I was able to get this supply for my population of children who have life-threatening reactions to egg. Remember- in accordance with the recommendations from the Centers for Disease Control the contraindication to the vaccine is a life-threatening reaction. Just having a positive allergy test to egg is not a contraindication nor is having a minor reaction to egg.

Those children with a serious reaction to egg can’t stand in line at school for this vaccination. We need to make special arrangements to take care of them.  In an effort to offer them protection against H1N1 we secured vaccine and we will be scheduling those children for the desensitization protocol.

I would love to be able to offer vaccine for all, however this limited supply was given to me for the use in children with serious reactions to egg only.

I picked this up yesterday and Ms. Meyer has been going through our list of children for whom we have done the desensitization procedure for seasonal influenza. I promised a number of my families that I would post this announcement.

See you in clinic,

Cover that cough and season’s greetings,
Fred Leickly

There are two excellent sources to look to for advice. The Academy of Pediatrics (AAP) has issued a policy statement  regarding influenza vaccination. Both the TIV and LAIV (the injection and the nasal spray) “should not be given to children who have a history of hypersensitivity, including anaphylaxis to egg, to any previous influenza vaccine or to any of the vaccine components”.

The Centers for Disease Control state that the TIV is “contraindicated when there is anaphylactic hypersensitivity to egg or other components of the vaccine unless the recipient has been desensitized” (taken from the CDC Statement). For the LAIV, the statement is a little different and reflects the AAP statement; “the LAIV is contraindicated in persons with a history of hypersensitivity, including anaphylaxis, to any of the components of LAIV or to eggs”.

In our specialty clinic at Riley Children’s Hospital we offer the TIV (the injection) and not the LAIV (nasal spray). This is because the vast majority of children who we see in both Allergy and Pulmonology have asthma. The intranasal vaccination is not indicated in the child who has asthma.

The CDC statement identifies only anaphylaxis- a serious life threatening reaction to egg as a contraindication to the TIV vaccination. With this guideline, a child with only a positive allergy test (skin prick test or specific IgE blood test), contact hives, diffuse hives, atopic dermatitis, eosinophilic esophagitis, and vomiting could get the immunization without any further discussion.

It is important to point out that both the AAP and the CDC state that it is a history of hypersensitivity to egg. This is an important point to make. It is the history of a reaction that dictates the approach. Allergy tests for foods have a high degree of false positivity. The history of a reaction and a test to verify the IgE (allergy) mechanism is required for the diagnosis of allergy. A test shows sensitization. A positive test alone to egg without any clinical correlates (history) is not the same as a history of an anaphylactic reaction to egg.

So how can we help? We found some guidance from an article by Robert A. Wood ( Pediatrics 122, Number 3, September 2008 e771-e777) . The article dealt with immunizations in general and it has some specifics on the influenza vaccination.

This is a summary of our approach to this problem;

1. Is there a history of an egg or vaccine reaction?

          a. If no, give the immunization

          b. If yes, ask if the reaction was anaphylaxis

          c. If unknown due to no known exposure to egg (see below)

2. If the reaction was anaphylaxis- a desensitization procedure is indicated.

3. If the reaction was not serious, not life threatening to egg

          a. Give the vaccine- watch 60 minutes OR

          b. Give the 10% of the vaccine wait 30 minutes

             then give the remaining 90% of the vaccine

             and watch 60 minutes Or

          c. Do the diagnostics- skin testing for reactivity to the vaccine-

            this includes a few intra-dermal tests all done in our allergy office.

4. If there has been no exposure to egg, but there is a positive allergy test to egg-

    This is one of the more difficult areas. There are a few choices here and they all depend upon the comfort level of the family and the physician-

          a. Give the full vaccine and watch OR

          b. Give 10% of the dose and watch for 30 minutes

            followed by the remaining 90% and

           watch for an additional 60 minutes

            OR

          c. Do the diagnostics in the allergy office (see 3c above)

Clearly the safest route is to do the desensitization. The desensitization takes about 3 hours and involves a number of injections (around five). However, there are a number of other approaches to look at. The use of these alternatives needs to consider the comfort level of the family and the primary caretaker in giving the vaccination.

Please note that this procedure applies for both the standard influenza vaccination (seasonal) and for the new H1N1 vaccine.

I do recommend getting the influenza vaccinations.

FEL

A young African-American girl of 11 months presented upon the recommendation of her pulmonologist. The pulmonologist saw the need for a flu shot however there was some concern about a positive allergy test to egg. This little girl had a ‘Phadia Specific IgE’ set of food allergy panels performed for about 31 foods (the bill to the mother was >$800). The test was performed because of a concern for a constant runny nose. The child was tested to the usual suspects for food allergy in young children. The test array went significantly further. As I have talked about previously, because of the marketing of these allergy blood tests to include extra items (at more expense) these are in most cases irrelevent. Many of the foods tested are not part of a young child’s diet. The test included foods that this young lady of 11 months has never ingested; lobster, shrimp, tree nuts, shrimp, and clams to name a few. So in the end mother was at risk to pay for information that was not relevent to the child’s situation or exposures. There is also the argument within this case regarding the pursuit of a food allergy for the complaint of a runny nose in an 11 month old child.

The test for egg was 0.51 kU/L. The cutoff for a negative response is <0.35 kU/L. When you look at the literature for critical cut-off levels for doing an egg challenge, this value would indicate that the child will have a high probability of a negative and successful egg challenge.

Now the real kicker. As we all know there is no better test for a food allergy than the challenge; give the food and see what happens. We do have to be careful depending upon the history of previous reactions for those challenges. In this baby’s history she had been eating scrambled eggs without any problems. There was no history of a cause/effect relationship with egg exposure.

Now let us add in the variable of the flu shot. The flu shot contains egg protein. The recommendations from the CDC and the AAP are to not give the flu shot if there is a history of a severe reaction. This pertains to what happened when egg was ingested. It does not pertain to the presence or size of an allery test for egg. In this case, cooked eggs have been ingested without any reactions. So in my opinion, the history of egg exposure and having no serious reactions with that exposure should clear the way for the flu immunization. For those children who have serious reactions to egg but can eat heated egg products, there is a need for considering a desensitization for the fluogen. The egg in the vaccine is more like cooked egg (scrambled, hard boiled, over easy etc) than heated egg (cakes, cookies, muffins, and waffles). The history of eating products with heated egg should not be considered a ‘safe’ for those with serious egg reactions.

The children need to be immunized for this upcoming flu season.

My humble opinion,

Fred Leickly