Steroids Tied to Local Reactions to Yellow Fever 17D Vaccine

April 29, 2013

By Will Boggs, MD

NEW YORK (Reuters Health) Apr 29 - Patients receiving systemic corticosteroids seem to be at particular risk for local reactions to the yellow fever 17D vaccine, French researchers say.

"Yellow fever vaccine, like other live attenuated vaccines, is contraindicated in immunocompromised persons," Dr. Solen Kerneis from Paris Descartes University and Cochin Hospital, Paris, France told Reuters Health by email.

On the other hand, she noted, "Yellow fever (YF) virus can cause very serious and sometimes deadly disease. There is no cure against YF and vaccination is the most important preventive measure."

"There is no clear evidence on the dose and duration of corticosteroids that cause significant immune suppression, but if corticosteroid therapy is either short term and/or low-to-moderate dose, it seems that the vaccine can be administered safely," Dr. Kerneis said.

In an observational study, Dr. Kerneis and her colleagues tracked 117 vaccinated adult travelers, including 40 who were receiving corticosteroids. Among the 24 patients on long-term steroids, all were receiving less than 20 mg prednisone-equivalent per day (and 21/24 were receiving less than 10 mg prednisone-equivalent per day).

There were no serious adverse events, and the overall onset and duration of local and systemic adverse events did not differ between the corticosteroid and control groups, the authors reported April 1st online in Arthritis Care & Research.

More patients on corticosteroids than controls reported moderate/severe local adverse events (12% vs 2%), but the incidence of moderate/severe systemic adverse events did not differ significantly between the groups (32% and 22%, respectively).

All vaccinated participants had neutralizing antibody titers of at least 1:10 (i.e., above the protective level), and levels did not differ between participants with a history of previous yellow fever 17D vaccine and those without.

"Our results are too preliminary to draw general recommendations on the use of yellow fever 17D vaccines in people undergoing systemic corticosteroid therapy," the authors conclude. "However, with a dose of 10 mg/day prednisone-equivalent, the yellow fever 17D vaccine seems to be well tolerated."

"We would advise patients in these situations to take the YF vaccine before traveling to endemic regions of Africa and Latin America, but would warn them on the possible occurrence of moderate/severe local reactions in the days following immunization," Dr. Kerneis said.

The vaccine should be withheld, however, from patients who've been taking more than 20 mg/day of corticosteroids for more than 14 days, Dr. Kerneis advises. "In these patients, we would prescribe a measurement of YF17D-specific neutralizing antibody titers to those with a previous history of YF immunization," she said. "Those with titers of at least 1:10 could be considered as protected against YF. Because of the lack of other effective preventive measures and the potential severity of YF disease we would advise the others to cancel their travel in an endemic area."

"Large-scale studies are needed to confirm these results," Dr. Kerneis and her colleagues wrote. "In the near future, an inactivated yellow fever vaccine would represent a very valuable alternative in these situations."

"Another very important point for clinicians is that immunizations, in particular those with live attenuated vaccines, should ideally be updated before starting immunosuppressive therapies," Dr. Kerneis added.

Two of the 14 authors received travel support from Sanofi-Pasteur-MSD, and a third author accepted employment with Sanofi Pasteur after completion of this study.


Arthritis Care Res 2013.