Influenza Vaccine

Testing

  • SPT with influenza TIV is not recommended due to data that neither SPT nor ID testing was predictive of vaccine tolerance. Most patients with a positive TIV SPT do not have an adverse reaction to the vaccine.

  • SPT with influenza TIV may be indicated in special cases, such as patients with allergy to the vaccine but not egg.



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Vaccine administration protocols


Egg-free TIV

  • Note that in egg-allergic patients ≥18 years old, an FDA-approved egg-free flu vaccine (i.e. Flublok or Flucelvax) may be given if available


TIV

Practice Parameter 2012

Patient Type
Recommended Protocol
If patient has negative skin prick test to egg, negative specific IgE to egg, or history of ingesting egg or foods containing egg without an adverse reaction
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Give TIV or LAIV without special precautions.
If patient with non-anaphylactic egg allergy (hives only)
  • Give full age appropriate dose and observe 30 minutes
  • May be given in primary care office if appropriate personnel and equipment are available to treat anaphylaxis
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If patient with history of more severe reaction to egg (cardiovascular, respiratory, or GI symptoms)
  • Give full age appropriate dose and observe 30 minutes in an allergist's office

Previously recommended (conservative) approaches:
  • 2-step protocol: give 10% of age appropriate dose, and observe 30 minutes. If no adverse reaction, give remaining dose (90%) and observe for 30 minutes.
  • Multiple-step protocols may be an option for select cases, such as patients with history of anaphylaxis to previous dose of TIV, H1N1, or another egg containing vaccine.
    • Example protocol for a 0.5 mL dose at 15-minute intervals: 0.05 mL of 1:10 dilution, 0.05 mL of full-strength, 0.1 mL of full-strength, 0.15 mL of full-strength, 0.20 mL of full-strength
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CDC ACIP 2012-2013 Algorithm

CDC algorithm egg flu.png

LAIV (Kelso)

  • Although the intranasally-administered live attenuated influenza vaccine (LAIV) contains a low amount of ovalbumin, all published studies to date have evaluated the injectable trivalent inactivated vaccine (TIV), and thus TIV rather than LAIV should be used for egg-allergic recipients
  • LAIV should not be used in children with asthma, which often coexists with egg allergy
  • Wood: although the intranasal vaccine contains low amounts of egg protein, it should not be used in egg allergic patients as there is little data on its safety



Ovalbumin content in flu vaccines

  • Previous data suggests that administration of vaccines containing ovalbumin ≤0.6 μg/0.5 mL (equal to ≤1.2 μg/1 mL) via a 2-step protocol was safe in patients with egg allergy (including those with anaphylaxis).
  • It is unknown whether ovalbumin is the primary allergen causing adverse reactions in egg allergic patients receiving the influenza vaccine
  • Vaccines with no egg content or with the lowest ovalbumin content (ideally ≤1 μg/0.5 mL) that are FDA approved for the age group to be vaccinated are preferred for patients with egg allergy


Ovalbumin in flu vaccines 2012-2013.png





Other Egg-containing Vaccines

Egg in vaccines.png
  • Per the yellow fever vaccine package insert, patients with egg allergy should be skin tested with the vaccine before administration
    • If skin test negative, give full dose and observe 30 min
    • If skin test positive, administered in graded doses under observation



References