Adverse reactions to vaccines practice parameter 2012 update
Upcoming SlideShare
Loading in...5
×
 

Adverse reactions to vaccines practice parameter 2012 update

on

  • 1,664 views

Adverse reactions to vaccines practice parameter 2012 update,

Adverse reactions to vaccines practice parameter 2012 update,

Presented by Sasikarn Suesirisawad, MD.

Statistics

Views

Total Views
1,664
Views on SlideShare
1,664
Embed Views
0

Actions

Likes
1
Downloads
28
Comments
0

0 Embeds 0

No embeds

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • rare
  • DTH contact dermatitis to neomycin, thimerosolAluminum containing vaccine rarely cause persistent nodule at injection site
  • Gelatin from bovine or porcine are very cross-reactive
  • Gelatin added many vaccine as stabilizer and responsible for many anaphylactic rxn to MMR, varicella, JEUS MMR & varicella still contained gelatin, japan and geramany removed gelatin or change to less allergenic gelatin, new JE not contained gelatinHx of allergy to ingestion of gelatin should sought before administration of gelatin-containing vaccine. Negative history not exclude allergic reaction to gelatin injected with vaccine.Gelatin-containg vaccine is either bovine or porcine origin, which are extensively cross-reactive.Some pt sensitized to beef or pork meat are also sensitized to beef or pork gelatin, which might place them risk for reaction to gelatin-containg vaccine.
  • pico= 10 -12Nano= 10 -9
  • Severe (anaphylactic) allergy to latex  Not administeredunless benefit > risk DNR=dry natural rubber
  • IPV ก็มีทั้งสามตัวนี้ ห้ามเหมือนกัน JACI 2004อ้างอ้ง paper MMR อันนี้ ไม่ได้ report IPV anaphylaxisCase reports:History of MP rash to topical neomycinMMR vaccine  immediate-type allergic reaction to neomycin has been reportedNo testing for IgE to neomycin
  • 31-year-old woman with AR and IBSConjunctivalerythema & local pain after using a thimerosal-containing contact lens solution TT 2 ½ years before this evaluation without any difficultyThimerosal-free pediatric influenza vaccine 4 months earlier with no adverse events.SPT using the full-strength adult influenza vaccine: 3-mm induration, 25 -mm of erythema with satellite lesions. Within 20 minutes, the patient developed generalized pruritus without hives, throat tightness, and a dry cough without wheezing.She was treated as anaphylaxis. All symptoms resolved within 10 minutes.
  • Vaccine 2010- Inactivated mouse brain-derived JE (ไม่ใช่ live ) VAERS: 300 AE(24 per 100,000 doses) 106 (35%) reports were classified as hypersensitivity reactions (8.4 per 100,000 doses) - 3–73 years (median 26 years),72 (68%)occurred in females - Of all 106 events, 40 (38%) had onset onthe day of vaccination - 11 (10%) hypersensitivity reactions were sub-classified as anaphylaxis, 14 (13%) as immediatenon-anaphylactic hypersensitivity, and 81 (76%) as delayed hypersensitivity - 10 (91%) occurred in women and the medianage was 26 years (range 20–44 years). - The onset interval:5min to 1 h (median 20min) - 6 (55%)generalized urticarial (n = 5) or non-urticarial (n =1)rash. 7 (64%) patients had facial flushing, including one eachwith an urticarial and non-urticarial rash. 3 (27%)had swelling of the face or upper airway while another 4 (36%)reported a sensation of throat closure. 5 patients reported difficulty breathing but none had bronchospasm; only one patienthad documented hypotension. - 5 (45%) anaphylactic reactionsoccurred after a first dose of JE vaccine, five (45%) after a second,and one (9%) after a third. In six (55%) reports, JE vaccinewas administered at the same time as one or more other vaccines.
  • HPVAustralia dose 1(n = 95 006, 83% coverage), dose 2 (n = 91 289, 80% coverage) and dose 3 (n = 83 845, 74% coverage)8 confirmed cases-6 cases were reported after dose 1 of the vaccine,2 cases were reported after dose 2 (No reaction to their first dose).No history of anaphylaxis with previous vaccinations.4/8 cases of anaphylaxis  All had negative reactions to SPT for baker’s yeast, and to SPT and ID testing for Gardasil, and Cervarix
  • 23-valent1)2 year-old non-atopic boy developed an anaphylactic reaction one minute after the first injection of Pneumo 23® Skin tests and RAST with 23-valent pneumococcal vaccine were positive in child reportinganaphylaxis, and negative in nine of control children. ID was slightly positive in a non-vaccinated childwith negative RAST. Skin tests and RAST with phenolwere negative in all the children studied.2) 3.5-year-old healthy French girl had tolerated three injectionsof Prevenar-7® before age 1 year. For unknown reasons, Pneumo-23® was injected, at age 3 years. Severe anaphylaxis occurredwithin1–2 minutes.Prick-tests were negative. Immediate responses in ID testswere observed with Pneumo-23® (mean diameter of thewheal/erythema: 12/22mm) and Prevenar-7® (8/17mm).7-valent9 of the 14 received other vaccines at the same time.12 of the 14 were receiving the pneumococcal vaccine for the first time
  • In diphtheria, tetanus, and pertussistoxoid vaccineRarely,subcutaneous nodules from aluminum injection become pruritic and painful andcan last for years, requiring surgical removal. Histology of these persistent nodulesshows retained aluminum and inflammatory cells consistent with a hypersensitivity
  • Vaccine skin test may cause false positive reaction.
  • A= Whenever possible, the same vaccine from the same manufacturer should be used.B= Only if present in the product associated with a reaction.C =For skin testing to egg and yeast (Saccharomycescerevisiae), Food and Drug Administration(FDA)-approved extracts are commercially available. For gelatin, there are currently no FDA-approved extracts available for testing; however, food-grade gelatin was used successfully inprevious studies.In addition, porcine gelatin, which may be antigenically different from bovinegelatin, is used in vaccines, whereas bovine gelatin is somewhat more common in the foodindustry.d These foods should be tested only percutaneously and not tested intradermally.e Found in only 1 type of influenza vaccine (FluzoneSanofi Pasteur Inc, Swiftwater, PA]).
  • Measuring level IgGAb to immunizing agent in vaccine suspected of causing adverse reaction to determine whether they are protective level can help determine whether subsequent doses are required.(B)If serologic evidence of immunity documented, can withhold additional doses, although magnitude and duration of immunity might be less than if all doses received.
  • Patient with GBS with history of GBS unrelated to influenza infection or vaccination who would benefit from immunization can be vaccinated.MMR has late-onset fever occurring 5-12 day after vaccination.MMR+varicella: increased risk only the first dose of vaccine (12-15 mo), not for second dose(4-6 y)
  • Changing DTP to DTaP reduce serious neurological event.Tetanus toxoid has some potential association with GBS and brachial neuritis.
  • Rash appears within 3 weeks of vaccination.Although varicella disease itself can more severe in children with AD, varicella vaccine can be safely administered to children with AD without increase risk of complication.Vaccine-associated viscerotropic disease occurred exclusively in first-time vaccine recipient and has 65% mortality.
  • Risk of transmitting live agent to fetusIncrease risk hospitalization from influenza in pregnancy, influenza vaccine indicated in women who pregnant during influenza season
  • C/I in immune suppression include XLA, CVID, SCID, severe HIV infection, leukemia, lymphoma, high dose steroid (2 wk of daily treatment with prednisolone, 20 mg or 2mg/kg/day)
  • confirmed by allergist based on history with allergic reaction within 2 hr of ingestion of egg with evidence of sIgE by skin or serum.
  • 1 pt received vaccine split dose because parent preference despite negative SPT1 positive SPT occurred in Fluzone in 22 mo who never ingesting but SPT 15 mm sIgE 2.57; child tolerate full dose seasonal vaccine by split dosing, same child with positive SPT to seasonal vaccine had negative to H1N1 vaccine and tolerate single dose on 2 occcasion1 of 34 pt with egg allergy received vaccine in divided dose because of equivocal SPT to seasonal fluzone vaccine
  • 263 of 292 vaccination used fluzone contained >1.2 μg/ml ovalbumin14 vaccination used lot U3176AA contained 1.421 μg/ml
  • Administration of full dose TIV as single shot, ;likelihood of receiving single shot at initial TIV immunization increased significantly over time (P=0.006)
  • 3 not receive vaccine because physician/parent preference
  • 1 of 13 anaphylactic pt receive 2 stage dosing and did not require booster
  • Used Sanofi-pasteur TIV, no correlation of ovalbumin content with reaction
  • Level usually much lower than claimed amount
  • Person with egg allergy might tolerate egg in baked product(bread or cake). Tolerance to egg-containing food does not exclude possibility of egg allergy.
  • More than 1600 pt with egg allergy vaccinated without any serious reaction.0-6.3% of vaccination involved reaction confined to skin(hive).0-4.8% of vaccination involved mild RS or GI symptom.No reaction involved symptom hypotension.None of these required tx with epinephrine.Evaluation include to detailed Hx of nature and timing of prior suspected reaction to egg.If Hx consistent with egg allergy, SPT to egg or sIgE for egg indicating confirm sensitization.Influenza vaccine should not witheld from undergoing egg allergy evaluation.Suspected egg allergy deserve evaluation, regardless of influenza vaccination status
  • Egg allergy included pt with Hx of anaphylaxis to egg ingestionThese pt with egg allergy tolerate vaccine without serious reaction.Vaccine skin testing unnecessary.Skin testing is utility in evaluation of patient with history of allergic reaction to influenza vaccine itself.
  • CDC and AAP concluded that person experienced only hives after exposure to egg should receive influenza vaccine and vaccine skin testing and dividing dose are no longer necessary or recommended.In pt with Hx more severe reaction to egg ingestion, CDC and AAP recommended should refer to allergist.185 pt with Hx anaphylaxis to egg ingestion vaccinated with TIV, 119 receiving divided dose, 66 received single dose, all without serious reactions.Vaccines used have contained as much as 0.7 ug/0.5 ml dose without serious reaction, implying that at least that much is generally well tolerated.
  • LAIV contain very low amount of ovalbumin .No published studies to date on exposure though intranasal route.TIV recommended until ongoing studies on LAIV published.
  • 54. 3640pt reported but not proved egg allergy given influenza vaccine; 1.2% had skin reaction, 0.7% had RS reaction, include 2 who given epinephrine, although author concluded that these not anaphylactic reaction52,54,55,57. included control subject without egg allergy, similar rate of reaction between 2 gr reported, indicating not all adverse reaction to influenza vaccine related egg allergy

Adverse reactions to vaccines practice parameter 2012 update Adverse reactions to vaccines practice parameter 2012 update Presentation Transcript

  • Sasikarn Suesirisawad, MD
  •  Anaphylactic reaction to vaccines are estimated to occur at 1/million doses. Fatalities from vaccine-induced anaphylaxis are exceedingly rare.(B) All serious event occurring after vaccine administration should reported to Vaccine Adverse Event Reporting System(VAER), even if it is not certain that vaccine was causal.(C) Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Mild local reaction and constitutional symptom are common and do not contraindicate future doses. DTH can cause injection-site nodule, this is not contraindication to subsequent vaccination.(C) Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  • Classification ofVaccine Allergy
  • Adverse reactions to vaccine IgE-mediated reactions Non-IgE-mediated reactions Vaccine Specific vaccines Vaccine Specific vaccinesconstituents constituents• Gelatin • Diphtheria • Pertussis • Neomycin • MMR• Egg • Hib • Pneumococcus • Thimerosal • Meningococcus• Latex • Hepatitis B • Rabies • Aluminum • Pertussis• Yeast • Influenza • Tetanus • Tetanus• ? ATB • JE • Varicella • Typhoid• ? Thimerosal • MMR • Yellow fever • Varicella • Meningococcus • Yellow fever Kelso JM. Adverse reactions to vaccines for infectious disease. In: Middleton’s Allergy Principles and Practice. 7th ed. 2009:1189-1204
  • • IgE- mediated reaction to vaccines are more often caused by additive or vaccine component, such as gelatin, rather than microbial immunizing agent itself.(B) Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Partially hydrolyzed collagen of bovine or porcine origin. A stabilizer in many vaccines. Responsible for many anaphylactic reactions to MMR, varicella, JE vaccines. Kelso JM. Adverse reactions to vaccines for infectious disease. In: Middleton’s Allergy Principles and Practice. 7th ed. 2009:1189-1204
  • Excipients table. Accessed December 10, 2010,at http://www.vaccinesafety.edu/components-Excipients.htm
  • Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Concern has existed over administration of vaccines ‘grown in eggs’ to egg-allergic recipients. : MMR vaccine : PCEC rabies vaccine : Influenza vaccine : Yellow fever vaccine Kelso JM. Adverse reactions to vaccines for infectious disease. In: Middleton’s Allergy Principles and Practice. 7th ed. 2009:1189-1204
  • Approach in egg- Vaccine Grown in Egg protein content allergic patientMeasles and mumps Chick embryo Picograms to Administer in usual fibroblast cell cultures nanograms mannerPurified chick embryo Chick embryo Picograms to Administer in usualrabies fibroblast cell cultures nanograms mannerInfluenza (killed Chick extra-embryonic Micrograms Skin test with vaccineinjected and live allantoic fluid prior to administrationattenuated nasal)Yellow fever Chick embryos Micrograms Skin test with vaccine prior to administration Kelso JM. Adverse reactions to vaccines for infectious disease. In: Middleton’s Allergy Principles and Practice. 7th ed. 2009:1189-1204
  •  If a person reports a severe (anaphylactic) allergy to latex, vaccines supplied in vials or syringes that contain DNR should not be administered. For other latex allergies (e.g., a history of contact allergy to latex gloves), vaccines supplied in vials or syringes that contain DNR or rubber latex can be administered. Kelso JM. In: Middleton’s Allergy Principles and Practice. 7th ed. 2009:1189-1204.
  •  HBV prepared by harvesting hepatitis B surface Ag from culture of Saccharomyces cerevisiae contain up to 5% of yeast protein. Yeast associated anaphylaxis after HBV in sensitized patient appear to be rare event. HBV & HPV4 contained yeast protein. Kelso JM. In: Middleton’s Allergy Principles and Practice. 7th ed. 2009:1189-1204. Kelso JM. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  • Allergens table. Accessed December 10, 2010,at http://www.vaccinesafety.edu/components-Excipients.htm
  •  Neomycin, polymyxin B, and streptomycin. A single report of immediate-type allergic reaction to MMR vaccine in person with a history of MP rash to topical neomycin. If a patient gives a history of an immediate-type reaction, it is appropriate to investigate before immunization with vaccine containing this antibiotic. Kelso JM, Li JT. Ann Allergy Asthma Immunol 2009;103:S1-S14. Kwittken PL, Rosen S, Sweinberg SK. AJDC 1993;147:128–9. Kelso JM. In: Middleton’s Allergy Principles and Practice. 7th ed. 2009:1189-1204.
  •  Mercury-containing organic compound. Preservative in a number of biological and drug products, including many vaccines. A single case report of immediate-type reaction that may have been caused by thimerosal in vaccine. Kelso JM, Li JT. Ann Allergy Asthma Immunol 2009;103:S1-S14. Zheng W, Dreskin SC. Ann Allergy Asthma Immunol. 2007;99:574–5.
  •  DTP vaccines induce production of IgE in substantial percentage of recipients who go on to receive subsequent dose without systemic reaction. CRM 197  Mutant diphtheria protein  H influenzae vaccine (HibTITER), Pneumococcal vaccine (Prevnar), Meningococcal vaccine (Meningitec, Menjugate, Menveo) Shinefield HR. Vaccine 2010;28:4335-9. Kelso JM. In: Middleton’s Allergy Principles and Practice. 7th ed. 2009:1189-1204.
  •  Immediate-type allergic reactions, consisting of urticaria with or without wheezing occurring 5–60 minutes after vaccination. Unusual, late-onset urticaria and angioedema reaction  1% of recipients, median interval = 2–3 days  Usually confined to the skin, some cases have involved hypotension or respiratory distress. Kelso JM. Adverse reactions to vaccines for infectious disease. In: Middleton’s Allergy Principles and Practice. 7th ed. 2009:1189-1204
  • MMR VACCINE VARICELLA VACCINE• Anaphylactic reactions:  Anaphylactic reactions 2–10 per million doses. : 3 per million doses.• Allergy to gelatin has  Gelatin allergy is the been determined to be cause of some of these likely cause (27–92%). reactions.• No relationship with egg allergy. Kelso JM. In: Middleton’s Allergy Principles and Practice. 7th ed. 2009:1189-1204
  •  Risk to be 1:600,000 vaccine doses. 180,895 reports to VAERS  107 reports of pre-existing yeast allergies  11 reports described probable or possible anaphylaxis after HBV; 4 cases were described after other vaccines The possible association between reaction to HBV and yeast allergy. DiMiceli L et al. Vaccine 2006;24:703-7. . Kelso JM. In: Middleton’s Allergy Principles and Practice. 7th ed. 2009:1189-1204
  •  12,424 reports to VAERS  3.1/100,000 doses for hypersensitivity reactions  0.1/100,000 doses for anaphylaxis 269,680 doses of qHPV vaccine  2.6/100,000 doses for anaphylaxis Girl anaphylaxis 1 hr after HPV(Gardasil),ID test with Gardasil, which contains polysorbate 80(PS80)positive, SPT to bivalent vaccine negative, SPT with PS80positive Slade BA et al. JAMA 2009;302:750-7. Brotherton JM et al. CMAJ 2008; 179(6):525-33 Badiu I et al. BMJ Case report 2012;10.1136
  •  2 case reports of anaphylaxis in child who received 23-valent pneumococcal vaccine.  IgE antibody to vaccine demonstrated by skin testing and in vitro assay. Ponvert C, Ardelean-Jaby D, Colin-Gorski A,et al. Vaccine 2001;19:4588-91. Ponvert C Scheinmann P, de Blic J. Vaccine 2011;10:8256-7. 7-valent pneumococcal vaccine  14 of the 4,154 VAERS reports Wise RP, Iskander J, Pratt RD, et al. JAMA 2004; 292(14):1702-1710.
  • YELLOW FEVER VACCINE INFLUENZA VACCINE Anaphylaxis reactions 7  Anaphylaxis 0.024 per per million doses. 100,000 doses. Related to  None of which was egg, chicken, and fatal, and none of gelatin. which occurred in persons known to be allergic to eggs. Kelso JM. Adverse reactions to vaccines for infectious disease. In: Middleton’s Allergy Principles and Practice. 7th ed. 2009:1189-1204
  •  1% of the general population demonstrates DTH by patch testing to neomycin. Skin patch testing: 100-1000 mcg of neomycin. Delayed-type contact dermatitis to neomycin  Small, temporary erythematous, pruritic papules at the injection sites 48-96 hours after vaccination.  Immunization can proceed in the usual fashion. Kelso JM. In: Middleton’s Allergy Principles and Practice. 7th ed. 2009:1189-1204 Madaan A, Maddox DE. Immunol Allergy Clin N Am 2003;23:555-588
  • Allergens table. Accessed December 10, 2010,at http://www.vaccinesafety.edu/components-Excipients.htm
  •  DTH to thimerosal is reported. Single case report of a generalized MP rash attributed to thimerosal in influenza vaccine. Lee-Wong M, Resnick D, Chong K. Ann Allergy Asthma Immunol 2005;94:90-4. May have large local reactions. Not contraindication to receive thimerosal- containing vaccine. Kelso JM In: Middleton’s Allergy Principles and Practice. 7th ed. 2009:1189-1204.
  • Allergens table. Accessed December 10, 2010,at http://www.vaccinesafety.edu/components-Excipients.htm
  •  Enhance immunogenicity of vaccines. Subcutaneous nodules are relatively common but usually resolve within a few weeks to months. Higher incidence of contact allergy to aluminum. No reports of anaphylaxis have been attributed specifically to aluminum. Kelso JM. In: Middleton’s Allergy Principles and Practice. 7th ed. 2009:1189-1204 Madaan A, Maddox DE. Immunol Allergy Clin N Am 2003;23:555-588
  •  Mild local reactions are relatively common. Arthus reaction has been postulated. In such individuals antitoxin levels should be evaluated before determining the need for a subsequent booster. Moylett EH, Celine Hanson IC. JACI 2004;114:1010-1020
  •  Many cases consistent with serum sickness have been reported. The timing of the reactions is from 2 to 21 days after vaccine administration. The symptoms have included those typical of serum sickness such as arthralgia, fever, malaise, urticaria has been prominent feature. Kelso JM. Adverse reactions to vaccines for infectious disease. In: Middleton’s Allergy Principles and Practice. 7th ed. 2009:1189-1204
  • Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Probable anaphylactic reaction: reaction occurring within 4 hr of vaccination and S/S ≥ 1 systems  Dermatologic  Respiratory  Cardiovascular  GI Possible anaphylactic reaction  S/S from only 1 system  S/S from ≥ 1 system but occurring > 4 hr after vaccination Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Vaccine skin test  SPT full strength vaccine (consider dilution of life- threatening reaction)  If SPT negative, ID test with 0.02 ml vaccine 1:100. Vaccine ingredient skin test/ in vitro test  SPT with commercial extract of egg(influenza&yellow fever)or Saccharomyces cerevisiae yeast(HBV& quadivalent HPV)  SPT with sugared gelatin ( Jello-O 1tsp in 5 ml NSS)  sIgE to vaccine contain gelatin ( influenza, MMR, rabies, varicella, yellow fever, zoster)  sIgE to latex Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  • Wood RA et al. Pediatrics 2008;122:e771-7.
  •  If level associated with protection from disease, consider withholding additional doses although magnitude and duration of immunity may be less than if all doses received Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  • Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Some nonanaphylactic reactions to vaccine might also require evaluation, but only few are absolute contraindication to future doses. Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Person with GBS within 6 weeks of influenza vaccination should avoid subsequent immunization with influenza vaccine. MMR + varicella: 2 fold higher risk of FS Recipient of MMR can have thrombocytopenia. Rubella vaccine can cause acute arthritis in 15% of adult women. Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Pertussis vaccine: encephalopathy occurring within 7 days following vaccine, absolute contraindication. 5% of tetanus toxoid-containing vaccine cause large local swelling at injection site, Arthus reaction. Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Varicella vaccine: reaction occur at injection site 3% and more generalize in 3%. Yellow fever  encephalopathy.  vaccine-associated viscerotrophic disease has occurred in immunocompromised, thymus disorder and age > 60 yr contraindication. Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Pregnant women should not be vaccinated with live vaccine. Pregnant woman should be given inactivated influenza vaccine, tetanus, HBV Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Live vaccine should not be given to persons who are immune compromised because of risk of generalized infection with immunizing agent. Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  • Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Specific vaccines or vaccination in general have been purported to have long-term consequences, including atopy, autism, multiple sclerosis. Epidemiologic studies have not supported such associations. Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  • How to give influenza vaccine in egg-allergic patients
  •  2002: 2 doses or multi-dose graded vaccination protocol depending on results of skin testing & egg content of vaccine. Zeiger RS. JACI 2002;110:834-40. 2009: Safe administration of influenza vaccine containing 1.2 mcg/ml of egg protein to egg allergic patients, initially in a 2- dose protocol (10% and 90%) and later as a single dose. Kelso JM, Li JT. Ann Allergy Asthma Immunol 2009;103:S1-S14 2009: Children with known severe allergic reactions (hives, angioedema, allergic asthma, systemic anaphylaxis) to chicken or egg proteins should not receive TIV. AAP Red Book 2009
  •  2-step graded challenge  Single dose without use of graded  10% of the age dose, with a 30-minute challenge. observation, then  Individuals should be observed for 30  90% of dose, with a 30-minute minutes observation  The same TIV brand should be used The same TIV brand should be used for booster vaccinations. for booster vaccinations.  Children who need a booster dose Children who need a booster dose can receive this without prior vaccine can receive this without prior vaccine skin testing, and as a single dose. skin testing, and as a single dose. If reaction is observed at any of the steps, subsequent steps should be withheld, and the patient should be evaluated by an expert in vaccine allergy. Greenhawt MJ et al. Ann Allergy Asthma Immunol 2011;106:11-6.
  •  2009-2010: diagnosis of egg allergy Full strength vaccine SPT  Negative: full dose  Positive, equivocal: vaccination 2-step protocol ( 10 %- 3o min-90%) Luke Webb. JACI July 2011
  •  152 pts (292 vaccination with seasonal and/or H1N1 influenza)  34(22%) of 152 pt had history of anaphylaxis to egg.  87(57%) pt had history of type I allergic to egg.  31(20%) pts had not knowingly consumed egg or no reaction but had level of egg IgE > 95% of predictive egg allergy. Luke Webb. JACI July 2011
  •  Age 7 mo-30 yr (median 3 yr) SPT performed before 85% of challenges 1 pt positive SPT, 6 pt equivocal 285(97%) performed by using single dosing:  65 vaccination(23%) in history severe egg allergy No systemic reaction in any pt  2 pt with negative vaccine SPT developed mild local reaction, both to full dose. ▪ 1 pt of these had history anaphylaxis to egg with egg SPT28 mm and sIgE 7.8 kU/L  1 pt sIgE 42 kU/L developed redness at injection site 24 hr after vaccination. Luke Webb. JACI July 2011
  •  Threshold of ovalbumin tolerate by most pt with egg allergy may higher than 1.2 μg/ml. Most individual with egg allergy can safely vaccinated by single dose of influenza vaccine. Do not support use of skin testing as predictor of reaction to vaccination. Luke Webb. JACI July 2011
  • P<0.006Laura E. Howe, MD. Ann Allegy Asthma Immunol. 2011;106:446-447
  •  Retrospective review of TIV immunization pattern for egg allergic children ages 6-36 mo at University of Michigan Allergy clinic from Oct 2004-Feb 2009. 193 potential EAC, 140 met inclusion criteria: 135 received TIV; none had significant complication: 5(4%) were not vaccinated after positive skin test Laura E. Howe, MD. Ann Allegy Asthma Immunol. 2011;106:446-447
  •  28 of 135(21%) safely received first TIV without skin test 17 children anaphylaxis to egg; 14(82%) safely received TIV (2 with positive SPT, 9 with negative SPT, 3 with no pretesting). Only minor reaction reported in 7 pt, none of whom had history anaphylaxis. Laura E. Howe, MD. Ann Allegy Asthma Immunol. 2011;106:446-447
  •  Prospective 69 EAC & 14 non-EAC during 2009-2010 influenza immunization. 34 EAC(49%) received SPT to TIV, 6 positive test(18%). If TIV test positive, vaccine administered in 2 steps. 68 0f 69 EAC tolerate single-dose administration of TIV as either first or booster dose. No serious allergic reaction to TIV 2 EAC had lip or mouth itching and hives and 2 non-EAC had hives and fever or rash. Laura E. Howe, MD. Ann Allegy Asthma Immunol. 2011;106:446-447
  •  Ovalbumin ranged from 0.3-1.087 μg/mL(always used Sanofi-Pasteur TIV) TIV skin test not necessary Allergic children tolerate TIV as single dose No difference in TIV tolerance between EAC with and without history of egg-induced anaphylaxis. Laura E. Howe, MD. Ann Allegy Asthma Immunol. 2011;106:446-447
  • Kelso JM. JACI 2010;126(6):1302-1304
  • Ovalbumin level reported for 2009-2010 Kristi K. McKinney. JACI June 2011
  • Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Vaxigrip  Not more than 0.05 mcg/0.5 ml Influvac  Not more than 1 mcg/0.5 ml Agrippal S1  Not more than 0.4 mcg/ml Available at: httpwww.aap1.fda.moph.go.th Accessed December 10, 2010
  • Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Patient with egg allergy should receive influenza vaccination(TIV) because risk of vaccination are outweight by risk of not vaccinating.(A) Persons with history of suspected egg allergy should be evaluated by allergist to determine status of their egg allergy, but this should not delay their influenza vaccination.(A) Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  A growing number of studies suggest that influenza vaccines can safely administered, even to patient with history of anaphylaxis to egg ingestion.(B) Skin testing with influenza vaccine itself in patient with egg (but without history of reaction to vaccine itself) dose not reliably identify patient who are at increase risk of reacting to vaccine and not recommended.(A) Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Influenza vaccine can be administered as single dose to patients with egg allergy. All influenza vaccine available in US contain low amounts of ovalbumin.(A) Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Patient with egg allergy  Patient with egg allergy should receive influenza with history only hives vaccines in setting in after egg ingestion can which clinicians receive influenza vaccine experienced in in primary care provider’s recognizing and treating office provided anaphylaxis and appropriated personnel equipment to manage and equipment are anaphylaxis are available, whereas those immediately available with history more severe and should be observed reaction to egg ingestion for 30 min after should receive their vaccination.(A) vaccine in allergist’s office.(C) Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Although intranasally administered LAIV contains low amount of ovalbumin, all published studies to date have evaluated injectable TIV, and thus TIV rather than LAIV should be used for recipients with egg allergy.(C) Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  •  Patient with history of allergic reaction to influenza vaccine itself, additional evaluation is appropriate, including skin testing with vaccine and vaccine ingredients. Patient with positive skin test result, vaccine can administered in multiple divided doses or can be withheld. Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  • Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  • Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  • Kelso et al. J Allergy Clin Immunol 2012 Jul;130(1):25-43
  • Category of evidenceIa Evidence from meta-analysis of RCTIb Evidence from at least 1 RCTIIa Evidence from at least 1 controlled study without RCTIIb Evidence from at least 1 other type of quasiexperimental studyIII Evidence from nonexperimental descriptive studiesIV Evidence from expert committee reports or opinion or autorities Strength of recommendation A Directly based on category I evidence B Directly based on category II evidence or extrapolated from category I C Directly based on category III evidence or extrapolated from category I or II D Directly based on category IV evidence or extrapolated from category I or II or III E Based on consensus of the joint task force on practice parameter