Sandra Adamson Fryhofer, MD
Fryhofer SA. Adult Immunization 2012: Politics, Process, and Progress. Ann Intern Med. 2012;156:243-245. doi: 10.7326/0003-4819-156-3-201202070-00389
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Published: Ann Intern Med. 2012;156(3):243-245.
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In this video, Sandra A. Fryhofer, MD, offers additional insight into her editorial, "Adult Immunization 2012: Politics, Process, and Progress.
Sandra Adamson, Fryhofer, MD, MACP
February 10, 2012
Flu Vaccination for Egg Allergic Patients: A Clarification
The 2012 Adult Immunization Schedule has a new feature. It includes a handy table listing "Contraindications and Precautions to Commonly Used Vaccines in Adults." (1) Some Annals readers have suggested the "contraindications table" listing for influenza vaccinations is confusing in light of new ACIP (Advisory Committee on Immunization Practices) guidance. (2)
As indicated on the table for every vaccine, "severe allergic reaction (e.g., anaphylaxis) after previous dose or to a vaccine component" is a contraindication. This is clear. But for TIV (trivalent inactivated influenza vaccine), the additional phrase, "including egg protein," might seem inconsistent with new ACIP guidance. (2) More clarity could have been provided by specifying that milder allergic reactions to eggs are not a contraindication to influenza vaccination.
Egg allergy is no longer a contraindication for TIV influenza vaccination for those with mild symptoms (hives only). Egg allergy is no longer an absolute contraindication for patients with more serious symptoms if benefits of flu protection outweigh the risks of vaccine egg protein exposure. Many TIV package inserts have been revised to say only "severe allergic reaction (e.g. anaphylaxis) to egg protein" is a contraindication. However, egg allergic patients with more serious reactions should be vaccinated only after thoughtful evaluation and in a closely monitored setting, with adequate anaphylaxis management available- -not in drive through clinics or at the grocery store. (2)
Another source of confusion is the description on the table used for TIV: "Influenza, injectable trivalent" (1) does not indicate that TIV is the "inactivated" vaccine. TIV is "injectable," but it is also "inactivated," in contrast to LAIV (live attenuated influenza vaccine), the nasal flu vaccine. The type of influenza vaccine is important. Only use of TIV (inactivated) influenza vaccine in egg allergic patients has been studied. Contraindications for LAIV on the table are clear. (2)
Flu Vaccination for Egg Allergic Patients: A New Frontier
Symptom severity Severity of egg allergy symptoms should be assessed. New CDC guidance published in August 26, 2011, edition of MMWR (2) contains an algorithm for assessing severity of egg allergy symptoms. Patients with history of mild egg allergy symptoms (hives "only") can be given TIV, but should be observed for at least 30 minutes after vaccination. (2) No skin tests are needed; the results aren't predictive. (2) There's no need to divide the dose; single dose studies showed no serious reactions; so you can give the entire vaccine dose at one time. (2) Patients with more "serious" egg related symptoms (hypotension, wheezing, nausea, vomiting, or any reaction requiring epinephrine or emergency medical attention) should be referred to "physician with expertise in management of allergic conditions for further evaluation." (2) Reassuring data presented at the June 2011 ACIP meeting revealed that egg allergy/flu vaccine studies have specifically included more than 200 patients with histories of severe anaphylaxis related to egg ingestion. These patients also tolerated influenza vaccine. (2, 3)
Ovalbumin content The August 26, 2011 MMWR (2) also contains a table listing published maximum content of egg protein (ovalbumin) in many flu vaccines. Available studies have shown that vaccines with ovalbumin content up to 1.4 mcg/ml (adult dose) or 0.7 mcg/0.5 ml (pediatric dose) have been well tolerated. (2)
Type of influenza vaccine (TIV only) Only TIV (trivalent inactivated) should be given because that is what has been studied. (2)
Be prepared Be on alert for adverse reactions and have emergency medications (like epinephrine) available. Observe egg allergy patients for at least 30 minutes after receiving influenza vaccination. (2, 4)
In perspective It is safer to give influenza vaccine in the context of egg allergy than previously thought. (2) Influenza infection causes 200,000 hospitalizations and up to 49,000 deaths each year. (5) For many, maybe most, egg allergic patients, it is safer to get vaccinated than to risk getting the flu. Summary of extensive discussion at the June 22-23, 2011 ACIP proceedings is available on line. (3)
Sandra Adamson Fryhofer MD
1. Advisory Committee on Immunization Practices. Recommended Adult Immunization Schedule: United States, 2012. Ann Intern Med. 2012:156:211-7.
2. Centers for Disease Control and Prevention (CDC). Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep. 2011; 60:1128-32. [PMID: 21866086]
3. Summary Report ,ACIP June 22-23, 2011 meeting. CDC website. Assessed February 9, 2012. Available at http://www.cdc.gov/vaccines/recs/acip/downloads/min-jun11.pdf).
4 CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011;60(No. RR-2). 5 " Have You Heard?" CDC Recommendations for Influenza Antiviral Medications Remain Unchanged, CDC website. Assessed February 9, 2012, Available at http://www.cdc.gov/media/haveyouheard/stories/Influenza_antiviral.html
I am a member of the ACP Adult Immunization Technical Advisory Committee
Infectious Disease, Vaccines/Immunization, Prevention/Screening.
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