Q:

10/31/2013
I am an allergist evaluating a 35 yr old atopic woman (moderate persistent asthma-well controlled, envt allergies) for a prior rxn to the flu vaccine itself. Patient does note hives and itchy throat after eating egg yolk but tolerated egg white-atypical. As child could not eat any part of egg but now eats egg whites frequently without rxns.

Pt received flu vaccine ten years ago (received prior once and tolerated it well). But last time within 15 minutes of vaccine developed large local swell at site and then hives up that same shoulder onto neck and itchy/scratchy throat. Pt treated in office (not by me) and no ER visit needed. Pt works in hospital and was told he would have to wear mask thru flu season if did not have flu vaccine this year-common now in NY state.

Pt's skin test NEG to egg white and egg yolk-despite dermographia.
Pt's skin test NEG TO GELATIN(she eats it w/o rxn)
Pt's skin test NEG to Fluzone prick and ID.

My concerns and questions are:
1. I do really believe she reacted to the flu vaccine with immediate rxn - when received it 10 yrs ago.

2. Am considering how to attempt to give her the fluzone and have concerns about just injecting her with it as usual.

3. Conserving giving 10% and if ok then 90% after waiting 30+ minutes VS following a "desensitization protocol" even through the skin test is negative – would not typically do this.

4. Do you think she should receive the egg free vaccine? And if so, should she be skin tested to it and/or given in a graded manner?

We are seeing numerous pts with hx of rxns to the flu vaccine not necessarily egg allergic.

A:

Thank you for your inquiry.

Before responding to your specific questions, I would like to list several resources from which my answer(s) are derived.

1. We have a very informative previous response on the “Ask the Expert” website entitled “Reactions to influenza vaccine - a combination of two previously published questions and responses” entered on 10/14/2013. It discusses a patient similar, but not identical, to the one you described and gives two different approaches. You can access it by going to the “Ask the Expert: website and typing “influenza vaccine” into the search box.

2. Adverse reactions to vaccines practice parameter 2012 update. The Journal of Allergy and Clinical Immunology, Volume 130, Issue 1 , Pages 25-43, July 2012, from which, for your convenience, I have copied the suggested protocol for the administration of vaccines in a graded dosage regimen. It is seen in Table V and is copied for you immediately below:

For a vaccine in which the full normal dose volume is 0.5 mL, give the following doses at 15-minute intervals as tolerated:
0.05 mL 1:10 dilution
0.05 mL full-strength
0.1 mL full-strength
0.15 mL full-strength
0.2 mL full-strength

3. A quote copied from the package insert of the egg-free vaccine, Flublok, to illustrate its contents. You will see this also copied immediately below for your reference.

“A single 0.5 mL dose of Flublok contains sodium chloride (4.4 mg), monobasic sodium phosphate (0.195 mcg), dibasic sodium phosphate (1.3 mg), and polysorbate 20 (Tween®20) (27.5 mcg). Each 0.5 mL dose of Flublok may also contain residual amounts of baculovirus and host cell proteins (≤ 28.5 mcg), baculovirus and cellular DNA (≤ 10 ng), and Triton X-100 (≤ 100 mcg).

Flublok contains no egg proteins, antibiotics, or preservatives. The stoppers used for the single-dose vials are not made with natural rubber latex.”

4. Here is a link to the Johns Hopkins Bloomberg School of Public Health Institute for Vaccine Safety where one can access the package inserts of almost all vaccines, including the influenza vaccines available for use in the United States.

With these resources in mind, I will try and answer your direct inquiries.

First of all, I think it is quite likely that your patient would be able to receive influenza vaccine without adverse effect. Also, my observations are not unlike yours in that quite often we see such reactions to influenza vaccine that do not seem to have any relationship to egg allergy. This is discussed by Dr. Greenhawt in the “Ask the Expert” response referenced above.

Finally, to answer your question directly, here are my suggestions specifically regarding your patient:

1. Although Fluzone contains very little, if any, egg allergen (approximately 0.1 micrograms per 0.5 ml), I would still suggest using the egg-free influenza vaccine for a number of reasons:

a. Psychologically this would free your patient of any concerns.

b. As you can see from the contents of this vaccine (shown above), it contains no other allergen commonly associated with allergic reactions to influenza vaccine.

c. The contents are dissimilar to other influenza vaccines and highly unlikely to cause a reaction. In addition, to date, to my knowledge, no anaphylactic reactions have occurred to this vaccine.

2. I don't think that you need to skin test to this vaccine prior to giving it.

3. I also think it would be safe to give this vaccine in a single dose, but if you are concerned in this regard, I would follow the suggested graded dosage regimen copied for you above when administering the vaccine. This gives you the reassurance that you are using a previously published protocol, and the protocol is simple and does not require an inordinate time to carry out.

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

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology