DTaP and recurrent post vaccine fever
Question:
3/9/2017
I was consulted for an adverse reaction (fever) to DTaP in a 9 month-old healthy boy without any chronic medical conditions. He reacted with fever over 104 for several days after his 2 months, 4 months, and 6 months vaccinations. This was presumed to be due to DTaP. Each subsequent fever lasted longer (2 to 4 days) and was higher, and one of the episodes of fever was over 105 F. No hives or other signs of an allergic/anaphylactic reaction occurred at any time. Parents are still committed to completing the DTaP series, but the pediatrician asked for advice.
This is listed as a "precaution" on the CDC website but not a contraindication. Would you recommend checking titers and deferring future vaccination if titers remain elevated? Trying to vaccinate again at an older age? Considering divided doses on separate days?
I have read prior submissions for DTaP allergy, but wondered whether you may have advice specific to this particular (non-allergic) reaction in this patient (other than weighing risks/benefits and involving parents in the decision).
Answer:
We sought the expert consultation of Dr. Miguel Park and this is his response:
“One of the greatest fears is for encephalopathy to pertuss-containing vaccines, which is one of the contraindications per the CDC. As you have stated, per the CDC (https://www.cdc.gov/vaccines/hcp/admin/contraindications-vacc.html) “Temperature of 105° F or higher (40.5° C or higher) within 48 hours after vaccination with a previous dose of DTP/DTaP” is a pre-caution which they describe as “Events or conditions listed as precautions should be reviewed carefully. Benefits of and risks for administering a specific vaccine to a person under these circumstances should be considered. If the risk from the vaccine is believed to outweigh the benefit, the vaccine should not be administered. If the benefit of vaccination is believed to outweigh the risk, the vaccine should be administered”.
Unfortunately, there is no specific guidelines for non-IgE mediated adverse reactions to vaccines including in the most recent Practice parameters on vaccine allergy (Adverse reactions to vaccines. Ann Allergy Asthma Immunol. 2009 Oct; 103 (4Suppl 2):S1-14); the up dated Practice parameters on vaccine allergy by Dr. Kelso JM et al. JACI 2012 Jul; 130(1): 25-43 and The international consensus (ICON): allergic reactions to vaccines (Dreskin SC et al. World Allergy Organ J. 2016; 9(1): 32. However, Dreskin SC et al. stated that “In almost all cases, the vaccine can be given according to general guidelines” under the section of nonimmediate reactions.
Hence, it is reasonable to administer the DTap 4th dose in 15 to 18 months as per CDC vaccine schedule after discussing the risks and benefits. However, it is also reasonable to check the IgG to the titers and deferring future vaccination if in the protective levels, if the parents do not want to take the risk after the discussion regarding the risk and benefits of the next DTap vaccination. One would be obligated to follow those titers regularly (frequency of checking the titer would be unknown) and would encourage vaccination if titers go below or is close to the minimum of the protective range.
Thank you again for your inquiry and hope this will serve your patient well.
Patricia McNally, MD, FAAAAI