protocol. Download: PNG larger image TIFF original image Table 1. Primer sequences with their respective nucleotide length and target gene. https://doi.org/10.1371/journal.pone.0361291.t001 Quality control NATEVPOS-6MC for enterovirus, NATEBV-005 for Epstein-Barr Virus, and NATVZV-0005 for Varicella-Zoster virus from NATrol (Helvetica Health Care, Geneva, Switzerland) were used as viral positive controls, and RNase/DNase-free water was used as a negative test control to ensure the quality of the laboratory result. Data management and statistical analysis The data were first coded, cleaned, and entered into Epi Info v 3.1, then transformed and analyzed with the Statistical Package for Social Sciences (SPSS) version 26 statistical software. The results of the analysis were presented in text, figures, or tables where appropriate. Categorical variables were summarized using frequencies and percentages. Skewed data were presented as the median with an interquartile range. The association between variables was assessed using binary logistic regression and multivariable regression analysis. All independent variables with p < 0.25 in bivariate analysis were included in multivariable analysis. The best-fit model was identified using forward logistic regression analysis. In all cases, p < 0.05 was considered statistically significant. Operational definitions A suspected meningitis case was defined as a patient with a sudden onset of fever, neck stiffness, or other meningeal signs. A Confirmed viral meningitis case was any suspected case with viral nucleic acid detected by PCR or RT-PCR in the CSF [ 14 , 15 ]. The GOS was categorized as (1- death; 2- vegetative state; 3- severe disability; 4- moderate disability; 5- good recovery) at discharge. Later, the scores were dichotomized into a favorable outcome (GOS = 5) and an unfavorable outcome (GOS = 1–4) [ 9 ]. To ensure that all assessors had a common understanding of the scale criteria and to reduce interpersonal variability, we conducted a 6-hour orientation. Any scoring discrepancies were addressed through consensus discussions among the assessors, as described in our previous bacterial meningitis study. Ethical consideration The study was performed in compliance with the Declaration of Helsinki and approved by the AHRI/ALERT Ethics Review Committee (AAERC) under protocol number PO-55–22. Data were collected after obtaining written informed consent from the study adult subjects or assent from parents/guardians for children or the unconscious. Results Demographic characteristics of the study participants Across the five sites, a total of 430 patients with suspected meningitis and PCR negative for bacterial meningitis were included in this study. The age of participants ranged from 1 month to 81 years. Of these, 223 (51.9%) were male, indicating a nearly equal sex distribution. The majority of the study participants, 389 (90.5%), were children under 18 years of age. UoGCSH contributed the largest proportion of participants, with 141 (32.6%), followed by Y12HMC, which had 110 (25.6%) ( Table 2 ). Download: PNG larger image TIFF original image Table 2. Sociodemographic characteristics of the study participants. https://doi.org/10.1371/journal.pone.0361291.t002 Prevalence and pathogen distribution Viral nucleic acid was detected in 227 (52.8%) participants. The leading viral agent was EVs 206 (47.9%), followed by HSV-1, 12 (2.8%), and HSV-2, 6 (1.4%). EBV was rare in this study, detected only in 3 (0.7%) participants. Although all participants were tested for VZV and the mumps virus, no cases were identified for either of the pathogens ( Fig. 1 ). Download: PNG larger image TIFF original image Fig 1. Inclusion of study participants. https://doi.org/10.1371/journal.pone.0361291.g001 As shown in Fig 1 , the overall prevalence of viral meningitis among suspected cases, including those with confirmed bacterial infections, was 28.21% (169/599), 37.9% (227/599), and EV remained the most common pathogen irrespective of the study sites ( Table 3 ) ( Fig 2 ). Download: PNG larger image TIFF original image Table 3. Distribution of viral etiologies and study sites. https://doi.org/10.1371/journal.pone.0361291.t003 Download: PNG larger image TIFF original image Fig 2. Agarose gel electrophoresis image of PCR amplification product bands of enterovirus by PanEV2-5′NTR on a 2.5% agarose gel. Lane 1 = 100-bp DNA ladder; Lane 2 = positive control; Lanes 3 and 4 = enterovirus-positive sample products 144 bp; and Lane 6 = NC, negative control. https://doi.org/10.1371/journal.pone.0361291.g002 Association of clinical presentation with the virus detected The common clinical presentations in this group of patients were fever 63% (271/430), vomiting 60.2% (259/430), lowered consciousness 43.7% (188/430), and neck stiffness 37.4% (161/430). These clinical presentations were more commonly seen among patients with PCR-confirmed viral meningitis compared to those who tested negative ( Table 4 ). Download: PNG larger image TIFF original image Table 4. Association of clinical presentation with the viruses detected. https://doi.org/10.1371/journal.pone.0361291.t004 Among PCR-positive patients, the most common symptoms were fever 70.9% (161/227), followed by vomiting 61.7% (140/227), neck stiffness 55.5% (126/227), lowered consciousness 50.7% (115/227), and seizure 33.9% (77/227) ( Table 4 ). Among patients positive for EVs, fever was the most common sign and symptom observed in 72.8% (150/206) of the patients, followed by vomiting and neck stiffness, with rates of 64.6% (133/206) and 54.9% (113/206), respectively. Likewise, among HSV-1 positive patients, seizure was the most common sign and symptom observed in 91.7% (11/12) of the patients, followed by lowered consciousness in 66.7% (8/12), and 50% (6/12) for both neck stiffness and fever ( Table 4 ). Outcomes and associated factors The outcome of the 430 patients was assessed using GOS. The overall unfavorable outcome was observed in 29 (6.7%) patients. There was one death (0.2%), which occurred in an EV-positive patient. The outcome of all HSV-2-positive patients was favorable. Overall, 130/430 (30.2%) of participants had taken an antibiotic before a hospital visit (data in S1 Text ). In bivariate logistic regression analysis, sex, duration from disease onset to hospital visit, and history of antibiotic intake before hospital visit were found to be associated with unfavorable outcomes. These variables remained significantly associated with unfavorable outcomes in multivariate analysis: sex (AOR = 2.684, 95% CI = 1.177–6.119), duration from disease onset to hospital visit (AOR = 1.433, 95% CI = 1.043–1.967), and history of antibiotic intake before hospital visit (AOR = 2.784, 95% CI = 1.270–6.104). In this study, being positive for a viral pathogen did not have a significant association with unfavorable outcomes ( Table 5 ). Download: PNG larger image TIFF original image Table 5. Bivariate and multivariable analysis of factors associated with unfavourable outcome (GOS = 1 to 4) at discharge in patients suspected of meningitis. https://doi.org/10.1371/journal.pone.0361291.t005 Discussion In this multicenter study, we investigated the etiologies, clinical features, and factors associated with unfavorable outcomes of viral meningitis. Viral meningitis was confirmed in 227 (52.8%) participants. This finding is consistent with data from Southern Africa [ 16 ] and Iran [ 17 ], but findings were lower than those of the previous studies from Brazil [ 18 ], Korea [ 19 ], and Qatar [ 7 ]. To our knowledge, this reported prevalence is the highest in Ethiopia [ 4 , 5 , 20 ]. This may be due to the larger sample size and multicenter design of the current study, which enhanced population representativeness and case ascertainment across multiple settings, as well as comprehensive screening for common viral etiologies, which identified cases that had been missed by previous studies with narrower diagnostic panels. Our findings identified EVs as the most common cause, accounting for 206 (47.9%) of viral meningitis cases. This aligns with the well-established understanding that EVs are the leading cause of viral meningitis by far [ 7 , 14 , 18 ]. Furthermore, our result aligns with the findings of earlier reports from Iran [ 21 ] and France [ 22 ]. The prevalence of EVs observed in this study is higher than in the previous studies in the country [ 4 , 5 , 20 ]. This could be due to the method of nucleic acid purification. In this study, nucleic acid extraction was done using a commercial kit to attain the maximum sensitivity (High Pure Viral Nucleic Acid Kit-Roche, Mannheim, Germany). Contrary to studies from the Republic of Korea [ 19 ], Tunisia [ 23 ], and Australia [ 24 ], HSV-1 was a more common cause of viral meningitis in our study, with 2.8% (12/430), than HSV-2, 1.4% (6/430). This finding was in agreement with studies in Iran [ 25 ] and a prior Ethiopian study [ 20 ], possibl
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