2014 Update on Egg Allergy and the Flu Vaccine
Much has changed about the perceived safety of influenza vaccine in egg allergic individuals. The Centers for Disease Control (CDC), American Academy of Pediatrics, and American Allergy and College of Allergy, Asthma, and Immunology no longer considers egg allergy a reason to avoid the flu vaccine. This decision came after several new research studies in the past 4 years showed once and for all the injectable influenza vaccine is safe for children with egg allergy.
In the past three years, the recommendations for flu vaccine and egg allergy have changed by:
- The American Academy of Allergy, Asthma, and Immunology (AAAAI)
- The American College of Allergy, Asthma, and Immunology (ACAAI)
- The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control.
The AAAAI and ACAAI most recently updated the practice parameter this past summer. The ACIP of the Centers for Disease Control updated its recommendations in August of 2012. The AAAAI/ACAAI and the ACIP recommendations have slight differences. But, the main points are the same:
- Skin testing to the vaccine is no longer advised, and is not necessary to receive the vaccine. Several studies have shown that this does not help predict who will develop a reaction to the vaccine. This is true even when the skin tests are positive. Bottom line—there is no reason for your child to be tested to the influenza vaccine because of egg allergy.
- The vaccine can be dispensed as a single dose. A two-step graded challenge dosing is no longer recommended. A single dose has proven to be safe even in children with a history of anaphylaxis to egg.
- The amount of egg (ovalbumin) in influenza vaccine is very low and has been for the past several years. The levels have hovered at or below 1 microgram/mL , which are far less than in the past, when high egg content was felt to be a potential issue. Keep in mind: ovalbumin in influenza vaccine has never proven to cause reactions in egg allergic individuals. (Adverse effects if the vaccine may be due to other ingredients known to trigger allergic reactions.) Recent studies show that ovalbumin levels higher than 1.2 micrograms/mL were well tolerated.
This argument is no longer of clinical relevance. The CDC has published this information in August of the past two years.
- Sanofi Pasteur’s Fluzone® was not included in those publications. But, the company has verified that Fluzone’s ovalbumin content is under 1mcg/mL. One of our medical advisors verified this through personal communication with Sanofi Pasteur.
- It is safe for ALL egg allergic patients to receive their influenza vaccine. This is true regardless of how severe their egg allergy was in the past. This includes children with anaphylaxis to egg. These individuals can receive their influenza vaccine as a single dose.
The CDC updated its latest guidelines in August 2014. These guidelines did not change from the previous year. CDC guidelines recommend:
- Children with a history of only hives from egg ingestion can receive the vaccine at the pediatrician's office.
- Children with a history of more severe egg reactions can still get the vaccine, but at an allergist's office.
The AAAAI and ACAAI 2013 Practice Parameter update states that the vaccine is safe to give in any setting. There is no special waiting time or other precautions. But the setting must have procedures in place to treat anaphylaxis.
Please note that the CDC has not adopted this as part of their 2014 recommendations.
Other important points:
- The safety of the intranasal spray form of the vaccine, known as FluMist®, in egg allergic children is under review. A recent Canadian study, published this fall about FluMist. In that study, FluMist® was safely administered to 68 egg allergic patients. But, these data was not available in time for the CDC and ACIP to review before making any changes to the 2014 recommendations. The CDC still recommends that those with egg allergy only receive the injectable vaccine, not the FluMist®. This guideline may change in 2015. Take note that patients with asthma cannot receive the FluMist vaccine.
- Children with an egg allergy can receive the injectable flu vaccine. They can get it in a pediatrician’s or an allergist’s office (depending on the egg allergy severity). A minute clinic, health department clinic or pharmacy should not give the vaccine.
- If your child has a history of reaction to the flu vaccine itself , this is a different scenario than someone with an egg allergy who has not ever reacted to the flu vaccine. Children who have reacted to the actual vaccine should see a board certified allergist. This is the only circumstance in which testing to the flu vaccine should be performed. The allergist will determine if it is safe for them to receive the vaccine in the future, and how best to do so.
- The package inserts for the influenza vaccine will still have the original wording that suggests persons with egg allergy should not receive the vaccine. (The CDC has no control over what companies may print). The contraindications with egg allergy will still be there. But the CDC now states it’s safe to administer to children with an egg allergy in a pediatrician’s or allergist’s office.
- Flublok® is an egg-free vaccine available for adults age 18 or older. However, it is not necessary for egg allergic adults to receive this vaccine. The standard injectable influenza vaccine is safe and well-tolerated. The 2013 updated practice parameters emphasize this point.
In conclusion, the thinking on the safety of the flu vaccine for those with egg allergy has changed a lot in recent years. Importantly, egg allergic individuals wanting to receive injectable influenza vaccine can now do so. The vaccine is no longer contraindicated because of egg allergy. The vaccine is safe even if there has been a severe past reaction to egg. Depending on the egg allergy severity, a pediatrician or an allergist can provide the flu vaccine.
Reviewed by Medical Advisors in October 2014.