Q:

9/16/2013
I have a one year-old patient with h/o egg, tree nut/peanut and gluten allergy. He had angioedema/urticaria previously to a multigrain cereal bar. Touching raw egg also has induced hives. He received a full influenza vaccine with observation and developed a small hive at site of injection. This resolved with Benadryl. But, 72 hours later, while in daycare he developed hives and lip swelling. Could this be a delayed reaction to the influenza vaccine? He is due for a booster in one month, how would you give the vaccine then? Would you skin test prior?

A:

Thank you for your inquiry.

I have copied three references below which deal directly with this issue. Each states that this child would be at very low if any risk whatsoever based on his allergy to egg of being allergic to influenza vaccine. In addition, it would be highly unlikely that a reaction 72 hours after the administration of the vaccine would represent an IgE reaction to the egg content of the vaccine. Also, it is questionable whether skin tests are predictive of a reaction to influenza vaccine.

Based on this information therefore, one would conclude ordinarily that your patient could receive influenza vaccine in a full dose safely without skin testing. However, this is an unusual situation, and if you are still concerned you could pick the vaccine with the lowest egg content as seen in Table 8 of the Kelso, Greenhawt, and Li 2012 publication cited below. Also, should you wish, there is, in Table 5, a protocol for a graded administration to vaccines that you could employ.

Thank you again for your inquiry and we hope this response is helpful to you.

Update on Egg Allergy and Influenza Vaccine (Nov 2011)

John M. Kelso, MD (Chief Editor), Matthew J. Greenhawt, MD, MBA (Chief Editor), James T. Li, MD, PhD (Chief Editor). Adverse reactions to vaccines practice parameter 2012 update. The Journal of Allergy and Clinical Immunology, Volume 130, Issue 1, Pages 25-43, July 2012.

John M. Kelso, Short communication. Administration of influenza vaccines to patients with egg allergy: Update for the 2010-2011 season. Journal of Allergy and Clinical Immunology 2010 (December), Vol. 126, Issue 6, Pages 1302-1304.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology