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COVID-19 vaccine and mild respiratory symptoms

Question:

12/29/2020
I have a COVID-19 vaccine allergic reaction: 67 year-old female pediatrician. H/o mild RAD; well controlled on qd Montelukast; adds Symbicort with onset of viral resp infections. Perennial AR; previously on AIT in our office > 10 yrs ago; did have a systemic rxn to an allergy shot (was on maintenance) - treated and cleared. No h/o vaccine reactions in the past. She and her husband tested + for COVID-19 in Oct; pt recovered; no resp complications. Husband was hospitalized with COVID-19 pneumonia; doing well now. Pt received the Pfizer vaccine nine days ago at our local hospital clinic. Immediately noted mild chest tightness (no wheezing or SOB) and lightheadedness; all resolved 100% with use of her Albuterol. 15 mins later, noted tingling sensation in the nose and face; resolved with Benadryl. Is it safe for her to receive the second vaccine which is scheduled on 1/10? She does want to get the vaccine to provide maximum immunity (still in practice; visits grandchildren). I was suggesting premedication with 40 mg of pred and 50 mg of Benadryl; she will bring Epi and Albuterol to the vaccine clinic (adjacent to ER). Was going to proceed in this direction unless the "experts" believe the risk is too great. She has no other underlying health problems.

Answer:

As allergist immunologists, we typically use the Mueller Anaphylaxis Scale. When assessing reaction to anaphylaxis, the Brighton criteria for anaphylaxis (1,2) The Brighton scale identifies major and minor criteria and assigns a clear definition for anaphylaxis. Based on the history provided, she had transient mild chest tightness and lightheadedness, resolving within 15 minutes. These symptoms do not meet the criteria for either major or minor criteria and therefore not anaphylaxis.

Based on the symptoms reported, your patient is not eligible for the second dose of the COVID-19 vaccine. This is based on a change in the CDC guidelines on December 30, 2020 (3) “Immediate allergic reaction‡ of any severity to a previous dose of an mRNA COVID-19 vaccine” should not receive second vaccine.

Discussions are underway and further guidance will be forthcoming for those that are unable to complete the series.

CDC guidelines on December 30, 2020
History of the following are contraindications to receiving either of the mRNA COVID-19 vaccines†:
• Severe allergic reaction (e.g., anaphylaxis) after a previous dose of an mRNA COVID-19 vaccine or any of its components
• Immediate allergic reaction‡ of any severity to a previous dose of an mRNA COVID-19 vaccine or any of its components^ (including polyethylene glycol)#
• Immediate allergic reaction of any severity to polysorbate^#

1) McNeil MM, Weintraub ES, Duffy J, Sukumaran L, et al. Risk of anaphylaxis after vaccination in children and adults. J Allergy Clin Immunol. 2016 Mar;137(3):868-78. doi: 10.1016/j.jaci.2015.07.048. Epub 2015 Oct 6. PMID: 26452420; PMCID: PMC4783279.

2) R├╝ggeberg JU, Gold MS, Bayas JM, et al. Brighton Collaboration Anaphylaxis Working Group. Anaphylaxis: case definition and guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine. 2007 Aug 1;25(31):5675-84. doi: 10.1016/j.vaccine.2007.02.064. Epub 2007 Mar 12. PMID: 17448577.

3) Interim Clinical Considerations for Use of mRNA COVID-19 Vaccines Currently Authorized in the United States
https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html

I hope you find this helpful.

Respectfully submitted,
Jeffrey G Demain, MD, FAAAAI