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This study was undertaken to evaluate the long-term neurological outcome for survivors of bacterial meningitis in rural Papua New Guinea. Children who were discharged from Nonga Base Hospital in Rabaul with a diagnosis of bacterial meningitis between 1992 and 2000 were evaluated in their home villages or on review at hospital. Neurological and developmental complications were documented. The outcomes for 80 of 121 eligible children were determined; eight had died following hospital discharge and 41 were lost to follow-up. Major neurological sequalae were found in 50 (63 per cent) of surviving children, and 27 (34 per cent) had multiple severe complications. In rural Papua New Guinea meningitis causes high rates of mortality and severe long-term disability in a high proportion of survivors. High-level resistance to chloramphenicol is likely to be part of the reason for this, but widespread availability of third-generation cephalosporins for the treatment of meningitis, although urgently required, will not overcome the other problems of delayed presentation with established complications. There is a need for the introduction of conjugate Haemophilus influenzae vaccine, and affordable vaccination strategies against Streptococcus pneumoniae. Richer countries could sponsor these vaccines in developing countries, and apply pressure on vaccine producers to lower the costs.