Estimating case fatality risk of severe Yellow Fever cases: systematic literature review and meta-analysis

Joseph L Servadio, Claudia Muñoz-Zanzi, Matteo Convertino

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


Background: Case fatality risk (CFR), commonly referred to as a case fatality ratio or rate, represents the probability of a disease case being fatal. It is often estimated for various diseases through analysis of surveillance data, case reports, or record examinations. Reported CFR values for Yellow Fever vary, offering wide ranges. Estimates have not been found through systematic literature review, which has been used to estimate CFR of other diseases. This study aims to estimate the case fatality risk of severe Yellow Fever cases through a systematic literature review and meta-analysis. Methods: A search strategy was implemented in PubMed and Ovid Medline in June 2019 and updated in March 2021, seeking reported severe case counts, defined by fever and either jaundice or hemorrhaging, and the number of those that were fatal. The searches yielded 1,133 studies, and title/abstract review followed by full text review produced 14 articles reporting 32 proportions of fatal cases, 26 of which were suitable for meta-analysis. Four studies with one proportion each were added to include clinical case data from the recent outbreak in Brazil. Data were analyzed through an intercept-only logistic meta-regression with random effects for study. Values of the I2 statistic measured heterogeneity across studies. Results: The estimated CFR was 39 % (95 % CI: 31 %, 47 %). Stratifying by continent showed that South America observed a higher CFR than Africa, though fewer studies reported estimates for South America. No difference was seen between studies reporting surveillance data and studies investigating outbreaks, and no difference was seen among different symptom definitions. High heterogeneity was observed across studies. Conclusions: Approximately 39 % of severe Yellow Fever cases are estimated to be fatal. This study provides the first systematic literature review to estimate the CFR of Yellow Fever, which can provide insight into outbreak preparedness and estimating underreporting.

Original languageEnglish (US)
Article number819
JournalBMC infectious diseases
Issue number1
StatePublished - Dec 2021

Bibliographical note

Funding Information:
This study was funded by the University of Minnesota Doctoral Dissertation Fellowship. The funding source had no contribution in the study design, analyses, manuscript preparation, or decision to publish. MC acknowledges the SOUSEI funding program and GSB Gi-CORE funding at Hokkaido University, JP.

Publisher Copyright:
© 2021, The Author(s).


  • Yellow Fever
  • case fatality risk
  • meta-analysis
  • systematic review


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