Do doctors follow guidelines regarding the flu vaccination in egg allergic individuals?

Published Online: September 27, 2013

In the past three years, there have been sweeping changes to the recommendations in providing trivalent seasonal influenza vaccine (TIV) to egg allergic individuals (EAI). These guidelines state that the vaccine should no longer be contraindicated because of egg allergy, but furthermore, that commonly used risk mitigating procedures such as vaccine skin testing (prick and intradermal), withholding the vaccine for a positive skin test, multi-stage desensitization, and using only the same vaccine lot for booster doses were unnecessary, and that patients should be observed for at least 30 minutes after vaccination as is done with immunotherapy. While most allergists would attest that these changes have enabled more egg allergic children to receive TIV, the implementation of these guidelines among practicing allergists has not been studied.

In an article recently published in the The Journal of Allergy and Clinical Immunology: In Practice, Drs. Matthew Greenhawt of the University of Michigan Medical School and Julie Wang of the Icahn School of Medicine at Mount Sinai detail a study of compliance with these guidelines from allergists affiliated with the American Academy of Allergy, Asthma, and Immunology (AAAAI).  A 21-question electronic survey about provider practice styles in vaccinating egg allergic children to TIV and provider attitudes pertaining to TIV administration to EAI was distributed to AAAAI members. Nearly 20% of the almost 5,000 allergists who received the email responded, a rate nearly double previous AAAAI distributed surveys. The survey results indicate a high level of support for and compliance with the recent guidelines. Specifically, only a small minority responded that  (1) TIV should be contraindicated in egg allergic children (1%), 4(2) they did not administer the vaccine to this population (4%), and risk-mitigating precautions commonly used in years past were necessary (13%). Less than half of the respondents (49%)  agreed that TIV can safely be administered to egg allergic patients in the primary care setting, and 42% advised their patients accordingly.

In comparing practice styles pre- and post-guideline implementation, significantly fewer providers reported performing intradermal vaccine testing or multi-step desensitization, and significantly more allergists observed patients for at least 30 minutes post-vaccination. Though there were no significant changes in the proportion of allergists performing vaccine prick skin testing, it was noted that significantly more administered TIV despite the patient having a positive TIV prick skin tests. Given the poor reported compliance with vaccine prick skin testing, further analyses  determined  that reading the guidelines, academic practice, and fewer years in practice were significantly associated with higher odds of compliance with this measure.

Overall these results are encouraging and indicate that allergists are, by and large, complying with the updated guidelines for providing TIV to egg allergic children. Over a relatively short time period there is evidence of significant shifts in allergist opinion and practice style consistent with compliance, except for vaccine prick skin testing. Continued study of compliance with the guidelines is needed, and greater adherence should be promoted.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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