Egg Allergy and Influenza Vaccinations
Dr. Vitalpur and I have had many calls about the influenza vaccination (both the usual annual vaccine and the new H1N1 vaccine) and children with egg allergy. We follow a number of children who are allergic to egg. Their reactions to egg include those who; are allergy test positive only, have hives with skin contact to egg, experience total body hives after eating eggs, undergo a flare of the dry itchy skin of atopic dermatitis, struggle with eosinophilic esophagitis, vomit with eggs, or experience a life-threatening reaction, anaphylaxis with exposure to egg. Their families and their pediatricians/family practitioners are concerned regarding what to do about the influenza vaccination(s). These vaccines contain egg and pose a potential risk to children who are egg allergic. The ability to eat foods that contain heated egg by the egg sensitive individual should not be considered as ‘safe’ criteria for the influenza vaccination. Both the regular flu vaccine, the H1N1, the injected, and the nasal spray all have egg in them. So what can we do? What are the recommendations for this situation?
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
October 8, 2009
· 
fleickly · 
6 Comments
Posted in: Allergies, Egg Allergy, Food Allergies, Immunizations
6 Responses
Does the age of the child also play a factor?
I have a normal, healthy infant who just turned one last week. She has shown a sensitivity to boiled eggs. She ate about 5 to 6 small bites of boiled eggs at 11 months of age. Within 15 minutes of eating the eggs ( which she loved) she was breaking out with hives from her nose down to her ankles. She was not irritable. The hives were better with benadryl, but did not go away until the next day.
Do I try boiled eggs again? Should she get the flu shot? If she could get the flu shot, should she get it where she would be closely monitored?
There are age restrictions in regards to who gets the vaccinations. The CDC recommendation for the seasonal flu immunization is all children over the age of 6 months.
Now by the history she seems to have an allergic reaction to egg showing itself as urticaria. The recommendations are to use the desensitization protocol for someone who has a serious reaction including anaphylaxis according the AAP and to use the desensitization protocol for anaphylaxis according to the CDC.
The egg reaction should be checked out. The reaction of urticaria that did not require any medical evaluation is not anaphylaxis.
You have choices and they need to be melded with your comfort level and your health care provider’s comfort level. Serious life-threatening reactions usually occur within three hours of the exposure. You could wait in the medical facility for that duration of time after the shot.
My guess is that you have another child with a food allergy (am I correct??). You may already have a few tools on hand and some experience to deal with any untoward situations. Sometime having another with a food allergy makes a family a bit more brazen (bold) about reactions and in other instances it intensifies worry and concern. Many times it is not required, but the desensitization process safely gets one through this. The compromise is the 10% of the dose followed by 90% if there are no problems.
Let me know if this make sense.
FEL
Thank you! This does make sense. My oldest daughter is a patient of yours, Michaela. Should we just come see you to have the infant receive her flu shot, with the strong family history of food allergies?
Thank you for writing your blog. It is very helpful.
Keep up your great work!
Each child has their own potential for developing food allergy. Granted, your family has more than what would be considered a ‘fair share’ of food allergy issues.
Check with comfort level of your primary caretaker as well as your own comfort level. The family history of food allergy is not on the decision tree for concerns with the influenza vaccine, it is the child’s personal history of anaphylaxis (severe reaction) that dictates how this should be handled.
I have not come across many children who have had a major allergic reaction to the influenza vaccination, thankfully.
Let us know how we can help.
FEL
Hi, Thanks for the informative posting.
My son (age 5) has a known allergy to eggs and his usual reaction is vomiting. In the past he has received flu vaccines with no issues. This year we gave his a seasonal flu vaccine and 48 hours later his arm swelled to twice it’s normal size (we measured), was rock hard, and very warm to the touch. We saw his pediatriacian and administered Benadryl. The arm returned to normal after about another 48 hours. My question now is: Should he receive the H1N1 vaccine? I’m very hesitant to have him get one, especially with such a recent, extreme reaction. Thank you, Jen
Allergies: A Leickly Story » Blog Archive » H1N1 Influenza Vaccine and Egg Allergy - December 9, 2009
[...] 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 … [...]