To the Editor: Dr. Arya correctly points out that there have been problems with degradation of live viral vaccines, including yellow fever vaccines, that have not been properly handled and stored at the point of use. However, in the United States and western Europe, yellow fever vaccines are stabilized and require the same storage facilities at the point of use as other vaccines routinely distributed by family physicians and pediatricians. Varicella vaccine (and even measles vaccine) is less stable than yellow fever vaccine but is distributed to all registered physicians in the United States. Since vaccines and other perishable medicines are typically shipped by overnight courier services using qualified methods that ensure maintenance of low temperature, there is no barrier to use of a similar system for yellow fever vaccine.

Empirical testing for antibody, viremia, or even surrogate markers of T-cell activation may be useful; however, it is difficult and expensive, involves unvalidated tests with unknown sensitivity and specificity, and is unnecessary, except under very special circumstances. A more direct measure of vaccine stability is direct potency measurement of samples stored at the point of use, as was done in the cited study in Nigeria by Adu et al. However, given the current controls on vaccine distribution in the United States, we do not believe that there would be a need to validate vaccine effectiveness at point of use in the event of a change of policy with respect to vaccinating centers. The cold-chain infrastructure and the training of medical personnel in vaccine storage and administration may not provide the same assurances in other countries. While our suggested changes to the system of yellow fever distribution may improve vaccine coverage and have other desirable benefits in the United States, they would not be appropriate for less stable systems for vaccine supply and use.

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