Influenza Vaccine and the Egg-allergic child- 2013-2014 Flu Season Recommendations

At this time of the year we are getting ready to protect our patients from influenza. Vaccination is an important step in prevention.

Some of the vaccines are made with egg and this presents a potential challenge with the egg-allergic child.

The live-attenuated influenza vaccine (LAIV) and the inactivated influenza vaccine (IIV)- have a listed contraindications in regards to the child with egg allergy. The recombinant influenza vaccine (RIV) does not carry the egg-allergy warning. There is no ovalbumin in this product- but its age indications are for those 18-49 years.

This leaves us with the LAIV and IIV formulations.  Table 1 from the CDC guidance (Summary Recommendations: Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices –(ACIP)- United States, 2013-2014) for this season has all the vaccines listed and the amount of ovalbumin each contains. For some of them you have to contact the manufacturer.

The following algorithm should be applied for the child with egg-allergy. This is taken directly from the ACIP guidance (Figure 2).

All influenza vaccines should be administered in a setting where personnel can recognize allergic reactions and where the equipment is available to treat a reaction.

In past years there were subtle differences between CDC and AAP flu vaccine recommendations. For the 2013-2014 season the AAP website (you will need to log – the site is for AAP members) has posted these ACIP recommendations regarding the egg-allergic child. This link should get you to the formal AAP Influenza vaccine recommendations for 2013.

Make sure that the question about egg-allergy focuses on the clinical experience with egg and not on the allergy test result. The size of an egg skin test and the value for an egg specific IgE has no relationship as to how allergic a child may be. It is improper to declare ‘significant’ allergy based on the test result. ‘Significant’ allergy to egg is what happens when there is exposure and ingestion of egg.

This year’s recommendations has taken urticaria (hives) out of the list of reaction concerns – those requiring consultation. Contact hives and diffuse hives are not a contra-indication for the vaccine.

 When asking about a history of egg allergy-

Can the child eat lightly cooked eggs (scrambled for example0 without any reaction? —YESAdminister the vaccine per the usual protocol

If the answer is NO

After eating eggs or egg- containing foods, doe the child experience ONLY hives? -YES–Administer flu vaccine IIV and OBSERVE FOR AT LEAST 30 MINUTES FOLLOWING VACCINATION

If the answer is NO

After eating eggs or egg-containing foods, does the child experience other symptoms such as;

  • Cardiovascular changes- hypotension (low blood pressure)
  • Respiratory distress- wheezing
  • Gastrointestinal problems- nausea/vomiting
  • A reaction that required injectable epinephrine
  • A reaction that required emergent medical attention  ——————-YES————————REFER TO ALLERGY

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    

                                                                                                                                                                                                                                                                                                                                          

Please Note- There is a difference in clinical tolerance to cooked egg and heated egg. Many children can eat heated egg products (cakes, cookies) without a problem. This tolerance to heated egg does not exclude a possible reaction from the vaccine. This has been used in the past as a clearance for the egg vaccine- eating heated egg products does not assure the safe administration of the egg-containing vaccines.

Please also note- many children have a positive allergy test to egg, but have never had any exposure.  You will see this in the population of children who have atopic dermatitis or those who have had allergy panels performed. In these cases you need to consult the allergy services.

References

Kelso JM, Greenhawt MJ, Li JT, Nicklas RA, Bernstein DI, Blessing-Moore J, et al. Adverse reactions to vaccines practice parameter 2012 update. J Clin All Immunol. 2012 Jul;130(1):25-43

Erlewyn-Lajeunesse M, Brathwaite N, Lucas JS, Warner JO. Recommendations for the administration of influenza vaccine in children allergic to egg. BMJ. 2009;339:b3680.

 

FEL 9-4-2013

September 4, 2013 · fleickly · No Comments
Tags:  · Posted in: Egg Allergy, Influenza vaccine, Uncategorized

Leave a Reply

You must be logged in to post a comment.