Question of the month: How to administer the flu vaccine to a patient allergic to eggs?

Image of the H1N1 Influenza Virus, CDC.

Recommendations regarding influenza vaccination for persons who report allergy to eggs - Advisory Committee on Immunization Practices (ACIP), 2011-12 influenza season. CDC.

Option 1

For the patient who is 6 months of age or older and has known egg allergy of any severity, except severe anaphylaxis, administer under observation by an allergist a vaccine that contains 0.7 micrograms ovalbumin or less per 0.5 mL dose as a single dose. The allergist staff will observe the patient for 30 minutes. Example vaccine: Fluvirin, Fluzone.

Option 2

If a vaccine that contains 0.7 micrograms ovalbumin or less per 0.5 mL dose is not available, or if the history of anaphylaxis was severe, administer the vaccine under observation by an allergist by a two-step protocol (10% of the dose, observe for 30 minutes, then administer the remaining 90% of the dose, then observe for 30 minutes).

Important: Live nasal vaccine should not be administered to patients with egg allergy.

Children aged 6 months–8 years who have never received influenza vaccine before should receive 2 doses. Those who only receive 1 dose in their first year of vaccination should receive 2 doses in the following year, spaced 4 weeks apart.

Both TIV (trivalent inactivated influenza vaccine) and LAIV (live-attenuated influenza vaccine) are produced in eggs. However, influenza vaccine can be administered in a single dose and it is well tolerated by nearly all recipients who have egg allergy. More conservative approaches, such as skin testing or a 2-step graded challenge, are no longer recommended for patients with mild reactions.

Mild reaction or severe reaction?

As a precaution, clinicians should determine if the presumed egg allergy is based on a mild or severe reaction.

Mild reactions are defined as hives alone.

Severe reactions involve cardiovascular changes, respiratory and/or gastrointestinal (GI) tract symptoms, or reactions that require the use of epinephrine.

When to consult an allergist?

Clinicians should consult with an allergist for children with a history of severe reaction (anything more than hives). Severe allergic reactions to eggs involve cardiovascular changes, respiratory and/or gastrointestinal (GI) tract symptoms, or reactions that require the use of epinephrine.

Most vaccine administration to people with egg allergy can happen without the need for referral. Only 1% of children have IgE–mediated sensitivity to egg, and of those, a very small minority have a severe allergy.

Standard preconditions

Standard immunization practice should include the ability to respond to acute hypersensitivity reactions. Therefore, influenza vaccine should be given to people with egg allergy with the following preconditions:

- Appropriate resuscitative equipment must be readily available

- Ovalbumin content up to 0.7 micrograms/0.5 mL per vaccine dose has been well tolerated. Click here for ovalbumin content of TIV. LAIV vaccine is not recommended for egg allergic individuals.

- After immunization, the vaccine recipient should be observed in the office for 30 minutes, the standard observation time after receiving immunotherapy.

- For children who need a second dose, the same product brand is preferred, if possible, but it does not need to be from the same lot as the first dose.

Higher-ovalbumin-content influenza vaccines are well tolerated in children with egg allergy - JACI 2010
The safety of the H1N1 influenza A vaccine in egg allergic individuals. Greenhawt MJ, Chernin AS, Howe L, Li JT, Sanders G. Ann Allergy Asthma Immunol. 2010 Nov;105(5):387-93.
Safety of influenza vaccine administration in egg-allergic patients. Chung EY, Huang L, Schneider L. Pediatrics. 2010 May;125(5):e1024-30. Epub 2010 Apr 5.
Administration of influenza vaccines to patients with egg allergy. Kelso JM. J Allergy Clin Immunol. 2010 Apr;125(4):800-2. Epub 2010 Mar 11.
2010-11 Influenza Prevention & Control Recommendations. CDC.
Patient with egg allergy who needs flu shot - what to do? (newsletter for referring physicians). You can use my template:
UpToDate, 2011.
Most egg-allergic children can be vaccinated with a low ovalbumin influenza vaccine without prior vaccine testing
First study to show safety of live attenuated influenza vaccine in patients with egg allergy.

Published: 11/22/2010
Updated: 03/03/2012

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