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Egg Allergy and Flu Vaccines

April 2011



2011 Update on Egg Allergy and the Flu Vaccine

By Matthew J. Greenhawt, M.D., M.B.A.

Flu vaccines for childrenIn the wake of the H1N1 pandemic last year, several research groups decided to re-investigate the risk of influenza vaccine, which contains egg protein in the form of ovalbumin, in egg allergic individuals.  For many years, it has been assumed that the residual egg protein poses a potential allergy risk to egg allergic individuals.  Thus, caution has been taken in vaccinating such individuals. Examples of steps taken to reduce the risk of reaction include skin testing to the vaccine, graded/staged dosing and since the late 1990's, use of vaccine that contained less than 1.2 micrograms of ovalbumin/mL.1   For those with a history of severe reaction to egg, the vaccine is technically contraindicated by the Center for Disease Control and Prevention2, the American Academy of Pediatrics3, and the individual vaccine makers, though many allergists have administered influenza vaccine to such patients for  many years, using one of the aforementioned steps to reduce risk. 

With the pandemic and a second influenza vaccine to give last year, three studies examined the safety issues surrounding the influenza vaccine. 4,5,6 Interestingly, it appears that many past assumptions about the vaccine not being safe for egg allergic individuals may be wrong.  The major findings from these studies included the following:
  • Skin testing to the vaccine does not appear to be necessary or helpful in predicting if someone will tolerate the vaccine.  Specifically, two of the large studies showed that patients could safely receive the vaccine without skin testing.4,5  A third showed that patients with positive skin tests to the vaccine did not react when given the vaccine, and that the vaccine may actually be a skin irritant and cause false positive testing.6

  • Either a single dose or a two step graded challenge seem to be acceptable ways to vaccinate egg allergic individuals, but multi-step desensitization is not necessary.

  • The amount of egg (ovalbumin) in influenza vaccine appears low, and under what was previously established to be a safe level.  Furthermore, nearly every manufacturer now lists how much ovalbumin is contained per mL of vaccine, which is of use in choosing the lowest ovalbumin containing vaccine.  Though 1.2 micrograms/mL is generally considered the "threshold" level below which the vaccine is safe7, no evidence exists that higher levels are associated with reactions.  Of note, there is also no evidence that egg allergic patients who have reacted to the influenza vaccine in the past actually reacted to the residual ovalbumin, as opposed to some other vaccine component.

  • Most, if not all egg allergic patients can safely receive the vaccine.  In fact, nearly 100 patients with a history of a severe allergy to egg received the vaccine in these studies without incident. 

These were reassuring findings, and have confirmed what many allergists had long suspected — that influenza vaccine was likely safe for those with egg allergy.  On the basis of the recent data from last year, the AAAAI and ACAAI jointly updated the practice parameters on this matter to reflect these findings.8

The take home messages are relatively simple.  Foremost, the time to withhold the vaccine from egg allergic patients as a group has passed, and the hope is that this will reduce influenza related illness and complications within the egg allergic population.  Since either a single dose or a two-step graded challenge seems to be sufficient, this gives providers flexibility in choosing a method with which they are comfortable administering the vaccine.  Observation for 30 minutes after being vaccinated is strongly recommended, and providers who chose to vaccinate egg allergic individuals must be prepared to treat anaphylaxis.  Though reactions are rare, they still have occurred, and providers must be prepared.  Another important principle emerging from these studies is that widespread skin testing to the vaccine is not recommended or helpful.

This past year has taught us much about our previous assumptions, and it appears that the vaccine is safe for egg allergic individuals.  While this issue is still being studied, and the concept is still somewhat in evolution, we are hopeful that a once vulnerable population will now begin to receive much needed protection against influenza!

Find other articles about Food Allergens in Vaccines written by Kids With Food Allergies Foundation.
If your child has a history of anaphylaxis to egg, you should discuss with your allergist whether your child should be vaccinated.  While there is evidence that persons with a history of anaphylaxis to egg can and have safely received the vaccine, further study is necessary before the contraindication is lifted.  As well, it is still a matter of debate as to in what setting the vaccine should be given — the primary care setting or the allergist's office. 



References
  1. Kelso J.  Administration of Influenza vaccine to patients with egg allergy: Update for the 2010-2011 season.  J Allergy Clin Immunol 2010; 126: 1302-3.
  2. Centers for Disease Control and Prevention. February 2011.  Chart of Contraindications and Precautions for Commonly Used Vaccines. Available at: http://www.cdc.gov/vaccines/recs/vac-admin/contraindications-vacc.htm. Accessed March 7, 2011.
  3. American Academy of Pediatrics. Policy Statement: Recommendations on the Prevention and Control of Influenza in Children, 2010-2011.  Pediatrics 2010;126;816-826.
  4. Chung EY, Huang L, Schneider L. Safety of influenza vaccine administration in egg-allergic patients. Pediatrics.2010;125:e1024-e1030.
  5. Gagnon R, Primeau MN, Des Roches A, et al; PHAC-CIHR Influenza Research Network . Safe vaccination of patients with egg allergy with an adjuvanted pandemic H1N1 vaccine. J Allergy Clin Immunol. 2010;126:317-323.
  6. Greenhawt MJ, Chernin AS, Howe L, Li JT, Sanders G. The safety of H1N1 influenza A vaccine in egg allergic children. Ann  Allergy Asthma Immunol. 2010;105:387-393.
  7. James JM, Zeiger RS, Lester MR, et al. Safe administration of influenza vaccine to patients with egg allergy. J Pediatr.1998;133:624-628.
  8. Greenhawt MJ, Li JT, Bernstein DI, et al. Administering influenza vaccine to egg allergic recipients: a focused practice parameter update. Ann Allergy Asthma Immunol. 2011;106:11-16.

Matthew Greenhawt, M.D., M.B.A. is assistant professor, Department of Internal Medicine, Division of Allergy & Clinical Immunology and the University of Michigan Food Allergy Center, University of Michigan Medical School; staff physician, University of Michigan Medical Center, Ann Arbor, Michigan and is a member of KFA’s Medical Advisory Team.

Approved by KFA's Medical Advisory Team April 2011.





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Page last updated 7/29/2012

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