Webinar Series on COVID-19 vaccine: Jointly organized by Malaysian Society of Infection Control and Infectious Diseases (MyICID) & Institute for Clinical Research (ICR), NIH Speaker: Dr. Soo Kok Foong, Emergency Medicine Physician in Sungai Buloh Hospital, Ministry of Health Malaysia.

1. Anaphylaxis Post
Vaccination
Dr. Soo Kok Foong
Emergency Physician Hospital Sungai Buloh

2. Disclaimers
•This slide was prepared for the Webinar Series on
COVID-19 session on 3rd March 2021, by Dr Soo
Kok Foong, Emergency Physician at the Hospital
Sungai Buloh, Malaysia.
•This is intended to share within healthcare
professionals, not for public.
•Kindly acknowledge “Clinical Updates in COVID-19
http://www.nih.gov.my/covid-19” should you plan to
share the information obtained from this slide with
your colleagues.
Jointly organized by Malaysian Society of Infection Control and Infectious Diseases (MyICID) & Institute for Clinical Research, NIH

3. Content/Outline
•Recognising anaphylaxis
•Differential diagnosis
•Setting up vaccination centers to
prepare for anaphylaxis
•Overview of management of
anaphylaxis

4. What is anaphylaxis?
WAO 2020:
“Anaphylaxis is a serious systemic hypersensitivity
reaction that is usually rapid in onset and may cause
death. Severe anaphylaxis is characterized by
potentially life-threatening compromise in airway,
breathing and/or the circulation, and may occur
without typical skin features or circulatory shock
being present.”

5. Incidence of post
vaccination anaphylaxis
Vaccine Hypersensitive data
CoronaVac(Sinovac,
China)
No anaphylaxis events during
Phase 3 trials (33,620
participants)
BBIBP-CorV
(Sinopharm)
No anaphylaxis events reported
during Phase 3 trials (48,000
participants)
Pfizer-BioNTech
BNT162b2
No anaphylaxis events attributed
to vaccine in clinical trials
(~22,000 Participants)
Approx. incidence of anaphylaxis
1:100,000 with routine use
ChAdOx1
(Oxford/AstraZeneca;
Covishield in India)
No anaphylaxis events reported
in clinical trials (~12,000
Participants)
Sputnik V
(Gamaleya
Research Inst)
No events report in
Phase 1/2 studies (N=76)

6. Sign and symptoms
Mucocutaneous
Eyes: Periorbital swelling.
Oral mucosa: Lips, tongue or uvula
swelling.
Skin: Urticaria, redness, itchiness
Cardiovascular
syncope, dizziness,
tachycardia,
hypotension, prolonged
CRT, cardiac arrest
Respiratory
Foreign body sensation,
stridor, voice hoarseness,
wheezing, breathlessness,
chest tightness, coughing,
hypoxia
Gastrointestinal
Severe abdominal cramp
Vomiting
Diarrhea

7. Amended diagnostic criteria
(WAO 2020)
• Stridor
• Vocal
changes
• Odynophagia

8. Differentiating features of
anaphylaxis, vasovagal and panic
attack
Anaphylaxis Vasovagal reaction Panic attack
Onset Usually within
15 minutes of
vaccine
administration, but
can occur within
hours
Immediate, usually
within minutes of,
or during, vaccine
administration
Sudden, occur
before, during or
after immunization
Respiratory Cough, wheeze,
hoarseness,
stridor,
tachypnoea, upper
airway swelling
(eg lip, tongue,
throat, uvula,
larynx)
Normal Hyperventilate,
sensation of
breathlessness

9. Anaphylaxis Vasovagal reaction Panic attack
Cardiovascular • Tachycardia
• Hypotension
(sustained and no
improvement
without specific
treatment)
• Hypotension
(transient)
• Bradycardia (slow,
weak but regular)
Tachycardia
Neurologic Anxiety, distress Faint, light headed Anxiety, lightheaded,
dizzy, paresthesias in
lips and fingertips
Cutaneous • Urticaria, pruritus
with or without
rash and
angioedema (face
and tongue)
• Warm skin,
progressing to
clammy and pallor
Sweating, clammy
skin, pallor
Sweating
• Gastrointestinal • Abdominal cramps
• Diarrhoea
• Nausea or vomiting
Nausea, vomiting Nausea
Abdominal pain

10. Preparing for anaphylaxis in
vaccination center
Planning, staff
training and
education
Dedicated observation
and treatment area
Skilled
personnel
Emergency medical
kit / trolley
Written
contingency plan
Situational
awareness
Easy access to
ambulance
Testing the system
Preparedness
, checklist

11. Example
1: waiting area
2: screening counter
3: Registration
4: Counselling and
consent
5: Vaccination area
6: Chaired
observation area
7: bedded
observation beds
8: Resuscitation bay

12. Equipment Medications
• Transport Stretcher
• Emergency Cart or Bag
• Wheelchair
• Cardiac monitor or Defibrillator
• Oxygen regulator
• Portable Oxygen Source
• Laryngoscope size 3,4
• Endotracheal tube size 7, 7.5 & 8
• Laryngeal mask airway (LMA) size 3
and 4
• Bag Valve Mask
• Medications Chart
• Portable Suction
• Glucometer
• Stethoscope
• Large Bore cannula (16G,18G and
20G)
• Adrenaline
• Normal Saline
• Salbutamol
• Chlorpheniramine
• Hydrocortisone
• Ranitidine

13. PDCA

14. Overview of anaphylaxis
management
Acute Management
•Get help immediately
•Lie supine with leg elevated
•IM Adrenaline 0.5mg (0.5ml 1:1000) at anterolateral
thigh/ vastus lateralis. Repeat as indicated every 5
minutes up to 3 doses.
•100% oxygen supplement
•Immediate intubation in impending airway obstruction
•Consider nebulised/ MDI salbutamol if persistent
bronchospasm
Remember: There is
NO absolute
contraindication for
adrenaline in
anaphylaxis
Prioritise
INTRAMUSCULAR
adrenaline

15. If refractory anaphylaxis:
•Reassess airway, breathing, circulation
•Further IV fluid boluses
•IV infusion adrenaline
•IV glucagon if patient who is on beta-blocker
experiencing refractory anaphylaxis
❑ IV glucagon 1mg-5mg over 5 minutes (slow bolus)
followed by IVI glucagon 5mcg-15mcg/min if resistant to
adrenaline infusion
❑ Side effect: vomiting

16. Adrenaline infusion
Precaution • Continuous cardiac, HR, Spo2 monitoring. BP every 3-5 minutes.
• Initiate by trained personnel or with guidance of specialists.
Preparation and dose ❑ Infusion pump is available:
• Add 3mg adrenaline (3ml 1:1000) in 47ml of normal saline in a 50ml
syringe.
• Initial dose can be set at 0.1mcg/kg/min using an infusion pump (eg.
in a 50kg patient, to start infusion adrenaline at 5ml/hour). Titrate to
effect.
❑ If no infusion pump:
• Dilute 0.5mg adrenaline in 500ml normal saline
• Run 2ml/minute. Slow increasing it to not more than 10ml/min
(titrate to effect)
Adjusting adrenaline
infusion
• Adjust the rate of infusion based on BP, HR and Spo2
• Consider to taper down and cease the infusion if anaphylaxis resolves
• Watch out for recurrence after cessation of adrenaline infusion.

17. Overview management of
anaphylaxis

18. Suggested flow chart of anaphylaxis
management out of hospital

20. Pitfall in anaphylaxis
management
•Failure to administer adrenaline
•Delay in adrenaline due to over reliance on
antihistamine and glucocorticoids
•Over-reliance on mucocutaneous signs or concepts
of more than 2 systems involvement for diagnosis

21. Take home message
•Anaphylaxis is a clinical diagnosis.
•IM Adrenaline is the cornerstone treatment
•Anticipate the worst, do the best preparation

22. References
• Turner PJ, Worm M, Ansotegui IJ, et al. Time to revisit the definition and clinical criteria
for anaphylaxis?. World Allergy Organ J. 2019;12(10):100066. Published 2019 Oct 31.
doi:10.1016/j.waojou.2019.100066
• Australian Immunisation Handbook, Department of Health Australia Government
• Turner et al. World Allergy Organization Journal (2021) 14:100517
http://doi.org/10.1016/j.waojou.2021.100517
• Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, et al.
World allergy organization anaphylaxis guidance 2020. The World Allergy Organization
journal. 2020;13(10):100472.
• Rukma P. Glucagon for refractory anaphylaxis. American journal of therapeutics.
2019;26(6):e755-e6.
• De Feo G, Parente R, Triggiani M. Pitfalls in anaphylaxis. Current opinion in allergy and
clinical immunology. 2018;18(5):382-6.

23. Email
•sookokfoong@gmail.com