Q:

3/26/2012
Do patients with selective IgA deficiency need to avoid live vaccines? I have a patient with IgA of 20 mg/dL, IgG: 1378 (IgG4 is <1, but IgG1,2 and 3 are WNL) and IgM: 234 who will need yellow fever vaccine since she plans to travel to Angola next year. Would this be contraindicated for her? I am in process of checking her Pneumococcal vaccine titers as her titers were low and she has chronic sinusitis. CBC with diff is WNL. Thank you.

A:

Thank you for your inquiry.

Unfortunately, the issue as to the safety of yellow fever vaccine in patients with IgA deficiency remains somewhat controversial and one gets different perspectives when one researches the use of live vaccines in general in patients with isolated IgA deficiency. The reason for this more than likely is that IgA deficiency is a heterogenous condition. The majority of patients with isolated IgA deficiency are normal - that is, have no clinically significant immune deficit. Some seem to have deficits only in antibody responses, but there are others (a small but significant minority) who have low levels of T cells, diminished production of T cell interferon, and decreased mitogenic responses. And some patients can progress to common variable immunodeficiency which, as you know, is quite often associated with defects in cell mediated immunity (1).

Because of this heterogeneity, perhaps it is not surprising that one can site different quotes as to the safety not only of live viruses in general but yellow fever vaccine in particular when administered to patients with selective IgA deficiency. For example, "Clinical Focus on Primary Immune Deficiencies," published by the Immune Deficiency Foundation, states the following:

"No formal studies of live viral vaccines have been performed in this group, but the lack of case reports of vaccine complications suggests that immunization with varicella and measles/mumps/rubella vaccines is safe." (Source: Immunization of the Immunocompromised Host. In: Clinical Focus on Primary Immune Deficiencies. Volume 1, Issue 1, October 1998. Written by William Moss, M.D., MPH; published by Immune Deficiency Foundation).

On the other hand, according to the CDC website, CDC recommendations for "vaccination of persons with primary and secondary immunodeficiencies" state that patients with "less severe antibody deficiencies" such as selective IgA deficiency should avoid vaccination with BCG and yellow fever, but that "other live vaccines appear to be safe." The link to the site listing these recommendations is as follows: http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/A/immuno-table.pdf.

Whereas, the most recent issue of UpToDate states that "Local live vaccines such as intranasal influenza vaccine and live rotavirus vaccine should not be given to patients with IgA deficiency until their immune status is fully evaluated, because the patient may have other underlying immune defects that preclude the use of these vaccines."

When one looks at our Parameters, there is no mention of a warning about the administration of yellow fever vaccine to patients with IgA deficiency (2).

Thus, at least based upon the information that I have been able to uncover, a definitive answer to your question is not available.

The one thing that I can suggest you do is contact the CDC directly with your question. The link to contact CDC by e-mail is as follows: cdcinfo@cdc.gov. In addition, they do have a telephone number that you can call during regular work hours. It is: 1-800-232-4636. Finally, the hard mail address is: 1600 Clifton Road, Atlanta, GA 30333.

I think that the most authoritative source, and the quickest way to settle these discrepancies, would be for you to contact them directly. I would be happy to do this for you, but that would run a greater risk of misinformation than if you contacted them directly.

Thank you again for your inquiry and we hope this response is helpful to you.

References:
Progression of selective IgA deficiency to common variable immunodeficiency. International Archives of Allergy and Immunology 2008; 147:87-92.
Kelso and Li. Adverse reactions to vaccines. Annals of Allergy, 2009; 1003:S1-S16.

Sincerely,
Phil Lieberman, M.D.

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