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Yellow Fever Vaccine for low CD4 count
Mar 20, 2010

Hello, I've been offered work in West Africa, a yellow fever hotspot. I'd like to accept this long term job but my CD4 count is 60 (but VL is now undetectable). I'm on HAART. I realize that the CDC is against this vaccination for CD4 < 200 but can you tell me how bad the risk is of a bad reaction at low CD4 counts? I feel healthy, have been diagnosed poz 6 months ago. Thanks very much.

Response from Dr. Young

Thanks for your post. I asked my colleague, Dr. John Hammer from Global Travel Health in Denver to provide an answer; he's expert in issues related to travel vaccinations.

"While work in West Africa certainly sounds potentially interesting and rewarding, the risk of contracting yellow fever certainly is a problem. The CDC estimates the risk of contracting yellow fever in West Africa over a 2 week stay is about 50/100,000 (with a risk of death of 10/100,000). This risk would generally accumulate over longer stays, depending on a host of factors such as work location, season and use of insect precautions. This associated risk of death might be higher as well in immunocompromised individuals with less than optimal access to healthcare facilities. Long term travel without vaccination is generally not advised.

As for the risk posed by vaccination, there is not much data in those HIV-infected individuals with CD4 counts <200 after the death of a vaccinated gentleman found to have a CD4 count of 108 (he was not known to have HIV at the time of vaccination). The vaccine is a live virus and can cause liver failure/death in any immunocompromised individual. Vaccine is clearly contraindicated in those with CD4 < 200 due to this potential for a fatal outcome. As you noted, however, vaccination felt to be relatively safe in those with CD4 counts > 200 for > than 3 months on therapy and this safety has been documented in a couple of small case series. The question of a protective response to vaccine in this group has been questioned as well but small series have shown an adequate response in most (though testing for response may be considered).

With respect to your dilemma, as you have recently been started on treatment, you should hope to have a beneficial CD4 response over time. If possible, you might try to delay your work in Africa for 1-2 years to see if you have a good CD4 response that might allow for vaccination. This might also allow for safe live-virus vaccination against other potential pathogens common in Africa (such as measles) as well. Good luck and safe travels!"



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