[CIS PIDD] [cis-pidd] yellow fever vaccine

Sun Sep 18 15:01:05 EDT 2016

Dr. Tichenor-- 

If the patient were immunocompetent, but received IVIG or other blood products for whatever reason (acute blood loss due to trauma, for instance), one actually does not need to wait any period of time to administer the live yellow fever vaccine (Kroger and Strikas, http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/general-recommendations-for-vaccination-immunoprophylaxis).  This is in variance to the standing recommendations for MMR and VZV vaccines -- which have to be delayed certain amounts of time after receipt of IVIG or other blood products, due to viral de-activation by existing antibody.

I would suggest a decent paper to review:  Slifka MK, et al., Transplantation 2013.   They showed that most IVIG lots have some anti-yellow fever neutralizing Ab ... but this is 10-100 fold less than what is seen in vaccinated patients' sera.  (Hence, much lower, since infused IVIG gets "diluted" in the patient's total blood volume, and them some).  The vaccine was B cell immunogenic in their patient (an adult 19 y s/p renal transplant, on cyclosporin and mycophenylate), but not T cell immunogenic.  The patient's ALT rose high enough that they were concerned about the possibility of viscerotropic disease, that they gave him IVIG.  (I'm not totally sold that this was what was happening to the patient, but understand why they thought they had to assume this).

Counter this with the sporadic report of death due to yellow fever vaccine-associated viscerotropic disease in immunocompetent patients (e.g., Gerasimon et al., South Med J 2005).  Considering the much smaller denominator for people receiving YFV ... the rate for this (0.8 per 100,000 doses) is probably higher than what we see for the other live vaccines.  There is a decent WHO white paper summarizes the data on this (Rafferty et al., http://www.who.int/immunization/sage/meetings/2013/april/4_Draft_article_YF-AVD_Elderly_19_Feb.pdf)

For what it's worth, the CDC has the blanket "primary immunodeficiencies" -- without any qualification as to level of severity -- as a contraindication to the vaccine (http://www.cdc.gov/travel-training/local/HistoryEpidemiologyandVaccination/page27324.html).  For acquired immunodeficiencies / HIV, the patient should not be symptomatic, have an AIDS diagnosis, or be CD4 T lymphopenic (200/uL cutoff).

I respectfully disagree with Drs. Rosenzweig and Keller -- I would lead towards giving the patient a medical waiver from receiving the vaccine (the yellow card would have to be marked as such).  The risks of the vaccine probably outweigh the risks of disease (this is yellow fever ... for the vast majority of infected patients, a minor flu-like illness).  Just hike up his IVIG dosing (it might work ... an "unpublished case" cited by Busowski, http://emedicine.medscape.com/article/232244-medication).  And strongly advise him on mosquito avoidance (DEET, avoidance of the outdoors in dawn and dusk, etc.).  Malaria prophylaxis if needed (it depends where in Ethiopia he's going to).

If he is insistent on getting the vaccine, the vaccine should be given with enough lead time that if he were to get viscerotropic disease (usually < 1 week post-vaccine), it happens in this country, where he could be evaluated and treated quickly.  For the case above, they used 0.5 gram/kg qday x 3. 

No easy answers on this case.  Good luck.

   - K

Karl O. A. Yu, M.D., Ph.D., F.A.A.P.
Instructor of Pediatrics (Pediatric Infectious Diseases)
University of Chicago - Comer Children's Hospital
5841 S Maryland Ave, MC 6054, Chicago IL 60637
Pager:  773-702-6800   x1744
Fax:  773-702-1196
Lab phone (Bubeck Wardenburg laboratory): 773-834-6976

________________________________________
From: CIS-PIDD [cis-pidd at lists.clinimmsoc.org]
Sent: Sunday, September 18, 2016 12:11 PM
To: CIS-PIDD
Subject: RE:[cis-pidd] yellow fever vaccine

The pt doesn't look to have any contraindication for YF vaccine...or strong indication for IgG replacement either. Not sure about the YF titers on US plasma donors as if present they should neutralize a live virus vaccine (for full info on simultaneous or sequential use of bilogicals -eg vaccines and IgG- check the ACIP/CDC recommendation guidelines)
Sergio

Sent from Email+ managed by MobileIron

On Sep 18, 2016 12:34:14 PM, CIS-PIDD <cis-pidd at lists.clinimmsoc.org> wrote:

Dear sir -

If your patient responded to pneumococcal vaccine, does not have hypogammaglobulinemia, and hasn't had issue with prior live vaccines, I would think that the yellow fever vaccine should be tolerated well and is probably advisable.

Has he received and tolerated zostavax?

Best regards,
Mike

Michael D. Keller, MD
Assistant Professor, Division of Allergy / Immunology
Center for Cancer and Immunology Research
Jeffrey Modell Diagnostic and Research Center for
Primary Immunodeficiency Disorders
Children's National Health System
111 Michigan Ave NW, M7745A
Washington, DC 20010
Clinic: 202.476.3016
Office: 202.476.5843
Fax: 202.476.2280
www.ChildrensNational.org

________________________________
From: CIS-PIDD [cis-pidd at lists.clinimmsoc.org]
Sent: Sunday, September 18, 2016 11:17 AM
To: CIS-PIDD
Subject: [cis-pidd] yellow fever vaccine

I have a patient who is a 50 year old man with S. aureus chronic rhinosinusitis with polyps.  He has been diagnosed with selective antibody deficiency, mild phenotype (responded to 20/23 serotypes).   His immunoglobulin  levels and IgG subtypes were normal, and he apparently responded to DT. I have not yet obtained the actual results yet from the DT.  CD3,4,8 were normal.  He was started on IgG replacement because he was not responsive to any other treatment.  There has been some improvement.

The patient is traveling to Ethiopia for which the live yellow fever vaccine is recommended.  The ID person who follows him is reluctant to give him the vaccination given his immunodeficiency diagnosis.  My thoughts are that since this would be considered a mild antibody deficiency, it would be advisable to give it.

Thoughts?

Thanks.

Sincerely,

Wellington S. Tichenor, M. D.
642 Park Avenue
New York, New York 10065
212 517-6611
wtichenor at sinuses.com<https://urldefense.proofpoint.com/v2/url?u=https-3A__register.concentric.com_home_apps_mail_mbox-5Fcompose.cgi-3FpTo-3Dwtichenor-40sinuses.com&d=DQMFAw&c=Zoipt4Nmcnjorr_6TBHi1A&r=mERX_I8PKb0Uil9coedoT1CtvFqkSey45L0vbcX0oKI&m=-QDXL0Bp28l2u4CZWxPOVyR5Sw2Y9-QRg2e1djGSkyA&s=ibJGGbfoMM-ob4NuY8WG43d5TrM7_sIBRRPPDmThHyo&e=>

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