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Flu vaccine allergy

Question:

2/15/2017
We are referred patients with a compelling history of an allergic reaction to the influenza vaccine. Following the guidelines in the 2012 practice parameter we performs skin testing and then graded challenge if indicated. However - I am unable to find any literature on the reliability if any of skin testing for influenza vaccine, or on the safety of the graded challenge (often erroneously referred to as a desensitization) in the setting of positive skin tests or compelling clinical histories. The Ask the Expert question on this topic from 10/15/14 says "results of testing do not predict reactions to vaccine" and "the most recent recommendations are not to perform prick testing," but the references provided to not address those issues, and they are discordant with the most recent practice parameter. Is there evidence to resolve the discrepancies?

Answer:

I am not sure if you are asking about egg allergic patients receiving flu vaccines and potentially having reactions or the rare patient who is not egg allergic and has a reaction to flu vaccine. As you are no doubt aware most of the focus in flu vaccine allergy has been centered on the egg allergic patient. The CDC yearly publishes very good guidelines that help provide clinical strategies for the management of these patients. In addition, Dr Kelso has written a very good editorial in JACI In Practice that highlights the major issues and advances in Flu vaccine administration in egg allergic individuals and addressed some of the concerns you have highlighted (J Allergy Clin Immunol: In Practice, Vol. 3, Issue 1, p140–141).

With regards to flu vaccine anaphylaxis in general, McNeil and colleagues reported an overall vaccine anaphylaxis rate or 1.3 per million vaccine (any) doses. The rate for influenza vaccine was 1.35 per million doses for inactivated trivalent influenza vaccine and 1.83 per million doses for inactivated monovalent influenza vaccine. (J Allergy Clin Immunol 2016;137:868-78 ). In this same issue of JACI, Nagao and colleagues investigated a cohort of patients who had influenza vaccine anaphylaxis and were not egg allergic. Interestingly, their data suggested that one of the excipients may have been etiologic but it was not entirely clear (J Allergy Clin Immunol 2016;137:861-7). As you are aware, different manufacturers produce vaccines with different excipients. It may be necessary to identify these individual excipients and correlate their presence with the patient past clinical history.

I was not able to find any definitive data regarding the reliability of skin testing to influenza vaccine nor any definitive data on the safety of graded challenges to influenza vaccine. I suspect this is related to the relative rarity of these events and ethical concerns that would surround formal experimentation.

I hope this has been helpful.
Andrew Murphy, MD FAAAA