{
  "_meta": {
    "title": "Per-case risks of serious outcomes from vaccine-preventable diseases (for benefit-risk comparison)",
    "compiled": "2026-10-09",
    "method": "Every value was read from the cited source in this session: CDC Pink Book web chapters (current edition) via cdc.gov; the Pink Book 13th edition (2015) chapter PDFs via web.archive.org (text extracted and read verbatim); CDC clinical/consumer pages; WHO fact sheets; peer-reviewed abstracts and full texts retrieved through the Europe PMC REST API. No value comes from memory. Values given in the source as '1 in N' or 'per million' are kept in their source form. Where a per-100,000 conversion or ratio was calculated, the note says 'DERIVED' and shows the arithmetic.",
    "fields": "disease, outcome, population, risk_value, risk_unit, ci_low, ci_high, range_low, range_high, source, doi_or_url, location_in_source, notes, era_flags",
    "conventions": {
      "risk_value": "Point estimate as stated. Null when the source gives only a range; the range is then in range_low/range_high. Ranges are not confidence intervals. ci_low/ci_high hold only intervals the source reports.",
      "risk_unit": "Usually 'per 100,000 cases' | 'percent of cases' | 'per 1,000 cases'. A few rows use other units ('per 1,000,000 ...', 'annual count (US)', 'relative incidence', 'percent of cervical cancers'). Those rows can't be placed directly on a per-case denominator and are marked comparable_per_case=false.",
      "era_flags": "prevaccine | postvaccine | outbreak | low_income | high_income | surveillance_reported_cases (the denominator is reported cases, which biases toward more severe illness) | hospital_based"
    },
    "caveats": [
      "Surveillance denominators are reported cases, not all infections. Mild or subclinical infections are under-counted, so per-case risks run high compared with per-infection risks.",
      "The current CDC Pink Book web chapters dropped many specific complication percentages (for example measles pneumonia and encephalitis). Those figures come from the archived 13th edition (2015) and are labeled that way.",
      "CDC clinical and consumer pages often give rounded '1 in N' figures without a cited era. The rows say so."
    ]
  },
  "risks": [
    {"disease":"Measles","outcome":"Acute encephalitis","population":"Reported US measles cases, 1985-1992 surveillance","risk_value":0.1,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases (Pink Book), 13th ed., 2015, Measles chapter","doi_or_url":"https://web.archive.org/web/2020/https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/meas.pdf","location_in_source":"Clinical Features > Complications, p.210 (and the side table 'Measles Complications', based on 1985-1992 surveillance data)","notes":"'Acute encephalitis occurs in approximately 0.1% of reported cases.' Equals 100 per 100,000 reported cases.","era_flags":["high_income","surveillance_reported_cases"],"comparable_per_case":true},
    {"disease":"Measles","outcome":"Acute encephalitis","population":"Measles cases (general; CDC clinical overview, no era stated)","risk_value":1,"risk_unit":"per 1,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC. Clinical Overview of Measles (HCP page)","doi_or_url":"https://www.cdc.gov/measles/hcp/clinical-overview/index.html","location_in_source":"Complications","notes":"'1 out of every 1,000 measles cases will develop acute encephalitis, which often results in permanent brain damage.' The consumer page (cdc.gov/measles/signs-symptoms) says 'About 1 child out of every 1,000 who get measles will develop encephalitis'.","era_flags":["high_income"],"comparable_per_case":true},
    {"disease":"Measles","outcome":"Death among patients with measles encephalitis; residual neurologic damage","population":"Patients with acute measles encephalitis (US, Pink Book 13th ed.)","risk_value":15,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book 13th ed., 2015, Measles chapter","doi_or_url":"https://web.archive.org/web/2020/https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/meas.pdf","location_in_source":"Clinical Features > Complications, p.210","notes":"Denominator is encephalitis cases, not all measles cases. 'The case-fatality rate is approximately 15%. Some form of residual neurologic damage occurs in as many as 25% of cases.'","era_flags":["high_income"],"comparable_per_case":false},
    {"disease":"Measles","outcome":"Seizures (with or without fever)","population":"Reported US measles cases, 1985-1992","risk_value":null,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":0.6,"range_high":0.7,"source":"CDC Pink Book 13th ed., 2015, Measles chapter","doi_or_url":"https://web.archive.org/web/2020/https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/meas.pdf","location_in_source":"Clinical Features > Complications, p.210","notes":"'Seizures (with or without fever) are reported in 0.6%-0.7% of cases.' Not limited to febrile seizures. For comparison, the current Pink Book gives MMR febrile seizure as about 1 per 3,000-4,000 doses.","era_flags":["high_income","surveillance_reported_cases"],"comparable_per_case":true},
    {"disease":"Measles","outcome":"Death","population":"Reported US measles cases, 1985-1992","risk_value":0.2,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book 13th ed., 2015, Measles chapter","doi_or_url":"https://web.archive.org/web/2020/https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/meas.pdf","location_in_source":"Clinical Features > Complications, p.211","notes":"'Death from measles was reported in approximately 0.2% of the cases in the United States from 1985 through 1992.' Pneumonia accounts for about 60% of deaths. The period includes the 1989-1991 resurgence.","era_flags":["high_income","outbreak","surveillance_reported_cases"],"comparable_per_case":true},
    {"disease":"Measles","outcome":"Death (death-to-case ratio)","population":"US reported measles cases, 1987-1992 (capture-recapture study)","risk_value":null,"risk_unit":"per 1,000 cases","ci_low":null,"ci_high":null,"range_low":2.54,"range_high":2.83,"source":"Gindler J, et al. Acute measles mortality in the United States, 1987-2002. J Infect Dis 2004;189 Suppl 1:S69-77","doi_or_url":"https://doi.org/10.1086/378565","location_in_source":"Abstract","notes":"'Overall the death-to-case ratio was 2.54 and 2.83 deaths/1000 reported cases, using the NCHS and NIP data, respectively.' 90% of deaths reported to NIP were in unvaccinated people. 16% (NCHS) and 14% (NIP) of deaths had immune-deficiency conditions.","era_flags":["high_income","outbreak","surveillance_reported_cases"],"comparable_per_case":true},
    {"disease":"Measles","outcome":"Death","population":"Children with measles (CDC clinical overview; no era stated)","risk_value":null,"risk_unit":"per 1,000 cases","ci_low":null,"ci_high":null,"range_low":1,"range_high":3,"source":"CDC. Clinical Overview of Measles (HCP page)","doi_or_url":"https://www.cdc.gov/measles/hcp/clinical-overview/index.html","location_in_source":"Complications","notes":"'1 to 3 out of every 1,000 children who become infected with measles will die from respiratory and neurologic complications.'","era_flags":["high_income"],"comparable_per_case":true},
    {"disease":"Measles","outcome":"Death (case-fatality ratio)","population":"Low- and middle-income countries, all ages, 1990-2015 (systematic review of 124 studies, modelled)","risk_value":2.2,"risk_unit":"percent of cases","ci_low":0.7,"ci_high":4.5,"range_low":null,"range_high":null,"source":"Portnoy A, et al. Estimates of case-fatality ratios of measles in low-income and middle-income countries. Lancet Glob Health 2019;7:e472-e481","doi_or_url":"https://doi.org/10.1016/S2214-109X(18)30537-0","location_in_source":"Abstract, Findings","notes":"Community-based settings: 1.5% (0.5-3.1). Hospital-based settings: 2.9% (0.9-6.0). Projected 2016-2030: 1.3% (0.4-3.7).","era_flags":["low_income"],"comparable_per_case":true},
    {"disease":"Measles","outcome":"Pneumonia","population":"Reported US measles cases, 1985-1992","risk_value":6,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book 13th ed., 2015, Measles chapter","doi_or_url":"https://web.archive.org/web/2020/https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/meas.pdf","location_in_source":"Clinical Features > Complications, p.210","notes":"'Pneumonia (in 6% of reported cases) may be viral or superimposed bacterial, and is the most common cause of measles-related death.' The CDC consumer page says 'As many as 1 out of every 20 children with measles gets pneumonia'. Otitis media was reported in 7% and diarrhea in 8% of cases in the same data.","era_flags":["high_income","surveillance_reported_cases"],"comparable_per_case":true},
    {"disease":"Measles","outcome":"Hospitalization","population":"Unvaccinated people in the US who get measles (current CDC page; no era stated)","risk_value":20,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC. Measles Symptoms and Complications","doi_or_url":"https://www.cdc.gov/measles/signs-symptoms/index.html","location_in_source":"Severe complications in children and adults","notes":"'About 1 in 5 unvaccinated people in the U.S. who get measles is hospitalized.' Prevaccine context from the CDC clinical overview: about 48,000 hospitalized per year in the decade before 1963.","era_flags":["high_income","postvaccine"],"comparable_per_case":true},
    {"disease":"Measles","outcome":"Subacute sclerosing panencephalitis (SSPE)","population":"Reported measles cases (US, Pink Book 13th ed.)","risk_value":null,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":0.5,"range_high":1.0,"source":"CDC Pink Book 13th ed., 2015, Measles chapter","doi_or_url":"https://web.archive.org/web/2020/https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/meas.pdf","location_in_source":"Clinical Features > Complications, p.211","notes":"Source: 'occurs in five to ten cases per million reported measles cases'. DERIVED conversion: 5-10 per million = 0.5-1.0 per 100,000. This is an older estimate. The newer cohort estimates below are much higher.","era_flags":["high_income","prevaccine"],"comparable_per_case":true},
    {"disease":"Measles","outcome":"SSPE","population":"Measles cases (CDC consumer page)","risk_value":null,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":7,"range_high":11,"source":"CDC. Measles Symptoms and Complications - About SSPE","doi_or_url":"https://www.cdc.gov/measles/signs-symptoms/index.html","location_in_source":"Long-term complications > About SSPE","notes":"Only the fragment '7 to 11 out of every 100,000 were estimated to be at risk for developing SSPE' was read. The full sentence, including its era and population, was not seen. Confirm before publishing.","era_flags":["high_income"],"comparable_per_case":true},
    {"disease":"Measles","outcome":"SSPE","population":"Children <5 years at measles, California measles cases 1988-1991 (SSPE cases 1998-2015)","risk_value":73.2,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Wendorf KA, et al. Subacute sclerosing panencephalitis: the devastating measles complication that might be more common than previously estimated. Clin Infect Dis 2017;65:226-232","doi_or_url":"https://doi.org/10.1093/cid/cix302","location_in_source":"Abstract, Results","notes":"Source: '1:1367 for children <5 years'. DERIVED: 100,000/1367 = 73.2 per 100,000. Denominator comes from the 1988-1991 outbreak.","era_flags":["high_income","outbreak","surveillance_reported_cases"],"comparable_per_case":true},
    {"disease":"Measles","outcome":"SSPE","population":"Infants <12 months at measles, California 1988-1991","risk_value":164.2,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Wendorf KA, et al. Clin Infect Dis 2017;65:226-232","doi_or_url":"https://doi.org/10.1093/cid/cix302","location_in_source":"Abstract, Results","notes":"Source: '1:609 for children <12 months at time of measles disease'. DERIVED: 100,000/609 = 164.2 per 100,000.","era_flags":["high_income","outbreak","surveillance_reported_cases"],"comparable_per_case":true},
    {"disease":"Measles","outcome":"SSPE","population":"Children infected <5 years, Germany 2003-2009 (capture-recapture)","risk_value":null,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":30.3,"range_high":58.8,"source":"Schonberger K, et al. Epidemiology of SSPE in Germany from 2003 to 2009: a risk estimation. PLoS One 2013;8:e68909","doi_or_url":"https://doi.org/10.1371/journal.pone.0068909","location_in_source":"Abstract","notes":"Source: '1:1700 to 1:3300'. DERIVED: 100,000/3300 = 30.3 and 100,000/1700 = 58.8 per 100,000. The authors note this is 'the same order of magnitude as the risk of a fatal acute measles infection.'","era_flags":["high_income"],"comparable_per_case":true},

    {"disease":"Mumps","outcome":"Orchitis","population":"Unvaccinated post-pubertal males","risk_value":30,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current web edition), Chapter 15: Mumps","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-15-mumps.html","location_in_source":"Clinical Features > Complications","notes":"'occurring in approximately 30% of unvaccinated and 6% of vaccinated post-pubertal males.' About half of patients with orchitis develop atrophy of the affected testis. The source says no study has shown a sterility risk. The same text is in the 13th ed., p.248.","era_flags":["prevaccine"],"comparable_per_case":true},
    {"disease":"Mumps","outcome":"Orchitis","population":"Vaccinated post-pubertal males with mumps","risk_value":6,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 15: Mumps","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-15-mumps.html","location_in_source":"Clinical Features > Complications","notes":"Breakthrough cases in vaccinated people.","era_flags":["postvaccine"],"comparable_per_case":true},
    {"disease":"Mumps","outcome":"Oophoritis; mastitis","population":"Post-pubertal women with mumps, prevaccine era","risk_value":7,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 15: Mumps","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-15-mumps.html","location_in_source":"Clinical Features > Complications","notes":"Oophoritis 7%, mastitis 30%. In vaccinated women, each is 1% or less.","era_flags":["prevaccine"],"comparable_per_case":true},
    {"disease":"Mumps","outcome":"Clinical aseptic meningitis","population":"Unvaccinated mumps patients","risk_value":null,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":10,"source":"CDC Pink Book (current), Chapter 15: Mumps","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-15-mumps.html","location_in_source":"Clinical Features > Complications","notes":"'Among unvaccinated patients, clinical aseptic meningitis occurred in up to 10%, pancreatitis in up to 4%, and sensorineural hearing loss in up to 4%.' The source says meningitis is usually mild.","era_flags":["prevaccine"],"comparable_per_case":true},
    {"disease":"Mumps","outcome":"Sensorineural hearing loss (transient or permanent)","population":"Unvaccinated mumps patients","risk_value":null,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":4,"source":"CDC Pink Book (current), Chapter 15: Mumps","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-15-mumps.html","location_in_source":"Clinical Features > Complications","notes":"'Hearing loss is usually transient but may be permanent' (13th ed. p.249). No separate figure for permanent deafness was found.","era_flags":["prevaccine"],"comparable_per_case":true},
    {"disease":"Mumps","outcome":"Meningitis, encephalitis, pancreatitis, hearing loss (each)","population":"All persons infected with mumps, postvaccine era (mostly vaccinated outbreak cases)","risk_value":null,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":1,"source":"CDC Pink Book (current), Chapter 15: Mumps","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-15-mumps.html","location_in_source":"Clinical Features > Complications","notes":"'reported rates of meningitis, encephalitis, pancreatitis, and hearing loss ... have all been 1% or less.' This is the only encephalitis figure found. 'Permanent sequelae and death are very rare.'","era_flags":["postvaccine","outbreak"],"comparable_per_case":true},

    {"disease":"Rubella","outcome":"Congenital infection after maternal rubella with rash, weeks 1-12","population":"Over 1,000 women with confirmed rubella in pregnancy, England and Wales (prospective)","risk_value":80,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Miller E, Cradock-Watson JE, Pollock TM. Consequences of confirmed maternal rubella at successive stages of pregnancy. Lancet 1982;2:781-784","doi_or_url":"https://doi.org/10.1016/S0140-6736(82)92677-0","location_in_source":"Abstract","notes":"'more than 80% during the first 12 weeks of pregnancy, 54% at 13-14 weeks, and 25% at the end of the second trimester. The infection rate then rose again to reach a high figure in the last month.' The value is a lower bound (>80%). Denominator: pregnancies with confirmed maternal rubella.","era_flags":["prevaccine","high_income"],"comparable_per_case":true},
    {"disease":"Rubella","outcome":"Congenital infection, weeks 13-14","population":"Same cohort","risk_value":54,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Miller E, et al. Lancet 1982;2:781-784","doi_or_url":"https://doi.org/10.1016/S0140-6736(82)92677-0","location_in_source":"Abstract","notes":"Denominator: maternal infections at 13-14 weeks.","era_flags":["prevaccine","high_income"],"comparable_per_case":true},
    {"disease":"Rubella","outcome":"Congenital infection, end of second trimester","population":"Same cohort","risk_value":25,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Miller E, et al. Lancet 1982;2:781-784","doi_or_url":"https://doi.org/10.1016/S0140-6736(82)92677-0","location_in_source":"Abstract","notes":"","era_flags":["prevaccine","high_income"],"comparable_per_case":true},
    {"disease":"Rubella","outcome":"Rubella defects (CRS) among infected infants, infection before week 11","population":"Infants with confirmed congenital infection, followed to age 2","risk_value":100,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Miller E, et al. Lancet 1982;2:781-784","doi_or_url":"https://doi.org/10.1016/S0140-6736(82)92677-0","location_in_source":"Abstract","notes":"'Rubella defects occurred in all infants infected before the 11th week (principally congenital heart disease and deafness).' Denominator: INFECTED infants, not all maternal infections. Risk per maternal infection is about infection rate x defect rate.","era_flags":["prevaccine","high_income"],"comparable_per_case":true},
    {"disease":"Rubella","outcome":"Rubella defects among infected infants, infection at weeks 13-16","population":"Infants with confirmed congenital infection","risk_value":35,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Miller E, et al. Lancet 1982;2:781-784","doi_or_url":"https://doi.org/10.1016/S0140-6736(82)92677-0","location_in_source":"Abstract","notes":"Deafness alone. No defects attributable to rubella were found in 63 children infected after 16 weeks.","era_flags":["prevaccine","high_income"],"comparable_per_case":true},
    {"disease":"Rubella","outcome":"Arthralgia or arthritis","population":"Adult women with rubella","risk_value":null,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":70,"source":"CDC. Clinical Overview of Rubella (HCP page)","doi_or_url":"https://www.cdc.gov/rubella/hcp/clinical-overview/index.html","location_in_source":"Complications","notes":"'Arthralgia or arthritis may occur in up to 70% of adult women with rubella.' For comparison, the Pink Book (Ch.20, Vaccine Safety) says joint symptoms occur in up to 25% of adult women after MMR. The 13th ed. says chronic arthritis is rare.","era_flags":[],"comparable_per_case":true},
    {"disease":"Rubella","outcome":"Hemorrhagic manifestations (thrombocytopenic purpura most common)","population":"Rubella cases","risk_value":33.3,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 20: Rubella; same in 13th ed. p.326","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-20-rubella.html","location_in_source":"Clinical Features > Complications","notes":"Source: 'approximately 1 per 3,000 cases'. DERIVED: 33.3 per 100,000. Covers all hemorrhagic manifestations, of which thrombocytopenic purpura is the most common. No ITP-specific rate was given. For comparison, the 13th ed. measles chapter gives MMR thrombocytopenia as 1 per 30,000-40,000 vaccinated susceptible persons.","era_flags":[],"comparable_per_case":true},
    {"disease":"Rubella","outcome":"Encephalitis","population":"Rubella cases","risk_value":16.7,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 20: Rubella","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-20-rubella.html","location_in_source":"Clinical Features > Complications","notes":"Source: '1 in 6000 cases and may be fatal'. DERIVED: 16.7 per 100,000.","era_flags":[],"comparable_per_case":true},

    {"disease":"Varicella","outcome":"Hospitalization","population":"Healthy children, US prevaccine era","risk_value":null,"risk_unit":"per 1,000 cases","ci_low":null,"ci_high":null,"range_low":1,"range_high":2,"source":"CDC Pink Book (current), Chapter 22: Varicella","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-22-varicella.html","location_in_source":"Clinical Features > Complications (prevaccine era)","notes":"'Hospitalization rates were approximately 1 to 2 per 1,000 cases among healthy children and 14 per 1,000 cases among adults.' About 10,500 hospitalizations per year prevaccine.","era_flags":["prevaccine","high_income"],"comparable_per_case":true},
    {"disease":"Varicella","outcome":"Hospitalization","population":"Adults, US prevaccine era","risk_value":14,"risk_unit":"per 1,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 22: Varicella","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-22-varicella.html","location_in_source":"Clinical Features > Complications","notes":"","era_flags":["prevaccine","high_income"],"comparable_per_case":true},
    {"disease":"Varicella","outcome":"Death","population":"Children aged 1-14 years, US prevaccine era","risk_value":1,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 22: Varicella","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-22-varicella.html","location_in_source":"Clinical Features > Complications","notes":"The source says most deaths occurred in immunocompetent children and adults. Since the vaccine program, varicella deaths have fallen 94% and hospitalizations 93%.","era_flags":["prevaccine","high_income"],"comparable_per_case":true},
    {"disease":"Varicella","outcome":"Death","population":"Persons aged 15-19 years, US prevaccine era","risk_value":6,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 22: Varicella","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-22-varicella.html","location_in_source":"Clinical Features > Complications","notes":"","era_flags":["prevaccine","high_income"],"comparable_per_case":true},
    {"disease":"Varicella","outcome":"Death","population":"Adults, US prevaccine era","risk_value":21,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 22: Varicella","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-22-varicella.html","location_in_source":"Clinical Features > Complications","notes":"","era_flags":["prevaccine","high_income"],"comparable_per_case":true},
    {"disease":"Varicella","outcome":"Neonatal death after maternal varicella near delivery (no antivirals)","population":"Neonates whose mothers had varicella onset around delivery","risk_value":null,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":30,"source":"CDC Pink Book (current), Chapter 22: Varicella","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-22-varicella.html","location_in_source":"Clinical Features > Complications (maternal varicella)","notes":"'fatality ratio as high as 30% if antivirals are not given'.","era_flags":[],"comparable_per_case":true},
    {"disease":"Varicella","outcome":"Encephalitis","population":"Unvaccinated children with varicella","risk_value":2,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 22: Varicella","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-22-varicella.html","location_in_source":"Clinical Features > Complications","notes":"Source: '1 per 50,000 cases of varicella in unvaccinated children'. DERIVED: 2 per 100,000. Cerebellar ataxia is 1 per 4,000 cases (= 25 per 100,000) and usually has a good outcome.","era_flags":["prevaccine"],"comparable_per_case":true},
    {"disease":"Varicella","outcome":"Invasive group A streptococcal (GAS) disease after chickenpox (relative risk)","population":"Children, Ontario, Canada, 1992-1996 (population-based active surveillance)","risk_value":58,"risk_unit":"relative risk","ci_low":40,"ci_high":85,"range_low":null,"range_high":null,"source":"Laupland KB, et al. Invasive group A streptococcal disease in children and association with varicella-zoster virus infection. Pediatrics 2000;105:e60","doi_or_url":"https://doi.org/10.1542/peds.105.5.e60","location_in_source":"Abstract, Results","notes":"Preceding chickenpox 'significantly increased the risk for acquisition of invasive GAS disease (RR: 58; 95% CI: 40-85)'. 15% of pediatric invasive GAS cases had recent chickenpox. Children with recent chickenpox were more likely to have necrotizing fasciitis (RR 6.3). Baseline pediatric invasive GAS incidence was 1.9 per 100,000 children per year. No absolute per-varicella-case rate was read. The Pink Book names bacterial skin infections as the most common cause of hospitalization but gives no figure.","era_flags":["prevaccine","high_income"],"comparable_per_case":false},
    {"disease":"Varicella","outcome":"Later herpes zoster (lifetime risk, general US population)","population":"US population (nearly all with prior wild-type varicella in the prevaccine cohorts)","risk_value":32,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 23: Zoster","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-23-zoster.html","location_in_source":"Secular Trends in the United States; Epidemiology > Occurrence","notes":"'The lifetime risk of zoster is estimated to be at least 32%' (lower bound). The same chapter says 'about 1 in 3 people' and '50% of persons living until age 85 years will develop zoster.' The denominator is the population, not varicella cases specifically. The varicella chapter says zoster risk after childhood vaccination is about 79% lower than after wild-type infection.","era_flags":["high_income"],"comparable_per_case":false},

    {"disease":"Herpes zoster","outcome":"Postherpetic neuralgia","population":"Adults >=22 years with HZ, Olmsted County MN, 1996-2001 (before zoster vaccine)","risk_value":18,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Yawn BP, et al. A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction. Mayo Clin Proc 2007;82:1341-1349","doi_or_url":"https://doi.org/10.4065/82.11.1341","location_in_source":"Abstract, Results","notes":"'Postherpetic neuralgia occurred in 18% of adult patients with HZ and in 33% of those aged 79 years and older.' 10% had at least one nonpain complication. Intermediate age bands are in the full text, which was not read.","era_flags":["prevaccine","high_income"],"comparable_per_case":true},
    {"disease":"Herpes zoster","outcome":"Postherpetic neuralgia","population":"Adults aged >=79 years with HZ, Olmsted County","risk_value":33,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Yawn BP, et al. Mayo Clin Proc 2007;82:1341-1349","doi_or_url":"https://doi.org/10.4065/82.11.1341","location_in_source":"Abstract, Results","notes":"","era_flags":["prevaccine","high_income"],"comparable_per_case":true},
    {"disease":"Herpes zoster","outcome":"Guillain-Barre syndrome within 2 months of HZ","population":"315,595 HZ patients, Taiwan national registry, 2003-2005","risk_value":24.7,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Kang JH, Sheu JJ, Lin HC. Increased risk of Guillain-Barre syndrome following recent herpes zoster: a population-based study across Taiwan. Clin Infect Dis 2010;51:525-530","doi_or_url":"https://doi.org/10.1086/655136","location_in_source":"Abstract, Results","notes":"Source: '78 from the study group (0.025% of the herpes zoster patients)' vs 0.001% of matched controls. Adjusted HR 18.37 (95% CI 10.22-33.01). DERIVED: 78/315,595 = 24.7 per 100,000. This is absolute risk, not excess. DERIVED excess: about 0.025% - 0.001% = about 24 per 100,000.","era_flags":["high_income"],"comparable_per_case":true},
    {"disease":"Herpes zoster","outcome":"Guillain-Barre syndrome, days 1-42 after HZ vs control window (rate ratio)","population":"US adults 18-64 (MarketScan 2010-2018) and >=65 (Medicare 2014-2018); self-controlled case series","risk_value":6.3,"risk_unit":"rate ratio","ci_low":1.8,"ci_high":21.9,"range_low":null,"range_high":null,"source":"Anderson TC, Leung JW, Harpaz R, Dooling KL. Risk of Guillain-Barre syndrome following herpes zoster, United States, 2010-2018. Hum Vaccin Immunother 2021;17:5304-5310","doi_or_url":"https://doi.org/10.1080/21645515.2021.1985890","location_in_source":"Abstract","notes":"RR 6.3 (1.8-21.9) for ages 18-64; 4.1 (1.9-8.7) for ages >=65. Counts: 11 of 489,516 (18-64) and 41 of 650,229 (>=65) HZ patients developed GBS within 1-365 days. DERIVED crude 1-year GBS risk: 2.2 and 6.3 per 100,000 HZ patients (not excess risk).","era_flags":["high_income"],"comparable_per_case":false},

    {"disease":"Pertussis","outcome":"Hospitalization","population":"Infants <12 months with pertussis (current CDC page; no era stated)","risk_value":33,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC. Clinical Features of Pertussis (HCP page)","doi_or_url":"https://www.cdc.gov/pertussis/hcp/clinical-signs/index.html","location_in_source":"Complications: Infants","notes":"Source: 'about a third need treatment in a hospital'. '33' stands for 'about a third'. The same page: 'The most common complications in this age group are apnea (68%) and pneumonia (22%).' The denominator for the 68%/22% isn't explicit; it may be hospitalized infants. Check before publishing.","era_flags":["postvaccine","high_income","surveillance_reported_cases"],"comparable_per_case":true},
    {"disease":"Pertussis","outcome":"Hospitalization (DERIVED from annual means)","population":"US infants (<1 year) with reported pertussis, 2000-2017","risk_value":37.9,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 16: Pertussis","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-16-pertussis.html","location_in_source":"Clinical Features > Complications","notes":"Source: infant annual mean cases 2,957 (range 1,803-4,994), hospitalizations 1,122 (544-1,938), deaths 15 (3-35). DERIVED: 1,122/2,957 = 37.9%. The years were not verified from the fetch summary. The 13th ed. gives the 2008-2011 figures (3,132 cases, 1,158 hospitalizations, 16 deaths), so the current edition's values are plausibly 2000-2017 like the adjacent text.","era_flags":["postvaccine","high_income","surveillance_reported_cases"],"comparable_per_case":true},
    {"disease":"Pertussis","outcome":"Death (DERIVED case-fatality from annual means)","population":"US infants (<1 year) with reported pertussis","risk_value":0.51,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 16: Pertussis","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-16-pertussis.html","location_in_source":"Clinical Features > Complications","notes":"DERIVED: 15 deaths / 2,957 cases per year = 0.51% (= 507 per 100,000 reported infant cases). Of 307 pertussis deaths in 2000-2017, children <2 months accounted for 84.0%. 13th ed. (2008-2011): 16/3,132 = 0.51% (DERIVED).","era_flags":["postvaccine","high_income","surveillance_reported_cases"],"comparable_per_case":true},
    {"disease":"Pertussis","outcome":"Pneumonia","population":"Infants <6 months with reported pertussis, US 2000-2017","risk_value":18.6,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 16: Pertussis","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-16-pertussis.html","location_in_source":"Clinical Features > Complications","notes":"Pneumonia occurred in 13.2% of all reported cases. The 13th ed. (1997-2000 data) gives 5.2% of all cases and 11.8% of infants <6 months.","era_flags":["postvaccine","high_income","surveillance_reported_cases"],"comparable_per_case":true},
    {"disease":"Pertussis","outcome":"Hospitalization; pneumonia; seizures","population":"Infants <6 months with reported pertussis, US 1997-2000","risk_value":63,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC. Pertussis - United States, 1997-2000. MMWR 2002;51(4):73-76","doi_or_url":"https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5104a1.htm","location_in_source":"Main text (Table 1 is an image and was not read)","notes":"'Among infants aged <6 months, 63% were hospitalized, 12% had radiographically confirmed pneumonia, and 1% had seizures.' risk_value is hospitalization. Seizures: 1% of cases. Encephalopathy: only an all-ages count was given (26 cases, 62 deaths), so no per-infant rate.","era_flags":["postvaccine","high_income","surveillance_reported_cases"],"comparable_per_case":true},

    {"disease":"Diphtheria","outcome":"Death (case-fatality ratio)","population":"Diphtheria cases overall (treated)","risk_value":null,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":5,"range_high":10,"source":"CDC Pink Book (current), Chapter 7: Diphtheria (same in 13th ed.)","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-7-diphtheria.html","location_in_source":"Clinical Features > Complications","notes":"'The estimated overall case fatality ratio for diphtheria is 5% to 10%.' No age-specific figures were given. Myocarditis and neuritis are the most frequent complications; no numeric rates were given.","era_flags":[],"comparable_per_case":true},
    {"disease":"Diphtheria","outcome":"Death, unvaccinated without proper treatment","population":"Unvaccinated individuals without adequate treatment","risk_value":30,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"WHO. Diphtheria fact sheet","doi_or_url":"https://www.who.int/news-room/fact-sheets/detail/diphtheria","location_in_source":"Key facts; Signs and symptoms","notes":"'diphtheria can be fatal in around 30% of cases'. WHO says children <5 are at greater risk of dying but gives no number.","era_flags":["low_income"],"comparable_per_case":true},
    {"disease":"Tetanus","outcome":"Death (case-fatality)","population":"Reported US tetanus cases, 'recent years' (Pink Book)","risk_value":11,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 21: Tetanus","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-21-tetanus.html","location_in_source":"Clinical Features > Complications","notes":"'In recent years, tetanus has been fatal in approximately 11% of reported cases.' 2009-2018: 297 cases, 19 deaths, all in adults >=55. 13th ed.: 18% fatal in persons >=60 and 22% in unvaccinated persons. Case-fatality was 13% among 197 cases with known outcomes in 2001-2008. Local tetanus is fatal in about 1%.","era_flags":["high_income","postvaccine"],"comparable_per_case":true},
    {"disease":"Tetanus","outcome":"Death (case-fatality)","population":"Unvaccinated persons with tetanus (US)","risk_value":22,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book 13th ed., 2015, Tetanus chapter","doi_or_url":"https://web.archive.org/web/2020/https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/tetanus.pdf","location_in_source":"Clinical Features > Complications","notes":"'Cases most likely to be fatal are those occurring in persons 60 years of age and older (18%) and unvaccinated persons (22%).'","era_flags":["high_income"],"comparable_per_case":true},

    {"disease":"Hib","outcome":"Death from Hib meningitis (case-fatality)","population":"Hib meningitis, prevaccine era US","risk_value":null,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":3,"range_high":6,"source":"CDC Pink Book (current), Chapter 8: Haemophilus influenzae","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-8-haemophilus-influenzae.html","location_in_source":"Clinical Features","notes":"'Meningitis accounted for 50% to 65% of cases with a fatality ratio of 3% to 6% (prevaccine era)'; 'despite appropriate antimicrobial therapy'. Prevaccine: about 20,000 cases per year, and about 1 in 200 children <5 developed invasive Hib disease.","era_flags":["prevaccine","high_income"],"comparable_per_case":true},
    {"disease":"Hib","outcome":"Hearing impairment or other neurologic sequelae","population":"Survivors of Hib meningitis","risk_value":null,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":15,"range_high":30,"source":"CDC Pink Book (current), Chapter 8: Haemophilus influenzae","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-8-haemophilus-influenzae.html","location_in_source":"Clinical Features","notes":"'Hearing impairment or other neurologic sequelae occur in 15% to 30% of survivors.' Denominator: meningitis survivors. The sentence doesn't say 'prevaccine', but it sits beside the prevaccine figures.","era_flags":["prevaccine","high_income"],"comparable_per_case":true},
    {"disease":"Hib","outcome":"Invasive Hib disease (cumulative risk)","population":"US children <5 years, prevaccine era","risk_value":500,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 8","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-8-haemophilus-influenzae.html","location_in_source":"Overview","notes":"Source: 'approximately one in 200 children in this age group developed invasive Hib disease.' DERIVED: 500 per 100,000 CHILDREN. The denominator is children, not cases.","era_flags":["prevaccine","high_income"],"comparable_per_case":false},

    {"disease":"Pneumococcal (invasive)","outcome":"Death from pneumococcal bacteremia","population":"Patients with bacteremia, overall; older adults","risk_value":20,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":60,"source":"CDC. Clinical Features of Pneumococcal Disease (HCP page)","doi_or_url":"https://www.cdc.gov/pneumococcal/hcp/clinical-signs/index.html","location_in_source":"Bacteremia","notes":"'The overall case-fatality rate for bacteremia is about 20%.' 'It may be as high as 60% among patients who are older adults.' (range_high = older adults). The Pink Book Ch.17 gives a different adult figure: bacteremia about 12%, pneumonia with bacteremia about 10%.","era_flags":["high_income"],"comparable_per_case":true},
    {"disease":"Pneumococcal (invasive)","outcome":"Death from pneumococcal meningitis","population":"Children","risk_value":8,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC. Clinical Features of Pneumococcal Disease (HCP page)","doi_or_url":"https://www.cdc.gov/pneumococcal/hcp/clinical-signs/index.html","location_in_source":"Meningitis","notes":"'The case-fatality rate of pneumococcal meningitis is about 8% among children and 22% among adults.' 'Neurologic sequelae can happen in as many as 50% of pneumococcal meningitis survivors.'","era_flags":["high_income"],"comparable_per_case":true},
    {"disease":"Pneumococcal (invasive)","outcome":"Death from pneumococcal meningitis","population":"Adults","risk_value":22,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC. Clinical Features of Pneumococcal Disease (HCP page)","doi_or_url":"https://www.cdc.gov/pneumococcal/hcp/clinical-signs/index.html","location_in_source":"Meningitis","notes":"The Pink Book Ch.17 says 'about 14% among adults'. The two CDC sources disagree.","era_flags":["high_income"],"comparable_per_case":true},

    {"disease":"Rotavirus","outcome":"Hospitalization by age 5 (cumulative risk per child)","population":"US children, prevaccine era","risk_value":1.43,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC. Prevention of Rotavirus Gastroenteritis Among Infants and Children: ACIP recommendations. MMWR Recomm Rep 2009;58(RR-2)","doi_or_url":"https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5802a1.htm","location_in_source":"Background (burden in the prevaccine era)","notes":"Source: by age 5, 'one in seven required a clinic or ED visit, one in 70 were hospitalized, and one in 200,000 died'. DERIVED: 1/70 = 1.43%; deaths 0.5 per 100,000. The denominator is ALL CHILDREN (four of five had rotavirus gastroenteritis by age 5), not cases. Per-case risk is therefore somewhat higher.","era_flags":["prevaccine","high_income"],"comparable_per_case":false},
    {"disease":"Rotavirus","outcome":"Hospitalizations per year (children <5)","population":"US, prevaccine era","risk_value":null,"risk_unit":"annual count (US)","ci_low":null,"ci_high":null,"range_low":55000,"range_high":70000,"source":"CDC Pink Book (current), Chapter 19: Rotavirus; also MMWR RR 2009;58(RR-2)","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-19-rotavirus.html","location_in_source":"Secular Trends in the United States","notes":"Also: 410,000 physician visits, more than 200,000 ED visits (MMWR: 205,000-272,000), 20-60 deaths per year, and an estimated 2.7 million infections per year. 95% of children were infected by age 5.","era_flags":["prevaccine","high_income"],"comparable_per_case":false},

    {"disease":"Hepatitis B","outcome":"Chronic infection","population":"Infants infected at birth or in infancy","risk_value":null,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":90,"source":"CDC Pink Book (current), Chapter 10: Hepatitis B","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-10-hepatitis-b.html","location_in_source":"Clinical Features (chronic HBV infection)","notes":"'As many as 90% of infants who acquire HBV infection from their mothers at birth or in infancy become chronically infected.'","era_flags":[],"comparable_per_case":true},
    {"disease":"Hepatitis B","outcome":"Chronic infection","population":"Children infected at age 1-5 years","risk_value":null,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":30,"range_high":50,"source":"CDC Pink Book (current), Chapter 10: Hepatitis B","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-10-hepatitis-b.html","location_in_source":"Clinical Features","notes":"","era_flags":[],"comparable_per_case":true},
    {"disease":"Hepatitis B","outcome":"Chronic infection","population":"Persons infected as adults","risk_value":5,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 10: Hepatitis B","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-10-hepatitis-b.html","location_in_source":"Clinical Features","notes":"'approximately 5%'. Fulminant hepatitis occurs in about 1%-2% of acutely infected persons. No case-fatality for fulminant hepatitis was given.","era_flags":[],"comparable_per_case":true},
    {"disease":"Hepatitis B","outcome":"Premature death from cirrhosis or liver cancer","population":"Persons chronically infected during childhood","risk_value":25,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 10: Hepatitis B","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-10-hepatitis-b.html","location_in_source":"Clinical Features","notes":"'Approximately 25% of persons who become chronically infected during childhood and 15% of those who become chronically infected after childhood will die prematurely from cirrhosis or liver cancer.' Denominator: chronically infected persons. DERIVED for perinatal infection: up to 90% x 25% = up to about 22% of infected infants. This is a simple product, not a source figure.","era_flags":[],"comparable_per_case":true},
    {"disease":"Hepatitis B","outcome":"Premature death from cirrhosis or liver cancer","population":"Persons chronically infected after childhood","risk_value":15,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 10: Hepatitis B","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-10-hepatitis-b.html","location_in_source":"Clinical Features","notes":"","era_flags":[],"comparable_per_case":true},

    {"disease":"HPV","outcome":"Cervical cancers attributable to HPV (any type)","population":"US","risk_value":91,"risk_unit":"percent of cervical cancers","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 11: Human Papillomavirus","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-11-human-papillomavirus.html","location_in_source":"Secular Trends in the United States","notes":"About 10,900 HPV-attributable cervical cancers per year in US women, out of 43,999 HPV-associated cancers per year in all. HPV also causes about 91% of anal, 69% of vulvar, 75% of vaginal, 63% of penile and 70% of oropharyngeal cancers. This is an attributable fraction of cancers, not a per-infection risk.","era_flags":["high_income"],"comparable_per_case":false},
    {"disease":"HPV","outcome":"Cervical cancers caused by HPV 16/18; by additional 9-valent types","population":"Worldwide","risk_value":66,"risk_unit":"percent of cervical cancers","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"CDC Pink Book (current), Chapter 11: Human Papillomavirus","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-11-human-papillomavirus.html","location_in_source":"Human Papillomavirus (overview); Prevention (screening)","notes":"Type 16 accounts for about 50% of cervical cancers worldwide, and types 16+18 for about 66%. Types 31/33/45/52/58 account for another 15%. Prevention section: 'up to 30%' of cervical cancers are caused by types not in the 2v/4v vaccines, and 15% by types not in the 9v vaccine.","era_flags":[],"comparable_per_case":false},

    {"disease":"Influenza","outcome":"GBS hospitalization attributable to influenza illness (within 6 weeks)","population":"Ontario, Canada, 1993-2011; self-controlled risk interval","risk_value":17.2,"risk_unit":"per 1,000,000 influenza-coded health-care encounters","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Kwong JC, et al. Risk of Guillain-Barre syndrome after seasonal influenza vaccination and influenza health-care encounters: a self-controlled study. Lancet Infect Dis 2013;13:769-776","doi_or_url":"https://doi.org/10.1016/S1473-3099(13)70104-X","location_in_source":"Abstract, Findings","notes":"'The attributable risks were 1.03 Guillain-Barre syndrome admissions per million vaccinations, compared with 17.2 ... per million influenza-coded health-care encounters.' DERIVED: 1.72 per 100,000 encounters vs 0.103 per 100,000 vaccinations. Relative incidence after an influenza encounter was 15.81 (10.28-24.32), vs 1.52 (1.17-1.99) after vaccination. The denominator is medically attended influenza encounters, not all infections.","era_flags":["high_income"],"comparable_per_case":true},
    {"disease":"Influenza","outcome":"GBS within 90 days of influenza-like illness (relative incidence)","population":"UK General Practice Research Database, 1990-2005; self-controlled case series","risk_value":7.35,"risk_unit":"relative incidence","ci_low":4.36,"ci_high":12.38,"range_low":null,"range_high":null,"source":"Stowe J, Andrews N, Wise L, Miller E. Investigation of the temporal association of Guillain-Barre syndrome with influenza vaccine and influenzalike illness using the UK GPRD. Am J Epidemiol 2009;169:382-388","doi_or_url":"https://doi.org/10.1093/aje/kwn310","location_in_source":"Abstract","notes":"Within 30 days: 16.64 (9.37-29.54). After vaccination: 0.76 (0.41-1.40), no increase. No absolute per-infection rate is given.","era_flags":["high_income"],"comparable_per_case":false},
    {"disease":"Influenza","outcome":"Net GBS risk from vaccination vs no vaccination (simulation)","population":"Hypothetical 45-year-old woman and 75-year-old man, Ontario-based inputs","risk_value":-0.36,"risk_unit":"per 1,000,000 vaccinations (excess GBS risk)","ci_low":-1.22,"ci_high":0.28,"range_low":null,"range_high":null,"source":"Hawken S, et al. Simulation study of the effect of influenza and influenza vaccination on risk of acquiring Guillain-Barre syndrome. Emerg Infect Dis 2015;21:224-231","doi_or_url":"https://doi.org/10.3201/eid2102.131879","location_in_source":"Abstract","notes":"45-year-old woman: -0.36/million (credible interval -1.22 to 0.28). 75-year-old man: -0.42/million (-3.68 to 2.44). Under typical conditions (influenza incidence >5%, vaccine effectiveness >60%), vaccination reduced net GBS risk.","era_flags":["high_income"],"comparable_per_case":false},

    {"disease":"COVID-19","outcome":"Myocarditis (excess events within 28 days of positive SARS-CoV-2 test)","population":"England, age >=16, Dec 2020-Aug 2021 (n=3,028,867 positive tests); self-controlled case series","risk_value":40,"risk_unit":"per 1,000,000 infections (excess)","ci_low":38,"ci_high":41,"range_low":null,"range_high":null,"source":"Patone M, et al. Risks of myocarditis, pericarditis, and cardiac arrhythmias associated with COVID-19 vaccination or SARS-CoV-2 infection. Nat Med 2022;28:410-422","doi_or_url":"https://doi.org/10.1038/s41591-021-01630-0","location_in_source":"Abstract; Results (excess events paragraph; Fig. 2 / Suppl. Table 10)","notes":"DERIVED: 4.0 per 100,000 positive tests. Comparison: an extra 2 (ChAdOx1), 1 (BNT162b2) and 6 (mRNA-1273) per million after dose 1, and 10 per million after mRNA-1273 dose 2. Under age 40: 10 (7-11) per million after a positive test vs 15 (12-16) after mRNA-1273 dose 2 and 3 (2-4) after BNT162b2 dose 2. Pre-Omicron, largely pre-vaccination infections.","era_flags":["high_income"],"comparable_per_case":true},
    {"disease":"COVID-19","outcome":"Myocarditis (excess events within 28 days of positive test)","population":"Men <40 years, England, Dec 2020-Dec 2021","risk_value":16,"risk_unit":"per 1,000,000 infections (excess)","ci_low":12,"ci_high":18,"range_low":null,"range_high":null,"source":"Patone M, et al. Risk of myocarditis after sequential doses of COVID-19 vaccine and SARS-CoV-2 infection by age and sex. Circulation 2022;146:743-754","doi_or_url":"https://doi.org/10.1161/CIRCULATIONAHA.122.059970","location_in_source":"Abstract, Results","notes":"Comparison: 97 (91-99) per million after a second dose of mRNA-1273 in men <40. Women <40: 8 (6-8) after a positive test vs 7 (1-9) after mRNA-1273 dose 2. IRR after a positive test before vaccination was 11.14 (8.64-14.36). Only the abstract was read; full age/sex tables were not retrieved (Europe PMC full text returned an error).","era_flags":["high_income"],"comparable_per_case":true},
    {"disease":"COVID-19","outcome":"Myocarditis (excess events within 28 days of positive test)","population":"Women <40 years, England","risk_value":8,"risk_unit":"per 1,000,000 infections (excess)","ci_low":6,"ci_high":8,"range_low":null,"range_high":null,"source":"Patone M, et al. Circulation 2022;146:743-754","doi_or_url":"https://doi.org/10.1161/CIRCULATIONAHA.122.059970","location_in_source":"Abstract, Results","notes":"","era_flags":["high_income"],"comparable_per_case":true},
    {"disease":"COVID-19","outcome":"Myocarditis (risk among patients with a COVID-19 diagnosis)","population":"US Premier Healthcare Database, >900 hospitals, Mar 2020-Jan 2021, all ages (n=1,452,773 with COVID-19)","risk_value":146,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Boehmer TK, et al. Association between COVID-19 and myocarditis using hospital-based administrative data - United States, March 2020-January 2021. MMWR 2021;70:1228-1232","doi_or_url":"https://doi.org/10.15585/mmwr.mm7035e5","location_in_source":"Abstract; Results; Table","notes":"Source: 0.146% with COVID-19 vs 0.009% without. Adjusted risk difference 0.126% (0.112-0.140), i.e. 126 per 100,000 excess. aRR 15.7 (14.1-17.2). Males 0.187% (aRD 0.165%, aRR 13.8); females 0.109% (aRD 0.100%, aRR 17.8). Denominator: patients diagnosed with COVID-19 in hospital inpatient/outpatient encounters. Not all infections; skews toward severe illness. ICD-coded, unadjudicated.","era_flags":["high_income","hospital_based"],"comparable_per_case":true},
    {"disease":"COVID-19","outcome":"Myocarditis, by age group","population":"US Premier database; COVID-19 patients aged <16 years","risk_value":133,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Boehmer TK, et al. MMWR 2021;70:1228-1232","doi_or_url":"https://doi.org/10.15585/mmwr.mm7035e5","location_in_source":"Table (age group rows)","notes":"Risk in COVID-19 patients: 0.133%; without COVID 0.004%. aRD 0.122% (0.065-0.179); aRR 36.8 (25.0-48.6). Some cases may be MIS-C (authors' note).","era_flags":["high_income","hospital_based"],"comparable_per_case":true},
    {"disease":"COVID-19","outcome":"Myocarditis, by age group","population":"US Premier database; COVID-19 patients aged 16-24 years","risk_value":98,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Boehmer TK, et al. MMWR 2021;70:1228-1232","doi_or_url":"https://doi.org/10.15585/mmwr.mm7035e5","location_in_source":"Table","notes":"0.098% vs 0.013% without COVID. aRD 0.088% (0.061-0.115), i.e. 88 per 100,000 excess. aRR 7.4 (5.5-9.2). Not sex-stratified within age.","era_flags":["high_income","hospital_based"],"comparable_per_case":true},
    {"disease":"COVID-19","outcome":"Myocarditis, by age group","population":"US Premier database; COVID-19 patients aged 25-39 years","risk_value":77,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Boehmer TK, et al. MMWR 2021;70:1228-1232","doi_or_url":"https://doi.org/10.15585/mmwr.mm7035e5","location_in_source":"Table","notes":"0.077% vs 0.010%. aRD 0.067% (0.052-0.081). aRR 6.7 (5.5-8.0).","era_flags":["high_income","hospital_based"],"comparable_per_case":true},
    {"disease":"COVID-19","outcome":"Myocarditis, by age group","population":"US Premier database; COVID-19 patients aged 40-49 years","risk_value":107,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Boehmer TK, et al. MMWR 2021;70:1228-1232","doi_or_url":"https://doi.org/10.15585/mmwr.mm7035e5","location_in_source":"Table","notes":"0.107% vs 0.010%. aRD 0.093% (0.078-0.109). aRR 10.0 (8.1-11.9).","era_flags":["high_income","hospital_based"],"comparable_per_case":true},
    {"disease":"COVID-19","outcome":"Myocarditis, by age group","population":"US Premier database; COVID-19 patients aged 50-64 years","risk_value":155,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Boehmer TK, et al. MMWR 2021;70:1228-1232","doi_or_url":"https://doi.org/10.15585/mmwr.mm7035e5","location_in_source":"Table","notes":"0.155% vs 0.008%. aRD 0.137% (0.121-0.154). aRR 17.0 (14.7-19.3).","era_flags":["high_income","hospital_based"],"comparable_per_case":true},
    {"disease":"COVID-19","outcome":"Myocarditis, by age group","population":"US Premier database; COVID-19 patients aged 65-74 years","risk_value":186,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Boehmer TK, et al. MMWR 2021;70:1228-1232","doi_or_url":"https://doi.org/10.15585/mmwr.mm7035e5","location_in_source":"Table","notes":"0.186% vs 0.008%. aRD 0.160% (0.135-0.184). aRR 23.0 (19.4-26.7).","era_flags":["high_income","hospital_based"],"comparable_per_case":true},
    {"disease":"COVID-19","outcome":"Myocarditis, by age group","population":"US Premier database; COVID-19 patients aged >=75 years","risk_value":238,"risk_unit":"per 100,000 cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Boehmer TK, et al. MMWR 2021;70:1228-1232","doi_or_url":"https://doi.org/10.15585/mmwr.mm7035e5","location_in_source":"Table","notes":"0.238% vs 0.007%. aRD 0.208% (0.179-0.237). aRR 31.6 (25.9-37.2).","era_flags":["high_income","hospital_based"],"comparable_per_case":true},

    {"disease":"Meningococcal disease","outcome":"Death (case-fatality)","population":"Invasive meningococcal disease, overall","risk_value":null,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":10,"range_high":15,"source":"CDC Pink Book (current), Chapter 14: Meningococcal Disease","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-14-meningococcal-disease.html","location_in_source":"Clinical Features","notes":"'The overall case-fatality ratio of meningococcal disease is 10% to 15%', even with appropriate antibiotics, and may be higher with meningococcemia. 'As many as 20% of survivors have permanent sequelae', such as hearing loss, neurologic damage or loss of a limb.","era_flags":["high_income"],"comparable_per_case":true},
    {"disease":"Meningococcal disease","outcome":"Disabling amputation; bilateral sensorineural hearing loss >=40 dB; major disabling deficits","population":"UK survivors of serogroup B disease aged 1 month-13 years (MOSAIC case-control, 2008-2010)","risk_value":1,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"Viner RM, et al. Outcomes of invasive meningococcal serogroup B disease in children and adolescents (MOSAIC): a case-control study. Lancet Neurol 2012;11:774-783","doi_or_url":"https://doi.org/10.1016/S1474-4422(12)70180-1","location_in_source":"Abstract, Findings","notes":"risk_value = disabling amputation: 3 (1%) of 239 survivors. Bilateral SNHL >=40 dB: 11 (5%) of 232 (vs <1% of controls; matched OR 4.8). Major disabling deficits: 21 (9%) of 244. Any deficit: 87 (36%) of 244 vs 15% of controls. Denominator: survivors (not all cases) who were assessed.","era_flags":["high_income"],"comparable_per_case":true},

    {"disease":"Polio","outcome":"Flaccid paralysis","population":"Poliovirus infections in children","risk_value":null,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":1,"source":"CDC Pink Book (current), Chapter 18: Poliomyelitis","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-18-poliomyelitis.html","location_in_source":"Clinical Features","notes":"'Less than 1% of all polio infections in children result in flaccid paralysis.' About 70% are asymptomatic, about 24% are minor illness, and 1-5% are nonparalytic aseptic meningitis. Denominator: INFECTIONS.","era_flags":["prevaccine"],"comparable_per_case":true},
    {"disease":"Polio","outcome":"Irreversible paralysis","population":"Poliovirus infections (WHO)","risk_value":0.5,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"WHO. Poliomyelitis fact sheet","doi_or_url":"https://www.who.int/news-room/fact-sheets/detail/poliomyelitis","location_in_source":"Symptoms and risk","notes":"'One in 200 infections leads to irreversible paralysis (usually in the legs).' DERIVED: 0.5% = 500 per 100,000 infections. 'Among those paralysed, 5-10% die when their breathing muscles become immobilized.'","era_flags":[],"comparable_per_case":true},
    {"disease":"Polio","outcome":"Death among paralytic cases","population":"Paralytic polio: children; adolescents/adults; bulbar","risk_value":null,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":2,"range_high":5,"source":"CDC Pink Book (current), Chapter 18: Poliomyelitis","doi_or_url":"https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-18-poliomyelitis.html","location_in_source":"Clinical Features","notes":"Children 2-5%; adolescents and adults up to 15-30%; with bulbar involvement 25-75%. Post-polio syndrome affects 25-40% of paralytic survivors after 15-40 years. Denominator: paralytic cases.","era_flags":["prevaccine"],"comparable_per_case":true},

    {"disease":"Rabies","outcome":"Death once clinical symptoms appear","population":"Clinical rabies (CNS infection), untreated/symptomatic","risk_value":100,"risk_unit":"percent of cases","ci_low":null,"ci_high":null,"range_low":null,"range_high":null,"source":"WHO. Rabies fact sheet","doi_or_url":"https://www.who.int/news-room/fact-sheets/detail/rabies","location_in_source":"Key facts / overview","notes":"'Once the virus infects the central nervous system and clinical symptoms appear, rabies is fatal in 100% of cases.' 44,203 deaths per year (2021 Global Health Estimates).","era_flags":["low_income"],"comparable_per_case":true}
  ],
  "not_found": [
    {"disease":"Measles","outcome":"ITP / thrombocytopenia after measles infection (per-case rate)","searched":"Current Pink Book Ch.13; Pink Book 13th ed. measles chapter (which says only that thrombocytopenia risk 'during rubella or measles infection is much greater than the risk after vaccination'); CDC clinical overview; Europe PMC title search","note":"No authoritative per-case figure was read. The rubella 'hemorrhagic manifestations 1 per 3,000' is rubella-only."},
    {"disease":"Measles","outcome":"Febrile seizure specifically (per case)","searched":"Pink Book 13th ed.","note":"Only 'seizures (with or without fever) 0.6-0.7%' was found (recorded)."},
    {"disease":"Mumps","outcome":"Encephalitis in unvaccinated/prevaccine era; permanent deafness rate","searched":"Current and 13th-ed. Pink Book; CDC mumps clinical overview (qualitative only)","note":"Only the postvaccine-era '1% or less' and the prevaccine 'hearing loss up to 4%' (mostly transient) were found."},
    {"disease":"Rubella","outcome":"ITP specifically","searched":"Pink Book","note":"Only aggregate hemorrhagic manifestations (1 per 3,000) were found."},
    {"disease":"Varicella","outcome":"Absolute invasive GAS / skin-infection risk per varicella case","searched":"Pink Book Ch.22; Laupland 2000 abstract","note":"Only the relative risk (58) was found."},
    {"disease":"Pertussis","outcome":"Encephalopathy and seizures among infants <12 months (current data); death rate per infant case from a cohort","searched":"Pink Book Ch.16; CDC clinical signs page; MMWR 2002 (Table 1 not machine-readable)","note":"Seizures 1% (infants <6 mo, 1997-2000) recorded. No infant encephalopathy rate. Infant CFR is DERIVED from annual means."},
    {"disease":"Diphtheria","outcome":"Age-specific case-fatality (<5 and >40 years)","searched":"Pink Book current and 13th ed.; WHO fact sheet","note":"Neither edition read here gives age-specific CFR."},
    {"disease":"Tetanus","outcome":"Neonatal tetanus case-fatality","searched":"Pink Book Ch.21","note":"Not given numerically. A WHO tetanus position paper (2017) was not retrieved."},
    {"disease":"Pneumococcal","outcome":"Overall IPD case-fatality by detailed age band (e.g., ABCs surveillance)","searched":"Pink Book Ch.17; CDC clinical signs","note":"Only children-vs-adults meningitis and the older-adult bacteremia upper bound were found. ABCs annual reports were not retrieved."},
    {"disease":"Rotavirus","outcome":"Intussusception after natural rotavirus infection","searched":"Pink Book Ch.19; ACIP 2009 MMWR (first 100k chars)","note":"Neither source addresses natural-infection intussusception risk."},
    {"disease":"Influenza","outcome":"GBS per 100,000 influenza INFECTIONS (Vellozzi modeled estimate)","searched":"Web search; Europe PMC","note":"No Vellozzi AJE paper with a per-infection figure was found. Vellozzi et al. 2014 is a CID review and an AJPH 2014 H1N1 cumulative-risk paper; neither was read. Kwong 2013 (per million medically attended influenza encounters) is the closest direct comparison and is recorded. Sivadon-Tardy 2009 CID abstract gives no per-infection rate."},
    {"disease":"Herpes zoster","outcome":"PHN by intermediate age bands (50-59, 60-69, 70-79)","searched":"Yawn 2007 abstract only","note":"Full text not accessible via Europe PMC."},
    {"disease":"COVID-19","outcome":"Patone Circulation 2022 full age/sex table for infection-associated excess myocarditis (e.g., males 13-17, 18-24)","searched":"Europe PMC fullTextXML PMC9439633 (HTTP 500)","note":"Only abstract-level <40 male/female values recorded."},
    {"disease":"Measles","outcome":"WHO position paper (2017) case-fatality statements","searched":"WHO measles fact sheet (no CFR); WER 2017 PDF not retrieved","note":"Portnoy 2019 Lancet Glob Health is used for low/middle-income CFR instead."}
  ]
}