THE 2016-2019 WILD YELLOW FEVER EPIDEMIC IN SAO PAULO, BRAZIL: ASSOCIATED FACTORS BEYOND VACCINE COVERAGE
DOI:
https://doi.org/10.14393/Hygeia2070448Palavras-chave:
Febre Amarela, Estudo ecológico, Modelos Bayesianos, Cobertura vegetal, População ruralResumo
Objectives: To describe the occurrence of yellow fever (YF) in the Brazilian state of Sao Paulo between 2016 and 2019, and after adjustment for vaccination coverage, evaluate associations with environmental and demographic variables. Methods: This ecological study on confirmed autochthonous cases of YF in SP between April 2016 to May 2019 considered latent Bayesian Gaussian models, spatial random effects at the municipality level, and zero-inflated and non-zero-inflated Poisson and negative binomial probability distributions where the incidence rate per 100,000 inhabitants were also considered. Results: Between 2016 and 2019, there were 648 human cases of YF, with lethality of 35.5%. Among the covariates considered in the models, native vegetation cover and total rural population were associated with YF occurrence, after adjustment for vaccine coverage. As expected, vaccine coverage was shown to have a protective effect: an increase in one standard deviation (SD) of coverage in a given municipality resulted in 82% fewer cases (relative risk [RR]=0.18; 95% credibility interval (CI): (0.11–0.27). Vegetation cover rate and rural population were shown to be risk factors, regardless of vaccination coverage. A one-SD increase in the values for these variables represented a 109% increase (RR= 2.09; 95% CI: 1.60–2.73) and 99% (RR=1.99; IC 95%: 1.41–2.87) in the number of YF cases, respectively. Conclusions: This study demonstrated that besides vaccination coverage, local factors such as vegetation cover and rural population size are involved in the occurrence of YF in affected municipalities. Since vaccine stocks are limited and large portions of the population are still unvaccinated, this information can help identify risk areas for increased vaccine coverage and broaden epidemiological and entomological surveillance activities.
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