Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at NSU
A 3-year-old girl is seen in the allergy clinic with a referral for a suspected allergy to the Diphtheria Toxoid and Acellular Pertussis (Tdap) vaccine. At age 2 months, after the first administration of Tdap vaccine, she became irritable approximately 2 hours after that, and she was screaming for more than 4 hours. The same behavior was repeated for 3-4 days. It was a traumatic experience for both the parents and the baby who required an ER visit. Since then, she was only administered the Td component, without the acellular pertussis component. She is otherwise a healthy girl, without symptoms of allergic disease.
Past Medical History: negative.
Medications: None. NKDA.
Physical Examination is unremarkable.
What is the most likely cause of her symptoms?
The described episode with screaming for more than 4 hours may occur in approximately 1 in 1000 of the immunizations for pertussis. An allergic reaction occurs in approximately 1 in a million doses. Her symptoms at age 2 months were not suggestive of an allergic reaction.
How to rule out allergic reaction to Tdap in this patient?
A graded dose challenge with Tdap vaccine was performed. The challenge followed the established protocol with monitoring of the vital signs and serial physical examinations every 15 minutes. She received 10% of the Tdap vaccine. After 30-minute observation, the remaining 90% of the vaccine was administered. She was observed in the clinic for another 30 minutes after the second dose. There were no signs of adverse effects to the vaccine.
Final diagnosis
History of adverse reaction to Tdap vaccine. Negative graded dose challenge with Tdap vaccine.
What would you suggest during the future administrations of the Tdap vaccine?
The graded dose challenge with Tdap vaccine was negative today and future doses can be administered in the pediatrician’s office with a 30-minute observation period after the administration of the vaccine.
What is the risk for encephalopathy with Tdap vaccine?
Acute encephalopathy occurs extremely rarely with whole-cell pertussis (DTP) vaccines (ratio of 0-10.5 cases to one million doses administered). Neither anaphylaxis nor encephalopathy occurred during clinical trials that involved administration of 26,000 doses of ACEL-IMUNE vaccine. Source: CDC.
Overdiagnosis of vaccine allergy is a major public health problem http://buff.ly/1tI9y44
Vaccine Adverse Reactions - Algorithms:
References
Management of an adult with a possible allergic reaction to DPT vaccine - advice from AAAAI Ask the Expert, 2012.
Published: 11/28/2011
Updated: 05/08/2012
Showing posts with label Vaccines. Show all posts
Showing posts with label Vaccines. Show all posts
Question of the month: How to administer the flu vaccine to a patient allergic to eggs?
Image of the H1N1 Influenza Virus, CDC.
Recommendations regarding influenza vaccination for persons who report allergy to eggs - Advisory Committee on Immunization Practices (ACIP), 2011-12 influenza season. CDC.
Option 1
For the patient who is 6 months of age or older and has known egg allergy of any severity, except severe anaphylaxis, administer under observation by an allergist a vaccine that contains 0.7 micrograms ovalbumin or less per 0.5 mL dose as a single dose. The allergist staff will observe the patient for 30 minutes. Example vaccine: Fluvirin, Fluzone.
Option 2
Option 2
If a vaccine that contains 0.7 micrograms ovalbumin or less per 0.5 mL dose is not available, or if the history of anaphylaxis was severe, administer the vaccine under observation by an allergist by a two-step protocol (10% of the dose, observe for 30 minutes, then administer the remaining 90% of the dose, then observe for 30 minutes).
Important: Live nasal vaccine should not be administered to patients with egg allergy.
Children aged 6 months–8 years who have never received influenza vaccine before should receive 2 doses. Those who only receive 1 dose in their first year of vaccination should receive 2 doses in the following year, spaced 4 weeks apart.
Both TIV (trivalent inactivated influenza vaccine) and LAIV (live-attenuated influenza vaccine) are produced in eggs. However, influenza vaccine can be administered in a single dose and it is well tolerated by nearly all recipients who have egg allergy. More conservative approaches, such as skin testing or a 2-step graded challenge, are no longer recommended for patients with mild reactions.
Mild reaction or severe reaction?
As a precaution, clinicians should determine if the presumed egg allergy is based on a mild or severe reaction.
Mild reactions are defined as hives alone.
Severe reactions involve cardiovascular changes, respiratory and/or gastrointestinal (GI) tract symptoms, or reactions that require the use of epinephrine.
When to consult an allergist?
Clinicians should consult with an allergist for children with a history of severe reaction (anything more than hives). Severe allergic reactions to eggs involve cardiovascular changes, respiratory and/or gastrointestinal (GI) tract symptoms, or reactions that require the use of epinephrine.
Most vaccine administration to people with egg allergy can happen without the need for referral. Only 1% of children have IgE–mediated sensitivity to egg, and of those, a very small minority have a severe allergy.
Standard preconditions
Standard immunization practice should include the ability to respond to acute hypersensitivity reactions. Therefore, influenza vaccine should be given to people with egg allergy with the following preconditions:
- Appropriate resuscitative equipment must be readily available
- Ovalbumin content up to 0.7 micrograms/0.5 mL per vaccine dose has been well tolerated. Click here for ovalbumin content of TIV. LAIV vaccine is not recommended for egg allergic individuals.
- After immunization, the vaccine recipient should be observed in the office for 30 minutes, the standard observation time after receiving immunotherapy.
- For children who need a second dose, the same product brand is preferred, if possible, but it does not need to be from the same lot as the first dose.
References
Both TIV (trivalent inactivated influenza vaccine) and LAIV (live-attenuated influenza vaccine) are produced in eggs. However, influenza vaccine can be administered in a single dose and it is well tolerated by nearly all recipients who have egg allergy. More conservative approaches, such as skin testing or a 2-step graded challenge, are no longer recommended for patients with mild reactions.
Mild reaction or severe reaction?
As a precaution, clinicians should determine if the presumed egg allergy is based on a mild or severe reaction.
Mild reactions are defined as hives alone.
Severe reactions involve cardiovascular changes, respiratory and/or gastrointestinal (GI) tract symptoms, or reactions that require the use of epinephrine.
When to consult an allergist?
Clinicians should consult with an allergist for children with a history of severe reaction (anything more than hives). Severe allergic reactions to eggs involve cardiovascular changes, respiratory and/or gastrointestinal (GI) tract symptoms, or reactions that require the use of epinephrine.
Most vaccine administration to people with egg allergy can happen without the need for referral. Only 1% of children have IgE–mediated sensitivity to egg, and of those, a very small minority have a severe allergy.
Standard preconditions
Standard immunization practice should include the ability to respond to acute hypersensitivity reactions. Therefore, influenza vaccine should be given to people with egg allergy with the following preconditions:
- Appropriate resuscitative equipment must be readily available
- Ovalbumin content up to 0.7 micrograms/0.5 mL per vaccine dose has been well tolerated. Click here for ovalbumin content of TIV. LAIV vaccine is not recommended for egg allergic individuals.
- After immunization, the vaccine recipient should be observed in the office for 30 minutes, the standard observation time after receiving immunotherapy.
- For children who need a second dose, the same product brand is preferred, if possible, but it does not need to be from the same lot as the first dose.
References
Recommendations for Prevention and Control of Influenza in Children, 2011–2012. PEDIATRICS Vol. 128 No. 4 October 1, 2011, pp. 813 -825, (doi: 10.1542/peds.2011-2295)
Diagram: Precautions for administering influenza vaccine to presumed egg-allergic recipients.
Ovalbumin content of TIV
Administering Influenza Vaccine to Egg Allergic Recipients. AAAAI (PDF).
Diagram: Precautions for administering influenza vaccine to presumed egg-allergic recipients.
Ovalbumin content of TIV
Administering Influenza Vaccine to Egg Allergic Recipients. AAAAI (PDF).
Higher-ovalbumin-content influenza vaccines are well tolerated in children with egg allergy - JACI 2010 http://goo.gl/KaGes
The safety of the H1N1 influenza A vaccine in egg allergic individuals. Greenhawt MJ, Chernin AS, Howe L, Li JT, Sanders G. Ann Allergy Asthma Immunol. 2010 Nov;105(5):387-93.
Safety of influenza vaccine administration in egg-allergic patients. Chung EY, Huang L, Schneider L. Pediatrics. 2010 May;125(5):e1024-30. Epub 2010 Apr 5.
Administration of influenza vaccines to patients with egg allergy. Kelso JM. J Allergy Clin Immunol. 2010 Apr;125(4):800-2. Epub 2010 Mar 11.
Safety of influenza vaccine administration in egg-allergic patients. Chung EY, Huang L, Schneider L. Pediatrics. 2010 May;125(5):e1024-30. Epub 2010 Apr 5.
Administration of influenza vaccines to patients with egg allergy. Kelso JM. J Allergy Clin Immunol. 2010 Apr;125(4):800-2. Epub 2010 Mar 11.
2010-11 Influenza Prevention & Control Recommendations. CDC.
Patient with egg allergy who needs flu shot - what to do? (newsletter for referring physicians). You can use my template: http://j.mp/oOFNB4
UpToDate, 2011.
Most egg-allergic children can be vaccinated with a low ovalbumin influenza vaccine without prior vaccine testing http://goo.gl/VA7Xt
First study to show safety of live attenuated influenza vaccine in patients with egg allergy. http://buff.ly/1wES9Zk
Patient with egg allergy who needs flu shot - what to do? (newsletter for referring physicians). You can use my template: http://j.mp/oOFNB4
UpToDate, 2011.
Most egg-allergic children can be vaccinated with a low ovalbumin influenza vaccine without prior vaccine testing http://goo.gl/VA7Xt
First study to show safety of live attenuated influenza vaccine in patients with egg allergy. http://buff.ly/1wES9Zk
Published: 11/22/2010
Updated: 03/03/2012
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