Q:

10/14/2013
This is the first time the Ask the Expert website has combined two questions with two separate responses about two separate (although similar) cases. As you can see these cases involved two children who had reacted to influenza vaccine. In one case, Ask the Expert requested a response from Dr. Matthew Greenhawt, who is a nationally known expert in influenza vaccine allergy, and in the other instance, the response was answered directly by Ask the Expert.

We thought it important to have a separate entry on our website with both questions and both responses because they represent similar approaches, but yet different concepts. Therefore we are posting a combination of these two (although we have published each separately) to be available as a reference to our readers, and to answer further questions that may come in that are similar.

The questions and answers are copied below:

A:

Question Number 1:
Have child who had hive reaction of face on same side as flu vaccine and hive at site after flu vaccine How do you rec testing the flu vaccine and administering in graded manner?

Response from Dr. Lieberman:
There are two very helpful and fairly recent publications which deal with the issues put forth by your inquiry. They are seen at the bottom of this e-mail. You should be able to access both of them quite easily.

Based on this child's history and the information in the above mentioned references, one would conclude ordinarily that your patient could receive influenza vaccine in a full dose safely without skin testing. But if you are still concerned, the skin test protocol consists first of an epicutaneous (prick) test with undiluted vaccine; then if negative, an intradermal (0.02 cc) of a 1:100 concentration. 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 to employ a graded challenge, there is, in Table 5 of this reference, a protocol for a graded administration to vaccines.

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. THe Journal of Allergy and Clinical Immunology 2010 (December), Vol. 126, Issue 6, Pages 1302-1304.

Question Number 2:
I have a 13 month old egg-allergic patient who had hives with his first dose of influenza vaccine at 6 months. This year, we tested him to fluzone by doing a scratch test with the vaccine at full dilution (was negative) and intradermal testing with 0.02cc of the vaccine diluted 1:100, which was strongly positive in duplicate. We elected to not give him the vaccine and will be pursuing vaccine component testing. Egg scratch testing was also positive on the day of influenza skin testing.

His mother's question to me was whether she should forego the influenza vaccine as well, as she is currently breastfeeding him twice daily.I feel that the possible passage of egg protein via her milk is likely extremely minimal and therefore poses minimal risk, but am interested to hear your opinion. The child is in daycare and the more protection he has from those around him, the better.

Response from Dr. Matthew Greenhawt:
I'd vaccinate, as I don’t trust vaccine intradermal testing as reliably telling you anything more than the vaccine is an irritant. My 2009 H1N1 study convinced me of that when ~1/3 of the kids had +ID to the test and 100% tolerated it (and this included 3 non-egg allergic controls with positive tests as well).We found one lot was in particular irritating, but lot concentrations of ovalbumin in general are very low. I don’t think this is an egg issue—probably just a coincidence. I think the egg allergy here is distracting a bit. This to me is more a pure flu vaccine reaction, rather than an egg-cross reactivity issue and I want to walk her down the practice parameter protocol for an adverse vaccine reaction. I could make a strong case that she has a very valid reason to do a multi-step desensitization if she really wants this child to get the vaccine. I’d probably recommend PST to gelatin and formaldehyde as the major components. One thing that would be great to know is exactly when the hives developed, and if the child had signs of viral illness at the time. For example, if this occurred a day later I vaccinate and don’t think twice about it, though I'd keep this child around the office to monitor. If it was within 1-2 hours, that is a bit of a different story. However, I think that a multi-step desensitization is the most conservative approach (see the 2012 JACI practice parameter for the specific protocol) to most safely provide the vaccine. Most importantly there is zero evidence that mom's receiving the influenza vaccine would pose any harm. Mom should get the vaccine as recommended by the CDC. The child really should get the vaccine as well given the exposure risk in daycare. This is why I highlight the desensitization as the most conservative option. I personally probably would not have done the ID, given my experience in my trial that it was irritating.

AAAAI - American Academy of Allergy Asthma & Immunology