yellow fever vaccine and immunocompromised hosts

Q: A 52-year-old male recovering in the ICU after a heart-kidney transplant announces he will travel to South Africa to celebrate his successful outcome and freedom from dialysis. He asks the intensivist for advice, who advises against such travel as he may need to take the yellow fever vaccine. Why should the yellow fever vaccine ideally be avoided in immunocompromised hosts?

Answer: It contains a live attenuated viral strain 

Ideally, immunocompromised travelers due to any underlying disease process (such as asplenia or thymic dysfunction) or drugs (such as steroids) should avoid the yellow fever vaccine, or wait 4-12 weeks after stopping such drugs. It contains a live attenuated viral strain. Experts even advise omitting such travel to endemic areas and even accepting deportation instead of accepting the yellow fever vaccine if forced on arrival. If absolutely required, peak season should be avoided.

Some patients who are on TNF-alpha inhibitors, interleukin-1– and interleukin-6–blocking agents, immunosuppressive monoclonal antibodies targeting immune cells, alkylating drugs, and antimetabolites may not be aware of underlying risk. Similarly, patients with asplenia, renal failure, chronic liver disease, advanced HIV, diabetes, myasthenia gravis, thymoma, or prior thymectomy are at particular risk.

Fatal myeloencephalitis or yellow fever vaccine–associated viscerotropic disease may occur.

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References:

1. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014; 58:e44.

2. Cetron MS, Marfin AA, Julian KG, et al. Yellow fever vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2002. MMWR Recomm Rep 2002; 51:1.

3. Mileno M. Preparation of Immunocompromised Travelers. In: Travel Medicine, 1st ed, Keystone JS, Freedman DP, Nothdurft HD, Connor BA (Eds), Mosby, Edinburgh 2004. p.249.

4. Kengsakul K, Sathirapongsasuti K, Punyagupta S. Fatal myeloencephalitis following yellow fever vaccination in a case with HIV infection. J Med Assoc Thai 2002; 85:131.